Medical Management of Angina Pectoris G. E. Burch, M.D., F.A.C.A. NEW
ORLEANS,
LOUISIANA
Ischemic heart disease is one of the most common and serious illnesses of man. It is particularly common in the Western world, where it exists almost as a plague among the middle-aged and old people. In spite of considerable effort and expense in the study of ischemic heart disease, its incidence continues unabated. This persistence is due to the nature of the primary etiologic agent, arteriosclerosis, which has no effective cure or even prevention, regardless of discussion and advice to the public concerning &dquo;risk factors.&dquo; Because of the high incidence of ischemic heart disease, physicians throughout the world must manage this disease and must be meticulously trained to apply existing knowledge to the best interest of patients suffering from the various syndromes of ischemic heart disease. Among these syndromes angina pectoris is the most common.
Axioms for Patient
Care
Certain aspects of medical management are truly axiomatic for effective care of patients with angina pectoris. l. Arteriosclerosis and aging are irreversible. Whether either can be slowed or even modified in any given individual is controversial. Nevertheless, the physician must approach his patient with the attitude that the advancement of these states can be slowed, and all aspects of existing knowledge should be applied in their management. 2. The treatment a patient receives depends on the doctor he consults. Each physician has a different approach to the management of angina pectoris. One approach is briefly presented later in this report. 3. The doctor-patient relationship is most important in diagnosis and management. A good, mutually respected personal relationship is necessary if the doctor is to obtain a valuable personal history, to assure the patient’s compliance in therapy, and to ensure mental and physical relaxation of tense and often frightened and frustrated patients. These and other aspects of management are extremely important for therapeutic success. From the Department of Medicine of Tulane University School of Medicine and the Charity Hospital of Louisiana, New Orleans, Louisiana. Supported by the Cardiovascular Research Fund, the Rowell A. Billups Fund for Research in Heart Disease, and the Feazel Laboratory.
667
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.
668 4. The physician must be a competent practicing general internist at all times. This is most essential. To be strictly a cardiologist is not adequate. The patient
with ischemic heart disease and angina pectoris never has only angina pectoris. The older patients may have many important illnesses such as emphysema, chronic bronchitis, arthritis, fatigability, hiatal hernia, cholelithiasis, diverticuli of the colon, generalized arteriosclerosis, diabetes mellitus, constipation, prostatism, poor dental health, malnutrition, cardiovascular insufficiency, chronic anemia, and many other problems such as loneliness and financial and domestic difficulties. It is impossible to treat angina pectoris satisfactorily unless the physician understands all of these diseases, many of which may exist simultaneously in any patient, and unless the &dquo;cardiologist&dquo; is a well-informed internist as well. All associated diseases contribute in different degrees to a patient’s total health, and each disease (all being extremely dynamic) is constantly changing, especially with therapy, not to mention the influence of drugs themselves. 5. The entire study of the patient must be made by the managing physician himself. Although the physician does not perform the technical laboratory procedures, he must be fully acquainted with the reliability of the laboratory that provides the data and certainly must be fully capable of interpreting all the data in relation to all information gathered from the history and physical examination. The managing physician himself, alone, must take the patient’s history and do the physical examination. It is absolutely impossible to manage a patient effectively and successfully if the history and physical examination are delegated to someone else, particularly to the house staff of a hospital or to a trainee. 6. Angina pectoris is a symptom complex which is diagnosed from the history only. Therefore it is impossible to exclude or make a diagnosis of angina pectoris unless a careful history is taken by the physician himself. Taking a history properly requires considerable time and often multiple sessions with the patient alone, and at times with the assistance of members of the family, as each situation dictates. 7. Thorough knowledge of the drugs and special studies and procedures em-
ployed is mandatory. 8. No recommendations are ever made by the physician without full consideration of the welfare of the patient’s entire family. For example, a young mother with 5 young children and a husband is responsible for the care and happiness of 7 people. She is not alone. Were she to die, the lives of the surviving 6 people would be seriously affected. And young children without their mother are rarely happy and are extremely prone to develop teenage problems and to be unhappy forever after.
