Download HeartRiskPPEScontent..

1. Do you smoke?
Yes responses should be evaluated using the following questions and discussion points:
Identify and document tobacco use status, frequency, types of tobacco used
Advise to quit. In a clear, strong, and personalized manner, urge tobacco user to quit.
Advice should be:
Clear—“It is important that you quit smoking (or using chewing tobacco) now, and I can help
you.” “Cutting down while you are ill is not enough.” “Occasional or light smoking is still
dangerous.”
Strong—“As your clinician, I need you to know that quitting smoking is the most important
thing you can do to protect your health now and in the future. The clinic staff and I will help
you.”
Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and
economic costs, and/ or the impact of tobacco use on children and others in the household.
“Continuing to smoke makes your asthma worse, and quitting may dramatically improve your
health.”
“Quitting smoking may reduce the number of ear infections your child has.”
Assess willingness to make a quit attempt.
Is the tobacco user willing to make a quit attempt at this time?
Assess patient’s willingness to quit: “Are you willing to give quitting a try?”
If the patient is willing to make a quit attempt at the time, provide assistance.
If the patient will participate in an intensive treatment, deliver such a treatment or link/refer to an
intensive intervention.
If the patient is a member of a special population (e.g., adolescent, pregnant smoker, racial/ethnic
minority), consider providing additional information.
If the patient clearly states that he or she is unwilling to make a quit attempt at the time, provide
an intervention shown to increase future quit attempts
Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and
provide or refer for counseling or additional treatment to help the patient quit.
A patient’s preparations for quitting:
Set a quit date. Ideally, the quit date should be within 2 weeks.
Tell family, friends, and coworkers about quitting, and request understanding and support.
Anticipate challenges to the upcoming quit attempt, particularly during the critical first few
weeks. These include nicotine withdrawal symptoms.
Remove tobacco products from your environment. Prior to quitting, avoid smoking in places
where you spend a lot of time (e.g., work, home, car). Make your home smoke-free.
Recommend the use of medications. Explain how these medications increase quitting success
and reduce withdrawal symptoms. First line medications include: Bupropion SR, nicotine gum,
inhaler, lozenge, nasal spray, patch, and varenicline; second line medications include: clonodine,
nortriptyline. (There is insufficient evidence to recommend meds for certain populations, i.e.
pregnant women, smokeless tobacco users, light smokers, adolescents).
Provide practical counseling:
Abstinence. Striving for total abstinence is essential. Not even a single puff after the quit date.
Past quit experience. Identify what helped and what hurt in previous quit attempts. Build on past
success.
Anticipate triggers or challenges in the upcoming attempt. Discuss challenges/triggers and how
the patient will successfully overcome them (e.g., avoid triggers, alter routines).
Alcohol. Because alcohol is associated with relapse, the patient should consider
limiting/abstaining from alcohol while quitting. (Note that reducing alcohol intake could
precipitate withdrawal in alcohol-dependent persons.)
Other smokers in the household. Quitting is more difficult when there is another smoker in the
household. Patients should encourage housemates to quit with them or to not smoke in their
presence.
Provide a supportive clinical environment while encouraging the patient in his or her quit
attempt. “My office staff and I are available to assist you.” “I’m recommending treatment that
can provide ongoing support.”
Provide supplemental materials, info on quit lines: Federal agencies, nonprofit agencies, national
quitline network (1-800-QUIT-NOW), or local/state/tribal health departments/quitlines
For patients unwilling to quit at the time, provide interventions designed to increase future quit
attempts.
Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts,
beginning within the first week after the quit date. A second follow-up contact is recommended
within the first month. Schedule further follow-up contacts as indicated.
Actions during follow-up contact: For all patients, identify problems already encountered and
anticipate challenges in the immediate future. Assess medication use and problems.
Remind patients of quitline support (1-800-QUIT-NOW). Address tobacco use at next clinical
visit (treat tobacco use as a chronic disease).
