CHIKITSASUTRA AND MANAGEMENT OF THE

DISEASE
OF

RASAVAHA SROTAS

SROTASAMULA
यसवहानाां स्त्रोतसाां ह्रदमां भूरां दश च धभन्म् |
( Cha.Vi.5/7 )
यसवहे द्रे तमोभर
ू ां ह्रदमां यसवाहहन्मस्त्च धभन्म् |
( Su.Sha.9/12 )
 There are two rasavaha srotasa. Their origin can be traced to the hrdaya
and rasavaha dhamanis ( दशधभन्म् - Charaka ).

NIDANA
गुरुशीतभततस्स्त्नग्धभततभारां सभश्नताभ ् |
यसवाहवतन दष्ु मस्न्त चचन््मानाां चाततचचन्तनात ् ||
( Cha.Vi.5/13 )
 Those who eat heavy, cold, too unctuous and in excessive quantity and
do excessive mental work suffer from the morbidity rasavaha srotasa.

DUSTILAKSHANA
अश्रद्धा चारुचचश्चास्त्मवैयस्त्मभयसऻता |
रृल्रासो गौयवां तन्द्रा साङ्गभदो ज्वयस्त्तभ् ||
ऩाण्डु्वां स्रोतसाां योध् क्रैब्मां साद् कृशाङ्गता |
नाशोऽग्नेयमथाकारां वरम् ऩलरतातन च ||
यसप्रदोषजा योगा,... ||
( Cha.Su.28/9-11 )
तर ववद्धस्त्म शोष्प्राणवहववद्धवच्च भयणां तस्ल्रङ्गातन च |
( Su.Sha.9/12 )
 Loss of desire for food, anorexia, distaste in mouth, loss of taste sensation,
nausea, heaviness, drowsiness, body-ache, fever, feeling of darkness, paleness,
obstruction in channels, impotency, malaise, leanness, loss of digestive power,
untimely wrinkles and grey hair-these are the disorders due to morbid affection
of rasadhatu.
 Penetrating injury to rasavaha dhamani leads to consumption and features as in
injury to pranavaha srotas and to death.
CHIKITSASUTRA
यसजानाां ववकायाणाां सवं रङ्घनभौषधभ ् |
( Cha.Su.28/25 )
 The remedy of disorders produced in rasa consists of all types of langhanas
(reducing measures).

चतष्ु प्रकाया सांशस्ु ्ध् वऩऩासा भारुताऩतौ |

ऩाचनान्मऩ
ु वास च व्मामाभ च इतत रङ्घनभ ् ||
( Cha. Su. 22/18 )
 There are 10 type of langhanas. They are – Vamana, Virechana, Niruhabasti,
Nasya, Pipasa, Pachana, Atapa, Maruuta, Upavasa, Vyayama

 Acco. to vagbhatta, There are 2 mainly type of langhans - Shodhana and

Shamana

रघूश्नतीक्श्नववशदां रूऺां सूक्ष्भां खयां सयभ ् |

कहिनां चैव मदद्रव्मां प्रामस्त्त रङ्घनां स्त्भत
ृ भ ् ||
( Cha. Su. 22/12 )
 Gunas of Langhana Dravyas – Laghu, Ushna, Teekshna, Ruksha, Vishada,
Sooksham, Khara, Sara, Kathina

 Dravyas of Langhana Dravyas – Guduchi, Musta, Haritaki, Amalaki, Bibhitaki,

Madhu, Vidanga, Shunthi, Yava, Shilajit, Priyangu, Shyamaka, Mudga, Kulattha,
Chakramarda, Patola, Takrarishta, Lauha bhasma.
 HRDUSHOOLA
DEFINITION OF SHULA
शूर योऩणवत ् ऩीडा मस्त्म आकस्त्भात ् प्रजामते।

त्ररशर
ू सांबवां च एनां शर
ू ां आहु् ऩयु ाववद्॥ (मो.य.शर
ू तनदानभ ्.३)

शङ्ख स्त्पोटनवत ् तस्त्म मस्त्भात ् तीव्रा च वेदना।

शर
ू ासक्तस्त्म बवतत तस्त्भात ् शर
ू भ ् इह उच्मते॥ (मो.य.शर
ू तनदानभ ्.४)

 Shankha sphotanavat tasya yasmaat teevraa cha vedanaa Shoolaasaktasya

bhavati tasmaat shoolam iha uchyate
(Ref – Yoga Ratnakara Shula Nidaanam 4)