Diagnosis The diagnosis must include not only a complete cardiac diagnosis but a complete medical inventory as well. There must be a complete diagnosis. In 98%
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
669
patients, nothing more is required for a complete diagnosis than a thorough history, careful physical examination, urinalysis, CBC, SMAI2, EPA, lateral teleoroentgenograms of the heart and lungs, ECG, and stool examination. Obviously, the physician must be well-trained and know his basic preclinical sciences, cardiovascular physiology and pathophysiology, and general internal medicine and clinical cardiology. Even further hazardous, nonhazardous, expensive, or &dquo;fancy&dquo; studies will not substitute for lack of adequate training, knowledge, and experience. The physician must collect all of his data objectively and employ the data intelligently and as logically as a mathematician employs his data. All disease states, regardless of how minor, contribute to the &dquo;total&dquo; state of health of the patient. They all contribute in some degree to his symptoms and influence directly or indirectly the cardiac state, the choice of drugs and other therapeutic measures, the patient’s compliance, and his response to therapy and prognosis. The patient’s medical record, the state of the heart-such as heart size and presence or absence of congestive heart failure and arrhythmias-the age of the patient, and many other factors influence therapy. Thus it is not sufficient to know only the diagnostic states present; it is important to know also their severity, duration, physiologic state, and many other obvious factors too numerous even to list in this brief presentation. or more
Therapeutic Management The treatment of angina itself consists of the following measures: Rest. Physical as well as mental rest constitute the most important measure in therapy. Mental, emotional, and psychic stress of any type must receive detailed attention. Problems related to the children, husband or wife, work, associates, and other factors must be determined and handled properly. This takes a great deal of time and usually requires discussions with other members of the
patient’s family, generally
the husband
or
wife
or
other
responsible
persons.
The financial state of the patient and the cost of therapy require careful attention and consideration and can cause considerable psychic stress to the patient. Psychic stress is an extremely important factor in angina pectoris and demands a great deal of time and patience on the part of the physician. Furthermore, if adequate attention is not given to psychic stress, therapeutic success should not be expected. Patients who are not relaxed mentally will not
respond to therapy adequately. Physical rest is also extremely important. The degree of exertion or physical or mental stress necessary to precipitate an attack of angina becomes evident when the history is taken. This aspect of history taking is very important. The physician must know how much exertion is necessary to produce an anginal episode and under what circumstances the episodes occur. The patient should restrict his physical activities to a level well below that which precipitates
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
670
anginal discomfort. anginal symptoms.
Patients should do
nothing
that
produces
an
episode
of
Patients know better than anyone what their limits are. They should retire to bed early at night and remain in bed late in the morning and also rest in bed for 1 hour or so each day after lunch. They should do everything slowly and in a relaxed manner, such as driving their automobile and walking. Golfing and other types of mild exercise may be permitted, depending on the patient’s general health and cardiac state. Patients who fail to respond to therapy on an ambulatory basis or patients who have severe angina, status anginosus, or &dquo;preinfarct angina&dquo; should be placed at complete bed rest for 30 days, preferably at home, if possible, or in the hospital, and treated in the same manner as a patient with myocardial infarction. It is far better to prevent an infarct than to delay treatment until the patient develops one and loses heart muscle that will never be regenerated or replaced. The physician who can develop a good doctor-patient relationship, who has a good bedside manner, and who makes a patent feel better by his presence has no difficulty keeping a patient confined to complete bedrest for 30 days. After the bedrest period, the process of ambulation must be slow, methodical, and proper. The fine details of instituting mental and physical rest are obvious and cannot be developed further in this brief discussion. Diet. The diet is extremely important in the care of the patient with angina pectoris. The patient should never eat a large full meal at any time. He should eat 5 to 6 small meals a day, and he should become primarily a vegetarian. The meals should include fresh fruits and fresh vegetables in the form of salads, as well as cooked vegetables. Foods should be sparingly salted, only for taste, and no salty foods should be consumed. &dquo;Heavy&dquo; beef must be totally avoided, as must any form of pork. For meattype dishes, the patient can depend upon breast of chicken, breast of turkey, and fish, broiled or baked. Lean veal or yearling may be consumed occasionally to interrupt the monotony of the diet. One or two eggs per week, or Egg-Beaters more frequently, may be added to the diet. Dairy fats, such as butter and cream, must be avoided; skim milk and cottage cheese only should be brought into the home. Oleomargarine and vegetable oils may be used for cooking. &dquo;Rich&dquo; French and Italian gravies must be avoided. The patient’s weight must be reduced to several pounds below the average weight recommended for the patient’s sex, age, and height. The rate of weight loss must be gradual, not to exceed 3 to 4 pounds per month, in order to avoid starvation acidosis and ketosis. Preparation of appetizing and pleasant foods must be learned so as to encourage the patient to follow the diet and to enjoy his meals. This is an important aspect of the dietary regimen.
