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117-401: In contrast to those with angina secondary to atherosclerosis , people with variant angina are generally younger and have fewer risk factors for coronary artery disease with the exception of smoking , which is a common and significant risk factor for both types of angina. Affected people usually have repeated episodes of unexplained (e.g., in the absence of exertion and occurring at sleep or in

234-475: A calcium blocker may benefit from addition of a long-acting nitroglycerin and/or a second calcium channel blocker of a different class than the blocker already in use. Nevertheless, about 20% of individuals fail to respond adequately to the two-drug calcium blocker plus long-acting nitroglycerin regimen. If these individuals have significant permanent occlusion of their coronary arteries, they may benefit by stenting their occluded arteries. However, coronary stenting

351-446: A candidate for angioplasty , coronary artery bypass graft (CABG), treatment only with medication, or other treatments. In hospitalized patients with unstable angina (or the newer term of "high-risk acute coronary syndromes"), those with resting ischaemic ECG changes or those with raised cardiac enzymes such as troponin may undergo coronary angiography directly. Angina pectoris occurs as a result of coronary blood flow insufficiency in

468-517: A chest pain evaluation service, for confirmation of the diagnosis and assessment of the severity of coronary heart disease. As of 2010, angina due to ischemic heart disease affects approximately 112 million people (1.6% of the global population) being slightly more common in males than females (1.7% to 1.5%). In the United States, 10.2 million are estimated to experience angina with approximately 500,000 new cases occurring each year. Angina

585-450: A communicating branch to unite with the lacrimal nerve (branch of the ophthalmic nerve of CN V 1 ) before synapsing at the lacrimal gland. These parasympathetic to the lacrimal gland control tear production. A separate group of parasympathetic leaving from the pterygopalatine ganglion are the descending palatine nerves (CN V 2 branch), which include the greater and lesser palatine nerves. The greater palatine parasympathetic synapse on

702-566: A condition often called microvascular angina (MVA). Small intramyocardial arterioles constrict in MVA causing ischemic pain that is less predictable than with typical epicardial coronary artery disease (CAD). The pathophysiology is complex and still being elucidated, but there is strong evidence that endothelial dysfunction, decreased endogenous vasodilators, inflammation, changes in adipokines, and platelet activation are contributing factors. The diagnosis of MVA may require catheterization during which there

819-422: A crucial role in heart rate regulation by modulating the response of sinoatrial node; vagal tone can be quantified by investigating heart rate modulation induced by vagal tone changes. As a general consideration, increased vagal tone (and thus vagal action) is associated with a diminished and more variable heart rate. The main mechanism by which the parasympathetic nervous system acts on vascular and cardiac control

936-473: A healthy heart, the main pacemaker is a collection of cells on the border of the atria and vena cava called the sinoatrial node. Heart cells have the ability to generate electrical activity independent of external stimulation. As a result, the cells of the node spontaneously generate electrical activity that is subsequently conducted throughout the heart, resulting in a regular heart rate. In absence of any external stimuli, sinoatrial pacing contributes to maintain

1053-501: A history of unexplained fainting. Complaints of chest pain should be immediately checked for an abnormal electrocardiogram (ECG). ECG changes compatible but not indicative of variant angina include elevations rather than depressions of the ST segment or an elevated ST segment plus a widening of the R wave to create a single, broad QRS complex peak termed the "monophasic curve". Associated with these ECG changes, there may be small elevations in

1170-425: A large body of evidence in morbidity and mortality benefits (fewer symptoms, less disability, and longer life) and short-acting nitroglycerin medications have been used since 1879 for symptomatic relief of angina. There are differing course of treatments for the patient depending on the type of angina the patient has. However, this second can provide a brief overview of the types of medications provided for angina and

1287-450: A manifestation of a more generalized episodic smooth muscle -contractile disorder such as migraine , Raynaud's phenomenon , or aspirin-induced asthma . Variant angina is also the major complication of eosinophilic coronary periarteritis , an extremely rare disorder caused by extensive eosinophilic infiltration of the adventitia and periadventitia, i.e. the soft tissues, surrounding the coronary arteries . Variant angina also differs from

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1404-509: A poorer prognosis than most other forms of this disorder. In these individuals but also in a small percentage of individuals without appreciable atherosclerosis of their coronary arteries, attacks of coronary artery spasm can have far more serious presentations such as fainting , shock , and cardiac arrest . Typically, these presentations reflect the development of a heart attack and/or a potentially lethal heart arrhythmia ; they require immediate medical intervention as well as consideration for

1521-484: A preventative impact. One study found that smokers with coronary artery disease had a significantly increased level of sympathetic nerve activity when compared to those without. This is in addition to increases in blood pressure, heart rate, and peripheral vascular resistance associated with nicotine, which may lead to recurrent angina attacks. In addition, the Centers for Disease Control and Prevention (CDC) reports that

1638-482: A standard exercise test include a thallium scintigram or sestamibi scintigram (in patients unable to exercise enough for the treadmill tests, e.g., due to asthma or arthritis or in whom the ECG is too abnormal at rest) or stress echocardiography . In patients in whom such noninvasive testing is diagnostic, a coronary angiogram is typically performed to identify the nature of the coronary lesion, and whether this would be

1755-486: A type of angina that differed from the classic cases of Heberden angina in that it commonly occurred in the absence of exercise or exertion. Indeed, it often woke patients from their normal sleep. This variant angina differed from the classical angina described by Dr. Heberden in that it appeared due to episodic vasospasm of coronary arteries that were typically not occluded by pathological processes such as atherosclerosis , emboli , or spontaneous dissection (i.e. tears in

1872-505: A vital role in phosphorylating the ryanodine receptor and LTCC, will usually increase Ca levels in the heart muscle cells, blocking contraction. Therefore, B1 blockade decreases the HR and contraction of the heart muscle, making it demand less oxygen. An important thing to note is that the B1 cardioselective blockers are cardioselective and not cardio-specific. This means that if the beta-adrenergic antagonist

