This is a disease characterized by excruciating pains in the cardiac region, a sense of utter powerlessness, and fear of impending dissolution. It has been divided into two varieties, the true and false.
Etiology — True angina is most frequently met with in males who are past forty years of age. A large proportion of these cases show fatty degeneration of the heart, with sclerosis or calcification of the coronary arteries; while in other cases it has appeared to depend upon aortitis, adherent pericardium, cardiac hypertrophy, aortic regurgitation or stenosis, and arterial sclerosis. In certain families there appears to be a hereditary tendency to development of such conditions as produce these paroxysms. Derangement of the alimentary canal, dilatation and distention of the stomach, and toxic agents as tobacco, tea, coffee and alcohol have each at times been recognized as causes. In many, the attacks are precipitated by over exertion or some pronounced mental emotion. The pseudo angina occurs in neurasthenics or the hysterical, during the early part of life and is frequently associated with uterine or ovarian irritation, dysmenorrhea and salpingitis.
Pathology: — It should be remembered that angina pectoris is a neurosis, no definite pathological change being constant, and yet structural changes are so frequently associated that they demand attention. | Among these changes are interstitial myocarditis with arterial sclerosis, especially of the coronary arteries, as well as fatty degeneration, and gummata with its attendant fibroid changes. Apart from the sclerosis as already mentioned, endarteritis deformans and obliterans have their influence, especially as they affect the nutrition of the heart. With this group should be placed structural changes in the aorta and coronary arteries and occlusion of the openings of the latter. Neuritis of the cardiac plexus of nerves has been demonstrated in a few cases.
Symptoms — True angina pectoris begins suddenly, usually during some mental emotion or marked exertion. The patient is seized with a most excrutiating pain which is griping in characacter, rendering the body motionless and involving the whole chest. The pains radiate to the left shoulder and arm, at times the right is involved. The pains may be felt in the neck and back and accompanied by a sensation of coldness and numbness, and a sense of impending death. The countenance becomes pale and is bathed in a cold perspiration. The respirations are shallow, but the patient can breathe deeply. The heart’s action may be regular and the arterial tension is usually increased. The duration of the attack varies from a second or two to an hour or longer, and is followed by eructation of gases, vomiting or passage of large quantities of pale urine.
The pseudo angina occurs most frequently in females of the hysterical and neurasthenic type, who suffer from derangement of the uterus and its appendages. There are frequently symptoms of disturbance of the vasomotor system. Careful examination reveals the hysterogenic spots and anesthetic area. The recurrence of the attack varies; it may return at any time, or months and years may intervene. If the patient is careful not to become exhausted and is of a calm disposition, the intervals between the attacks may be lengthened. It has been observed that as dilatation of the heart takes place, the attacks become less frequent and less severe.
Diagnosis: — This is dependent upon the pain which comes quickly, is most severe in and confined to the region of the heart, and radiates to the shoulder, the mental anxiety; and the inability of the patient to move. He is past the meridian of life and is apt to present indications of circulatory disturbances.
Pseudo angina is seen most frequently in hysterical and neurasthenic females. The attack is often produced by some emotion. The patient does not keep quiet, and the pain may radiate all over the body. Neuralgia of the heart is found from tobacco and alcohol, but there is the odor and other evidences pointing to these as the cause. Lead poisoning is indicated by the abdominal colic, the blue line on the gums, and the constipation. Intercostal neuralgia and cardiac asthma should be remembered as they have been mistaken for angina pectoris.
Prognosis — In real angina this is always grave, especially if there is arterial sclerosis, disease of the valves, or myocardial degeneration. If fatty accumulation is the cause, the prognosis is more favorable. In those cases where it is dependent upon a toxic condition, its removal renders the prognosis better. In those cases where it is due to neurotic condition, recurrence is common, but it does not kill.
Treatment — If anything permanent is to be accomplished by treatment, a most careful examination of the individual case must be made. Not the attack alone, but the habits of the patient, his family history and environments must all be studied in every possible light. In the management, each case must be considered separately and the causes that excite an attack sought after. Many of these patients already have recognized the cause in their own case and often it is some irregularity of diet, exercise or mental condition. Many times it is not an easy matter to control the mental state, as the worry and strain of business life presses upon many of these patients, and is responsible for many cases of arterial degeneration that give rise to apoplexy, Bright ‘s disease, aneurysm or angina pectoris. The age and occupation of the patient, and the condition of the vascular system should be taken into consideration.
Following an attack the condition of the heart may require absolute rest, from a day to a week or more; this is especially true if the attacks are precipitated by a slight degree of exercise, which shows that the heart is not able to propel the blood under anything but normal conditions. Under no condition should quick movements and strong emotions be associated. Steady quiet exercise as walking upon level ground is beneficial. If the cardiac weakness is such as to forbid this, massage, or the resistance exercise of the Schott’s method may be tried. This exercise should not follow immediately after a meal.