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671
Nitroglycerin. This agent is the most important and indispensable drug for the treatment of angina pectoris. There may be definite differences of opinion about how nitroglycerin relieves the patient of his episodes of anginal discomfort, but everyone agrees that it functions very well both in therapy and diagnosis. The patient, more than anyone, is impressed and convinced of its value. There is no doubt that it dilates the coronary arterial vessels, and it may have a direct beneficial effect on the myocardium. Nitroglycerin must be fresh and readily available for immediate use. When fresh, nitroglycerin tablets of 1/400 to 1/200 gr are all that are necessary. When fresh, the nitroglycerin administered sublingually invariably relieves anginal discomfort. Patients should be advised to buy a fresh supply of the tablets every 3 months from a drug store where sales are large and the turnover of drugs is rapid so that only fresh nitroglycerin (TNG) would be expected to be found at all times. The patient should be advised to determine that the TNG is fresh by the fact that the drug stings, pricks, or burns under the tongue when fresh. Fresh and active TNG may produce a mild headache, a facial flush and slight palpitation. Patients learn these symptoms and learn to tolerate them. However, when the headache is severe, the tablet is too strong and, more importantly, the patient will prefer to bear the chest pain rather than experience the headache. The patient should then be advised to reduce the size of the dose by breaking a small piece of~ the tablet before placing the remainder sublingually. The dose of TNG must be varied among patients, but fresh active TNG tablets of gr 1/400 to gr 1/200 are all that are needed for therapy. Remember that patients with migraine headaches or other types of headaches are prone to develop severe TNG headaches. In patients prone to develop headaches, all vasodilators must be used cautiously and carefully, but they can be used. TNG is inactivated by light, heat, metals, and moisture. Patients must be advised of this in order to keep their TNG active. The TNG must be used immediately at the onset of an episode of angina. The earlier it is used, the more effective it will be. And, more importantly, early use, with the abortion of an episode of angina, prevents the complications of angina such as arrhythmias, infarction, and acute pulmonary edema. The drug must be readily available all the time, in the patient’s pocket or purse, at the bedside, on the desk at work, or the like. The patient must never have to rush for it or even search for it. And there must be no cotton plug in the drug bottle or anything that would interfere with immediate use. As stated above, nitroglycerin is indispensable and the best drug available for the treatment of angina pectoris. Nitroglycerin paste may be used, but it must be used cautiously at first until the proper dose for each patient is determined by careful trial. -
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672
Long-Acting Vasodilators. These drugs should be tried cautiously, according those noted above for TNG. Their effectiveness varies from patient to patient in accordance with the type and dosage of the drug. I usually prescribe Isordil (isosorbide dinitrate), using 40 mg Tembids twice daily at 12hour intervals with 10 mg tablets two or three times between the Tembids. Patients should not be awakened to take any vasodilators unless they have nocturnal angina, and nocturnal angina requires specially directed care. There are many other types of vasodilators besides Isordil. When a patient is using any long-acting coronary vasodilator, that drug should be continued if it is effective. Never change the drug merely to make a change. All vasodilators can produce headaches and, therefore, as with TNG, the size of the dose should be varied to satisfy the patient’s needs and response merely by breaking tablets in halves or quarters. Every patient’s needs and responses can be fulfilled by discussing them with the patient. This requires time and effort, but it is necessary for good therapeutic results. Propranolol (Inderal) is a useful but not always effective drug. It is advisable to begin administration with 10 mg four times daily, and to increase the dose gradually while carefully and closely observing the patient. As much as 100 mg four times a day may be necessary. This drug is not a substitute for TNG. When discontinued, its dose must be reduced slowly to prevent undesirable withdrawal effects. Remember, it can produce hypotension and thus reduce the perfusion pressure that is so important for the circulation of blood through arteriosclerotic coronary arteries. Raudixin (rauwolfia serpentina) is a very useful drug in the management of angina pectoris, especially if the patient has arterial hypertension. Raudixin is administered three or four times a day, with 100 mg in each dose. Patients who are sensitive to drugs may initially use 50-mg tablets. The patients must be warned about the nasal congestion and the nightmares that can develop as sideeffects of the drug. When these develop, the drug should not be discontinued, but rather the dose should be reduced. Raudixin and other drugs used in the management of cardiovascular disease can produce impotence. This side effect is best not mentioned because it does not always develop. Should it develop, the drugs in use and their dosages can be reviewed with the patient. Raudixin will reduce the heart rate, seems to reduce a- and #-sympathetic nerve activity, and may even reduce the intensity of action of serotonin. It also has a sedative effect. The depressing effect is primarily doserelated. Any patient taking any drug must be followed carefully until the effect of the drug and its dosage on the patient is adequately evaluated. Sedatives are usual adjuncts to therapy for patients with angina pectoris. However, it is much better to employ reasoning and training to solve these patients’ problems, which produce unhappiness, tension, anxiety, and frustration, rather than to rely on sedatives. The sedatives must be selected with careful to the