1989-471: Is a form of acute coronary syndrome ) is defined as angina pectoris that changes or worsens or beings suddenly at rest. Unstable angina is a medical emergency and requires urgent medical treatment from a doctor. It has at least one of these three features: UA may occur often unpredictably and even at rest, which may be a serious indicator of an impending heart attack. The primary factor differentiating unstable angina from stable angina (other than symptoms)

2106-549: Is also interest in using rho-kinase inhibitors, such as fasudil (available in Japan and China but not the USA), and blocker of alpha-1 adrenergic receptors such as prazosin (which when activated cause vasodilation) but studies are needed to support their clinical utility in variant angina. Individuals with certain severe complications of variant angina require immediate therapy. Individuals presenting with potentially lethal irregularities in

2223-931: Is an assessment of the microcirculatory response to adenosine or acetylcholine and measurement of coronary and fractional flow reserve. New techniques include positron emission tomography (PET) scanning, cardiac magnetic resonance imaging (MRI), and transthoracic Doppler echocardiography. Managing MVA can be challenging, for example, females with this condition have less coronary microvascular dilation in response to nitrates than do those without MVA. Females with MVA often have traditional risk factors for CAD such as obesity, dyslipidemia, diabetes, and hypertension. Aggressive interventions to reduce modifiable risk factors are an important component of management, especially smoking cessation, exercise, and diabetes management. The combination of non-nitrate vasodilators, such as calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors along with HMG-CoA reductase inhibitors (statins), also

2340-893: Is believed caused by spasms of the artery . It occurs more in younger women. Coital angina, also known as angina d'amour , is angina subsequent to sexual intercourse . It is generally rare, except in patients with severe coronary artery disease . Routine counseling of adults by physicians to advise them to improve their diet and increase their physical activity has, in general, been found to induce only small changes in actual behavior. Therefore, as of 2012, The U.S. Preventive Services Task Force does not recommend routine lifestyle counseling of all patients without known cardiovascular disease, hypertension, hyperlipidemia, or diabetes, and instead recommends selectively counseling only those patients who seem most ready to make lifestyle changes and using available time with other patients to explore other types of intervention that would be more likely to have

2457-421: Is characterized by angina-like chest pain, in the context of normal epicardial coronary arteries (the largest vessels on the surface of the heart, prior to significant branching) on angiography . The original definition of cardiac syndrome X also mandated that ischemic changes on exercise (despite normal coronary arteries) were displayed, as shown on cardiac stress tests . The primary cause of microvascular angina

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2574-993: Is concurrently associated with elevations in the ST segment on electrocardiography recordings, that often occurs during the late evening or early morning hours in individuals who are at rest, doing non-strenuous activities, or asleep, and that is not associated with permanent occlusions of their coronary vessels. The disorder seems to occur more often in women than men, has a particularly high incidence in Japanese males as well as females, and affects individuals who may smoke tobacco products but exhibit few other cardiovascular risk factors. However, individuals exhibiting angina symptoms that are associated with depressions in their electrocardiogram ST segments, that are triggered by exertion, and/or who have atherosclerotic coronary artery disease are still considered to have variant angina if their symptoms are caused by coronary artery spasms. Finally, rare cases may exhibit symptom-free coronary artery spasm that

2691-508: Is contraindicated in drug-refractory individuals who do not have significant organic occlusion of their coronary arteries. For drug-refractory individuals without blockage, other, less fully investigated drugs may provide symptom relief. Statins , e.g. fluvastatin , while not evaluated in large-scale double-blind studies, are reportedly helpful in reducing variant angina attacks and should be considered in patients when calcium channel blockers and nitroglycerin fail to achieve good results. There

2808-553: Is effective in many women, and new drugs, such as Ranolazine and Ivabradine, have shown promise in the treatment of MVA. Other approaches include spinal cord stimulators, adenosine receptor blockade, and psychiatric intervention. Hospital admission for people with the following symptoms is recommended, as they may have unstable angina: pain at rest (which may occur at night), pain on minimal exertion, angina that seems to progress rapidly despite increasing medical treatment. All people with suspected angina should be urgently referred to

2925-428: Is in charge of one particular tissue or region, for the most part the pelvic splanchnics each contribute fibers to pelvic viscera by traveling to one or more plexuses before being dispersed to the target tissue. These plexuses are composed of mixed autonomic nerve fibers (parasympathetic and sympathetic) and include the vesical, prostatic, rectal, uterovaginal, and inferior hypogastric plexuses. The preganglionic neurons in

3042-492: Is little risk of a heart attack whilst others may have a heart attack and experience little or no pain. In some cases, angina can be quite severe. Worsening angina attacks, sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms of unstable angina (usually grouped with similar conditions as the acute coronary syndrome ). As these may precede a heart attack, they require urgent medical attention and are, in general, treated similarly to heart attacks. In

3159-463: Is more often the presenting symptom of coronary artery disease in females than in men. The prevalence of angina rises with increasing age, with a mean age of onset of 62.3 years. After five years post-onset, 4.8% of individuals with angina subsequently died from coronary heart disease. Males with angina were found to have an increased risk of subsequent acute myocardial infarction and coronary heart disease related death than women. Similar figures apply in

3276-424: Is no longer advised unless the risk of myocardial infarction is very high. Exercise is also a very good long-term treatment for the angina (but only particular regimens – gentle and sustained exercise rather than intense short bursts), probably working by complex mechanisms such as improving blood pressure and promoting coronary artery collateralisation. Though sometimes used by patients, evidence does not support

3393-419: Is nonetheless associated with cardiac muscle ischemia (i.e. restricted blood flow and poor oxygenation) along with concurrent ischemic electrocardiographic changes. The term vasospastic angina is sometimes used to include all of these atypical cases with the more typical cases of variant angina. Here, variant angina is taken to include typical and atypical cases. For a portion of patients, variant angina may be