For patients who are abstinent, congratulate them on their success.
If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence.
For patients unwilling to make a quit attempt at the time, address tobacco dependence and
willingness to quit at next clinic visit.
Sources: Clinical Interventions for Tobacco Use and Dependence, 2008 Update, US Department
of Health and Human Services, 2008.
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
http://www.aafp.org/afp/20030615/us.html
2. Is your blood pressure 140/90 mmHg or higher, OR have you been told by your doctor
that your blood pressure is too high?
Yes responses indicate an increased risk for heart issues. Provide behavior and diet counseling
including the following:
Suggestions for Interventions:
Weight loss. Counseling that results in a modest reduction in body weight provides benefits both
during and after the active therapy. In one study, persons who were assigned to weight-loss
intervention reduced their body weight by 3.5 kg (7.7 lb); their systolic and diastolic blood
pressures decreased by 5.8 and 3.2 mm Hg, respectively. The incidence of hypertension at 7-year
follow-up was 18.9% in those who underwent weight-loss therapy and 40.5% in the control
group.5
Dietary sodium reduction. In overweight persons, a 100 mmol/d increase in dietary sodium
intake is associated with an increase in stroke (32%), stroke mortality (89%), coronary heart
disease mortality (44%), cardiovascular heart disease mortality (61%), and mortality from all
causes (39%).6 In 12 randomized controlled trials, normotensive persons who lowered their
sodium intake by an average of 77 mmol/d reduced their systolic and diastolic blood pressures
by 1.9 and 1.1 mm Hg, respectively.7
Increased physical activity. The quantity of exercise (the Surgeon General recommends 30
minutes a day most days of the week8) appears to be more important than its intensity.9 In 27
randomized controlled trials, normotensive persons who engaged in aerobic exercise were able to
lower their systolic blood pressure an average of 4.04 mm Hg.9
Moderation in alcohol consumption. A reduction in self-reported consumption of alcohol by a
median of 76% in 15 randomized controlled studies was associated with a decrease in systolic
and diastolic blood pressures of 3.56 and 1.80 mm Hg, respectively.10 The relationship between
reduced alcohol intake and lower blood pressure was dose-dependent.
Potassium supplementation. In 12 trials that included normotensive persons, potassium
supplementation of 75 mmol/d reduced blood pressure by 1.8 mm Hg systolic and 1.0 mm Hg
diastolic. The effects were greatest in those who had higher sodium intake.11
Modification of whole diets (DASH diet). The DASH diet emphasizes increased consumption
of fruits, vegetables, and low-fat dairy products and reduced intake of saturated and total fat.
Among normotensive persons who followed the DASH diet, systolic blood pressure decreased
by 3.5 mm Hg.12
Interventions with Less Proven Efficacy
Calcium supplementation. The reduction in blood pressure associated with calcium
supplementation is modest and has been observed only in hypertensive persons.12 However,
advise patients that adequate calcium intake (1000 to 1200 mg/d for adults) is important to
overall health.
Fish oil supplementation. High doses (greater than 3 g/d) of a fish oil supplement may reduce
the risk of coronary heart disease and stroke as well as provide a small reduction in blood
pressure.13,14 The effect of fish oil is greatest in hypertensive patients.13 Adverse effects include
eructation and a fishy taste.
Herbal and botanic dietary supplements. Although the use of herbal products has increased in
recent years, few studies have shown that they are effective in preventing or treating
hypertension or heart disease. The FDA does not regulate these products; thus, the amount of
active ingredient can vary widely among different brands. Always ask patients whether they take
herbal supplements, and keep in mind the possibility of herb-drug interactions.
Sources: US Department of Health and Human Services. Physical Activity and Health: A Report
of the Surgeon General. Atlanta: US Dept of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion;
1996:28.
National High Blood Pressure Education Program Working Group on Hypertension Control in
Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure in
Children and Adolescents: a working group report from the National High Blood Pressure
Education Program. Pediatrics. 1996;98:649-658.
