Chronic angina is one of the widespread manifestations of IHD (ischaemic heart disease). According to the study by Hemingway H. (2008), the prevalence of angina is about 6% across different countries. The ailment occurs slightly more often in women than in men. It is associated with significant worsening of the quality of individuals’ life, enlarged risk of heart attack occurrence, and can lead to fatal outcome. Therefore, timely treatment of this serious disease is the key priority for patients and their doctors. In this article, we will look at the causes and symptoms of chronic angina, and also tell you about modern methods of treating the disease.
Definition and Causes of Chronic Angina
Chronic angina (also stable angina) is a syndrome that is manifested as chest pain emerging when it becomes hard for the heart to work. It occurs due to discrepancy between the requirements of the myocardium in oxygen and the possibilities of its delivery. The cause of angina pectoris, as well as ischemic heart disease, is the atherosclerosis-induced narrowing of the coronary vessels. Angina attacks develop with a narrowing of the lumen diameter of the coronary arteries by 50-70%. The more serious atherosclerotic stenosis, the more severe angina occurs. Although attacks of the disease usually develop suddenly, vascular lesions can develop gradually over years.
The risk factors for the development of the disease include:
- hyperlipidemia (increased "bad" cholesterol & triglycerides rate in the blood);
- obesity (high BMI and a large percentage of body fat);
- inadequate physical activity (this factor can lead to the disorder of lipid metabolism and increased cholesterol levels);
- smoking (this harmful habit causes oxygen deficiency in cells, so in patients with atherosclerosis who smoke, the ailment appears earlier);
- anemia (this condition is associated with a decrease in the delivery of oxygen to the heart);
- diabetes mellitus (the higher the blood glucose level, the higher the risk of heart ailments);
- increase in blood viscosity (this factor enlarges the risk of thrombosis);
- psychoemotional stress (during stress, the heart experiences increased workload).
Symptoms of the Ailment
Patients suffering from angina feel pain in the chest during the attack that can be caused by intensive physical activity, increased blood pressure, stressful emotional excitement, severe hypothermia, eating large amounts of food and other factors. These factors force the heart to work harder and consume larger oxygen quantities. The pain is usually pressing and constricting. Patients can describe it by applying their clenched fist or palm to the chest. The pain often extends to the patient’s neck, left arm & left shoulder. It can also irradiate into the jaw, the zone between the shoulder blades, to the right arm, the epigastric region, etc. Very rarely the pain is localized only in the abdomen or in the head. In such cases, the diagnosis of the disease is very difficult.
How to Recognize Pain Syndrome Caused by Angina?
Features of the pain syndrome with angina pectoris:
- it is characterized by paroxysmal nature, that is, has a clearly expressed time of onset and termination;
- it occurs under certain conditions (physical activity, stress, overeating, etc.);
- it lasts from 1 to 15 minutes,
- pain does not increase with coughing or breathing;
- the pain begins to subside or completely disappears when the load stops and / or after using high-speed nitrates (for example, nitroglycerin);
- the intensity of pain increases with the continuation or intensification of physical exercise, but it subsides or disappears within a few minutes when the patient stops exercising (being in a state of rest).
What are the Dangers of Angina?
Short-term ischemia that occurs during an attack of angina and lasts from 5 to 10 minutes usually does not cause significant changes in the myocardium. Nevertheless, with time (with frequent attacks) in the area of limited blood supply to the cardiac muscle, fibrosis develops and, as a consequence, the failure of the myocardium.
A very prolonged attack of angina that lasts 20 minutes or more is associated with severe changes in the heart muscle and the onset of necrosis (infarction). The disease enlarges the risk of heart rhythm disorders and sudden death.
Chronic Angina Treatment – Main Methods
Treatment of the disease has two main objectives:
- improvement of the prognosis of the disease (reduction of the possibility of myocardial infarction occurrence to a minimum);
- reducing symptoms of angina by preventing or stopping them.
Treatment of angina should be comprehensive. It includes correction of lifestyle, lowering cholesterol, the use of medications, and possibly surgery.