3510-452: Is not usually sharp or stabbing or influenced by respiration. Antacids and simple analgesics do not usually relieve the pain. If chest discomfort (of whatever site) is precipitated by exertion, relieved by rest, and relieved by glyceryl trinitrate, the likelihood of angina is increased. In angina patients momentarily not feeling any chest pain, an electrocardiogram (ECG) is typically normal unless there have been other cardiac problems in

3627-758: Is only useful in individuals who have concomitant coronary atherosclerosis on coronary angiogram. Most individuals with variant angina have a favorable prognosis provided they are maintained on calcium channel blockers and/or long-acting nitrates; five-year survival rates in this group are estimated as over 90%. The Japanese Coronary Spasm Association established a clinical risk scoring system to predict outcomes for variant angina. Seven major factors (i.e. history of out of hospital cardiac arrest [score = 4]; smoking, angina at rest, physically obstructive coronary artery disease, and spasm in multiple coronary arteries [score = 2]; and presence of ST segment elevations on ECG and history of using beta blockers [score = 1]) where assigned

Variant angina - Misplaced Pages Continue

3744-491: Is prescribed in higher doses, it can lose the selectivity aspect and begin causing hypertension from B2 adrenergic stimulation of smooth muscle cells. This is why in therapy for patients with angina, the vasodilatory organonitrates complement the use of B-blockers when prescribed the use of angina. The preference for Beta-1 cardioselective blockers is for B1 cardioselective blockers without instrinsic sympathetic activity. Beta blockers with intrinsic sympathetic activity will still do

3861-399: Is responsible for miosis or constriction of the pupil (in response to light or accommodation). There are two motors that are part of the oculomotor nerve known as the somatic motor and visceral motor. The somatic motor is responsible for moving the eye in precise motions and for keeping the eye fixated on an object. The visceral motor helps constrict the pupil. The parasympathetic aspect of

3978-410: Is responsible for stimulation of "rest-and-digest" or "feed-and-breed" activities that occur when the body is at rest, especially after eating, including sexual arousal , salivation , lacrimation (tears), urination , digestion , and defecation . Its action is described as being complementary to that of the sympathetic nervous system , which is responsible for stimulating activities associated with

4095-535: Is suspected of causing significant rises in the blood levels of catecholamines may trigger variant angina. The mechanism that causes such intense vasospasm, as to cause a clinically significant narrowing of the coronary arteries is so far unknown, but there are three relevant hypotheses: Other factors thought to be associated with the development of variant angina include: intrinsic hypercontractility of coronary artery smooth muscle; existence of significant atherosclerotic coronary artery disease; and reduced activity of

4212-569: Is that of chest discomfort and associated symptoms precipitated by some activity (running, walking, etc.) with minimal or non-existent symptoms at rest or after administration of sublingual nitroglycerin . Symptoms typically diminish several minutes after activity and recur when activity resumes. In this way, stable angina may be thought of as being similar to intermittent claudication symptoms. Other recognized precipitants of stable angina include cold weather, heavy meals, and emotional stress . Unstable angina (UA) (also " crescendo angina "; this

4329-433: Is the most common cause of stenosis (narrowing of the blood vessels) of the heart's arteries and, hence, angina pectoris. Some people with chest pain have normal or minimal narrowing of heart arteries; in these patients, vasospasm is a more likely cause for the pain, sometimes in the context of Prinzmetal's angina and syndrome X . Myocardial ischemia also can be the result of factors affecting blood composition, such as

4446-424: Is the so-called respiratory sinus arrhythmia (RSA). RSA is described as the physiological and rhythmical fluctuation of heart rate at the respiration frequency, characterized by heart rate increase during inspiration and decrease during expiration. Another role that the parasympathetic nervous system plays is in sexual activity. In males, the cavernous nerves from the prostatic plexus stimulate smooth muscles in

4563-638: Is the underlying pathophysiology of the atherosclerosis . The pathophysiology of unstable angina is the reduction of coronary blood flow due to transient platelet aggregation on apparently normal endothelium , coronary artery spasms, or coronary thrombosis . The process starts with atherosclerosis, progresses through inflammation to yield an active unstable plaque, which undergoes thrombosis and results in acute myocardial ischemia, which, if not reversed, results in cell necrosis (infarction). Studies show that 64% of all unstable anginas occur between 22:00 and 08:00 when patients are at rest. In stable angina,

4680-429: Is unknown, but factors apparently involved are endothelial dysfunction and reduced flow (perhaps due to spasm) in the tiny "resistance" blood vessels of the heart. Since microvascular angina is not characterized by major arterial blockages, it is harder to recognize and diagnose. Microvascular angina was previously considered a rather benign condition, but more recent data has changed this attitude. Studies, including

4797-421: Is usually normal in the absence of current symptoms. Two-thirds of these individuals do have concurrent atherosclerosis of a major coronary artery , but this is often mild or not in proportion to the degree of their symptoms. Persons who have atherosclerosis-based occlusion that is ≥70% in a single coronary artery or that involves multiple coronary arteries are predisposed to develop a variant angina form that has

Variant angina - Misplaced Pages Continue

4914-522: The Kounis syndrome (also termed allergic acute coronary syndrome) in which coronary artery constriction and symptoms are caused by allergic or strong immune reactions to a drug or other substance. Treatment of the Kounis syndrome very much differs from that for variant angina. Angina Angina , also known as angina pectoris , is chest pain or pressure, usually caused by insufficient blood flow to

5031-487: The ST segment or an elevated ST segment plus a widening of the R wave during symptoms that are triggered by a provocative agent (e.g. ergonovine or acetylcholine ). The electrocardiogram may show depressions rather than elevations in ST segments but in all diagnosable cases clinical symptoms should be promptly relieved and ECG changes should be promptly reversed by rapidly acting sublingual or intravenous nitroglycerin . However,