3. Has your doctor told you that your total cholesterol level is 200 mg/dL or higher, OR
your HDL (good cholesterol) is less than 40 mg/dL?
Yes responses indicate an increased risk for heart issues.
Promote targeted changes in individual lifestyle to produce significant reductions in an
individual patient’s risk. Initiate outcome measurements that will be tracked during scheduled
follow-up visits.
Physicians, dietitians, and other relevant health professionals should go beyond monitoring
adherence to actively helping individuals overcome barriers and promote new behaviors.
Promote ATP III TLC diet using: Individualized diet counseling that provides acceptable
substitutions for favorite foods contributing to a patient’s elevated LDL level – counseling often
best performed by a registered dietitian
Reinforcement of dietary principles during follow-up visits at which LDL response to diet is
assessed
Consideration of readiness to change and level of motivation
Follow Surgeon General recommendations for physical activity.
Promote regular physical activity for individuals using: Specific recommendations to increase
physical activity based on a patient’s cardiac status, age, and other factors
Specific advice regarding how physical activity could be integrated into the patient’s lifestyle
Follow-up visits to monitor physical activity level, and follow-up counseling regarding barriers
to daily physical activity
Follow Obesity Education Initiative (OEI) guidelines for weight management.
Promote prevention of weight gain: Calculate BMI for every patient at every visit
Anticipate high-risk times for weight gain (perimenopausal years, times of significant life stress)
and counsel patient on ways to prevent weight gain
Follow-up visits to discuss success of weight gain prevention strategies
Discuss 10% weight loss goals for persons who are overweight:
Discuss lifestyle patterns that promote weight loss
Portion control
Daily physical activity
Follow-up visits to examine weight/BMI and discuss
Barriers to adherence
During the first three months of dietary therapy, priority is given to lowering LDL cholesterol. In
the first visit, the physician should address a few key questions and obtain an overall assessment
of the individual’s current life habits:
Does the patient consume excess calories in the form of LDL-raising nutrients?
Is the patient overweight or obese? Is abdominal obesity present?
Is the patient physically active or inactive?
If the patient is overweight/obese and/or physically inactive, is the metabolic syndrome present?
Food Items to Choose More Often
Breads and Cereals
≥6 servings per day, adjusted to caloric needs
Breads, cereals, especially whole grain; pasta; rice; potatoes; dry beans and peas; low fat
crackers and cookies
Vegetables
3–5 servings per day fresh, frozen, or canned, without added fat, sauce, or salt
Fruits
2–4 servings per day fresh, frozen, canned, dried
Dairy Products
2–3 servings per day Fat-free, 1/2%, 1% milk, buttermilk, yogurt, cottage cheese; fat-free & lowfat cheese
Eggs
≤2 egg yolks per week
Egg whites or egg substitute
Meat, Poultry, Fish
≤5 oz per day
Lean cuts loin, leg, round; extra lean hamburger; cold cuts made with lean meat or soy protein;
skinless poultry; fish
Fats and Oils
Amount adjusted to caloric level: Unsaturated oils; soft or liquid margarines and vegetable oil
spreads, salad dressings, seeds, and nuts
TLC Diet Options
Stanol/sterol-containing margarines; viscous fiber food sources: barley, oats, psyllium, apples,
bananas, berries, citrus fruits, nectarines, peaches, pears, plums, prunes, broccoli, brussels
sprouts, carrots, dry beans, peas, soy products (tofu, miso)
Food items to choose less often
Breads and Cereals
Many bakery products, including doughnuts, biscuits, butter rolls, muffins, croissants, sweet
rolls, Danish, cakes, pies, coffee cakes, cookies
Many grain-based snacks, including chips, cheese puffs, snack mix, regular crackers, buttered
popcorn
Vegetables
Vegetables fried or prepared with butter, cheese, or cream sauce
Fruits
Fruits fried or served with butter or cream
Dairy Products
Whole milk/2% milk, wholemilk yogurt, ice cream, cream, cheese
