Angina Pectoris

Chapter 13

Angina Pectoris Chapter Objectives After studying this chapter you should be able to: 1. Explain the treatment limitations of using integrative Chinese medicine 2. Describe the mechanisms of angina pectoris 3. Describe the role of Chinese medicine during the indication stage 4. Discuss treatment methods in Chinese medicine 5. Summarize the context of the patient’s role in personalizing medicine

OVERVIEW This chapter describes the stages of angina pectoris and the possibility of integrated medicine in treatment. Xiong bi or chest obstruction is the classification in Chinese medicine. Coronary artery disease is the key feature within the mechanisms of the disease and the genetic determinants. Signs include low oxygen distribution, blood clots, arterial spasms and plaque deposits in the main and micro arteries of the heart. Health care providers should consider the types of angina, the genetic determinants and mechanisms, seasonal factors, and lifestyle choices when personalizing the treatment approach.

Types of Angina The four types of angina pectoris include stable, unstable, variant and microvascular. Stable angina involves regular episodes of chest pain which is relieved by rest and medication. Unstable angina involves irregular unpredictable episodes of chest pain and microvascular features and it occurs primarily in women.

Mechanisms and Genetic Determinants The mechanisms involve low oxygen distribution, blood clot formation, arterial spasms and plaque build-up in the microvessels. The genetic factors Integrative Cardiovascular Chinese Medicine. DOI: http://dx.doi.org/10.1016/B978-0-12-420014-2.00010-7 © 2014 Elsevier Inc. All rights reserved.

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involve problems with cell aging and lysis, plaque formation, methionine synthesis, and failure to control homocysteine levels.

Seasonal Factors G

G

Cold weather in winter contributes to deficiency of qi and yang, which causes stress during physical effort Hot weather in summer contributes to loss of qi and yin fluid, which raises body temperature and causes sweating

Lifestyle Choices G

G G

Consider genetic factors that contribute to increased risk of cardiovascular disease Reduce the amount of fats in the diet Wean off cigarette smoking and tobacco use

Treatment success using integrative medicine focuses mostly on prevention and control during the stable angina stage.

Key Points G G G

G

G G

G G G

G

G

G

G

Angina pectoris is classified under xiong bi. There are four types: stable, unstable, variant and microvascular. Stable angina pain happens during physical effort and is relieved by rest and medication. Unstable angina is not relieved by rest but is relieved by medication, usually sublingual nitroglycerine. Variant angina occurs at night and can be fatal. Microvascular angina occurs primarily in women and is not relieved by rest or medication. DKN2A and DKN2B are genes involved with plaque formation. MTAP is involved in methionine production and homocysteine levels. Myocardial and Na1/K1 pump failures increase H1 production which lowers pH. Troponin is a cardiac marker which elevates within a few hours after cardiac injury and persists for up to 14 days. BNP/NT pro BNP is a cardiac marker, and levels indicate increased risk of infarction. CK-MB (creatine kinase) is a cardiac marker which elevates when there is damage to myocardial cells. Coronary angiography and CABG: determines the magnitude of coronary artery block. Next, healthy vessels from another area of the body are surgically used to bypass or replace the blocked section.

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PATHOGENESIS Chinese Medicine Angina pectoris is classified under xiong bi chest obstruction and heartache, and involves various disharmonies between the heart, liver, kidney and spleen. The pathogenic factors are qi deficiency, blood stasis and stagnation and phlegm stasis. The complication to avoid is the fatal separation of yin and yang.

Western Medicine a. Stable angina: G Pain is relieved by rest and medicine G Pain lasts for a few minutes and is predictable G Low oxygen distribution G Narrow arteries blocked with plaque, especially coronary arteries G Difficulty with physical effort G Emotional upset G Smoking G Seasonal weather extremes b. Unstable angina: G Pain is not relieved by rest or medicine G Arterial blockage by plaque and blood clots G Pain occurs during rest or physical effort, and is unpredictable c. Variant angina: G Cornonary artery spasm G Occurs during sleep at night G Relieved by medicine d. Microvascular: G Pain is longer in duration and is not relieved by medicine or rest

DETERMINANTS AND MECHANISMS Genetic Determinants DKN2A and DKN2B. These genes are involved with regulating cellular aging and lysis, and the formation of plaque within the arteries. MTAP. High levels of homocysteine are a risk factor for atherosclerosis. This gene is involved in the processing of cellular waste products into methionine which metabolizes excess homocysteine. Mutations are involved in failures in these processes.

Constitutional Factors See Table 13.1.

