intestinal angina

angina

[an-ji´nah, an´jĭ-nah] spasmodic, choking, or suffocative pain; now used almost exclusively to denote angina pectoris. adj., adj an´ginal.agranulocytic angina agranulocytosis.crescendo angina old term for unstable angina.angina cru´ris intermittent claudication.herpes angina (angina herpe´tica) herpangina.intestinal angina generalized cramping abdominal pain occurring shortly after a meal and persisting for one to three hours, due to ischemia of the smooth muscle of the bowel.Ludwig's angina see ludwig's angina.angina pec´toris acute pain in the chest resulting from ischemia" >myocardial ischemia (decreased blood supply to the heart muscle); the condition has also been called cardiac pain of effort and emotion because the pain is brought on by physical activity or emotional stress that places an added burden on the heart and increases the need for blood being supplied to the myocardium. Some patients can predict the kinds of events that will precipitate an attack while others are unaware of any relationship between onset of an attack and any particular situation in their lives.
Angina pectoris occurs more frequently in men than in women, and in older persons than in younger persons. It is not a disease entity but a symptom of an underlying disease process involving the arteries that supply blood to the heart muscle. About 90 per cent of all cases can be attributed to coronary atherosclerosis. Studies have shown that at least one of the three major coronary arteries usually is stenosed before angina develops. In most cases, all of the major coronary arteries are involved.
Angina pectoris also can result from stenosis of the aorta, pulmonary stenosis and ventricular hypertrophy, or connective tissue disorders such as systemic lupus erythematosus and periarteritis nodosa that affect the smaller coronary arteries.Symptoms. The chief symptom is chest pain, usually unmistakably distinguished by the patient as different from other types of pain such as that caused by indigestion. It is generally described as a feeling of tightness, strangling, heaviness, or suffocation and is usually concentrated on the left side, beginning just under the sternum; it sometimes radiates to the neck, throat, and lower jaw and down the left arm, and occasionally to the stomach, back, or across to the right side of the chest. The pain seldom lasts more than 15 minutes and is usually relieved by rest and relaxation or by administration of nitrates. If it is not relieved in 10 to 15 minutes, the physician should be notified and the patient taken to a cardiac care unit. The decreased blood supply to the heart makes it especially vulnerable to arrhythmias" >arrhythmias and myocardial infarction, which are the cause of death in about one third of all cases.
Coronary arteriography and ventriculography are valuable in determining the prognosis for angina pectoris. The mortality rate for patients having a narrowing of all three main coronary arteries is higher than for those who have only one vessel involved. Severity of pain is not a good prognostic indicator; some patients with severe discomfort live for many years, while others with mild symptoms die suddenly. An enlarged heart, a third heart sound, ECG abnormalities at rest, and hypertension are all indicative of a poor prognosis.Treatment and Patient Care. Relief from pain by rest and prevention of attacks by avoiding situations which precipitate them are the first steps in the care of the patient with angina. In most cases patients are eager to learn about the disease process causing the pain and want to know how they can participate in control of their attacks. However, compliance with the prescribed regimen usually requires a change in life style and the breaking of some lifelong habits. The known risk factors for coronary heart disease are explained to the patient, and a regimen designed to avoid further damage to the arteries is prescribed.
Organic nitrates may be administered orally or sublingually for relief from anginal pain. They act by dilating the arteries and may be used to treat acute attacks, for long-term prophylaxis and management, or for prophylaxis in situations likely to provoke an attack. Commonly used nitrates are erythrityl tetranitrate, isosorbide dinitrate, and nitroglycerin.
Beta-adrenergic blocking agents, such as propranolol, are used to treat patients who do not respond to weight control and treatment with vasodilators and whose angina significantly limits their activities. These agents decrease the heart rate, blood pressure, and myocardial oxygen consumption and increase the patient's exercise tolerance.
The calcium channel blocking agents (nifedipine, verapamil, diltiazem, and others) are drugs that are particularly beneficial in relieving pain in patients whose angina is the result of coronary artery spasm or constriction. They act by selectively inhibiting the transport of calcium across the cell membrane of myocardial cells and also by reducing myocardial oxygen utilization. Patients most likely to obtain dramatic relief from drugs of this kind are those who experience chest pain while resting or sleeping, upon exposure to cold, or during emotional stress.
Surgical procedures involving arterial bypass and angioplasty have become fairly common as a form of treatment of certain types of ischemic heart disease and resulting angina pectoris. The surgical procedures attempt to bypass the diseased portion of the coronary artery by suturing a vein graft or the internal mammary artery from the aorta to one or more coronary arteries beyond the area of obstruction. In most instances the graft is obtained from the patient's saphenous vein. Angioplasty reestablishes patency of the vessels; in most cases, it is now accompanied by insertion of a stent to help prevent restenosis.
An attitude of calmness and efficiency is most important when caring for a person suffering from an attack of angina pectoris. The pain produces emotional reactions and the strongest of these is fear. Most of these patients know that their pain is resulting from an insufficient supply of oxygen to the heart and they frequently have a feeling of impending death. It usually helps to raise the patient to a sitting position so that breathing is less difficult. The prompt administration of nitroglycerin or the specific drug ordered by the physician should shorten the attack and relieve pain. Above all, the calm presence of someone who knows how to care for them can do much to reassure patients and help them relax, thus lessening the severity of the attack.Plaut's angina necrotizing ulcerative gingivostomatitis.preinfarction angina angina that lasts longer than 15 minutes; it is a symptom of worsening cardiac ischemia.Prinzmetal's angina a variant of angina pectoris in which the attacks occur during rest, exercise capacity is well preserved, and attacks are associated electrocardiographically with elevation of the ST segment. It is cyclic in nature and is believed to be caused by coronary artery spasm.pseudomembranous angina necrotizing ulcerative gingivostomatitis.stable angina chest pain of cardiac origin that has not changed in character, frequency, intensity, or duration for 60 days.unstable angina chest pain of cardiac origin that is variable, usually increasing in frequency and intensity and with irregular timing.variant angina Prinzmetal's angina.Vincent's angina see vincent's angina.