Eggs
Egg yolks, whole eggs
Meat, Poultry, Fish
Higher fat meat cuts: ribs, t-bone steak, regular hamburger, bacon, sausage; cold cuts: salami,
bologna, hot dogs; organ meats: liver, brains, sweetbreads; poultry with skin; fried meat; fried
poultry; fried fish
Fats and Oils
Butter, shortening, stick margarine, chocolate, coconut
Recommendations for Weight Reduction
Weigh Regularly
Record weight, BMI, & waist circumference
Lose Weight Gradually
Goal: lose 10% of body weight in 6 months. Lose 1/2 to 1 lb per week
Develop Healthy Eating Patterns
Choose healthy foods, Limit number of eating occasions, Select sensible portion sizes, Avoid
second helpings, Identify and reduce hidden, fat by reading food labels to choose products lower
in saturated fat and calories, and ask about ingredients in ready-to-eat foods prepared away from
home, Identify and reduce sources of excess carbohydrates such as fat-free and regular crackers;
cookies and other desserts; snacks; and sugar-containing beverages
Make Physical Activity Part of Daily Routines
Reduce sedentary time, Walk, wheel, or bike-ride more, drive less; Take the stairs instead of an
elevator; Get off the bus a few stops early and walk the remaining distance; Mow the lawn with a
push mower; Rake leaves; Garden; Push a stroller; Clean the house; Do exercises or pedal a
stationary bike while watching television; Play actively with children; Take a brisk 10-minute
walk or wheel before work, during your work break, and after dinner
Make Physical Activity Part of Exercise or Recreational Activities
Walk, wheel, or jog; Bicycle or use an arm pedal bicycle; Swim or do water aerobics; Play
basketball; Join a sports team; Play wheelchair sports; Golf (pull cart or carry clubs); Canoe;
Cross-country ski; Dance; Take part in an exercise program at work, home, school, or gym
4. Has your father or brother had a heart attack before age 55, OR has your mother or
sister had one before age 65?
Family history of heart disease increases patient’s risk for developing heart disease or conditions
that lead to heart disease. Medical history questions should include:
Which parent and/or sibling suffered the heart attack? Age?
Do you know your cholesterol numbers?
Have you been told your blood pressure is high?
If patient has high cholesterol, begin statin medication.
Conduct screening at each visit
While there are no national guidelines for screening patients with family history of heart disease,
the following tests/labs should occur at each visit, especially if patient’s family doctor is not
already acting on risk level.
Lipid screening beginning at age 20
Blood pressure screening for adults 18 and older
Risk factor assessment should begin at age 20. Risk factors, to be recorded at least every two
years include, smoking status, diet alcohol intake, physical activity, blood pressure, BMI, waist
circumference, and pulse.
A lipid profile and fasting blood glucose measurement should be made according to the patient's
risk for hyperlipidemia and diabetes.
Inform patient that family history of heart disease increases risk – recommend the following key
methods for decreasing risk:
Quit smoking or remain smoke-free
Exercise: Regularly participating in moderately vigorous physical activity can reduce risk of fatal
heart disease by nearly a quarter. Federal guidelines recommend at least 30 to 40 minutes of
moderate activity on most days.
Maintain a heart healthy diet: Consistently eating a diet rich in fruits, vegetables, whole grains,
and low-fat sources of protein and certain types of fish also can reduce risk of heart disease.
Omega-3 fatty acids may decrease risk of heart attack, protect against irregular heartbeats, and
lower blood pressure. Some fish are a good natural source of omega-3s. However, pregnant
women and women of childbearing age should avoid shark, swordfish, king mackerel and tilefish
because they contain levels of mercury high enough to pose a danger to a developing fetus. But
for most others, the health benefits of fish outweigh any risks associated with mercury. Drink
alcohol in moderation. No more than two drinks a day for men, one a day for women.