Modification of Lifestyle & Diet
To prevent possible negative consequences of the disease, patients should adjust their lifestyle. They need to give up smoking and alcohol abuse, factors that have a bad effect on the state of the cardiovascular system. Specialists advise to limit consumption of alcohol to 1 drink per day for females or 2 drinks for males. It is also recommended to engage in moderate physical activity & reduce weight to a normal level. In addition, patients need to modify their diet:
- limit salt intake (up to 5 g per day according to WHO recommendations);
- limit the intake of saturated fats;
- do not eat food products containing dangerous trans fats (for instance, fast food, margarines, spreads);
- enrich the diet in a sufficient number of fruits and vegetables (at least 400 g or 5 servings daily);
- eat fish containing Omega-3 or special supplements containing this indispensable component of a healthy diet.
Treating High Cholesterol
As we have mentioned above, atherosclerosis of arteries is the triggering factor of the ailment. Atherosclerosis is caused, in particular, by high rates of cholesterol in the blood. To prevent the development of atherosclerotic changes and worsening angina, patients may be prescribed anti-cholesterol medical remedies, such as statins. In addition, the decrease in cholesterol is favored by the modification of the lifestyle and diet that have been described above.
The surgical method for curing the ailment is angioplasty with stenting. During the surgery, a surgeon inserts a small balloon in the affected artery. Then the balloon is inflated and the stent is inserted for keeping the vessel in open position. Stents may be made of metal (probably with synthetic fabric covering).
There are many medicaments developed to cure the ailment. Let’s consider main groups of these meds.
- Aspirin or Clopidogrel. These drugs prevent the blood clots forming.
- β-blockers. They reduce the frequency of contractions of the heart and its need for oxygen.
- Nitrates. These drugs dilate blood vessels & lower the pressure. They quickly stop the attack of the disease.
This list is not exhaustive. In medicine, other meds can be used to cure the disease. One of the innovative meds against angina is Ranozaline.
Ranolazine – Modern Medication to Cure Chronic Angina
Ranolazine is a pharmacological agent that is the main active substance of the brand drug called Ranexa. Also it is sold as Ranozex, generic medicament produced by Indian manufacturers. Ranolazine was patented in 1980s but the FDA approved it as anti-angina medical remedy only in 2006.
Ranolazine is used mainly in combination with β-blockers, calcium antagonists, and nitrate-containing meds. However, in the case of intolerance for common anti-ischemic agents or patients' predisposition for lowering arterial pressure & bradycardia, monotherapy with ranolazine is possible.
The drug has a pronounced antianginal & antiischemic effect. It reduces the frequency of chronic angina attacks and increases tolerance to physical exercising in patients suffering from angina. It also reduces the need for myocardium in oxygen. During treatment with ranolazine, the number of arrhythmia attacks decreases.
Mechanism of Action of the Drug
Angina arises from ischemia of the myocardium. During ischemia, cardiomyocytes (heart muscle cells) are overloaded with calcium ions, which in turn leads to disturbance of myocardial relaxation during diastole (interval between cardiac contractions) and disruption of the diastolic filling of the coronary arteries, thereby provoking the onset of an angina attack. Ranolazine is a powerful selective suppressor of late sodium current (or late INa). Preventing the overload of cardiomyocytes with sodium ions, this medicine blocks reverse sodium-calcium metabolism and, accordingly, the accumulation of calcium ions in the cell. Due to this, coronary blood flow (blood current in the blood vessels of the myocardium) enhances and the patient's condition improves significantly.
How to Take Ranexa (Ranozex)?
Both Ranexa and Ranozex come in 500mg & 1000mg dosages (tablet form). According to the official instructions of manufacturers of the meds, patients should take a 500mg pill twice daily. If the need arises, the dosage can be increased to 1000mg two times per day. After taking the medicament, the maximum concentration of active substance in the blood is reached within 2-6 hours.
Side Effects, Interactions
The medical remedy may cause the following side effects:
- dizziness & constipation (the most common undesirable effects);
- pain in the extremities;
- anxiety, sleeping problems;
- bad appetite, etc.
Simultaneous use of the drug with strong inhibitors of the CYP3A4 isoenzyme (itraconazole, ketoconazole, etc.) is contraindicated. This enzyme is responsible for removing drugs from the body. Therefore, if its activity is suppressed, the concentration of ranolazine significantly increases, as does the risk of side events. It is also undesirable to take the drug in combination with grapefruit, since this fruit also affects the CYP3A4 enzyme.
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