same
rules
as
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
673
thought. Patients vary considerably in their sensitivity to sedatives and to dosage, and in their response to different drugs. Rest, relaxation, and adequate sleep are important considerations. Patients must rest and sleep adequately, but excessive sedation, especially to the extent of producing excessive hypotension and reduced coronary arterial perfusion pressure, must be prevented. Caffeine beverage consumption by the patient must be reduced to no more than once daily. Decaffeinated coffee or very dilute tea may be substituted. Smoking should be stopped completely, except for well-understood psychologic reasons. Very old people may often be allowed to smoke one or two cigars or pipes of tobacco per day. Alcoholic mixtures, except for an occasional drink, or occasional wine or beer, must be forbidden. Regular and heavy drinking of alcohol must be stopped. Again, very old people may be allowed one drink daily. Cold foods, such as ice cream or sherbert, and ice-cold drinks should not be allowed in order to avoid reflex coronary arterial constriction. Cool drinks may be permitted on a trial basis. Hypertension must of course be treated, as must congestive heart failure. But the management of these states cannot be discussed in this paper. Patients with high hematocrits, 50% or more, should be bled to reduce blood viscosity and thereby facilitate coronary blood flow. When phlebotomy is seriously considered, the reason and plan should be discussed with the patient. The blood can be withdrawn at the blood bank or in the doctor’s office. My practice is to withdraw 250 cc each day or every other day until the patient’s hematocrit is reduced to 46 to 47%. After every bleeding, the patient should rest supine for an hour or so to allow for sympathetic and vascular adjustments. It is a good practice to have a member of the family with the patient at the time of venesection who can take the patient home later. Usually, a total of 750 to 1200 cc of blood must be removed to achieve the desired hematocrit and blood viscosity levels. Then the hematocrit should be checked periodically for future venesection. Once the desired hematocrit level is reached, one or two venesections of 250 to 300 cc annually are usually all that is necessary to maintain a normal hematocrit. Routine use of anticoagulants is not only inadvisable but is dangerous. Anticoagulant therapy has not been shown to benefit patients with angina pectoris. I do not use anticoagulants for my patients; but if they are used, the prothrombin time and partial thromboplastin time (PTT) must be closely watched to prevent hemorrhage. Once an anticoagulant is administered, the drug must never be discontinued suddenly, except in an emergency. Associated disease states should be treated along with angina pectoris. The anginal state should receive priority in therapeutic considerations. Hiatal hernia, constipation, dyspepsia, diverticulitis, periodontoclasia, and other such disorders must be treated, but not in a way that would disturb the ischemic heart disease. Transfusions should be avoided unless there is a definite need for
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674
patient to build his own blood by the measures required. reasonable low hematocrit may be advisable because of the Maintaining associated low viscosity of the blood. Cardiac arrhythmias must be treated carefully and without the use of antiarrhythmic drugs if possible. When specific drugs are indicated, they must be used carefully. This aspect of management is also beyond the scope of this presentation. This discussion has been limited to medical management of angina pectoris; but because of the prevailing pressure to visualize the coronary arteries by coronary angiography and to perform coronary artery bypass surgery, Table 1 is included. Coronary angiography is not without hazard and therefore is not indicated unless bypass surgery is planned. The value of bypass surgery in the management of angina pectoris is controversial. Most of the complex, expensive, and often hazardous tests to which many patients with anginal symptoms are submitted, such as the treadmill stress test, VCG, apexcardiogram, Holter monitoring, jugular venogram, carotid arteriogram, and echocardiogram, are unnecessary, often contraindicated, difficult to interpret, and often beyond the patient’s financial means. Remember that angina pectoris is a symptom complex, and no one has ever seen, known, or been able to learn which coronary artery is responsible for that symptom complex, even with coronary angiography. Because of this fact, the average family physician can manage angina pectoris satisfactorily and without a sense of inferiority or inadequacy. The special tests and procedures mentioned above are them. Allow the a
TABLE 1 Medical Versus
Surgical Management of Ischemic
Question marks indicate that the precise data
are
not
Heart Disease
available; these
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are
rough estimates.
675
rarely, if ever, necessary. Furthermore, angina pectoris can be treated best in the patient’s own home or small community hospital. George
E. Burch, M.D., F.A.C.A.
Tulane University School of Medicine 1430 Tulane A venue New Orleans, Louisiana 70112
Bibliography 1.Friedberg, C. K.: Diseases of the Heart. Third edition. Philadelphia, W. B. Saunders, 1966. 2. Gorlin, R.: Coronary Artery Disease—Major Problems in Internal Medicine. Volume XI. Philadelphia, W. B. Saunders, 1976. 3. Hurst, J. W., Logue, R. B., Schlant, R. C., et al.: The Heart Arteries and Veins. Third edition. New York, McGraw-Hill, 1974.
4. Manninen, V., Halonen, P. I. (Eds.): Advances in Cardiology: Physical Activity and Coronary Heart Disease, New York, S. Karger AG, 1976. 5. Vlodaver, Z., Amplatz, K., Burchell, H. B., et al.: Coronary Heart Disease: Clinical, Angiographic and Pathologic Profiles. New York, Springer-Verlag, 1976.