DEFINITION OF HRDUSHOOLA
कपवऩ्तावरुद्धस्त्तु भारुतो यसभस्ू च्छू त् ||१३१||
रृहदस्त्थ् कुरुते शूरभुच््वासायोधकां [१] ऩयभ ् |
स रृच्छूर इतत ख्मातो यसभारुतसम्बव् ||१३२||
 Vata obstructed by kabha and pitta and engulfed by rasa gets localized in the
cardiac region and produces severe pain which causes great difficulty in
respiration. This condition is known as hrudshoola and is due to rasa and
vata.

CHIKITSA OF HRDUSHOOLA
तरावऩ कभाूलबहहतां मदक्
ु तां रृद्ववकारयणाभ ् |१३३|
 The therapeutic measures described for the heart disease should be carried
out this condition also.
CHIKITSA

A. CHIKITSASUTRA - व्माचधप्र्मनीकभ ् -
1) शभनभ ्
2) स्त्नेहनभ ्
3) स्त्वेदनभ ्

B. IDEAL DRUGS - भख्

ु मौषधभ ् -
1) हरयणशङ्
ृ गभ ्
2) सुवणूबस्त्भ
3) अजुन
ू ्
4) आद्रकभ ्

In Brhta Trayi, Hrdya Herbs are…

...अम्रां ह्र्दद्मानाां... |
( Cha.Su.25/40 )
ͻ Acco. to Charaka, Amla rasa is hrdya.

आम्राम्रातकलरकुचकयभदू वऺ
ृ ाम्राम्रवेतसकुवरफदयदाडीभभातुरन्गानीतत दशेभातन ह्र्दद्मातन
बवस्न्त|
( Cha.Su.4/10 )
ͻ Hrdya Dasemani – Amra, Amrataka, Likucha, Karmarda, Vrukshamla, Amlavetasa,
Kuvala, Badara, Dadima, Matulunga.

ͻ Acco. to Sushruta, Bruhtyadi, Utpaladi and Trapuaadi Gana drugs are Hrdya.
ͻ Acco. to Vagbhatta, Vidaryadi, Shyamadi Gana drugs are Hrdya.
C. NIDANA PARIVARJANA -
NIDANA PARIVARJANA
व्मामाभ Vishrama
चचन्ताबमरास Satvavajaya chikitsa
वेगसन्धायण Vega Nivruti
अन्न अततभारोऩसेववतै्
Samyaka matra bhojana,
ववरुद्धा्मशनाजीणू
Snigdha & Shita anna
उष्णरूऺान्न

तीक्ष्णाततववये कफस्स्त्त ?
कशून Brimhana
गदाततचाया Proper management of gada

D. SAMSHAMANA -
आभ्यन्तरशमनौषधम ्

प्रकारः कल्ऩः मात्रा काऱः अनऩ

ु ानं
भध+
ु घत
ृ ां
वातज् हरयणशग
ृ लभश्रणभ ् २ – 4 गुञ्जा अन्तयाबक्तां ३ वायां
अजुन
ू लसद्ध ऺीयां
दशभूरारयष्ट् १ – २ कषू् अन्तयाबक्तां ३ वायां जरां
शालरऩणीऩो्तरव १ – २ कषू् अन्तयाबक्तां ३ वायां जरां
कपानुफन्धज् कायस्त्कयकल्ऩ् २ – 4 गुञ्जा अधोबक्तां २ वायां अजुन
ू लसद्ध ऺीयां
वऩतज् भाऺीकलभश्रणां ४ – ८ गञ्
ु जा अन्तयाबक्तां २ वायां भध+
ु लसतोऩरा
स्त्वणूशख
े ययस् ४ – ८ गञ्
ु जा अन्तयाबक्तां २ वायां आभरकावरेह्
कपज् शांग्ृ माहदक्वाथ् २|| - ५ कषू् अन्तयाबक्तां २ वायां
कुभायवआसवलभश्रणां २ – ३ कषू् अन्तयाबक्तां ३ वायां जरां
श्वासकुिायलभश्रणां १ – १|| भाष् अन्तयाबक्तां ३ वायां भधु
हे भगबूलभश्रणां १ – २ गुञ्जा अन्तयाबक्तां ३ वायां भधु
कायस्त्कयकल्ऩ् २ – 4 गुञ्जा अधोबक्तां २ वायां भधु
सास्न्नऩातज् मथादोषां चचकक्स्त्म्
 कृलभज् कृलभभद्
ु गयलभश्रणां ४ – ८ गञ्
ु जा अन्तयाबक्तां ३ वायां भधु
ववडन्गारयष्ट् १ – २ कषू् अन्तयाबक्तां ३ वायां जरां