5148-431: The ciliary ganglion located just behind the orbit (eye). From the ciliary ganglion the postganglionic parasympathetic fibers leave via short ciliary nerve fibers, a continuation of the nasociliary nerve (a branch of ophthalmic division of the trigeminal nerve (CN V 1 )). The short ciliary nerves innervate the orbit to control the ciliary muscle (responsible for accommodation ) and the iris sphincter muscle , which

5265-457: The dorsal nucleus of the vagus nerve and the nucleus ambiguus in the CNS. The vagus nerve can be readily identified in the neck both on ultrasound and magnetic resonance imaging. It has several branches. The largest branch is the recurrent laryngeal nerve . From the left vagus nerve the recurrent laryngeal nerve hooks around the aorta to travel back up to the larynx and proximal esophagus while, from

5382-419: The facial nerve controls secretion of the sublingual and submandibular salivary glands , the lacrimal gland , and the glands associated with the nasal cavity. The preganglionic fibers originate within the CNS in the superior salivatory nucleus and leave as the intermediate nerve (which some consider a separate cranial nerve altogether) to connect with the facial nerve just distal (further out) to it surfacing

5499-438: The fight-or-flight response . Nerve fibres of the parasympathetic nervous system arise from the central nervous system . Specific nerves include several cranial nerves , specifically the oculomotor nerve , facial nerve , glossopharyngeal nerve , and vagus nerve . Three spinal nerves in the sacrum (S2–4), commonly referred to as the pelvic splanchnic nerves , also act as parasympathetic nerves. Owing to its location,

5616-634: The gold standard for diagnosing variant angina is to visualize coronary arteries by angiography before and after injection of a provocative agent such as ergonovine , methylergonovine or acetylcholine to precipitate an attack of vasospasm. A positive test to these inducing agents is defined as a ≥90% (some experts require lesser, e.g. ≥70%) constriction of involved arteries. Typically, these constrictions are fully reversed by rapidly acting nitroglycerin. Individuals with variant angina may have many undocumented episodes of symptom-free coronary artery spasm that are associated with poor blood flow to portions of

5733-597: The heart muscle (myocardium). It is most commonly a symptom of coronary artery disease . Angina is typically the result of partial obstruction or spasm of the arteries that supply blood to the heart muscle . The main mechanism of coronary artery obstruction is atherosclerosis as part of coronary artery disease. Other causes of angina include abnormal heart rhythms , heart failure and, less commonly, anemia . The term derives from Latin angere  'to strangle' and pectus  'chest', and can therefore be translated as "a strangling feeling in

5850-545: The lesser petrosal nerve and exit through the foramen ovale to synapse at the otic ganglion . From the otic ganglion postganglionic parasympathetic fibers travel with the auriculotemporal nerve (mandibular branch of trigeminal, CN V 3 ) to the parotid salivary gland. The vagus nerve , named after the Latin word vagus (because the nerve controls such a broad range of target tissues – vagus in Latin literally means "wandering"), contains parasympathetic fibers that originate in

5967-409: The muscarinic and nicotinic cholinergic receptors. Most transmissions occur in two stages: When stimulated, the preganglionic neuron releases ACh at the ganglion , which acts on nicotinic receptors of postganglionic neurons. The postganglionic neuron then releases ACh to stimulate the muscarinic receptors of the target organ. Niconitic receptors transmit outgoing signals from the presynaptic to

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6084-643: The parasympathetic nervous system (which normally functions to dilate blood vessels). Although variant angina has been documented in approximately 2% to 10% of angina patients, it can be overlooked by cardiologists who stop further evaluations after ruling out typical angina. Individuals who develop cardiac chest pain are generally treated empirically as an " acute coronary syndrome ", and are immediately tested for elevations in their blood levels of enzymes such as creatine kinase isoenzymes or troponin that are markers for cardiac damage. They are also tested by ECG which may suggest variant angina if it shows elevations in

6201-407: The peritoneal cavity becomes inflamed or if the bowel is suddenly distended, the body will interpret the afferent pain stimulus as somatic in origin. This pain is usually non-localized. The pain is also usually referred to dermatomes that are at the same spinal nerve level as the visceral afferent synapse . Heart rate is largely controlled by the heart's internal pacemaker activity. Considering

6318-489: The CNS into a ganglion that is either very close to or embedded in their target organ. As a result, the postsynaptic parasympathetic nerve fibers are very short. The oculomotor nerve is responsible for a number of parasympathetic functions related to the eye. The oculomotor PNS fibers originate in the Edinger-Westphal nucleus in the central nervous system and travel through the superior orbital fissure to synapse in

6435-518: The Women's Ischemia Syndrome Evaluation (WISE), suggest that microvascular angina is part of the pathophysiology of ischemic heart disease, perhaps explaining the higher rates of angina in females than in males, as well as their predilection towards ischemia and acute coronary syndromes in the absence of obstructive coronary artery disease. Angina pectoris can be quite painful, but many patients with angina complain of chest discomfort rather than actual pain:

6552-424: The abdomen include the pancreas, kidneys, liver, gall bladder , stomach and gut tube. The vagus contribution of parasympathetic continues down the gut tube until the end of the midgut . The midgut ends two thirds of the way across the transverse colon near the splenic flexure . The pelvic splanchnic nerves , S2–4, work in tandem to innervate the pelvic viscera . Unlike in the cranium, where one parasympathetic

6669-477: The activity of the intestinal musculature, increasing gastric secretion, and relaxing the pyloric sphincter. It is called the “rest and digest” division of the ANS. The parasympathetic nervous system decreases respiration and heart rate and increases digestion. Stimulation of the parasympathetic nervous system results in: The terminology ‘Parasympathetic nervous system’ was introduced by John Newport Langley in 1921. He

