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Advances in angina treatment.

November 18, 2012

I have chronic angina and have gone through many drugs and treatments to try to alleviate my condition.  Seeking support online, I have met many other women in my situation.  We are women who were once active and busy like everyone else, but are now limited by frequent chest pain.  In my case, the pain is caused primarily by spasms of one of my coronary arteries.  Some people have primarily microvascular disease, which means the very small vessels in their hearts don’t dilate appropriately in response to increased demand.  Others have atherosclerotic disease (hardening of the arteries).  For a more detailed explanation of angina symptoms and causes, see my earlier article What is angina and why isn’t it the same for everybody?

The primary treatment for angina is revascularization through angioplasty or coronary artery bypass surgery.  These techniques have worked wonders for those suffering from coronary artery disease (lesions in the big vessels of the heart).  I’ve had angioplasty with stent placement myself, for an acute blockage of the left anterior descending (LAD) artery.  In my case, this was a life saving procedure, as I most likely would have died without prompt intervention.  For most people, revascularization takes care of the problem and they remain relatively pain free for some time.  In other cases such as my own and those of other people I know, this is not enough.

The next step is medication.  The primary medication used is nitroglycerin.  This is used for acute episodes of pain and comes in sublingual tablet or spray form.  Long acting formulations are also used such as nitroglycerin patches or slower nitrates such as isosorbide mononitrate.  Beta blockers, such as metoprolol or carvedilol, are helpful for many people.  This type of medicine reduces the workload and oxygen demand of the heart by slowing heart rate.  It also reduces the resistance the heart beats against by dilating arteries and lowering blood pressure.  Calcium channel blockers, such as diltiazem or amlodipine, are useful when pain is caused by coronary artery spasm or microvascular disease.  CCB’s reduce heart rate modestly and dilate arteries, allowing the cardiac muscle to receive better blood flow.

In cases where these medications do not adequately control angina, other methods are used to control pain.  Many people take medication to reduce anxiety, such as lorazepam (Ativan) or alprazolam (Xanax).  These help angina by reducing emotional demands on the heart.  Some take opiate pain medications such as hydrocodone, morphine, or hydromorphone (Dilaudid).  These also reduce oxygen demand of the heart and dilate vessels besides relieving pain.

A relatively new approach is using a spinal cord stimulator to mask the unrelieved cardiac pain.  This method has been used in Europe for several years and is gaining acceptance in the US.  Spinal cord stimulators have been used for back pain for many years.  They work by generating electrical impulses which are delivered to nerve roots where they exit the spinal cord.  This can help pain anywhere innervated by that nerve.  A less invasive version of this type of treatment is the use of a TENS unit which delivers impulses to electrodes placed on the skin in the affected area.  A friend of mine is in the process of obtaining a spinal cord stimulator.  The test run was successful beyond her wildest dreams.  She is hopeful the SCS will reduce her need for opiate pain relievers.

The University of Chicago Chronic Angina Program is conducting studies on the use of spinal cord stimulators, gene therapy, and Transmyocardial Laser Revascularization (a surgical procedure).  Swedish Medical Center in Seattle has a pain program that uses innovative approaches as well.  This is where my friend is being treated.

I hope in the future cardiologists will place a higher priority on pain management in chronic angina.  Many doctors still belittle the importance of treating these symptoms once they have assured themselves no blockage exists in the large vessels of the heart.  From my perspective, both as a nurse and as a patient suffering from chronic angina, our quality of life is of great importance.  Without pain relief, it is much harder to exercise and try to improve cardiovascular function.  Also chronic unrelieved pain leads to depression and hopelessness, neither of which improve the cardiac patient’s survival.

2 Comments leave one →
  1. November 18, 2012 10:38 am

    An excellent review of pain reilef techniques for angina sufferers. As a woman with chronic severe angina who has exhausted all the typical first lines of treatment for angina, and as someone who’s just undergone a trial with spinal cord stimulation (SCS) for angina, it is clear that new techniques, such as SCS, are the wave of the future of angina treatment.

    I especially resonate with your last comments– that chronic unrelieved (and unbelieved) pain can be extremely destructive for the sufferer. I understand that depression that often accompanies unrelieved/believed pain can significantly decrease cardiac patient survival. That fact alone should be enough to get physicians and researchers moving!

    Thanks for putting together a cogent and succinct article! You have such a way with words!

    Love,
    Melissa

  2. Carolyn Thomas permalink
    November 28, 2012 9:30 am

    Fantastic overview of symptom management in angina. I’m a ‘regular’ at our Regional Pain Clinic where – lucky me! – my pain specialist there happens to have completed a 2-year fellowship in Sweden studying Coronary Microvascular Disease (my own Dx).

    I’d like to add to your list the portable TENS unit that’s been prescribed for me for the past year. This has significantly reduced my nitro usage for chest pain.

    Since 2001, the U.K. National Refractory Angina Group has in fact recommended TENS therapy for angina in heart patients:

    “Neuromodulation owes its origins to Melzack and Wall’s gate theory of pain that predicted that stimulation of vibratory afferent nerves would reduce or gate the transmission of pain traffic relaying through the spinal cord at the same point.

    “Transcutaneous electrical nerve stimulation (TENS) was specifically designed to make use of this predicted effect and was used to treat a variety of pain conditions before it was shown to be effective in angina.

    “Neuromodulation should be offered as part of a multidisciplinary angina management programme based on the current guidelines.“

    My pain specialist has already discussed both spinal cord stimulator implant and stellate ganglion block procedures if for some reason my little black box stops controlling my pain symptoms as it now successfully does. This is truly life-altering, as you wisely point out: day to day living (like being motivated to incorporate heart-healthy lifestyle improvements) is tragically impacted in those living with pain.

    TENS therapy is now routinely recommended here (Canada) and in the U.K. for MVD patients – still wondering why U.S. cardiologists seem unaware/uninterested in prescribing this, particularly for those with debilitating angina pain that does not respond to conventional meds? More on this at: http://myheartsisters.org/2010/08/26/tens-for-chest-pain/

    Thanks so much for pointing out intriguing developments in pain management here.
    regards,
    C.

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