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
ORLEANS,
LOUISIANA
Ischemic heart disease is one of the most common and serious illnesses of man. It is particularly common in the Western world, where it exists almost as a plague among the middle-aged and old people. In spite of considerable effort and expense in the study of ischemic heart disease, its incidence continues unabated. This persistence is due to the nature of the primary etiologic agent, arteriosclerosis, which has no effective cure or even prevention, regardless of discussion and advice to the public concerning &dquo;risk factors.&dquo; Because of the high incidence of ischemic heart disease, physicians throughout the world must manage this disease and must be meticulously trained to apply existing knowledge to the best interest of patients suffering from the various syndromes of ischemic heart disease. Among these syndromes angina pectoris is the most common.
Axioms for Patient
Care
Certain aspects of medical management are truly axiomatic for effective care of patients with angina pectoris. l. Arteriosclerosis and aging are irreversible. Whether either can be slowed or even modified in any given individual is controversial. Nevertheless, the physician must approach his patient with the attitude that the advancement of these states can be slowed, and all aspects of existing knowledge should be applied in their management. 2. The treatment a patient receives depends on the doctor he consults. Each physician has a different approach to the management of angina pectoris. One approach is briefly presented later in this report. 3. The doctor-patient relationship is most important in diagnosis and management. A good, mutually respected personal relationship is necessary if the doctor is to obtain a valuable personal history, to assure the patient’s compliance in therapy, and to ensure mental and physical relaxation of tense and often frightened and frustrated patients. These and other aspects of management are extremely important for therapeutic success. From the Department of Medicine of Tulane University School of Medicine and the Charity Hospital of Louisiana, New Orleans, Louisiana. Supported by the Cardiovascular Research Fund, the Rowell A. Billups Fund for Research in Heart Disease, and the Feazel Laboratory.
667
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
.
668 4. The physician must be a competent practicing general internist at all times. This is most essential. To be strictly a cardiologist is not adequate. The patient
with ischemic heart disease and angina pectoris never has only angina pectoris. The older patients may have many important illnesses such as emphysema, chronic bronchitis, arthritis, fatigability, hiatal hernia, cholelithiasis, diverticuli of the colon, generalized arteriosclerosis, diabetes mellitus, constipation, prostatism, poor dental health, malnutrition, cardiovascular insufficiency, chronic anemia, and many other problems such as loneliness and financial and domestic difficulties. It is impossible to treat angina pectoris satisfactorily unless the physician understands all of these diseases, many of which may exist simultaneously in any patient, and unless the &dquo;cardiologist&dquo; is a well-informed internist as well. All associated diseases contribute in different degrees to a patient’s total health, and each disease (all being extremely dynamic) is constantly changing, especially with therapy, not to mention the influence of drugs themselves. 5. The entire study of the patient must be made by the managing physician himself. Although the physician does not perform the technical laboratory procedures, he must be fully acquainted with the reliability of the laboratory that provides the data and certainly must be fully capable of interpreting all the data in relation to all information gathered from the history and physical examination. The managing physician himself, alone, must take the patient’s history and do the physical examination. It is absolutely impossible to manage a patient effectively and successfully if the history and physical examination are delegated to someone else, particularly to the house staff of a hospital or to a trainee. 6. Angina pectoris is a symptom complex which is diagnosed from the history only. Therefore it is impossible to exclude or make a diagnosis of angina pectoris unless a careful history is taken by the physician himself. Taking a history properly requires considerable time and often multiple sessions with the patient alone, and at times with the assistance of members of the family, as each situation dictates. 7. Thorough knowledge of the drugs and special studies and procedures em-
ployed is mandatory. 8. No recommendations are ever made by the physician without full consideration of the welfare of the patient’s entire family. For example, a young mother with 5 young children and a husband is responsible for the care and happiness of 7 people. She is not alone. Were she to die, the lives of the surviving 6 people would be seriously affected. And young children without their mother are rarely happy and are extremely prone to develop teenage problems and to be unhappy forever after.