ab·dom·i·nal an·gi·na

, angina abdominisintermittent abdominal pain, frequently occurring at a fixed time after eating, caused by inadequacy of the mesenteric circulation resulting from arteriosclerosis or other arterial disease. Synonym(s): intestinal angina

A condition characterised by intermittent severe ischaemia, resulting in abdominal colic, beginning 15–30 mins post-prandially, lasting 1–2 hours, and appearing when 2 or all 3—superior and inferior mesenteric and celiac—major abdominal arteries have severe atherosclerosis; because the intestine’s O2 demand increases with meals, patients avoid the pain by not eating, and thus lose weight; malabsorption may occur since absorption is O2-dependent
Management Bypass, endarterectomy, vascular reimplantation, percutaneous transluminal angioplasty

chronic mesenteric ischaemia

A condition characterised by intermittent severe ischaemia resulting in abdominal colic, beginning 15–30 minutes post-prandially and lasting 1-2 hours, which appears when 2 or all 3 of the superior and inferior mesenteric and coeliac major abdominal arteries have severe atherosclerosis. Because the intestine’s O2 demand increases with meals, patients may avoid the pain by not eating, thus losing weight. Malabsorption may occur because absorption is O2-dependent.
Popularly known as abdominal angina, chronic mesenteric ischaemia is preferred by journals that use British English, while chronic intestinal ischemia is used in journals that publish in American English.