In many of these cases the diet is most important. Generally they are good feeders on rich and strong food. First the quantity must be reduced, for the great majority eat too much. All food that distresses the patient in any form should be forbidden, especially those that give rise to flatulence. In cases where there is marked indication of atheroma and calcification of the arteries, those articles of food that contain an excess of lime, as milk, eggs, cheese, etc., should be eliminated so far as possible. In those cases that are known as false angina, the neurasthenia and hysteria must be overcome. At times a positive diagnosis that no serious heart lesion is present, is of great benefit to the patient. Some patients know of an approach of an attack due to some indiscretion in diet, and take steps to relieve the stomach of the offending meal.
During an attack, a pearl containing five drops of the nitrate of amyl should be broken on a towel and the vapor inhaled. This drug will give better results in cases of true angina than in the false form. One or two drops of the first centesimal of glonoine by the mouth, will often cut an attack short. It is advisable to let the patient have one or both of these drugs with him, to be taken in an emergency, for it is seldom that a physician can reach the patient in time to render any service during the attack. In giving the patient these drugs he should be warned of the dangers from them.
In pseudo angina, magnesia phos. in hot water, a dose every three to five minutes will often bring relief. Cold applications to the chest or swallowing pieces of ice have been known to break the paroxysm.
Natrum iod. — This remedy in from five to twenty grains three times a day, will be found to give most excellent results where there is organic disease of the heart, associated with the angina pectoris. There is an oppression in the region of the heart that is attended with a fear of death and a feeling as if something dreadful was about to happen.
Kali iod. — Severe pains in the centre of the chest which extends to the shoulder. The pains in the chest are very severe; the patient desires to get into the fresh air; there is oppressed breathing and loss of voice.
Spongia — There are sudden cramping pains within the chest with oppressed breathing and sensation of suffocation. The face is pale, a feeling of nausea is complained of. The lower portion of the body feels numb while the upper portion is sore.
Cactus grand — When with the angina pectoris there is an organic lesion. There is a sensation as if the heart were grasped by an iron band preventing its normal movements, with a continuous palpitation of the heart, which is aggravated by walking, and at night when lying on the left side.
Arsenicum — When the attacks are periodical, are attended with faintness and extreme weakness, worse after midnight and from motion. There is great mental and bodily anxiety with severe pain that extends down the arm, and great prostration and dyspnea. The surface of the body is cold, and there is marked prostration following the attacks.
Spigelia — There is constriction and painfulness in the left side of the chest which arrests the breathing and causes a sensation of suffocation. The palpitation of the heart is pronounced and the pains are aggravated by motion and leaning forward.
Cuprum- — Where there is but little vitality; in feeble individuals, with slow pulse that have suffered during a long period. The attacks appear suddenly, are attended with great dyspnea, the surface of the body is cold and blue and there is a tendency to cramps.
Laurocerasus — In recent cases where there is marked structural lesion. The attacks are severe, are attended with great suffering, gasping for breath and loss of speech. The skin is moist and cold.
Aurum mur. — The attacks are precipitated by walking in the open air; the palpitation begins and grows worse, and the pain more severe while in the open air; but relief is found by going to a closed room where the patient can walk for an indefinite period with no discomfort.
Veratrum alb. — This remedy will be found of service in functional cases where there is a feeling of impending suffocation, with constriction of the chest and cutting pains that arrest the breathing.
Tabacum — When this remedy is indicated there is an intermittent pulse, pallor with cold, clammy perspiration, vertigo and deathly nausea. There are accumulations of white tenacious mucus in the mouth, and great thirst with deathly nausea and vomiting, which comes in paroxysms and is made worse by motion. The stomach feels relaxed as if sinking in. There is violent palpitation of the heart with paroxysms of precordial oppression and pain between the shoulders. The pulse is feeble, soft, slow and intermittent. The patient complains of great weakness and debility, is restless and desires to change his position often.
Lilium tigrinum — This remedy will be found of service in nervous affections of the heart. The patient is usually of the female sex and suffers from ovarian and uterine diseases. She is depressed in spirits and inclined to weep. She feels that things must be done at once but is unable to perform the task, and mental irritation results. The abdomen is distended, and there is such a dragging downwards of the organs of the abdomen and chest that she supports the abdomen with her hands. She is a subject of morning diarrhea, when there is great pressure in the rectum and a constant desire to go to stool. There is a constant desire to urinate, which is worse during the day; the discharge is scanty and is followed by a burning and smarting in the urethra. There is a sensation as though the pelvic organs would press through the vulva, with sharp pains in the ovarian region; she finds relief by pressing the hand against the parts. A constant distress about the heart is complained of with sharp quick pains, also a fluttering and palpitation of the heart and a feeling as if it was squeezed in a vise, or was alternately grasped and relaxed. Her limbs are cold, with burning of the palms of the hands and soles of the feet. She is worse at night and finds relief during the day by keeping busy.
Nux vomica — Should be studied in the gouty, hemorrhoidal patient, where it is so frequently indicated.
Aconite — In pseudo angina, has relieved when its characteristic symptoms are present, as well as digitalis and naja.
Excerpted from: Diseases of the Heart by A.L. Blackwood MD