Diagnosis The diagnosis must include not only a complete cardiac diagnosis but a complete medical inventory as well. There must be a complete diagnosis. In 98%
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
669
patients, nothing more is required for a complete diagnosis than a thorough history, careful physical examination, urinalysis, CBC, SMAI2, EPA, lateral teleoroentgenograms of the heart and lungs, ECG, and stool examination. Obviously, the physician must be well-trained and know his basic preclinical sciences, cardiovascular physiology and pathophysiology, and general internal medicine and clinical cardiology. Even further hazardous, nonhazardous, expensive, or &dquo;fancy&dquo; studies will not substitute for lack of adequate training, knowledge, and experience. The physician must collect all of his data objectively and employ the data intelligently and as logically as a mathematician employs his data. All disease states, regardless of how minor, contribute to the &dquo;total&dquo; state of health of the patient. They all contribute in some degree to his symptoms and influence directly or indirectly the cardiac state, the choice of drugs and other therapeutic measures, the patient’s compliance, and his response to therapy and prognosis. The patient’s medical record, the state of the heart-such as heart size and presence or absence of congestive heart failure and arrhythmias-the age of the patient, and many other factors influence therapy. Thus it is not sufficient to know only the diagnostic states present; it is important to know also their severity, duration, physiologic state, and many other obvious factors too numerous even to list in this brief presentation. or more
Therapeutic Management The treatment of angina itself consists of the following measures: Rest. Physical as well as mental rest constitute the most important measure in therapy. Mental, emotional, and psychic stress of any type must receive detailed attention. Problems related to the children, husband or wife, work, associates, and other factors must be determined and handled properly. This takes a great deal of time and usually requires discussions with other members of the
patient’s family, generally
the husband
or
wife
or
other
responsible
persons.
The financial state of the patient and the cost of therapy require careful attention and consideration and can cause considerable psychic stress to the patient. Psychic stress is an extremely important factor in angina pectoris and demands a great deal of time and patience on the part of the physician. Furthermore, if adequate attention is not given to psychic stress, therapeutic success should not be expected. Patients who are not relaxed mentally will not
respond to therapy adequately. Physical rest is also extremely important. The degree of exertion or physical or mental stress necessary to precipitate an attack of angina becomes evident when the history is taken. This aspect of history taking is very important. The physician must know how much exertion is necessary to produce an anginal episode and under what circumstances the episodes occur. The patient should restrict his physical activities to a level well below that which precipitates
Downloaded from ang.sagepub.com at UCSF LIBRARY & CKM on April 9, 2015
670
anginal discomfort. anginal symptoms.
Patients should do
nothing
that
produces
an
episode
of
Patients know better than anyone what their limits are. They should retire to bed early at night and remain in bed late in the morning and also rest in bed for 1 hour or so each day after lunch. They should do everything slowly and in a relaxed manner, such as driving their automobile and walking. Golfing and other types of mild exercise may be permitted, depending on the patient’s general health and cardiac state. Patients who fail to respond to therapy on an ambulatory basis or patients who have severe angina, status anginosus, or &dquo;preinfarct angina&dquo; should be placed at complete bed rest for 30 days, preferably at home, if possible, or in the hospital, and treated in the same manner as a patient with myocardial infarction. It is far better to prevent an infarct than to delay treatment until the patient develops one and loses heart muscle that will never be regenerated or replaced. The physician who can develop a good doctor-patient relationship, who has a good bedside manner, and who makes a patent feel better by his presence has no difficulty keeping a patient confined to complete bedrest for 30 days. After the bedrest period, the process of ambulation must be slow, methodical, and proper. The fine details of instituting mental and physical rest are obvious and cannot be developed further in this brief discussion. Diet. The diet is extremely important in the care of the patient with angina pectoris. The patient should never eat a large full meal at any time. He should eat 5 to 6 small meals a day, and he should become primarily a vegetarian. The meals should include fresh fruits and fresh vegetables in the form of salads, as well as cooked vegetables. Foods should be sparingly salted, only for taste, and no salty foods should be consumed. &dquo;Heavy&dquo; beef must be totally avoided, as must any form of pork. For meattype dishes, the patient can depend upon breast of chicken, breast of turkey, and fish, broiled or baked. Lean veal or yearling may be consumed occasionally to interrupt the monotony of the diet. One or two eggs per week, or Egg-Beaters more frequently, may be added to the diet. Dairy fats, such as butter and cream, must be avoided; skim milk and cottage cheese only should be brought into the home. Oleomargarine and vegetable oils may be used for cooking. &dquo;Rich&dquo; French and Italian gravies must be avoided. The patient’s weight must be reduced to several pounds below the average weight recommended for the patient’s sex, age, and height. The rate of weight loss must be gradual, not to exceed 3 to 4 pounds per month, in order to avoid starvation acidosis and ketosis. Preparation of appetizing and pleasant foods must be learned so as to encourage the patient to follow the diet and to enjoy his meals. This is an important aspect of the dietary regimen.