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TABLE 13.1 Constitution

General Incidence of Angina Pectoris

Teenage and young adult

Establishing of lifestyle habits: childhood obesity poor dietary choices and age of onset of smoking habit may set the health condition for middle age

Middle-age

Metabolic changes and adaptation to severe weather during summer and winter months impose additional demand during physical efforts

General geriatric

Blood pressure changes, cardiac conduction problems and excess blood lipoprotein disorders, may also cause plaque, fibrosis and blood clots which block arteries

Mechanisms a. Biochemical changes: G Lactate, potassium ion accumulation at the cardiac nerve contribute to pain sensation b. Contractility changes: G Myocardial and Na1/K1 pump failures increase H1 production, which lowers pH G Papillary muscle dysfunction is due to dysfunction of the left ventricle G Myocardial contractility decreases with left ventricular failures

EXAMINATION OF THE PATIENT Visual Observation Perform a neurologic examination for stroke by noticing the patient’s gait upon entering the room and bilateral grip strength.

Listening G

G

Assess memory, judgment and speech for neurological problems before or after treatment Emotions: vexation, moody and temperamental restlessness

Physical Examination G G

Measurement of temperature, waist circumference, weight and height Evaluate the effects of blood pressure by viewing the retina, which can predict future patterns of cardiovascular disease

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TABLE 13.2 Lab

Detections

C-reactive protein

Elevations detect inflammation presence in the body

CBC- complete blood count

Detects anemia through the activity of blood components such as red blood cells, white blood cells and platelets

Metabolic panel

Checks lipoproteins, blood sugar, acid/base, liver enzymes, kidney functioning and electrolytes

Troponin

Marker which elevates within a few hours after cardiac injury and persists for up to 14 days

BNP/NT pro BNP

Increased levels indicate increased risk of infarction

CK-MB (creatine kinase)

Marker which elevates when there is damage to myocardial cells

a. Blood pressure: G This is taken in a sitting, standing or supine position, and readings indicate stages of hypertension b. Pulse in TCM: G Chinese pulse diagnosis: G Irregular 5 weak heart qi G Tight 5 pain and cold syndrome G Weak 5 deficiency G Wiry 5 qi stagnation G Thready 5 hyperactive kidney G Rolling 5 dampness, phlegm

Auscultation Heart: G

G

G

First palpate the apical impulse for left ventricular enlargement or hypertrophy Listen for an early sign of hypertension, the fourth heart sound (S4) which indicates left atrium overwork Listen for underlying signs of heart disease, the third heart sound (S3) which indicates left ventricula malfunction

LABORATORY TESTS Routine Tests See Table 13.2.

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Other Tests a. Chest X-ray: determines heart enlargement. b. Stress test: determines the magnitude of symptoms during stress. G a very rapid heart rate due to pulmonary causes or ischemia G normal activity, but develops shortness of breath with exertion c. Coronary angiography and CABG: determines the magnitude of coronary artery block. A catheter is inserted through an artery in the arm leg or neck towards the coronary arteries. A contrast dye is injected, providing a view or the artery condition on X-ray. Healthy vessels from another area of the body are surgically used to bypass or replace the blocked section. d. Transthoracic echocardiogram. This test identifies the condition, size and dimensions of the left and right atria, the left and right ventricles, valves, and the presence of thrombus.

CLINICAL TREATMENT Western Medicine Work up and Treatment G Family history of hypertension, heart disease or other systemic diseases G BMI .30 G Mild hyperlipidemia G Smoker and alcohol drinker G High stress relationships, lifestyle or occupation G Increase physical activity G Diet: irregular, high fat and sugar, low in fresh fruits and vegetables G Stop smoking

Chinese Medicine See Figure 13.1. a. Clinical presentation: pain sensation in the chest area, palpitations, dyspnea, spontaneous sweating. Tongue 5 red Pulse 5 weak See Figure 13.2.

FIGURE 13.1

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FIGURE 13.2

FIGURE 13.3

FIGURE 13.4

b. Treatment: G Therapeutic principle: tonify qi, nourish blood, balance yin and yang G Medicine: pulse-activating powder G Exercise: tai qi c. Modifiable medicated diet: gruel with astralagus, and Chinese date for breakfast. See Figure 13.3. a. Clinical presentation: palpitations, chest oppression with shortness of breath. Tongue 5 pale with greasy white coat Pulse 5 tight See Figure 13.4. b. Treatment: G Therapeutic principle: warm the yang, remove chest obstruction G Medicine: gui zhi tang G Exercise: tai qi