6786-676: The arterial widening are often used at the same time. Coronary bypass surgery involves bypassing constricted arteries with venous grafts. This is much more invasive than angioplasty . Calcium channel blockers (such as nifedipine (Adalat) and amlodipine ), isosorbide mononitrate and nicorandil are vasodilators commonly used in chronic stable angina. A new therapeutic class, called If inhibitor, has recently been made available: Ivabradine provides heart rate reduction without affecting contractility leading to major anti-ischemic and antianginal efficacy. ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit. Statins are

6903-421: The autonomic nervous system, in which the parasympathetic nervous system receives input from cranial nerves exclusively and the sympathetic nervous system from thoracic to sacral spinal nerves. The afferent fibers of the autonomic nervous system, which transmit sensory information from the internal organs of the body back to the central nervous system, are not divided into parasympathetic and sympathetic fibers as

7020-557: The beta blockade of the heart muscle cells and have a decreased ionotrophic and chronotropic effect, but this effect will be to a lesser extent than if the beta blocker did not have the instrinsic sympathetic activity. A common beta-blocker with ISA prescribed for the treatment of angina is Acebutolol. Non-selective beta-adrenergic antagonists will yield the same action on B1 receptors, however will also act on B2 receptors. These medications, such as Propranolol and Nadolol, act on B1 receptors on smooth muscle cells as well. B1 blockade occurs in

7137-414: The bladder and the urethra, allowing the bladder to void. Also, parasympathetic stimulation of the internal anal sphincter will relax this muscle to allow defecation. There are other skeletal muscles involved with these processes but the parasympathetic plays a huge role in continence and bowel retention. A study published in 2016, suggests that all sacral autonomic output may be sympathetic; indicating that

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7254-435: The bladder. At the same time, parasympathetics cause peristalsis of the urethral muscle, and the pudendal nerve causes contraction of the bulbospongiosus (skeletal muscle is not via PN), to forcibly emit the semen. During remission the penis becomes flaccid again. In the female, there is erectile tissue analogous to the male yet less substantial that plays a large role in sexual stimulation. The PN cause release of secretions in

7371-538: The blood levels of cardiac damage marker enzymes, especially during long attacks. Some individuals with otherwise typical variant angina may show depressions, rather than elevations in the ST segments of their ECGs during angina pain; they may also show new U waves on ECGs during angina attacks. A significant percentage of those with variant angina have symptom-free episodes of coronary artery spasm. These episodes may be far more frequent than expected, cause myocardial ischemia (i.e. insufficient blood flow to portions of

7488-451: The calcium channel blocker regimen in individuals responding sub-optimally to the channel blockers. However, individuals commonly develop tolerance , or resistance, to the efficacy of continuously used long-acting nitroglycerin formulations. One strategy to avoid this is to schedule nitroglycerin-free periods of between 12 and 14 hours between doses of long-acting nitroglycerin formulations. Individuals whose symptoms are poorly controlled by

7605-416: The central nervous system to their targets by a system of two neurons . The first neuron in this pathway is referred to as the preganglionic or presynaptic neuron . Its cell body sits in the central nervous system and its axon usually extends to synapse with the dendrites of a postganglionic neuron somewhere else in the body. The axons of presynaptic parasympathetic neurons are usually long, extending from

7722-414: The central nervous system. Just after the facial nerve geniculate ganglion (general sensory ganglion) in the temporal bone , the facial nerve gives off two separate parasympathetic nerves. The first is the greater petrosal nerve and the second is the chorda tympani . The greater petrosal nerve travels through the middle ear and eventually combines with the deep petrosal nerve (sympathetic fibers) to form

7839-418: The chest". An urgent medical assessment is suggested to rule out serious medical conditions. There is a relationship between severity of angina and degree of oxygen deprivation in the heart muscle. However, the severity of angina does not always match the degree of oxygen deprivation to the heart or the risk of a heart attack (myocardial infarction). Some people may experience severe pain even though there

7956-414: The developing atheroma (a fatty plaque) is protected with a fibrous cap . This cap may rupture in unstable angina, allowing blood clots to precipitate and further decrease the area of the coronary vessel's lumen or the interior open space within an artery. This explains why, in many cases, unstable angina develops independently of activity. Microvascular angina , also known as cardiac syndrome X ,

8073-453: The discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain and is because the spinal level that receives visceral sensation from the heart simultaneously receives cutaneous sensation from parts of

8190-458: The early 20th century, severe angina was seen as a sign of impending death. However, modern medical therapies have improved the outlook substantially. Middle-age patients who experience moderate to severe angina ( grading by classes II, III, and IV ) have a five-year survival rate of approximately 92%. Also known as 'effort angina', this refers to the classic type of angina related to myocardial ischemia . A typical presentation of stable angina

8307-624: The early morning hours) chest pain, tightness in throat, chest pressure, light-headedness, excessive sweating, and/or reduced exercise tolerance that, unlike atherosclerosis-related angina, typically does not progress to myocardial infarction (heart attack). Unlike cases of atherosclerosis-related stable angina , these symptoms are often unrelated to exertion and occur in night or early morning hours. However, individuals with atherosclerosis-related unstable angina may similarly exhibit night to early morning hour symptoms that are unrelated to exertion. Cardiac examination of individuals with variant angina

8424-432: The efferent fibers are. Instead, autonomic sensory information is conducted by general visceral afferent fibers . General visceral afferent sensations are mostly unconscious visceral motor reflex sensations from hollow organs and glands that are transmitted to the CNS. While the unconscious reflex arcs normally are undetectable, in certain instances they may send pain sensations to the CNS masked as referred pain . If

8541-510: The face of increased oxygen demand. The principal goal in the prevention and relief of angina is to limit the oxygen requirement of the heart so it can meet the inadequate oxygen supply derived through the blood supplied from the stenosed or constricted arteries. The main goals of treatment in angina pectoris are relief of symptoms, slowing progression of the disease, and reduction of future events, especially heart attacks and death. Beta blockers (e.g., carvedilol , metoprolol , propranolol ) have

