Despite great strides in heart disease treatment, and perhaps paradoxically because of them, chest pain is on the rise.
More people visit emergency rooms for chest pain each year than for any other symptom except abdominal complaints. The American Heart Association estimates that 6.8 million Americans have the chronic, stable form of angina pectoris: chest discomfort caused by reduced coronary blood flow.
Unstable angina, the more worrisome cousin of stable angina, led to more than three-quarters of a million hospitalizations in 2001, the latest numbers available.
Researchers expect the number of Americans living with angina to grow as new treatments improve survival after heart attacks. ”This is the price of success,” said Dr. Eugene Braunwald of Harvard Medical School. ”Many of those people who would have died are your patients with angina.”
But experts say common drugs that can relieve angina are often ignored in favor of more aggressive approaches like bypass surgery or stenting, the insertion of wire mesh tubes that prop open narrowed coronary arteries. At the same time, cardiologists have realized that such treatments, while effective at alleviating chest pain, do not reduce the risk of heart attacks for most stable angina patients.
”A lot of people come away and think, I got the surgery; I’m cured,” said Dr. Stephen Glasser of the University of Minnesota. ”Often that’s not the case.”
Angina is often considered to be the signature of a sedentary modern lifestyle. But in 1772, Dr. William Heberden, an English physician, described 20 patients who suffered from ”a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue.”
Such patients, Dr. Heberden wrote, ”are seized while they are walking (more especially if it be uphill, and soon after eating).’‘
”But the moment they stand still,” he continued, ”all this uneasiness vanishes.”
In fact, exercise is one of what doctors call the four E’s of angina. The others are eating, emotional stress and exposure to cold. All increase the heart’s workload.
In healthy people, the coronary blood vessels respond, supplying the heart with extra fuel in the form of oxygen. But ”if one or two fuel lines get narrowed,” said Dr. Bertram Pitt of the University of Michigan, ”that engine starts to sputter.”
The result is often angina.
Episodes of stable angina usually develop slowly and last two to five minutes. Discomfort may radiate to the neck, shoulders or back. Shortness of breath is common.
A sudden change in this pattern suggests unstable angina. Pain that occurs without exertion, lasts longer than 10 minutes, or is not relieved by rest or nitroglycerin signals a higher risk for a heart attack.
”Call 911 and get to the hospital,” said Dr. Braunwald, who was chairman of a national committee that developed guidelines for treatment of unstable angina.
Sometimes, a diagnosis of angina can be missed. This is particularly likely, experts say, in women, who tend to experience symptoms different from men’s. When Elizabeth Barnes, a retired gunnery instructor in San Mateo, Calif., developed chest pain three years ago, for example, a cardiologist told her she had indigestion.
A stress test was negative. But a second test eventually revealed ischemia, restricted blood flow to her heart.
”You feel as if your chest is going to cave in sometimes,” said Ms. Barnes, who is 83. ”It was a scary feeling.”
Three classes of medication can quickly ease the symptoms of angina. Nitrates like nitroglycerin widen the heart’s fuel lines by relaxing blood vessels. Beta blockers decrease the heart’s workload. Calcium antagonists — verapamil or nifedipine, for example — have both effects.
But doctors often favor high-tech treatments over these familiar drugs, said Dr. Jonathan Abrams of the University of New Mexico, who was an author of the national guidelines for treating stable angina.
”They’re so standard they’re like your old family relatives,” Dr. Abrams said.
In a recent study of 693 heart disease patients, 510 of them with stable angina, Dr. Samer Jabbour, of the Lown Cardiovascular Research Foundation in Brookline, Mass., and his colleagues found that in a majority of cases, intensive medical treatment and reduction of the risk factors for heart disease allowed patients safely to postpone or avoid bypass surgery or stenting. The study appeared in the Feb. 1 issue of The American Journal of Cardiology.
If medications fail, the next step may be bypass surgery, in which healthy blood vessels are stitched onto the heart to bypass diseased vessels, or angioplasty, using a catheter to force open blocked vessels from the inside, sometimes followed by stenting. For unstable angina patients and a minority of stable angina patients with certain types of artery blockage, such interventions can be lifesaving. But patients should realize that these procedures do nothing to treat dangerous cholesterol plaques elsewhere in the heart’s blood vessels.
Since undergoing angioplasty three years ago, for example, Ms. Barnes has had little chest discomfort. But her doctor continues to prescribe heart disease medications.
Patients with angina can reduce their risk of a heart attack with a variety of medications, including aspirin and other drugs that prevent clotting, and statins, which lower L.D.L., the so-called bad cholesterol. Statins, studies show, may slow, stabilize or even reverse cholesterol buildup in the coronary arteries and over time may even decrease angina pain. National treatment guidelines also recommend dieting, exercising and quitting smoking, as well as keeping diabetes and blood pressure in check.
New anti-angina drugs, including nicorandil, already allowed in Europe, and ranolazine, still in clinical trials, may offer more options if they are approved here.
Meanwhile, Barbara Fletcher, president of the Preventive Cardiovascular Nurses Association, suggests that patients recognize situations that set off their angina and use their medicine properly.
”We can’t cure everything,” Ms. Fletcher said. ”We have to help these patients learn to manage their daily lives.”
Source:The New York Times