Maintain a healthy weight: BMI numbers 25 and higher are associated with higher blood fats,
higher blood pressure, and an increased risk of heart disease and stroke. Reducing weight by 10
percent can decrease blood pressure, blood cholesterol level, and reduce risk of diabetes.
Conduct regular health screenings including blood pressure and cholesterol levels.
Sources:
National Institutes of Health
United States Preventive Services Task Force
American Heart Association
http://www.mayoclinic.com/health/heart-disease-prevention/WO00041
5. Do you have diabetes OR a fasting blood sugar of 126 mg/dL or higher, OR do you need
medicine to control your blood sugar?
Yes response may indicate an increased risk for heart issues.
Patients with diabetes are twice as likely as someone who does not have diabetes to have heart
disease or a stroke. Patients with diabetes also tend to develop heart disease or have strokes at an
earlier age than others. Women who have not gone through menopause usually have less risk of
heart disease than men of the same age. However, women of all ages with diabetes have an
increased risk because diabetes cancels out the protective effects of being a woman in her
childbearing years.
6. Are you over 55 years old?
Women over the age of 55 are at increased risk for developing hypertension. In combination
with other factors, i.e. diabetes, obesity, smoking, family history or BMI over 25, her risk for
heart disease increases substantially.
Recommend the following actions to help reduce compounding risk factors:
If smoker, stop smoking.
If patient is diabetic, she should control her glucose (blood sugar) level.
For overweight patients, encourage weight loss.
Exercise regularly. For example, walk or ride a bicycle for 30 minutes at least three times a
week.
Eat fewer high-fat foods, like butter, cheese, meat, and some vegetable fats (palm oil and cocoa
butter). Foods that are high in saturated fat should be less than 7 percent of your total daily
calories.
Eat more high-fiber foods, like vegetables, fruits, grains, and whole-grain breads, cereals, and
pasta.
Sources: http://www.aafp.org/afp/20020115/howtph.html
7. Do you have a body mass index (BMI) score of 25 or more?
Yes response indicates an increased risk for heart conditions.
The BMI ranges are based on the relationship between body weight and disease and death.
Overweight and obese individuals are at increased risk for many diseases and health conditions,
including the following:
Hypertension
Dyslipidemia (for example, high LDL cholesterol, low HDL cholesterol, or high levels of
triglycerides)
Type 2 diabetes
Coronary heart disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea and respiratory problems
Some cancers (endometrial, breast, and colon)
If patient is overweight and expresses interest in losing weight, provide patient with information
about dietary adjustments:
A low calorie Step I diet:
Nutrient Recommended Intake
Calories: Approximately 500 to 1,000 kcal/day reduction from usual intake
A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2
pounds/week. Alcohol provides unneeded calories and displaces more nutritious foods. Alcohol
consumption not only increases the number of calories in a diet but has been associated with
obesity in epidemiologic studies as well as in experimental studies. The impact of alcohol
calories on a person’s overall caloric intake needs to be assessed and appropriately controlled.
Total fat: 30 percent or less of total calories
Fat-modified foods may provide a helpful strategy for lowering total fat intake but will only be
effective if they are also low in calories and if there is no compensation by calories from other
foods.
Saturated fatty acids: 8 to 10 percent of total calories
Patients with high blood cholesterol levels may need to use the Step II diet to achieve further
reductions in LDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7
percent of total calories, and cholesterol levels to less than 200 mg/day. All of the other nutrients
are the same as in Step I.
Monounsaturated fatty acids Up to 15 percent of total calories
Polyunsaturated fatty acids Up to 10 percent of total calories
Cholesterol: <300 mg/day
Patients with high blood cholesterol levels may need to use the Step II diet to achieve further
reductions in LDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7
percent of total calories, and cholesterol levels to less than 200 mg/day. All of the other nutrients
are the same as in Step I.
Protein: Approximately 15 percent of total calories
Protein should be derived from plant sources and lean sources of animal protein.