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Nitroglycerin. This agent is the most important and indispensable drug for the treatment of angina pectoris. There may be definite differences of opinion about how nitroglycerin relieves the patient of his episodes of anginal discomfort, but everyone agrees that it functions very well both in therapy and diagnosis. The patient, more than anyone, is impressed and convinced of its value. There is no doubt that it dilates the coronary arterial vessels, and it may have a direct beneficial effect on the myocardium. Nitroglycerin must be fresh and readily available for immediate use. When fresh, nitroglycerin tablets of 1/400 to 1/200 gr are all that are necessary. When fresh, the nitroglycerin administered sublingually invariably relieves anginal discomfort. Patients should be advised to buy a fresh supply of the tablets every 3 months from a drug store where sales are large and the turnover of drugs is rapid so that only fresh nitroglycerin (TNG) would be expected to be found at all times. The patient should be advised to determine that the TNG is fresh by the fact that the drug stings, pricks, or burns under the tongue when fresh. Fresh and active TNG may produce a mild headache, a facial flush and slight palpitation. Patients learn these symptoms and learn to tolerate them. However, when the headache is severe, the tablet is too strong and, more importantly, the patient will prefer to bear the chest pain rather than experience the headache. The patient should then be advised to reduce the size of the dose by breaking a small piece of~ the tablet before placing the remainder sublingually. The dose of TNG must be varied among patients, but fresh active TNG tablets of gr 1/400 to gr 1/200 are all that are needed for therapy. Remember that patients with migraine headaches or other types of headaches are prone to develop severe TNG headaches. In patients prone to develop headaches, all vasodilators must be used cautiously and carefully, but they can be used. TNG is inactivated by light, heat, metals, and moisture. Patients must be advised of this in order to keep their TNG active. The TNG must be used immediately at the onset of an episode of angina. The earlier it is used, the more effective it will be. And, more importantly, early use, with the abortion of an episode of angina, prevents the complications of angina such as arrhythmias, infarction, and acute pulmonary edema. The drug must be readily available all the time, in the patient’s pocket or purse, at the bedside, on the desk at work, or the like. The patient must never have to rush for it or even search for it. And there must be no cotton plug in the drug bottle or anything that would interfere with immediate use. As stated above, nitroglycerin is indispensable and the best drug available for the treatment of angina pectoris. Nitroglycerin paste may be used, but it must be used cautiously at first until the proper dose for each patient is determined by careful trial. -
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Long-Acting Vasodilators. These drugs should be tried cautiously, according those noted above for TNG. Their effectiveness varies from patient to patient in accordance with the type and dosage of the drug. I usually prescribe Isordil (isosorbide dinitrate), using 40 mg Tembids twice daily at 12hour intervals with 10 mg tablets two or three times between the Tembids. Patients should not be awakened to take any vasodilators unless they have nocturnal angina, and nocturnal angina requires specially directed care. There are many other types of vasodilators besides Isordil. When a patient is using any long-acting coronary vasodilator, that drug should be continued if it is effective. Never change the drug merely to make a change. All vasodilators can produce headaches and, therefore, as with TNG, the size of the dose should be varied to satisfy the patient’s needs and response merely by breaking tablets in halves or quarters. Every patient’s needs and responses can be fulfilled by discussing them with the patient. This requires time and effort, but it is necessary for good therapeutic results. Propranolol (Inderal) is a useful but not always effective drug. It is advisable to begin administration with 10 mg four times daily, and to increase the dose gradually while carefully and closely observing the patient. As much as 100 mg four times a day may be necessary. This drug is not a substitute for TNG. When discontinued, its dose must be reduced slowly to prevent undesirable withdrawal effects. Remember, it can produce hypotension and thus reduce the perfusion pressure that is so important for the circulation of blood through arteriosclerotic coronary arteries. Raudixin (rauwolfia serpentina) is a very useful drug in the management of angina pectoris, especially if the patient has arterial hypertension. Raudixin is administered three or four times a day, with 100 mg in each dose. Patients who are sensitive to drugs may initially use 50-mg tablets. The patients must be warned about the nasal congestion and the nightmares that can develop as sideeffects of the drug. When these develop, the drug should not be discontinued, but rather the dose should be reduced. Raudixin and other drugs used in the management of cardiovascular disease can produce impotence. This side effect is best not mentioned because it does not always develop. Should it develop, the drugs in use and their dosages can be reviewed with the patient. Raudixin will reduce the heart rate, seems to reduce a- and #-sympathetic nerve activity, and may even reduce the intensity of action of serotonin. It also has a sedative effect. The depressing effect is primarily doserelated. Any patient taking any drug must be followed carefully until the effect of the drug and its dosage on the patient is adequately evaluated. Sedatives are usual adjuncts to therapy for patients with angina pectoris. However, it is much better to employ reasoning and training to solve these patients’ problems, which produce unhappiness, tension, anxiety, and frustration, rather than to rely on sedatives. The sedatives must be selected with careful to the