Management
Bypass, endarterectomy, vascular reimplantation, percutaneous transluminal angioplasty.

intestinal 'angina'

Chronic intermittent occlusion of intestinal arteries, analogous to angina pectoris, causing sporadic claudication of the vascular supply to the intestine; ingestion of food causes IA as digestion ↑ blood flow through the gut, which is supplied by the celiac axis, superior and inferior mesenteric arteries; postprandial abdominal pain implies major atherosclerotic narrowing of > one vessel given the rich anastomotic network among these vessels

ab·dom·i·nal an·gi·na

, angina abdominis (ab-dom'i-năl an'ji-nă, an'ji-nă ab-dō'mi-nis) Intermittent abdominal pain, frequently occurring at a fixed time after eating, caused by inadequacy of the mesenteric circulation resulting from arteriosclerosis or other arterial disease, with associated significant weight loss.
Synonym(s): intestinal angina.

angina

(an-ji'na, an'ji-) [L. angina, quinsy, fr. angere, to choke] 1. Angina pectoris.2. Acute sore throat. anginal (an-ji'nal, an'ji-nal), adjective

abdominal angina

Abdominal pain that occurs after meals, caused by insufficient blood flow to the mesenteric arteries. This symptom typically occurs in patients with extensive atherosclerotic vascular disease and is often associated with significant weight loss. Synonym: intestinal angina; bowel ischemia

Patient care

Medical intervention for abdominal angina can include supportive care including anticoagulant therapy. Surgical intervention includes angioplasty, partial colectomy, (removing the ischemic section of the bowel and reconnecting the remaining ends). It may be necessary to create a colostomy or ileostomy and to correct blockages in the mesenteric arteries. The patient must be monitored for signs and symptoms of peritonitis and/or sepsis. As the patient recovers, patient education focuses on prevention of further episodes, recognition of signs and symptoms including cramping abdominal pain after eating, blood in the stool, red or black stools, diarrhea and/or constipation. It also includes instructions and support for living with permanent or temporary colostomy or ileostomy.

angina decubitus

Attacks of angina pectoris occurring while a person is in a recumbent position.

angina of effort

Angina pectoris with onset during exercise. Synonym: exertional angina

exertional angina

Angina of effort.

intestinal angina

Abdominal angina.

Ludwig angina

See: Ludwig angina

ANGINA PECTORIS

angina pectoris

An oppressive pain or pressure in the chest caused by inadequate blood flow and oxygenation to heart muscle. It is usually due to atherosclerosis of the coronary arteries and in Western cultures is one of the most common emergent complaints bringing adult patients to medical attention. It typically occurs after (or during) events that increase the heart's need for oxygen, e.g., increased physical activity, a large meal, exposure to cold weather, or increased psychological stress. See: illustration; table

Symptoms

Patients typically describe a pain or pressure located behind the sternum and having a tight, burning, squeezing, or binding sensation that may radiate into the neck, jaw, shoulders, or arms and be associated with difficulty in breathing, nausea, vomiting, sweating, anxiety, or fear. The pain is not usually described as sharp or stabbing and is usually not aggravated by deep breathing, coughing, swallowing, or twisting or turning the muscles of the trunk, shoulders, or arms. Women, diabetics, and the elderly may present with atypical symptoms, such as shortness of breath without pain.

Treatment

In health care settings, oxygen, nitroglycerin, and aspirin are provided, and the patient is placed at rest. Morphine sulfate is given for pain that does not resolve after about 15 min of treatment with that regimen. Beta-blocking drugs (such as propranolol or metoprolol) are used to slow the heart rate and decrease blood pressure. They are the mainstay for chronic treatment of coronary insufficiency and are indispensable for treating unstable angina or acute myocardial infarction. At home, patients should rest and use short-acting nitroglycerin. Patients with chronic or recurring angina pectoris may get symptomatic relief from long-acting nitrates or calcium channel blockers. Patients with refractory angina may be treated with combinations of all of these drugs in addition to ranolazine, a sodium channel blocker.