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c. Modifiable medicated diet: G Gruel with cinnamon and ginger for breakfast in the morning G Thin soup with seaweed onions and ginger with lunch and dinner See Figure 13.5. a. Clinical presentation: palpitations, chest pain and oppression, irritability, vertigo, tinnitus, insomnia and excessive dreaming during sleep. Tongue 5 no significance Pulse 5 wiry See Figure 13.6. b. Treatment: G Therapeutic principle: soothe liver qi, nourish yin, harmonize heart and kidneys, tranquilize the mind G Medicine: tian ma gou teng yin G Medicated diet: gruel or soup using astralagus and ginseng for breakfast and lunch for energy production during the day Choose herbs from the formula as a base for a soup at dinner and take the formula in the evening before bedtime. See Figure 13.7. a. Clinical presentation: oppressed chest sensation, palpitations, precordial and hypochondrial area pain, heavy body sensation, shortness of breath and exhaustion.

FIGURE 13.5

FIGURE 13.6

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FIGURE 13.7

FIGURE 13.8

FIGURE 13.9

Tongue 5 pale, purple, greasy white coating Pulse 5 irregular, wiry, rolling See Figure 13.8. b. Treatment: G Therapeutic principle: free the flow of qi, invigorate blood and promote circulation and drain dampness G Medicine: xue fu zhu yu tang c. Modifiable medicated diet: gruel with hawthorn, fleeceflower root, chinaberry, and Chinese date for breakfast. Thin soup with seaweed onions and ginger with lunch and dinner. See Figure 13.9.

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FIGURE 13.10

a. Clinical presentation: dyspnea, palpitations, irritability, coldness, spontaneous sweating. Tongue 5 no significance Pulse 5 very deep, irregular and rapid See Figure 13.10. b. Treatment: G Therapeutic principle: nourish yin and blood, tonify yang and qi G Modifiable medicine: xu ming decoction c. Modifiable medicated diet: G Gruel with hawthorn, fleeceflower root, chinaberry, and Chinese date for breakfast. Thin soup with seaweed onions and ginger with lunch and dinner

MEDICINES A. Western Medicine Drugs See Table 13.3.

B. Chinese Medicine Formulas See Table 13.4.

SUMMARY IN THE CONTEXT OF PATIENT PERSPECTIVES FOR PERSONALIZING MEDICINE Health practitioners treating patients with hypertension may wish to consider information from the patient narrative, especially when the patient describes the symptoms of physical impairment during regular activities. Angina pectoris is a serious condition which progresses over time. The purpose of early treatment is to prevent or control symptoms and to guide in reversing lifestyle factors which contribute to disease progression. Patients who benefit the most using Chinese medicine treatments alone are those who may have not experienced a myocardial infarction. Once myocardial tissue injury or necrosis has occurred, integrating Chinese and

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TABLE 13.3 Medicine

Action

Nitroglycerine

Vasodilator

Beta blocker

Blocks the binding receptor on heart, kidney, arteries, smooth muscle cells that respond to epinephrine, the stress response

Calcium channel blocker

Antihypertensive that decreases blood pressure

ACE inhibitor

Vasodilator that lowers blood pressure

Antiplatelet

Inhibits formation of thrombus

Anticoagulant

Inhibits formation of thrombus

Aspirin

Antiplatelet drug

TABLE 13.4 Medicine

Action

Xu ming decoction

Clears heat and activates blood flow

Xue fu zhu yu tang

Moves blood, promotes circulation, stops pain

Tian ma gou teng yin

Calms liver, clears heat, tranquilizes the mind

Gui zhi tang

Relieves the exterior, harmonizes wei qi and ying qi

Pulse activating powder

Replenishes qi, nourishes and astringes yin

Dan shen dripping pills

Promotes blood circulation, removes stasis, relieves pain

Western medicine may be indicated at the hospital inpatient level where close monitoring can guide more favorable results during the course of treatment. On a base level in treatment, ren shen (ginseng) alone, or featured in formulas, has the marvellous ability to rescue a patient on the brink of poor prognosis, and may prevent the separation of yin and yang.

FURTHER READING [1] Guoliang S, Zhaohui P. Observation of the curative effect on Alprostadil injection combined with she xiang bao xin wan on angina pectoris. China Med J 2012;:1673 7210. [2] Broadbent HM, et al. Susceptibility to coronary artery disease and diabetes is encoded by distinct, tightly linked SNPs in the ANRIL locus on chromosome 9p. Hum Mol Genet 2008;17(6):806 14. [3] Helgadottir A, et al. A common variant on chromosome 9p 21 affects the risk of myocardial infarction. Science 2007;316(5830):1491 3.