8658-554: The female that decrease friction. Also in the female, the parasympathetics innervate the fallopian tubes , which helps peristaltic contractions and movement of the oocyte to the uterus for implantation. The secretions from the female genital tract aid in sperm migration. The PN (and SN to a lesser extent) play a significant role in reproduction. The parasympathetic nervous system uses chiefly acetylcholine (ACh) as its neurotransmitter , although peptides (such as cholecystokinin ) can be used. The ACh acts on two types of receptors,

8775-402: The fibrous trabeculae of the coiled helicine arteries of penis to relax and allow blood to fill the two corpora cavernosa and the corpus spongiosum of the penis, making it rigid to prepare for sexual activity. Upon emission of ejaculate, the sympathetics participate and cause peristalsis of the ductus deferens and closure of the internal urethral sphincter to prevent semen from entering

8892-484: The functions of the parasympathetic nervous system is SSLUDD ( sexual arousal , salivation , lacrimation , urination , digestion and defecation ). The functions promoted by activity in the parasympathetic nervous system are associated with our day-to-day living. The parasympathetic nervous system promotes digestion and the synthesis of glycogen , and allows for normal function and behavior. Parasympathetic action helps in digestion and absorption of food by increasing

9009-447: The hard palate and regulate mucous glands located there. The lesser palatine nerve synapses at the soft palate and controls sparse taste receptors and mucous glands. Yet another set of divisions from the pterygopalatine ganglion are the posterior, superior, and inferior lateral nasal nerves; and the nasopalatine nerves (all branches of CN V 2 , maxillary division of the trigeminal nerve) that bring parasympathetic innervation to glands of

9126-648: The heart and subsequent irregular and potentially serious heart arrhythmias . Accordingly, individuals with variant angina should be intermittently evaluated for this using long-term ambulatory cardiac monitoring . Numerous methods are recommended to avoid attacks of variant angina. Affected individuals should not smoke tobacco products. Smoke cessation significantly reduces the incidence of patient-reported variant angina attacks. They should also avoid any trigger known to them to trigger these attacks such as emotional distress, hyperventilation, unnecessary exposure to cold, and early morning exertion. And, they should avoid any of

9243-400: The heart associated with the pain of angina. These drugs also reduce systemic vascular resistance, of both veins and arteries but the veins to a greater extent. The decrease in the resistance of the arteries and veins decreases the myocardial oxygen demand, which also reduces myocardial oxygen demand. Nitroglycerin is a potent vasodilator that decreases myocardial oxygen demand by decreasing

9360-483: The heart rate in the range of 60-100 beats per minute (bpm). At the same time, the two branches of the autonomic nervous system act in a complementary way increasing or slowing the heart rate. In this context, the vagus nerve acts on sinoatrial node slowing its conduction thus actively modulating vagal tone accordingly. This modulation is mediated by the neurotransmitter acetylcholine and downstream changes to ionic currents and calcium of heart cells. The vagus nerve plays

9477-427: The heart's workload. Nitroglycerin should not be given if certain inhibitors such as sildenafil , tadalafil , or vardenafil have been taken within the previous 12 hours as the combination of the two could cause a serious drop in blood pressure. Treatments for angina are balloon angioplasty , in which the balloon is inserted at the end of a catheter and inflated to widen the arterial lumen . Stents to maintain

9594-489: The heart), and be accompanied by potentially serious abnormalities in the rhythm of heart beats, i.e. arrhythmias . The only evidence of the presence of totally asymptomatic variant angina would be detection of diagnostic changes on fortuitously conducted ECGs. The intake of certain agents have been reported to trigger an attack of variant angina. These agents include: In addition, hyperventilation and virtually any stressful emotional or physical (e.g. cold exposure) event that

9711-533: The indicated scores. Individuals with scores of 0 to 2, 3 to 5, and ≥6 experienced an incidence of a major cardiovascular event in 2.5, 7.0, and 13.0% of cases. Dr. William Heberden is credited with being the first to describe in a 1768 publication the occurrence of chest pain attacks (i.e. angina pectoris ) that appeared due to pathologically occluded coronary arteries. These attacks were triggered by exercise or other forms of exertion and relieved by rest and nitroglycerin . In 1959, Dr. Myron Prinzmetal described

9828-406: The level of entering the thorax are the cardiac branches of the vagus nerve . These cardiac branches go on to form cardiac and pulmonary plexuses around the heart and lungs. As the main vagus nerves continue into the thorax they become intimately linked with the esophagus and sympathetic nerves from the sympathetic trunks to form the esophageal plexus. This is very efficient as the major function of

9945-489: The mortality rate difference between the two groups was statistically insignificant. Women with myocardial ischemia often have either no or atypical symptoms, such as palpitations, anxiety, weakness, and fatigue. Additionally, many females with angina are found to have cardiac ischemia, yet no evidence of obstructive coronary artery disease on cardiac catheterization. Evidence is accumulating that nearly half of females with myocardial ischemia have coronary microvascular disease,

10062-404: The most frequently used lipid/cholesterol modifiers, which probably also stabilize existing atheromatous plaque. Low-dose aspirin decreases the risk of heart attack in patients with chronic stable angina, and was part of standard treatment. However, in patients without established cardiovascular disease, the increase in hemorrhagic stroke and gastrointestinal bleeding offsets any benefits and it

10179-399: The nasal mucosa . The second parasympathetic branch that leaves the facial nerve is the chorda tympani. This nerve carries secretomotor fibers to the submandibular and sublingual glands. The chorda tympani travels through the middle ear and attaches to the lingual nerve (mandibular division of trigeminal, CN V 3 ). After joining the lingual nerve, the preganglionic fibers synapse at

10296-401: The need for oxygen. The other class of medication that can be used to treat angina are the organic nitrates. Organic nitrates are used extensively to treat angina. They improve coronary blood flow of the coronary arteries (arteries which supply blood to the heart muscle) by reversing and preventing vasospasm, which increases the blood flow to the heart, improving perfusion and oxygen delivery to

