Coronary disease includes a series of clinical conditions including angina pectoris, silent ischemia, coronary vasospasm and acute myocardial infarct.
The most frequent cause of cardiac ischemia is arteriosclerosis of the coronary arteries, followed by embolisms, arteritis and congenital abnormalities.
Angina pectoris is the clinical manifestation of myocardial ischemia, which is mostly caused by aterosclerotic obstruction of the coronary arteries.
Other conditions that cause angina are aortic valvulopathy, hypertrophic myocardiopathy and coronary vasospasm.
This is characterised by painful pressure and a choking or knotted feeling, which is usually retrosternal and may spread to the arms, shoulders, neck, jaw, epigastric or interscapular regions.
Pain is sometimes felt in the areas to which the pain extends, without affecting the precordial region.
This is usually accompanied by vegetative symptoms, and on occasions can present with dyspnoea and painless arrhythmia.
Resting and taking sublingual nitrates relieve pain.
Angina can be stress-induced when triggered by exercise and increased myocardial demand for oxygen, both in the resting and mixed states.
- I: related to physical exertion
- II: when ordinary activity is slightly affected.
- III: when the limitation is serious.
- IV: when it is impossible to do anything without triggering angina
Angina can present as stable and remain stable, or it can be progressive with deterioration with regard to its intensity, frequency, duration or the level of stress that triggers it.
- The long-term management of angina is achieved associating of several pharmacological agents once the cause has been defined.
In selected cases, surgical interventional may be the preferred course of action, such as coronary angioplasty or surgery
- Long-acting nitrates: Their side effects are headaches, serious hypotension, tachycardia, dizziness and syncope.
- Beta blockers: These all have anti-angina properties. Their side effects are asthenia, bronchial spasm, functional deterioration of the left ventricle, depression and difficulty recognizing hypoglycemia in diabetics.
- Calcium antagonists: These are very helpful when combined with other medications, but verapamil can cause hypotension, bradycardia, AV blockage, heart failure and lead to digitalis intoxication. In addition, it can worsen left ventricular failure when associated with beta blockers or disopiramid. Nephadipin can cause hypotension, tachycardia, headaches, dizziness and oedema.
- Acetilsalicilic acid: This seems to be beneficial, as it lowers the incidence of AMI in chronic stable angina post myocardial infarct.
- Silent ischemia is characterised by myocardial ischemia in the absence of the symptoms of angina. The study, recommendations and treatment are the same as those for angina.
- Coronary vasospasm is localised and intermittent, and the pain is similar to that caused by angina, although more it is more intense and usually occurs while resting. During spasm-induced ischemia, acute infarct or malign arrhythmia may present, which, when associated with arteriosclerosis, are associated with a less favourable prognosis. Treatment consists of long-acting nitrates and calcium antagonists.
Advice on Angina pectoris
- The patient must not drive with angina.
- Nitroglycerine must be carried inside the vehicle.
- If angina appears, the driver must stop and administer sublingual nitroglycerine. The dose can be repeated at five-minute intervals and if the thoracic pain persists for longer than ten minutes in spite of administering two or three doses, help must be sought to get to the nearest emergency facility.
- Patients should be warned that nitroglycerine can cause headaches, tachycardia, dizziness and syncope. If this occurs the patient should not drive even if the angina has disappeared.
- Patients who suffer from angina when carrying out normal daily activities should not drive and should follow their doctors’ advice.
- Coronary risk factors include smoking, hypertension, dyslipidemia, diabetes, hyperthyroidism and overweight, factors that also affect driving in diverse ways. The patient should be reassured and given methods for reducing these risk factors.
- The patient should be encouraged to lose weight, spread meals out throughout the day and not to eat too much, to drink water, do exercise and try and avoid upsets and stress.
- In this regard, we have to help our patients become calm drivers who enjoy driving, which will not trigger stress and angina.
Advice on angina of chest and the drugs associated to its treatment
- Patients must be warned of the side effects of the medications that might interfere with driving, and be told that if this does happen they should contact their doctors who will change the dose or the medication.
- Patients who have undergone a coronary revascularlisation should be symptom free and have adequate cardiac function. The authorization of the specialist will indicate at what point in time the patient may drive again.
Advice on Silent ischemia and Coronary vasospasm
- The doctors individual assessment of the patient and the patients’ response to treatment will determine whether or not driving should be permitted.
- While the patient is being studied and until the risk diagnosis has been made, driving must not be permitted.
- If the coronary spasm has damaged the myocardium or has caused arrhythmia, the patient may not drive until the specialist gives written permission. This will be when the condition evolves favourably and after waiting for a suitable interval in the interests of safety.
- The patient should be warned any side effects of the medication that could limit driving.