Vasospastic angina

Vasospastic angina is associated with ventricular arrhythmias, acute myocardial infarction and sudden arrhythmic death. The main ischemic mechanism in vasospastic angina is coronary spasm. Because the demonstration of spontaneous coronary spasm is difficult, a number of methods which can provoke spasm in susceptible patients were imagined. The most used clinical methods of diagnostic provocation testing were analyzed.     

Affect and angina

The influence of mood on exercise tolerance was studied in 186 patients with chest pain presenting to a cardiology clinic for diagnostic exercise stress testing. Mood was measured using the Hospital Anxiety and Depression Scale and patients were exercised using a standard protocol. One hundred and fourteen patients had positive exercise tests indicating the presence of coronary artery disease and 72 patients had negative or inconclusive tests. Patients with negative exercise tests were younger, more commonly female, had atypical chest pain, and significantly higher anxiety and depression scores compared with those with positive exercise tests. In patients with positive exercise tests there was a significant negative correlation between the exercise duration and both anxiety and depression scores. Thus, mood influences the symptomatology of ischaemic heart disease. Many patients with atypical chest pain have significant abnormalities of mood which may be causally related to their pain.     

SCS in intractable angina

Despite a wide range of therapeutic choice in the treatment of angina pectoris, there is a small but increasing population of patients that doesn't benefit of conventional therapy and whose life is invalidated by frequent attack of anginal pain. For this population, nonresponders to drug therapy not suitable for revascularization (coronary bypass surgery, angioplasty), neurostimulation of dorsal column has been described as an effective and safe therapy. The mechanism of action is not completely known, but is safety is sufficiently established. It may become a useful choice in the treatment of patients with intractable angina.     

Management of unstable angina

One-hundred and seven patients with unstable angina were treated between 1981 and 1987. Platelet dysfunction and elevation of fibrinogen was observed. The efficacy of aspirin, dipyridamole and heparin on coagulation profile is compared. Left main disease was seen in 11.4 per cent. Left anterior descending was occluded in 90.7 per cent. Aortocoronary bypass graft using saphenous vein graft was carried out on all patients. On an average, each patients received 3.5 grafts. Emergency surgery was done in nineteen. Associated ventricular aneurysm was resected in nine. Thirteen patients died. Operative mortality decreased to nil in 1986–1987. Perioperative infarction was seen in five patients. Clinical improvement was seen in 80.3 per cent and 48.9 per cent were asymptomatic. Actuarial survival was 92 per cent after six years. Postoperative coronary angiography in 28 patients showed patency of grafts in 18, partial patency in six and occlusion in four. Aspirin was found useful after surgery to relieve angina. Spiroergometry and Thallium²⁰¹ scintigraphy was useful to assess medical and surgical treatment.     

Surgical management of unstable angina

Unstable angina pectoris encompasses a broad spectrum of clinical subsets with varying prognoses. It is impossible to identify which patients have severe obstructive coronary disease and, therefore, coronary arteriography should be employed. In patients with severe obstructive disease, coronary bypass surgery has resulted in dramatic symptomatic improvement and has improved the survival of patients with 2-and 3-vessel disease, as compared to medically treated groups. Aggressive preoperative medical management coupled with improved anesthetic and surgical techniques have aided in the salvage of these unstable patients.

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Résumé Le terme angor instable couvre une grande variété de tableaux cliniques de pronostic variable. Il est impossible de reconnaître les malades qui ont des sténoses coronaires importantes et il faut donc utiliser la coronarographie. Chez les malades présentant des sténoses graves de 2 ou 3 troncs coronaires, les bypass améliorent beaucoup mieux la Symptomatologie et la survie que le traitement médical. Les thérapeutiques médicales préopératoires aggressives et l'amélioration des techniques anesthésiques et chirurgicales ont beaucoup amélioré le pronostic de l'angor instable.

     

Surgery for unstable angina.

A series of 84 patients with unstable angina, treated surgically by grafting procedures between October 1970 and September 1976, have been reviewed. The study indicates that extensive coronary artery disease is common in these patients, and suggests that operation may favourably influence mortality, both immediate and delayed, but does not reduce the risk of myocardial infarction. Eighty per cent of the patients were relieved of angina and able to lead a reasonably normal existence.     

Transdermal nitroglycerin in angina pectoris

Stress is sometimes involved in cardiac patients when a number of different drugs are necessary for treatment that are taken in a variety of dose regimes. Any new method for drug delivery that can relieve some of this stress is therefore of interest. Such a preparation is glyceryl trinitrate (GTN) in the form of a skin patch (Transiderm-Nitro) and this was compared to placebo in a double-blind cross-over trial. Following a one-week control period, patients were randomly allocated to three weeks treatment with placebo followed by three weeks with Transiderm-Nitro (1–15 mg in 24 h) or vice versa. Analysis was performed on 77 cases, 37 in the placebo first group (group A) and 40 in the Transiderm-Nitro first group (group B). Irrespective of treatment order, mean weekly anginal attack rates and GTN requirements were significantly less on the active patch than on placebo. Thus, there was a 21 per cent reduction in anginal attacks on placebo but 53 per cent reduction on Transiderm-Nitro (p<O.OOl); while the mean GTN requirement was reduced by 29 per cent on placebo but 56 per cent on Transiderm-Nitro (p<O.OOl). There were no significant changes in pulse rate or recumbent or upright blood pressure. Patients' preferences (blind) were in favour of Transiderm-Nitro (p<O.OOl). The most frequent side-effect was headache, which occurred in 22 per cent of patient; on Transiderm-Nitro but in only 3 per cent on placebo (p<O.Ol). Skin rashes occurred in 5 per cent on Transiderm-Nitro and 4 per cent on placebo (NS). This short-term trial demonstrated highly significant effects from the transdermal GTN preparation in comparison to placebo.     

Vascular reconstruction in intestinal angina

Chronic intestinal ischemia is rare because of the great capacity to form abundant collaterals. The experience with ten patients is discussed and the literature is reviewed. Diagnosis is easily missed because of the lack of specific symptoms. All but one of the patients showed the classical triad (postprandial pain, weight loss, epigastric bruit). The diagnostic value of endoscopy based on remarkable ischemic mucosal findings is stressed. These findings have not been described before. Most of the patients suffered from generalized atherosclerosis and therefore had a high operative risk. There was a considerable postoperative morbidity, but no postoperative mortality. In all patients long-term results were satisfactory. Vascular reconstruction is strictly indicated in case of intestinal angina, not only to diminish severe complaints, but also to prevent acute ischemic infarction. In our opinion there is no indication for prophylactic surgery in case of asymptomatic arterial stenosis or occlusion.     

Airway management in Ludwig's angina

A 37-year-old 91 kg man presented with features of Ludwig's angina. Anaesthesia for incision and drainage of his submandibular abscess was undertaken by two specialist anaesthetists with an otorhinolaryngological surgeon prepared for immediate tracheostomy. After preoxygenation, gas induction with sevoflurane in oxygen was followed by a gush of pus into the oral cavity and laryngospam causing acute upper airway obstruction. This resolved with 25 mg of suxamethonium and an endotracheal tube was passed into the trachea with difficulty. Options for management of the difficult airway in Ludwig's angina are discussed.