10413-410: The nerve of the pterygoid canal . The parasympathetic fibers of the nerve of the pterygoid canal synapse at the pterygopalatine ganglion , which is closely associated with the maxillary division of the trigeminal nerve (CN V 2 ). The postganglionic parasympathetic fibers leave the pterygopalatine ganglion in several directions. One division leaves on the zygomatic division of CN V 2 and travels on

10530-474: The parasympathetic system is commonly referred to as having "craniosacral outflow", which stands in contrast to the sympathetic nervous system, which is said to have "thoracolumbar outflow". The parasympathetic nerves are autonomic or visceral   branches of the peripheral nervous system (PNS). Parasympathetic nerve supply arises through three primary areas: As in the sympathetic nervous system, efferent parasympathetic nerve signals are carried from

10647-433: The parasympathetic will cause peristaltic movements of the ureters and intestines, moving urine from the kidneys into the bladder and food down the intestinal tract and, upon necessity, the parasympathetic will assist in excreting urine from the bladder or defecation. Stimulation of the parasympathetic will cause the detrusor muscle (urinary bladder wall) to contract and simultaneously relax the internal sphincter muscle between

10764-409: The past. During periods of pain, depression, or elevation of the ST segment may be observed. To elicit these changes, an exercise ECG test ("treadmill test") may be performed, during which the patient exercises to his/her maximum ability before fatigue, breathlessness, or pain intervenes; if characteristic ECG changes are documented (typically more than 1 mm of flat or downsloping ST depression),

10881-476: The pathophysiology of angina in females varies significantly as compared to males. Non-obstructive coronary disease is more common in females. Angina should be suspected in people presenting tight, dull, or heavy chest discomfort that is: Some people present with atypical symptoms, including breathlessness, nausea, or epigastric discomfort, or burning. These atypical symptoms are particularly likely in older people, women, and those with diabetes. Anginal pain

10998-454: The pathway do not synapse in a ganglion as in the cranium but rather in the walls of the tissues or organs that they innervate. The fiber paths are variable and each individual's autonomic nervous system in the pelvis is unique. The visceral tissues in the pelvis that the parasympathetic nerve pathway controls include those of the urinary bladder, ureters, urinary sphincter, anal sphincter, uterus, prostate, glands, vagina, and penis. Unconsciously,

11115-984: The postsynaptic cells within the sympathetic and parasympathetic nervous system, and are the receptors used in the somatic nervous system for signalling muscular contraction in the neuromuscular junction . The muscarinic receptors are mainly present in the parasympathetic nervous system but also appear in the sweat glands of the sympathetic nervous system. The five main types of muscarinic receptors: In vertebrates, nicotinic receptors are broadly classified into two subtypes based on their primary sites of expression: muscle-type nicotinic receptors (N1) primarily for somatic motor neurons; and neuronal-type nicotinic receptors (N2) primarily for autonomic nervous system. Sympathetic and parasympathetic divisions typically function in opposition to each other. The sympathetic division typically functions in actions requiring quick responses. The parasympathetic division functions with actions that do not require immediate reaction. A mnemonic to summarize

11232-563: The presence of, and specific treatment regimens for, their disorder. Variant angina should be suspected by a cardiologist when a) an individual's symptoms occur at rest or during sleep; b) an individual's symptoms occur in clusters; c) an individual with a history of angina does not develop angina during treadmill stress testing (variant angina is exercise tolerant); d) an individual with a history of angina shows no evidence of other forms of cardiac disease; and/or e) an individual without features of coronary artery atherosclerotic heart disease has

11349-597: The production of the naturally occurring vasodilator, prostacyclin . During acute attacks, individuals typically respond well to fast-acting sublingual, intravenous, or spray nitroglycerin formulations. The onset of symptom relief in response to intravenous administration, which is used in more severe attacks of angina, occurs almost immediately while sublingual formulations of it act within 1–5 minutes. Spray formulations also require ~1–5 minutes to act. As maintenance therapy, sublingual nitroglycerin tablets can be taken 3-5 min before conducting activity that causes angina by

11466-434: The pulse rate and the blood pressure increases. Chest pain lasting only a few seconds is normally not angina (such as precordial catch syndrome ). Myocardial ischemia comes about when the myocardium (the heart muscle) receives insufficient blood and oxygen to function normally either because of increased oxygen demand by the myocardium or because of decreased supply to the myocardium. This inadequate perfusion of blood and

11583-423: The purpose by which they are prescribed. Beta blockers , specifically B1 adrenergic blockers without intrinsic sympathomimetic activity, are preferred for angina treatment, out of B1 selective and non-selective as well as B1 ISA agents. B1 blockers are cardioselective blocking agents (such as nevibolol, atenolol, metoprolol, bisoprolol, etc.) which result in blocking cAMP in the heart muscle cells. cAMP, which plays

11700-455: The recreational and therapeutic drugs listed in the above signs and symptoms and risk factors sections as well as blockers of beta receptors such as propranolol which may theoretically worsen vasospasm by inhibiting beta-2 adrenergic receptor 's vasodilation effect mediated by these receptors' naturally occurring stimulator i.e. epinephrine . In addition, aspirin should be used with caution and at low doses since at high doses it inhibits

11817-407: The rectum, bladder and reproductive organs may only be innervated by the sympathetic nervous system. This suggestion is based on detailed analysis of 15 phenotypic and ontogenetic factors differentiating sympathetic from parasympathetic neurons in the mouse. Assuming that the reported findings most likely applies to other mammals as well, this perspective suggests a simplified, bipartite architecture of

11934-426: The reduced oxygen-carrying capacity of blood , as seen with severe anemia (low number of red blood cells), or long-term smoking . Angina results when there is an imbalance between the heart's oxygen demand and supply. This imbalance can result from an increase in demand (e.g., during exercise) without a proportional increase in supply (e.g., due to obstruction or atherosclerosis of the coronary arteries). However,

