Angina

aSt.R.iE

 The English word angina (which comes intact in its written form from Latin) refers to a painful constriction or tightness somewhere in the body, and may refer to: Angina pectoris, chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle Abdominal angina, postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet visceral demands Ludwig's angina, a serious, potentially life-threatening infection of the tissues of the floor of the mouth Prinzmetal's angina, a syndrome typically consisting of cardiac chest pain at rest that occurs in cycles Vincent's angina, trench mouth, infection of the gums leading to inflammation, bleeding, deep ulceration and necrotic gum tissue Angina tonsillaris, an inflammation of the tonsils

Epidemiologi
It's thought that nearly 7 million people in the United States suffer from angina. About 400,000 patients go to their doctors with new cases of angina every year. Angina occurs equally in men and women. It can be a sign of heart disease, even when initial tests don't show evidence of CAD.

Definisi
Angina (angina pektoris) merupakan nyeri dada sementara atau suatu perasaan tertekan, yang terjadi jika otot jantung mengalami kekurangan oksigen akibat pembuluh darah yang menyempit. Angina terjadi bila penyumbatan blok telah mencapai 70 persen atau lebih. Biasanya penyumbatan disebabkan oleh lemak.

Types of Angina
Stable Angina Stable angina is the most common type. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. If you know you have stable angina, you can learn to recognize the pattern and predict when the pain will occur. The pain usually goes away in a few minutes after you rest or take your angina medicine. Stable angina isn't a heart attack, but it makes a heart attack more likely in the future.

Unstable Angina Unstable angina doesn't follow a pattern. It can occur with or without physical exertion and isn't relieved by rest or medicine. Unstable angina is very dangerous and needs emergency treatment. It's a sign that a heart attack may happen soon. Variant (Prinzmetal's) Angina Variant angina is rare. It usually occurs while you're at rest. The pain can be severe. It usually happens between midnight and early morning. This type of angina is relieved by medicine.

Klasifikasi
Berdasarkan beratnya angina:
Kelas I: Angina yg berat untuk pertama kali, atau makin bertambah beratnya nyeri dada. Kelas II: Angina pada waktu istirahat dan terjadinya subakut dalam 1 bulan, tapi tak ada serangan angina dalam waktu 48 jam terakhir. Kelas III: Adanya serangan angina waktu istirahat dan terjadinya secara akut baik sekali atau lebih, dalam waktu 48 jam terakhir.

 Berdasarkan keadaan klinis:

Kelas A: Angina tak stabil sekunder, karena adanya anemia, infeksi lain atau febris. Kelas B: Angina tak stabil yang primer, tak ada faktor extra cardiac. Kelas C: Angina yang timbul setelah serangan infark jantung.

 Berdasarkan intensitas pengobatan:

Tak ada pengobatan atau hanya mendapat pengobatan minimal. Timbul keluhan walaupun telah dapat terapi yang standar. Masih timbul serangan angina walaupun telah diberikan pengobatan yang maksimum, dengan beta bloker, nitrat & antagonis kalsium.

Etiologi
Coronary artery disease Coronary artery spasm Pleuritis Pericarditis Pneumonia Pulmonary embolism etc

Patofisiologi
Jika arteri menyempit atau tersumbat sehingga aliran darah ke otot tidak dapat memenuhi kebutuhan jantung akan oksigen, maka bisa terjadi iskemia dan menyebabkan nyeri.

Angina dapat terjadi di saat : Latihan atau Olahraga Setelah makan Stress atau emosi yang berlebihan

Manifestasi Klinis
Angina is usually felt as: pressure, heaviness, tightening, squeezing, or aching across the chest, particularly behind the breastbone. This pain often radiates to the neck, jaw, arms, back, or even the teeth. Patients may also suffer: indigestion heartburn weakness sweating, nausea cramping, and shortness of breath

Diagnosis
Electrocardiogram (EKG) Exercise stress test: In patients with a normal resting EKG, exercise treadmill or bicycle testing can be useful screening tools for coronary artery disease. During an exercise stress test (also referred to as stress test, exercise electrocardiogram, graded exercise treadmill test, or stress ECG), EKG recordings of the heart are performed continuously as the patient walks on a treadmill or pedals on a stationary bike at increasing levels of difficulty. The occurrence of chest pain during exercise can be correlated with changes on the EKG, which demonstrates the lack of oxygen to the heart muscle. When the patient rests, the angina and the changes on the EKG which indicate lack of oxygen to the heart can both disappear. The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%.

