Angina pectoris pain is a clinical syndrome causing pain or pressure in the centre of the chest. Usually exercise – sometimes acute anxiety & stress – brings on angina pectoris pain. This is because angina pectoris pain can accompany myocardial ischaemia and coronary artery disease. Angina pain may be severe and felt also in arms and the jaw.

Neurologically, ischaemia (associated with angina pectoris pain) stimulates pain fibres which pass to the sympathetic ganglia between vertebra C7 and T4 (i.e. top of the upper back).

Epidemiology of Angina Pectoris Pain

Angina pectoris pain affects approximately 1% of the population. This is made up of about 726,000 men and around 393,000 women in the UK (British Heart Foundation). Angina pectoris pain affects people aged between 35 and 75 years. Incidence of angina pectoris pain increases with age.

Types of Angina Pectoris Pain

- Chronic Stable Angina
- Nocturnal Angina
- Unstable Angina
- Variant Angina (Prinzmetal’s)
- Decubitus Angina
- Syndrome X (angina)

The chest pain (associated with angina pectoris pain) can also be caused by cold wind, emotion, or digesting a heavy meal. Usually what happens is the muscles of the heart do not receive enough oxygen, via the blood, for the work they are doing. This may cause the patient to breathe more deeply, thus recruiting the accessory muscles of inspiration. All the respiratory muscles are located in the neck and thoracic regions.

Heart

Another reason for why the patient may be breathing deeply could be due to his history of heart attacks (associated with angina pectoris pain). After a heart attack, scar tissue will replace the dead myocardial tissue, which is not contractile. This means the remaining contractile tissue has to work harder to compensate for this loss of efficiency. As a result, there is a decrease of oxygen supply to the body, so the patient will try to breathe deeper to increase their oxygen supply. Again, they will do this by recruiting the accessory muscles of inspiration, which can fatigue thereby causing pain and hypertonia. This can also cause angina pain (or angina pectoris pain).

The heart can generate its own electrical impulses, which initiate contraction. The sino-atrial node (SAN) is like the natural pace maker of the heart. Waves of excitation spread right across both atria. If a heart were taken out of the body, it would beat at a very fast rate.

Cardiac referred pain radiates from substernal and left pectoral regions to the left shoulder and the medial aspect of the left upper limb.
The heart receives its nerve supply from the vagus nerve. The parasympathetic nerve supply decrease this rate and strength of contraction, similar to the gentle braking of a car travelling down a steep hill. The nerve supply of the pericardium is from phrenic nerves C3, 4, 5, vagus nerves and sympathetic trunks.

An enlarged heart can impinge on the phrenic nerve and left recurrent phalangeal nerve are its posterior relations. In this case, the patient may lose their voice! The right and left bronchi lie superoposteriorly to the heart, which can also be affected if the heart is enlarged.

The relations of the heart laterally are the lungs. Posteriorly there is the oesophagus, and anteriorly the posterior surface of the sternum and costal cartilage. The diagphragm and central tendon are inferior to the apex of the heart.

Patients with angina pectoris pain often present with muscular pain due to their posture. For example, every time they have an angina pectoris pain attack, they usually flex their thoracic region for comfort and relief. Similarly, tissue changes in an area after an operation can alter the posture.

Treatment for Angina Pectoris

Medication for angina pectoris pain includes sublingual nitroglycerin (placed or sprayed under the tongue for absorption through the oral mucosa), glycerin trinitrate and propanolol. Its purpose is to dilate the coronary arteries, increases blood flow to the heart and usually relieves angina pectoris pain.

Osteopathic treatment for angina pectoris pain will relax tight, hypertonic muscles. As mentioned above, there is a neurological link to vertebra from C7 to T4. Your Osteopath may help improve neurological flow in this area to help alleviate angina pectoris pain symptoms. Patients with heart conditions tend to be very anxious and stressed. People who have had a heart attack usually describe a “crushing” substernal pain (deep to the sternum) that does not disappear with rest.

Relaxation may prove very useful to reduce anxiety and/or stress e.g. with yoga, meditation, aromatherapy – especially during an attack of angina pectoris pain.

Stress can also cause lower back pain in some people. If you spend most of your day at a desk, it is important to ensure your ergonomics are correct to reduce stress.

Posted by Mr. Trishul Vadi (Principal Osteopath in West Wickham, Beckenham, Bromley & South East London) on Thursday, August 12th, 2010