Patient care

The pattern of pain, including OPQRST (onset, provocation, quality, region, radiation, referral, severity, and time), is monitored and documented. Cardiopulmonary status is evaluated for evidence of tachypnea, dyspnea, diaphoresis, pulmonary crackles, bradycardia or tachycardia, altered pulse strength, the appearance of a third or fourth heart sound or mid- to late-systolic murmurs over the apex on auscultation, pallor, hypotension or hypertension, gastrointestinal distress, or nausea and vomiting. The 12-lead electrocardiogram is monitored for ST-segment elevation or depression, T-wave inversion, and cardiac arrhythmias. A health care provider should remain with the patient and provide emotional support throughout the episode. Desired treatment results include reducing myocardial oxygen demand and increasing myocardial oxygen supply. The patient is taught the use of the prescribed form of nitroglycerin for anginal attacks and the importance of seeking medical attention if prescribed dosing does not provide relief. Based on his needs, the patient should be encouraged and assisted to stop smoking, maintain ideal body weight, lower cholesterol by eating a low-fat diet, keep blood glucose under control (if the patient is diabetic), limit salt intake, and exercise (walking, gardening, or swimming regularly for 45 min to an hour every day). The patient is also taught about prescribed beta-adrenergic or calcium channel blockers and any other needed interventions should they become necessary.

Four major forms of angina are identified: 1. stable: predictable frequency and duration of pain that is relieved by nitrates and rest; 2. unstable: pain that is more easily induced and increases in frequency and duration; 3. variant: pain that occurs from unpredictable coronary artery spasm; and 4. microvascular: impairment of vasodilator reserve that causes angina-like chest pain even though the patient’s coronary arteries are normal. Severe and prolonged anginal pain is suggestive of a myocardial infarction.

Class	Description
I	Ordinary physical activity, such as walking or climbing stairs, does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.
II	Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or in wind, under emotional stress, only during the few hours after awakening, or walking more than two level blocks and climbing more than one flight of stairs at a normal pace and in normal conditions.
III	Marked limitation of ordinary physical activity. Angina occurs on walking one to two level blocks and climbing one flight of stairs in normal conditions at a normal pace.
IV	Inability to carry on any physical activity without discomfort—angina symptoms may be present at rest.

preinfarction angina

Angina pectoris occurring in the days or weeks before a myocardial infarction. The symptoms may be unrecognized by patients without a history of coronary artery disease.

silent angina

Unrecognized angina pectoris that presents with symptoms other than chest pain or pressure. The patient may experience dyspnea on exertion, heartburn, nausea, pain in the arm, jaw pain, tenderness in back or arms (in women), or other atypical symptoms. Silent angina pectoris occurs most often in older adults, in women, in postoperative patients who are heavily medicated, or in patients with diabetic neuropathy.

stable angina

Angina that occurs with exercise and is predictable. It is usually promptly relieved by rest or nitroglycerin.

unstable angina

Abbreviation: UA
Angina that has changed to a more frequent and more severe form. Its symptoms include chest pain that occurs with minimal exertion (or that progresses from pain with exertion to pain occurring with minimal exertion or at rest) and may be an indication of a severe obstruction in a coronary artery and impending myocardial infarction. It is a medical emergency, and should be aggressively managed.

variant angina

Angina due to spasm of the coronary arteries rather than from exertion or other increased demands on the heart. The pain typically occurs at rest. During coronary catheterization the spasm is usually found near an atherosclerotic plaque, often in the right coronary artery. Infusions of ergonovine may provoke it. On the electrocardiogram, the diagnostic hallmark is elevation of the ST segments during episodes of resting pain. Treatments include nitrates and calcium channel blocking drugs. Beta-blocking drugs, frequently used as first-line therapy in typical angina pectoris, are often ineffective with this angina. Synonym: Prinzmetal angina

Vincent angina

Necrotizing ulcerative gingivitis.

ab·dom·i·nal an·gi·na

, angina abdominis (ab-dom'i-năl an'ji-nă, an'ji-nă ab-dō'mi-nis) Intermittent abdominal pain, frequently occurring at a fixed time after eating, caused by inadequate mesenteric circulation.
Synonym(s): intestinal angina.