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Ischemic heart disease is a major cause of death and disability worldwide, while angina (short for “angina pectoris”) represents its most common symptom.1 Angina has been shown to double the risk of major cardiovascular events.2 There are currently 4.1 million deaths due to coronary artery disease (CAD) in Europe each year, with 82% of these deaths in people older than 65 years.1

43%

of angina patients remain underrecognized

50%

of patients do not adhere to treatment

30,000-40,000 cases of angina per million in Western countries

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The annual incidence of angina is 1% for the Western male population aged 45–65 years, with a slightly higher incidence in women. The prevalence increases with age in both genders. The main age of patients with angina is 65 years for men and 70 years for women.

The incidence and prevalence of patients with angina is anticipated to increase in the coming decade as a result of the aging of the population, the epidemic of obesity, the greater use of life-prolonging therapies, and the better management of acute coronary syndromes.3Angina also has a negative impact on quality of life and leads to a 3-fold higher risk of disability7, a 1.5-fold higher risk of job loss7, and 4-fold higher risk of depression.8

Angina is a pain or discomfort in the chest caused by the insufficiency of oxygen in the cardiac cells. It often has a squeezing or pressure-like feel in the chest and usually lasts for no more than 2 to 10 minutes. Traditionally, typical angina should meet all the following criteria: typical chest pain in terms of quality and duration, it should be provoked by exertion or emotional stress, and it should be relieved by rest and/or nitrates within minutes.

However, many angina patients suffer from atypical angina. These patients do not have a typical chest pain and could complain about: a shortness of breath, excessive sweatiness, extreme fatigue, pain at a site other than the chest, a sensation of indigestion or discomfort in the upper part of the abdomen. This complicates angina diagnosis and contributes to its frequent under recognition by physicians and misinterpretation by patients.9

A careful history during the medical visit remains the cornerstone for the diagnosis of chest pain and objective tests are often necessary to confirm the diagnosis.1

An in-depth understanding of the pathophysiology of angina is essential for timely diagnosis and optimal management. In many patients, the underlying pathology is atherosclerotic narrowing and obstruction of one or more major coronary arteries. This reduces blood flow to the heart muscle, causes a mismatch between the oxygen demand and delivery and leads to angina attacks.1

Angina may also occur in the absence of coronary artery disease and obstructive lesions, or even in the presence of normal coronary arteries.1 The underlying mechanisms of angina in these patients are the functional alterations of the coronary circulation at the level of the coronary microcirculation.1

This actually is not a rare situation.  In some registries, almost   2/3 of the newly diagnosed patients don’t have significant coronary obstructions11, which makes clarification of the underlying mechanisms of angina even more important.

Strategies to improve management of angina remain a priority for healthcare professionals in order to decrease the risk of major cardio-vascular events and mortality.

Implementing healthy lifestyle behaviors is an indispensable part of antianginal management. This includes smoking cessation, regular physical activity, healthy diet and maintaining a healthy weight. Such lifestyle changes could significantly decrease the risk of future cardiovascular events and death. Benefits after implementing healthier lifestyle behaviors are evident as early as 6 months.12

When it comes to the medical therapy, current guidelines recommend conservative antianginal treatment to control symptoms, prior to invasive coronary artery revascularization.9

Clinical trials have demonstrated that coronary revascularization is not superior to optimal medical therapy. The recent ISCHEMIA trial confirmed that an initial invasive strategy did not reduce the risk of ischemic cardiovascular events or death from any cause. That is why pharmacological treatment intensification is recommended as a first step for angina patients prior to an invasive strategy.13

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References
  1. Balla C, Pavasini R, Ferrari R, Cardiology 2018;140:52–67.
  2. Mozaffarian D et al. Circulation. 2016; 33(4): e38-e360.
  3. Ohman EM. N Engl J Med. 2016; 374:1167-1176.
  4. Maddox TM, Reid KJ, Spertus JA, et al: Angina at 1 year after myocardial infarction: prevalence and associated findings. Arch Intern Med 2008; 168: 1310–1316.
  5. Qintar M et al., Eur Heart J Qual Care Clin Outcomes.2016;2(3):208-214.
  6. Alexander KP et al. Interact J Med Res. 2016;5(2): e12.
  7. Padala SK et al. J Cardiovasc Pharmacol Ther. 1074248417698224 2017 Jan 01.
  8. Jespersen L et al. Clin Res Cardiol. 2013; 102: 571-58.
  9. Douglas PS et al. N Engl J Med. 2015;372:1291-1300.
  10. Ambrosio G et al. Angiology. 2019;70(5):397-406.
  11. Westermann D. J Clin Exp Cardiol. DOI:10.4172/2155-9880.1000387
  12. Knuuti J et al. Eur Heart J. 2020; 41(3):407-477.
  13. Maron J et al. N Engl J Med. 2020; 382:1395-1140.
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