Thoracic / Chest

Chronic Refractory Angina Pectoris

Definition

Chronic refractory angina pectoris is a feeling of pressure or heaviness, or chest pain caused by vascular insufficiency of the heart muscle, whereby conventional medication and revascularisation treatments have no or inadequate effect.

Aetiology

Chronic refractory angina pectoris is caused by vascular insufficiency of the heart muscle (more than 75% stenosis in one or more of the major coronary arteries). Frequently, there is a combination of physical load and emotion, resulting in the heartbeat becoming stronger and therefore the requirement of more oxygen.

Pain from a sudden obstruction in a coronary artery due to a thrombus or embolism is similar, but usually more severe in nature. When there is complete obstruction, a heart attack will occur at some point. Spasm of the coronary arteries, rather than narrowing, can lead to angina pectoris.

Risk factors for angina pectoris are: smoking, obesity, hypertension, diabetes mellitus and hypercholesterolemia.

In the Netherlands, the incidence of chronic refractory angina pectoris is estimated to be 500 patients/year. Due to the ageing population, patient numbers will only increase.

Signs and symptoms

The clinical signs and symptoms of angina pectoris are characteristic. Substernal pain is provoked by physical load, and disappears when the patient is at rest.

During physical load, patients with a serious coronary disease experience changing substernal pain which, in particular, radiates to the left-hand side of the body, for example, to the arm, neck, throat, jaws, and even to the teeth.

Pain is often accompanied by other symptoms, such as transpiration, nausea and sometimes vomiting. At rest, the threshold of angina pectoris is clearly influenced by emotional stress, cold, meals, and smoking.

Diagnostics

Physical Examination

Physical examination should exclude other diseases, such as pulmonary, gastro-intestinal, musculoskeletal, aorta dissection, herpes zoster, and panic disorders.

In view of the nature of chronic refractory angina pectoris, it is preferable for a cardiologist to perform the evaluation in these patients.

Additional Somatic Diagnostics

  • Diagnosis can be made with an ECG at the instant the patient experiences pain.
  • In addition, exertion ECG, a cardiologist can perform stress ultrasound and coronary angiography.
  • The gold standard is a coronary angiography or CT coronary angiography.
  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment Interventional Pain Treatment