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Angina Pectoris Management
Source: Disturbances Of The Heart
While a number of causes of true cardiac pain may be eliminated by
improvement in any loss of compensation, by improvement of the heart
tone, by more or less recovery from myocardial or endocardial
inflammation, and by the withdrawal of nicotin, which may cause
cardiac pains, still, true angina pectoris once occurring is likely
to be caused by a progressive, incurable condition, and the attacks
will become more frequent until the final one. It is possible that a
true angina may be due to a coronary artery disease or obstruction,
and that a collateral circulation may become established and repair
the deficiency. While this probably can take place, it must be rare.
Occasionally when the intense pain has ceased, the patient may be
nauseated and actually vomit, or he may soon pass a large amount of
urine of low specific gravity, or have a copious movement of the
The first attack, and subsequent ones more and more readily, are
precipitated by any exertion which increases the work of the heart,
as walking up hill, walking against the wind, going upstairs,
physical strains, as suddenly getting out of bed, leaning over to
put on the shoes, straining at stool, or even mental excitement.
Exertion directly after eating a large meal is especially liable to
precipitate an attack. Food which does not readily digest, or food
which causes gastric flatulence may precipitate attacks. Any
indiscretion in the use of coffee, tea, alcohol or tobacco may be
the cause of the attack.
For treatment of the immediate pain, if the physician arrives soon
enough, anything may be given which quickly relieves local or
general arterial spasm and spasm of the muscles. The moment that the
heart and its arterioles relax, the attack is often over. The most
quickly acting drug for this purpose is amyl nitrite, inhaled. If
amyl nitrite is not at hand, or has been found previously to cause
considerable disturbance of the head or a feeling of prolonged
faintness, nitroglycerin is the next most rapidly acting drug. It
may be given hypodermically, or a tablet may be dissolved on the
tongue. The amyl nitrite should be in the emergency case of the
physician in the form of ampules, or may be carried by the patient
after he has had one or more attacks. The ampules now come made of
very thin glass with an absorbent and silk covering ready for
crushing with the fingers, and are thus immediately ready for
inhalation. One of these is generally all that it is necessary to
use at any one time. Nitroglycerin, if given hypodermically, should
be in dose of 1/100 grain. If given by mouth the dose should be the
same, repeated in ten minutes if the pain has not stopped.
Almost coincidently with the administration of nitroglycerin or the
amyl nitrite, a hypodermic injection of 1/8 or 1/6 grain of morphin
sulphate should be given without atropin, as full relaxation is
desired without any stimulation of atropin.
Alcohol is also a valuable treatment of this pain, when the drugs
mentioned are not at hand. The dose should be large; whisky or
brandy is best, and should be administered in hot or at least warm
water. The physiologic action of alcohol, which dulls or benumbs the
nervous system and dilates the peripheral blood vessels, is exactly
in line with the clinical indications.
If a patient is home and at rest at the time of an attack, a hot-
water bag but slightly filled, or a pad electrically heated, may be
placed over the heart some times with marked advantage and relief
from pain. Occasionally even such gentle applications are not
After the attack is over, absolute rest for some hours, at least, is
positively necessary. If the attack was severe, the patient should
rest several days, as there seems to be a great tendency for such
attacks to come in groups, the cause being acutely present for at
least some time. But little food should be given; nothing very hot
or very cold, and no large amount of liquids; gentle catharsis may
be induced on the following day, if deemed advisable; no stimulating
drugs should be administered, and nothing which would raise the
The question often arises as to whether or not the patient shall be
told of the seriousness of his condition. It is hardly wise to
withhold this knowledge from him, and generally is not necessary.
The ordinary alert patient knows how serious the condition is by his
own feelings, and will even reprove or joke with his physician for
minimizing the danger. It is best that the whole subject be
discussed carefully with him and his life regulated and ordered, and
emergency drugs prepared and given him with proper instructions, to
the family, so that he may possibly prevent other attacks and, if
they occur, may have the best immediate treatment.
The acute symptoms being over, a careful analysis of the probable
cause of the anginal attack should be made. If it is a general
sclerosis, the treatment should be directed to that condition. If it
is a myocarditis, a fatty degeneration of the heart or a fatty
heart, this should be properly treated as previously described. If
it is due to a toxemia from intestinal disturbance, that may readily
be remedied. If due to nicotin, it need not again occur from that
reason, and perhaps the damage caused by the nicotin may be removed.
Any organic kidney trouble must, of course, be managed according to
its seriousness, and if there is hypertension without any serious
lesion, the treatment should be directed toward its relief.
Not infrequently, whether a patient is suffering from real angina
pectoris or a pseudo-angina pectoris, the absorption of toxins irons
the intestines, due to indigestion and fermentation, adds to these
cardiac pains, and may even be a cause of them. Consequently,
eliminative treatment and a temporary rigid diet, and various
treatments to prevent intestinal indigestion, are of great value in
It may be even advisable for twenty-four hours or so to give nothing
but water, and then perhaps a skimmed milk diet for a few days. This
treatment, combined with almost absolute rest, and later graded
exercise, with other measures to lower the blood pressure, and with
the absence of tobacco, sometimes is very successful treatment.
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