ANGINA PECTORIS

Chapter II DISEASES OF THE HEART AND THE BLOOD VESSELS

1. ANGINA PECTORIS GENERAL CONSIDERATION
     Angina pectoris is usually due to an arteriosclerotic heart disease, but in rare instances it may occur in the absence of a significant disease of the coronary arteries as a result of coronary spasm, stenosis or insufficiency, syphilitic aortitis, increased metabolic demands as in hyperthyroidism or after thyroid therapy, marked anemia or paroxysmal tachycardias with rapid ventricular rates. The underlying mechanism is a discrepancy between the myocardial demands for oxygen and the amount

delivered through the coronary arteries.
     Symptmatically, the condition equals "Chest Bi" (stagnant cardiac blood) and Zi xin Tong in traditional Chinese medicine and is

usually thought to be caused by
eating too much heavy and fattening food and delicious drinks.
CLINICAL MANIFESTATIONS
     The distribution of the distress may vary widely in different patients, but is always the same for each individual. In 80 to 90%

of cases the discomfort is felt
behind or slightly to the left of the sternum. When it begins farther to the left or uncommonly on the right, it characteristically

moves centrally and is felt deep in the chest. Although angina may radiate to any segment from C8 to T4, it radiates most often to

the left shoulder and upper arm, frequently moving down the inner volar
aspect of the arm to the elbow, forearm, wrist, or the fourth and fifth fingers.
Radiation to the right shoulder and distally is less common, but the characteristics
are the same. Occasionally, angina may be referred to or felt initially in the lower
jaw, the base or back of the neck, the iaterscapular area or high in the left back.
     Patients often do not refer to angina as a "pain" but as a sensation of squeezing, burning, pressing, choking, aching, bursting,

"gas", or tightness. The diagnosis of angina pectoris is strongly supported if 0.4rag of nitroglycerin invariably shortens an attack

and if that amount taken immediately before exertion invariably permits greater exertion before the onset of angina or prevents

angina entirely. Angina most commonly occurs during walking, especially up an incline or a flight of stairs.
     Electrocardiography is normal in over one-fourth of patients with angina on that resting condition. It can be examined by

exercise stress test, usually it shows patterns of left ventricular hypertrophy. Old myocardial infarction or non-specific ST-T

changes also can be examined by radioisotope studies and some patients need
examination by coronary angiography and left ventricular angiography.
DIAGNOSIS
     Essentials of diagnosis.
     ? Squeezing or pressurelike pain, retrosternal or slightly to the left, that appears quickly during exertion, may radiate in a set

pattern and subside with rest.
     ? Seventy percent have diagnostic electrodiographic abnormalities after mild
exercise; the remaining thirty percent have normal tracings or nondiagnostic abnormalities.
TREATMENT
I. Treatment in Western medicine.
     A. Nitroglycerin is the drug of choice; it acts in about 1 to 2 minutes. As soon as the attack begins, place one flesh 0.3mg

tablet under the tongue and allow it to dissolve.
     B. Amyl nitrite, 1 pearl crushed and inhaled, acts in about 10 seconds.
     C. Sublingual nifedipine, 10 to 20mg, may rapidly relieve angina, especially if spasm is the cause.
     D. Oral isosorbide dinitrate, 2.5 to 10mg, 3 or more times daily.
     E. Beta-blocking agents:
     Propranolol (Inderal), 10 to 80mg,  3 to 4 times daily by mouth.
     F. Platelet-inhibiting agents:
     Aspirin, 0.3g/per day.
     G. Inhibitors of the calcium slow-channel ionicflux:
     Nifedipine, I0 to 20mg, 3 times daily by mouth is often helpful, especially when the patient suffers from hypertension.
     H. General measures:
     The patient must avoid all habits and activities known to bring on an attack.
Most patients with angina do not require prolonged bed rest, but rest and relaxation
are beneficial. Adequate mental rest is also important. Obese patients should be
placed on a reducing diet and their weight brought to normal or slightly subnormal
levels. Use of tobacco should be stopped or avoided because it produces tachycardia
and elevation in blood pressure and because cigarette smoking has been shown to be
a risk factor in coronary heart disease.
II. Treatment in traditional Chinese medicine.
     1. Herb therapy
     A. For angina pectoris caused by stagnation of vital energy (qi) and blood. In this type the patients often feel squeezing,

burning, pressing, choking, aching, bursting of the left of the sternum, radiating most often to the left shoulder and the upper arm,

with distress of the chest, cold limbs, cyanosis, deep and rapid pulse and purple colour of the tongue.
     The rule of treatment with herbs is to eliminate stagnation and activating blood with Tiao Heng Shi Wo Tang Jia Jian.
     Constituents:
     Milk veteh 35g
     Chinese angelica 25g
     Unpeeled root of herbaceous peony 25g
     Chuanxiong 15g
     Peach kernel 10g
     Safflower 10g
     Cattail pollen 12g
     Faeces of flying squirrel 12g
      Corydalis turtschaninovii 12g
      Root of red rooted salvia 30g
      Root of pseudo-ginseng 3g
      Licorice root 6g
      Cassia 12g
      Decoction and dosage. Put all the above herbs together to be simmered twice
and then the broth of each mixed, half of the mixed broth each time, twice a day.
      B. For Chest Bi type. This symptom complex, due to the interference with the
flow of the Yang Qi and the stagnation of the phlegm and the damp pathogen in the
chest, chiefly manifests upper back pain, feeling of suffocation in the chest, shortness of breath, deep and rapid pulse, and purple

colour of the tongue.
     The rule of treatment with Chinese herbs is to clear the stagnation of the phlegm
and invigorate the Yang with Gua Wei Jiu Bai Tang Jia Jian.
     Constituents:
     Mongolian snake gourd 25g
     Onio