Chronic stable Angina pain

Chronic stable angina has been known since the 17th century, long before the 20th century epidemic of heart attacks.

It can go on unchanged for many years.

Fifty years ago, cardiologists had their eyes, ears, hands and ECG to diagnose angina or otherwise².

These days a suspicion of this is often enough to have a cardiologist wanting to arrange a coronary angiogram. There is an old saying that to a man with a hammer, everything starts to look like a nail.

Research published³ in 2012 from Europe found that in a large group of suspects (from clinical and stress electrocardiogram (ECG) evaluation,) instead of the 60% expected to have coronary artery narrowing, only 25% did so.

From this research "Preliminary results suggest that heart disease can be diagnosed in the majority of cases without needing a catheterization and that many patients with chest pain receive unnecessary invasive procedures."(Medscape)

Even non-invasive stress testing or coronary CT angiography has trebled the rate of subsequent invasive "revascularization" with angioplasty and stents. The question is being asked "Does our current practice lead to the stenting of asymptomatic patients in the inevitable cases where the inciting pain was non-cardiac? And, most importantly, does our practice improve outcomes?" (Medscape)

The answer to the first question is almost certainly yes and to the second question no.4

Various other types have been described, including angina of first arising and postural angina where a change in blood pressure may be the factor precipitating angina pain. Linked angina is that brought on by pain from another organ, such as the gall bladder or a hiatal hernia. Angina decubitus is angina coming on after retiring to bed.

Mesenteric angina is the same condition in the bowel - blocked mesenteric artery, pain when the bowel has to work harder, after a meal.

Prinzmetal (variant) angina is due to the coronary artery suddenly tightening up. I suspect this is related to disturbance in the thoracic spine and to emotional tension.

Notes and references for chronic stable angina

2. An example is in an article "Chest pain due to Depression" by J. E. Gault MRACP in the Medical Journal of Australia December 3rd 1966.
He wrote up a series of people he saw with chest pain like angina, but due to depression. One passage from the article is about the duration of pain and speed of relief...
"The opening gambit – “tight pain across the upper chest,” or “pain when I work relieved by rest” – is immediately suggestive of angina, and several patients have been referred with such a diagnosis.
However, the duration of the pain is never brief (a few minutes or so), but is always longer lasting (half an hour or longer), and sometimes present for days at a time.
The pain of coronary insufficiency may be longer lasting, but when it is described the intensity of the pain always comes through in the description, and there is never much delay in seeking medical advice. However , with these patients the pain is described in a more placid manner while at the same time their underlying nervous state often shows through. When rest, or sometimes trinitrin, is described as giving relief, one finds that it takes half an hour or longer for the pain to disappear, unlike that of angina" (relieved within a few minutes.)

My old boss Dr. Kenneth Grice, was flown from one little jungle landing strip to another, in the New Guinea highlands. There would be a group of children waiting for him at each, for him to decide on the spot which of them should be sent to Australia for possible cardiac surgery.
He had only his eyes, hands, ears and stethoscope to use in this.


4. Dr Vinay Prasal et al re Percutaneous intervention and stenting




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