Carbohydrate: 55 percent or more of total calories
Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of
vitamins, minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley,
and most fruits and vegetables, may be effective in reducing blood cholesterol levels. A diet high
in all types of fiber may also aid in weight management by promoting satiety at lower levels of
calorie and fat intake. Some authorities recommend 20 to 30 grams of fiber daily, with an upper
limit of 35 grams.
Sodium chloride: No more than 100 mmol/day (approximately 2.4 g of sodium or approximately
6 g of sodium chloride)
Calcium: 1,000 to 1,500 mg/day
During weight loss, attention should be given to maintaining an adequate intake of vitamins and
minerals. Maintenance of the recommended calcium intake of 1,000 to 1,500 mg/day is
especially important for women who may be at risk of osteoporosis.
Fiber: 20 to 30 g/day
Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of
vitamins, minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley,
and most fruits and vegetables, may be effective in reducing blood cholesterol levels. A diet high
in all types of fiber may also aid in weight management by promoting satiety at lower levels of
calorie and fat intake. Some authorities recommend 20 to 30 grams of fiber daily, with an upper
limit of 35 grams.
If diet and behavior modifications are unsuccessful, drugs may be used as adjunctive therapy in
patients with a BMI ≥ 30 or ≥ 27 with other risk factors or diseases.
Weight loss surgery is an option for weight reduction in patients with clinically severe obesity,
i.e., a BMI ≥40, or a BMI ≥ 35 with comorbid conditions. Weight loss surgery should be
reserved for patients in whom other methods of treatment have failed and who have clinically
severe obesity (once commonly referred to as “morbid obesity”). Weight loss surgery provides
medically significant sustained weight loss for more than 5 years in most patients. Two types of
operations have proven to be effective: those that restrict gastric volume (banded gastroplasty)
and those that, in addition to limiting food intake, also alter digestion (Roux-en-Y gastric
bypass).
Sources: NIH: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
8. Do you get less than a total of 30 minutes of physical activity on most days?
Yes responses indicate increased risk for heart disease. If patient is willing to exercise more
frequently, discuss the following recommendations.
Examples of moderate amounts of physical activities:
Common Chores and Sporting Activities
Washing and waxing a car for 45–60 minutes
Playing volleyball for 45–60 minutes
Washing windows or floors for 45–60 minutes
Playing touch football for 45 minutes
Gardening for 30–45 minutes
Walking 13/4 miles in 35 minutes (20 min/mile)
Wheeling self in wheelchair for 30–40 minutes
Basketball (shooting baskets) for 30 minutes
Pushing a stroller 1 1/2 miles in 30 minutes
Bicycling 5 miles in 30 minutes
Raking leaves for 30 minutes
Dancing fast (social) for 30 minutes
Walking 2 miles in 30 minutes (15 min/mile)
Water aerobics for 30 minutes
Shoveling snow for 15 minutes
Swimming laps for 20 minutes
Stair walking for 15 minutes
Basketball (playing a game) for 15–20 minutes
Jumping rope for 15 minutes
Running 1 1/2 miles in 15 minutes (15 min/mile)
For the beginner, or someone who leads a very sedentary lifestyle, very light activity would
include increased standing activities, room painting, pushing a wheelchair, yard work, ironing,
cooking, and playing a musical instrument.
Light activity would include slow walking (24 min/mile), garage work, carpentry, house
cleaning, childcare, golf, sailing, and recreational table tennis.
Moderate activity would include walking a 15-minute mile, weeding and hoeing a garden,
carrying a load, cycling, skiing, tennis, and dancing.
High activity would include jogging a mile in 10 minutes, walking with a load uphill, tree
felling, heavy manual digging, basketball, climbing, and soccer.
Be careful to communicate a nonjudgmental attitude that distinguishes between the weight
problem and the patient with the problem. Ask about the patient’s weight history and how
obesity has affected his or her life. Express your concerns about the health risks associated with
obesity, and how obesity is affecting the patient.
