FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

ANGINA PECTORIS - A REAL PAIN IN THE CHEST

Question: I've had some chest pain that my doctor has diagnosed as angina. He gave me medicine that has helped. Now, he wants me to see a cardiologist for a test he called a catheterization. Do I really need more tests if I'm feeling OK with the medicine?

Answer: Let me take a moment and explain some of the terms you used so my other readers will understand your question. First, "angina" or more precisely angina pectoris is pain produced by insufficient blood supply to the heart. The problem develops when the coronary arteries that supply the heart muscle are narrowed sufficiently to prevent enough oxygen from reaching the heart to keep it pumping at an appropriate pace for your current level of activity. This produces pain, or angina, which is felt in the chest, and occasionally also in the jaw or left shoulder.

So, your doctor thinks you probably have some amount of blockage in your coronary arteries. There are several tests that can demonstrate the extent of this blockage, and this is important because nearly complete blockage greatly increases the risk of heart attack. The standard against which all tests are compared for their accuracy is the cardiac "catheterization" your doctor has recommended for you. In this test a small tube called a catheter is passed through an artery, usually one in the leg or arm, and threaded along it until the tip reaches the heart. There, a special dye that shows up on X-rays is injected into the blood. This makes it possible to study the heart's function by observing movies taken with X-rays.

Perhaps what your doctor has recommended is better described by the term coronary arteriography. In this procedure, the dye, or contrast material, used to make the blood show up on X-rays is injected into the coronary arteries instead of the heart chambers. It is quite accurate at showing any narrowing in the passageways of the coronary arteries.

Now for your question about the need for this test. A "yes" or "no" answer isn't possible because of differences in opinion in the medical profession, although both medical and surgical approaches strive to minimize the amount of pain experienced while allowing the maximum amount of activity. Coronary arteriography can give a definitive answer to the question "how much blockage is there?" And it has become increasingly common in our country to open up blocked sections of coronary arteries using a procedure known as angioplasty at the same time as the arteriography. This treatment is effective at relieving pain over 90 percent of the time. Unfortunately, it does have some risks associated with it.

In most hospitals doing angioplasty, the risk of death from the procedure is less than one-half of one percent. The risk of suffering a non-fatal heart attack from it is about five percent, and the need to have that same area of blockage dilated a second time is nearly 20 percent.

There are methods to gauge the extent of coronary blockage that are less risky than arteriography. The stress test, nucleotide stress test and echo cardiography are the most common. These procedures are often used to gauge both the effectiveness of medications at relieving the pain and the level of reduced physical endurance caused by the angina. There is some research data that suggests controlling cholesterol and taking certain angina medications at the same time may even slowly reverse blockage in the coronary arteries.

So, it becomes a matter of opinion as to the best treatment for angina. Some doctors recommend immediate coronary arteriography with a "game plan" to break up any blockage found with angioplasty, and if that doesn't work, to use coronary bypass surgery. This is done with the hope for a surgical "cure." Others elect to use medical management, including medication to bring relief from the angina, a high-fiber, low-fat diet, exercise, cutting back alcohol use and eliminating tobacco use. Talk to your doctor until you understand his or her reasoning for the recommended treatment and you agree with it.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.