 Stress echocardiography Stress echocardiography combines echocardiography with exercise stress testing. Abnormalities in muscle contraction can be detected by echocardiography. Stress echocardiography and thallium stress tests are both about 80% to 85% accurate in detecting significant coronary artery disease. Cardiac catheterization

 Menurut ACC dan AHA perbedaan angina tak stabil & infark tanpa elevasi segmen ST (NSTEMI: non ST elevation myocardial infarction) ialah apakah iskemi yang timbul cukup berat sehingga dapat menimbulkan kerusakan pada miokardium, sehingga adanya petanda kerusakan miokardium dapat diperiksa. Diagnosis angina tak stabil:
Keluhan iskemi ada, tapi tidak ada kenaikan troponin maupun CK-MB, dengan atau tanpa perubahan EKG untuk iskemi.

Manajemen
Treatment options include: rest, medications (nitroglycerin, beta blockers, calcium channel blockers), percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass graft surgery (CABG).

Stratifikasi Risiko
Risiko rendah:

Tidak punya angina sebelumnya Sudah tidak ada serangan angina Sebelumnya tidak memakai obat anti angina EKG normal atau tak ada perubahan dari sebelumnya Enzim jantung tidak meningkat Usia muda
Ada angina yang baru dan makin Angina waktu istirahat Tak ada perubahan segmen ST Enzim jantung & troponin tidak meningkat

Risiko sedang:

 Risiko tinggi:
Angina waktu istirahat Angina berlangsung lama atau angina pasca infark Sebelumnya sudah mendapat terapi yang intensif Usia lanjut Perubahan segmen ST Kenaikan troponin Keadaan hemodinamik tidak stabil

Nitroglycerin
Nitroglycerin tablets (placed under the tongue), and nitroglycerin sprays all relieve angina by reducing the heart muscle's demand for oxygen. Nitroglycerin also relieves spasm of the coronary arteries and can redistribute coronary artery blood flow to areas that need it most. Short-acting nitroglycerin can be repeated at five minute intervals. When 3 doses of nitroglycerin fail to relieve the angina, further medical attention is recommended. Shortacting nitroglycerin can also be used prior to exertion to prevent angina. Longer-acting nitroglycerin preparations, such as Isordil tablets, Nitro-Dur transdermal systems (patch form), and Nitrol ointment are useful in preventing and reducing the frequency and intensity of episodes in patients with chronic angina.

Beta blockers
Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart. Inhibiting adrenaline decreases the heart rate, lowers the blood pressure, and reduces the pumping force of the heart muscle, all of which reduce the heart muscle's demand for oxygen. Ex: acebutolol (Sectral), atenolol (Tenormin), bisoprolol (Zebeta), metoprolol (Lopressor, Lopressor LA, Toprol XL), nadolol (Corgard), propranolol (Inderal), timolol (Blocadren)

Calcium Channel Blockers

Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping force of the heart muscle, thereby reducing muscle oxygen demand. Calcium channel blockers also relieve coronary artery spasm. Ex: amlodipine (Norvasc), bepridil (Vascor), diltiazem (Cardizem), felodipine (Plendil), isradipine (Dynacirc), nicardipine (Cardene), nifedipine (Adalat, Procardia), nimodipine (Nimotop), nisoldipine (Sular), verapamil (Calan)

Prognosis
The prognosis for a patient with angina depends on its origin, type, severity, and the general health of the individual. A person who has angina has the best prognosis if he or she seeks prompt medical attention and learns the pattern of his or her angina, such as what causes the attacks, what they feel like, how long episodes usually last, and whether medication relieves the attacks. If patterns of the symptoms change significantly, or if symptoms resemble those of a heart attack, medical help should be sought immediately.

Prevention
In most cases, the best prevention involves changing one's habits to avoid bringing on attacks of angina. Proper diet, weight control, blood cholesterol levels, and blood pressure. Stop smoking.

Referensi
IPD UI Jilid III Yayasan Jantung Indonesia www.nhlbi.nih.gov www.medicinenet.com www.healthatoz.com