The patient must be an active partner in the consultation and must participate in setting goals for
behavior change. It is the patient who must make the changes to achieve weight loss; the patient
already has goals concerning weight loss and how to achieve it. These goals may be different
from those the provider would select. The provider can be a source of general information,
perspective, support, and some measure of guidance, but cannot cause the patient to meet goals
that he or she does not endorse.
Setting goals should be a collaborative activity. From all the available dietary and physical
activity changes that might be made, a small number should be selected on the basis of their
likely impact on weight and health, the patient’s current status, and the patient’s willingness and
ability to implement them. Once goals are selected, an action plan can be devised to implement
change.
Sources: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
9. Has your doctor told you that you have angina (chest pains), OR have you had a heart
attack?
Yes responses should be considered high risk for heart disease.
Definition of Angina Pectoris
Angina Pectoris is a term that describes chest pain caused by myocardial ischemia - a condition
in which the amount of oxygen getting to the heart muscle is insufficient. It usually occurs on
exertion and is relieved by rest. Angina generally is a symptom of coronary artery disease. In
most severe cases, it may occur with minimal effort or at rest.
Description of Angina Pectoris
Angina is a common manifestation of coronary artery disease. The pain is caused by reduced
blood flow to a segment of heart muscle (myocardial ischemia). It usually lasts for only a few
minutes, and an attack is usually quickly relieved by rest or drugs (such as nitroglycerin). Also, it
is possible to have myocardial ischemia without experiencing angina.
Typically, angina is described as a "pressure" or "squeezing" pain that starts in the center of the
chest and may spread to the shoulders or arms (most often on the left side, although either or
both sides may be involved), the neck, jaw or back. It is usually triggered by extra demand on the
heart: exercise, an emotional upset, exposure to cold, digesting a heavy meal are common
examples.
Some people experience angina while sleeping or at rest. This type of angina may be caused by a
spasm in a coronary artery, which most commonly occurs at the site of atherosclerotic plaque in
a diseased vessel.
Most people with angina learn to adjust their lives to minimize attacks. There are cases, however,
when the attacks come frequently and without provocation - a condition known as unstable
angina. This is often a prelude to a heart attack and requires special treatment, primarily with
drugs. Angina affects both men and women, usually in middle age. Men are much more likely
than women to experience it before age 60. It may develop weeks, months or even years before a
heart attack, or may be experienced only after a heart attack has occurred.
Treatment of Angina Pectoris
In most instances, drugs are recommended for the treatment of angina before surgery is
considered. The major classes of drugs used to treat angina include the following:
Nitrates. These come in several forms: nitroglycerine tablets to be slipped under the tongue
during or in anticipation of an attack; ointment to be absorbed through the skin; long-acting
medicated skin discs; or long-acting tablets. The latter three forms are used mostly to prevent
rather than relieve attacks. The nitrates work by reducing the oxygen requirements of the heart
muscle.
Beta-blocking Drugs. These agents act by blocking the effect of the sympathetic nervous system
on the heart, slowing heart rate, decreasing blood pressure, and thereby, reducing the oxygen
demand of the heart. Recent studies have found that these drugs also can reduce the chances of
dying or suffering a recurrent heart attack if they are started shortly after suffering a heart attack
and continued for two years.
Calcium-channel Blocking Drugs. These drugs are prescribed to treat angina that is thought to be
caused by coronary artery spasm. They can also be effective for stable angina associated with
exercise. All muscles need varying amounts of calcium in order to contract. By reducing the
amount of calcium that enters the muscle cells in the coronary artery walls, the spasms can be
prevented. Some calcium-channel blocking drugs also decrease the workload of the heart and
some lower the heart rate as well.
Source: http://www.nlm.nih.gov/medlineplus/angina.html
Medline plus is a resource division of National Institute of Health
Resources:
http://healthlibrary.epnet.com/GetContent.aspx?Token=8767ffbe-d284-4611-bed8c8ffc1e4f6a2&ChunkIID=11986