12051-513: The remainder of the Western world. All forms of coronary heart disease are much less-common in the Third World , as its risk factors are much more common in Western and Westernized countries; it could, therefore, be termed a disease of affluence . The condition was named "hritshoola" in ancient India and was described by Sushruta (6th century BC). The first clinical description of angina pectoris

12168-588: The resulting reduced delivery of oxygen and nutrients are directly correlated to blocked or narrowed blood vessels. Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous system ) such as nausea , vomiting , and pallor . Major risk factors for angina include cigarette smoking , diabetes , high cholesterol , high blood pressure , sedentary lifestyle , and family history of premature heart disease. A variant form of angina— Prinzmetal's angina —occurs in patients with normal coronary arteries or insignificant atherosclerosis. It

12285-626: The rhythm of their heart beating or a history of episodic fainting spells due to such arrhythmias require implantation of an internal defibrillator and/or cardiac pacemaker to stop such arrhythmias and restore normal heart beating. Other rare but severe complications of variant angina, e. g. myocardial infarction , severe congestive heart failure , and cardiogenic shock require the same immediate medical interventions that are used for other causes of these extremis conditions. In all of these emergency cases, percutaneous coronary intervention to stent areas where coronary arteries evidence spasm

12402-420: The right vagus nerve, the recurrent laryngeal nerve hooks around the right subclavian artery to travel back up to the same location as its counterpart. These different paths are a direct result of embryological development of the circulatory system. Each recurrent laryngeal nerve supplies the larynx, the heart, the trachea and the esophagus. Another set of nerves that come off the vagus nerves approximately at

12519-497: The risk of CHD (Coronary heart disease), stroke, and PVD (Peripheral vascular disease) is reduced within 1–2 years of smoking cessation. In another study, it was found that, after one year, the prevalence of angina in smokingmales under 60 after an initial attack was 40% less in those having quit smoking compared to those that continued. Studies have found that there are short-term and long-term benefits to smoking cessation. Myocardial ischemia can result from: Atherosclerosis

12636-429: The skin specified by that spinal nerve's dermatome , without an ability to discriminate the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating, and nausea in some cases. In this case,

12753-579: The small percentage of patients who experience angina infrequently and only when doing such activity. For most affected individuals, antianginals are used as maintenance therapy to avoid attacks of variant angina. Calcium channel blockers of the dihydropyridine class (e.g. nifedipine , amlodipine ) or non-dihydropyridine class (e.g. verapamil , diltiazem ) are regarded as first-line drugs to avoid angina attacks. Long-acting nitroglycerins such as isosorbide dinitrate or intermittent use of short-acting nitroglycerin (to treat acute symptoms) may be added to

12870-459: The smooth muscle cell from B1 blockade is not desirable since it explains the hypertension that may arise with patients taking that medication. Calcium channel blockers act to decrease the heart's workload , and thus its requirement for oxygen by blocking the calcium channels of the heart muscle cell. With decreased intracellular calcium, the calcium-troponin complex does not form in the heart muscle cell and it does not contract, therefore reducing

12987-549: The smooth muscle cells. Specifically cAMP is responsible for inhibiting Myosin Light Kinase, the enzyme responsible for acting on Actin-Myosin. The inhibition of B1 will result in decreased levels of cAMP which will lead to increased levels of Myosin Light Chain Kinase in the smooth muscle cells, the enzyme responsible for acting on Actin-Myosin and leading to contraction of the smooth muscle cell. This increased contraction of

13104-437: The submandibular ganglion and send postganglionic fibers to the sublingual and submandibular salivary glands. The glossopharyngeal nerve has parasympathetic fibers that innervate the parotid salivary gland. The preganglionic fibers depart CN IX as the tympanic nerve and continue to the middle ear where they make up a tympanic plexus on the cochlear promontory of the mesotympanum. The tympanic plexus of nerves rejoin and form

13221-399: The test is considered diagnostic for angina. Even constant monitoring of the blood pressure and the pulse rate can lead to some conclusions regarding angina. The exercise test is also useful in looking for other markers of myocardial ischemia: blood pressure response (or lack thereof, in particular, a drop in systolic blood pressure), dysrhythmia, and chronotropic response. Other alternatives to

13338-592: The use of traditional Chinese herbal products (THCP) for angina. Identifying and treating risk factors for further coronary heart disease is a priority in patients with angina. This means testing for elevated cholesterol and other fats in the blood, diabetes and hypertension (high blood pressure), and encouraging smoking cessation and weight optimization . The calcium channel blocker nifedipine prolongs cardiovascular event- and procedure-free survival in patients with coronary artery disease. New overt heart failures were reduced by 29% compared to placebo; however,

13455-405: The vagus nerve from there on will be control of the gut smooth muscles and glands . As the esophageal plexus enter the abdomen through the esophageal hiatus anterior and posterior vagus trunks form. The vagus trunks then join with preaortic sympathetic ganglion around the aorta to disperse with the blood vessels and sympathetic nerves throughout the abdomen. The extent of the parasympathetic in

13572-432: The walls of coronary arteries). Variant angina had been described twice in the 1930s by other authors and was referred to as cardiac syndrome X (CSX) by Kemp in 1973, in reference to patients with exercise-induced angina who nonetheless had normal coronary angiograms. CSX is now termed microvascular angina , i.e. angina caused by disease of the heart's small arteries. Some key features of variant angina are chest pain that

13689-418: Was by a British physician Dr. William Heberden in 1768. Parasympathetic nervous system The parasympathetic nervous system ( PSNS ) is one of the three divisions of the autonomic nervous system , the others being the sympathetic nervous system and the enteric nervous system . The autonomic nervous system is responsible for regulating the body's unconscious actions. The parasympathetic system

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