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This is a name applied to pain in the region of the heart caused by a disturbance in the heart itself. Heart pains and heart aches from various kinds of insufficiency of the heart, or heart weakness, are not exactly what is understood by angina pectoris. It is largely an occurrence in patients beyond the age of 30, and most frequently occurs after 50, although attacks between the ages of 40 and 50 are becoming more frequent. It is a disturbance of the heart which most frequently attacks men, probably more than three fourths of all cases of this disease occurring in men; in a large majority of the cases the coronary arteries are diseased.

Various pains which are not true angina pectoris occur in the left side of the chest; these have been called pseudo-anginas. They will be referred to later. True angina pectoris probably does not occur without some serious organic disease of the heart, mostly coronary sclerosis, fatty degeneration of the heart muscle, adherent pericarditis and perhaps some nerve degenerations. Various explanations of the heart pang have been suggested, such as a spasm or cramp of the heart muscle, sudden interference with the heart's action, as adherent pericarditis, a sudden dilatation of the heart, an interference with the usual stimuli from auricle to ventricle and therefore a very irregular contraction, a sudden obstruction to the blood flow through a coronary artery, or a sudden spasm from irritation associated with some of the intercostal or more external chest muscles causing besides the pang a sense of constriction. Perhaps any one of these conditions may be a cause of the heart pang, and no one be the only cause.

In a true angina, death is frequently instantaneous. In other instances, death occurs in a few minutes or a few hours; or the patient's life may be prolonged for days, with more or less constant chest pains and frequent anginal attacks. Here there is a gradual failing of the heart muscle, with circulatory insufficiency, until the final heart pang occurs.

Anginal attacks before the age of 40, presumed, from a possible narrowing of the aortic valve, to be due to coronary sclerosis, are frequently due to a long previous attack of syphilis. In these cases, active treatment of the supposed cause should be inaugurated, including perhaps an injection of the arsenic specific, and certainly a course of mercury and iodid, with all the general measures for managing and treating general arteriosclerosis, as previously described.

Symptoms

The pain of true angina pectoris generally starts in the region of the heart, radiates up around the left chest, into the shoulders, and often down the left arm. This is typical. It may not follow this course, however, but may be referred to the right chest, up into the neck, down toward the stomach, or toward the liver. The attack may be coincident with acute abdominal pain, almost simulating a gastric crisis of locomotor ataxia. There may also be coincident pains down the legs. It has been shown, as mentioned in another part of this book, that disturbances in different parts of the aorta may cause pain and the pain be referred to different regions, depending on the part affected.

Instances occasionally occur in which a patient had an anginal attack, as denoted by facial anxiety, paleness, holding of the breath, and a slow, weak pulse, without real pain. This has been called angina sine dolore. The patient has an appearanece of anxious expectation, as though he feared something terrible was about to happen.

The position of the patient with true angina pectoris is characteristic. He stops still wherever he is, stands perfectly erect or bends his body backward, raises his chin, supports himself with one hand, leans against anything that is near him, and places his other hand over his heart, although he exercises very little pressure with this hand. The position assumed is that which will give the left chest the greatest unhampered expansion, as though he would relieve all pressure on the heart.

Besides the feeling of constriction, even to some spasm, perhaps, of the intercostal muscles, respiration is slowed or very shallow, because of the reflex desire of the patient not to add to the pain by breathing. The face is pale, the eyes show fear, and the whole expression is almost typical of cardiac anxiety. The patient feels that he is about to die. The pulse is generally slowed, may be irregular, and may not be felt at the wrist. The blood pressure has been found at times to be increased. It could of course be taken only in those cases in which there were more or less continued anginal pains; the true typical acute angina pectoris attack is over, or the patient is dead, before any blood pressure determination could be made. When there is more or less constant ache or frequent slight attacks of pain, the blood pressure may be raised by the causative disease, arteriosclerosis. During the acute attack with inefficient cardiac action and a diminished force and frequency of the beat, the peripheral blood pressure can only be lowered.

The duration of an acute attack, that is, the acute pain, is generally but a few seconds, sometimes a few minutes, and rarely has lasted for several hours. In the latter cases some obstruction to an artery has been found at necropsy, but not sufficient to stop the circulation at a vital point. Repeated slight attacks, more or less severe, may occur frequently throughout one or more days, or even perhaps a series of days, caused by the least exertion, even that of turning in bed.

While most cases of sudden death with cardiac pain are due to a local disease in or around the heart, it is quite probable that some disturbance in the medulla oblongata may cause acute inhibitory stoppage of the heart through the pneumogastric (vagi) nerves. The power of the pneumogastric reflex to inhibit the action of the heart is, of course, easily demonstrated pharmacologically. Clinically reflexes down these nerves interfering with the heart's action cause faintness and serious prostration, if not actual shock, and perhaps, at times, death. The most frequent cause of such a reflex is abdominal pain, perhaps due to some serious condition in the stomach, to gastralgia, to an intestinal twist, to intussusception or other obstruction, or to hepatic or renal colic. A severe nerve injury anywhere may cause such a heart reflex. Hence serious nerve pain must always be stopped almost immediately, else cardiac and vasomotor shock will occur. In serious pain morphin becomes a life saver.

Tags: Heart Disease