Angina Pectoris Management

Categories: Uncategorized
Sources: 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 frequen 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

bowels.



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

tolerated.



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

blood pressure.



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

angina pectoris.



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.