same
rules
as
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thought. Patients vary considerably in their sensitivity to sedatives and to dosage, and in their response to different drugs. Rest, relaxation, and adequate sleep are important considerations. Patients must rest and sleep adequately, but excessive sedation, especially to the extent of producing excessive hypotension and reduced coronary arterial perfusion pressure, must be prevented. Caffeine beverage consumption by the patient must be reduced to no more than once daily. Decaffeinated coffee or very dilute tea may be substituted. Smoking should be stopped completely, except for well-understood psychologic reasons. Very old people may often be allowed to smoke one or two cigars or pipes of tobacco per day. Alcoholic mixtures, except for an occasional drink, or occasional wine or beer, must be forbidden. Regular and heavy drinking of alcohol must be stopped. Again, very old people may be allowed one drink daily. Cold foods, such as ice cream or sherbert, and ice-cold drinks should not be allowed in order to avoid reflex coronary arterial constriction. Cool drinks may be permitted on a trial basis. Hypertension must of course be treated, as must congestive heart failure. But the management of these states cannot be discussed in this paper. Patients with high hematocrits, 50% or more, should be bled to reduce blood viscosity and thereby facilitate coronary blood flow. When phlebotomy is seriously considered, the reason and plan should be discussed with the patient. The blood can be withdrawn at the blood bank or in the doctor’s office. My practice is to withdraw 250 cc each day or every other day until the patient’s hematocrit is reduced to 46 to 47%. After every bleeding, the patient should rest supine for an hour or so to allow for sympathetic and vascular adjustments. It is a good practice to have a member of the family with the patient at the time of venesection who can take the patient home later. Usually, a total of 750 to 1200 cc of blood must be removed to achieve the desired hematocrit and blood viscosity levels. Then the hematocrit should be checked periodically for future venesection. Once the desired hematocrit level is reached, one or two venesections of 250 to 300 cc annually are usually all that is necessary to maintain a normal hematocrit. Routine use of anticoagulants is not only inadvisable but is dangerous. Anticoagulant therapy has not been shown to benefit patients with angina pectoris. I do not use anticoagulants for my patients; but if they are used, the prothrombin time and partial thromboplastin time (PTT) must be closely watched to prevent hemorrhage. Once an anticoagulant is administered, the drug must never be discontinued suddenly, except in an emergency. Associated disease states should be treated along with angina pectoris. The anginal state should receive priority in therapeutic considerations. Hiatal hernia, constipation, dyspepsia, diverticulitis, periodontoclasia, and other such disorders must be treated, but not in a way that would disturb the ischemic heart disease. Transfusions should be avoided unless there is a definite need for
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patient to build his own blood by the measures required. reasonable low hematocrit may be advisable because of the Maintaining associated low viscosity of the blood. Cardiac arrhythmias must be treated carefully and without the use of antiarrhythmic drugs if possible. When specific drugs are indicated, they must be used carefully. This aspect of management is also beyond the scope of this presentation. This discussion has been limited to medical management of angina pectoris; but because of the prevailing pressure to visualize the coronary arteries by coronary angiography and to perform coronary artery bypass surgery, Table 1 is included. Coronary angiography is not without hazard and therefore is not indicated unless bypass surgery is planned. The value of bypass surgery in the management of angina pectoris is controversial. Most of the complex, expensive, and often hazardous tests to which many patients with anginal symptoms are submitted, such as the treadmill stress test, VCG, apexcardiogram, Holter monitoring, jugular venogram, carotid arteriogram, and echocardiogram, are unnecessary, often contraindicated, difficult to interpret, and often beyond the patient’s financial means. Remember that angina pectoris is a symptom complex, and no one has ever seen, known, or been able to learn which coronary artery is responsible for that symptom complex, even with coronary angiography. Because of this fact, the average family physician can manage angina pectoris satisfactorily and without a sense of inferiority or inadequacy. The special tests and procedures mentioned above are them. Allow the a
TABLE 1 Medical Versus
Surgical Management of Ischemic
Question marks indicate that the precise data
are
not
Heart Disease
available; these
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are
rough estimates.
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rarely, if ever, necessary. Furthermore, angina pectoris can be treated best in the patient’s own home or small community hospital. George
E. Burch, M.D., F.A.C.A.
Tulane University School of Medicine 1430 Tulane A venue New Orleans, Louisiana 70112
Bibliography 1.Friedberg, C. K.: Diseases of the Heart. Third edition. Philadelphia, W. B. Saunders, 1966. 2. Gorlin, R.: Coronary Artery Disease—Major Problems in Internal Medicine. Volume XI. Philadelphia, W. B. Saunders, 1976. 3. Hurst, J. W., Logue, R. B., Schlant, R. C., et al.: The Heart Arteries and Veins. Third edition. New York, McGraw-Hill, 1974.
4. Manninen, V., Halonen, P. I. (Eds.): Advances in Cardiology: Physical Activity and Coronary Heart Disease, New York, S. Karger AG, 1976. 5. Vlodaver, Z., Amplatz, K., Burchell, H. B., et al.: Coronary Heart Disease: Clinical, Angiographic and Pathologic Profiles. New York, Springer-Verlag, 1976.
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