VATAJA HRDROGA
तैरां ससौवीयकभस्त्तत
ु क्रां वाते प्रऩेमां रवणां सख
ु ोष्णभ ् |
भर
ू ाम्फलु सद्धां रवणैश्च तैरभानाहगल्
ु भाततूरृदाभमघ्नभ ् ||
( Cha. Chi. 26/81 )
ͻ Give warm oil prepared with sauviraka, mastu, takra, lavana.
ͻ Give Oil prepared with gomutra, kanji, panchlavana.

ऩुननूवाां दारु सऩञ्चभूरां यास्त्नाां मवान ् त्रफल्वकुर्थकोरभ ् |

ऩक््वा जरे तेन ववऩाच्म तैरभभ्मङ्गऩानेऽतनररृद्गद्नभ ् ||
हयवतकीनागयऩुष्कयाह्वैवम
ू ्कमस्त्थारवणैश्च कल्कै्|
सहहङ्गुलब् साचधतभग्र्मसवऩूगल्
ुू भे सरृ्ऩाश्वूगदे ऽतनरो्थे ||
( Cha. Chi. 26/82-83 )
ͻ Give drink with punarnava, devadaru, panchmula, rasna, yava, bilwa, klattha
and kola.
ͻ Give Ghrta prepared with kalka of haritaki, sunthi, pushkarmula, guduchi,
lavana, hingu

सऩष्ु कयाह्वां परऩयू भर

ू ां भहौषधां शट्मबमा च कल्का् |
ऺायाम्फस
ु वऩूरव
ू णैववूलभश्रा् स्त्मव
ु ाूतरृद्रोगववकततूकाघ्ना् ||
क्वाथ् कृत् ऩौष्कयभातुरुङ्गऩराशबूतीकशटवसुयाह्वै् |
सनागयाजास्जवचामवानीऺाय् सुखोष्णो रवणश्च ऩेम् ||
( Cha. Chi. 26/84-85 )
ͻ Give kalka of pushkarmula, bijapura, sunthi, sati, haritaki with kshara, jala,
ghrta, lavana.
ͻ Give pana of decoction of pushkarmula, bijapuramula, palash, bhutika, sati
devdaru mixed with sunthi, jiraka, vacha, yavani, yavakshara, saindhava.

ऩथ्माशटवऩौष्कयऩञ्चकोरात ् सभातुरुङ्गाद्मभकेन कल्क् |

गुडप्रसन्नारवणैश्च बष्ृ टो रृ्ऩाश्वूऩष्ृ िोदयमोतनशूरे ||
( Cha. Chi. 26/86 )
ͻ Kalka of haritaki, sati, pushkarmula, panchkola, matulunga fried with ghrta and
taila and add guda, prasanna, lavana.

स्त्मा््मूषणां द्वे त्ररपरे सऩािे तनहदस्ग्धकागोऺुयकौ फरे द्वे |

ऋवद्धस्त्रहु टस्त्ताभरकी स्त्वगुप्ता भेदे भधक
ू ां भधक
ु ां स्स्त्थया च ||
 शतावयव जीवकऩस्ृ श्नऩण्मौ द्रव्मैरयभैयऺसभै् सुवऩष्टै ् |
प्रस्त्थां घत
ृ स्त्मेह ऩचेद्ववचधऻ् प्रस्त्थेन द्ना ्वथ भाहहषेण ||
भाराां ऩरां चाधूऩरां वऩचांु वा प्रमोजमेन्भाक्षऺकसम्प्रमक्
ु ताभ ् |
श्वासे सकासे ्वथ ऩाण्डुयोगे हरवभके रृद्रहणीप्रदोषे ||
( Cha. Chi. 26/87-89 )

ͻ Make with 1 prastha ghrta, 1 prastha dadhi and 1 tola drug of each drug - kalka
of trikatu, dwaya triphala(1.haritaki,bibhitaki,amalaki &
2.draxa,gambhari,parshaka ), patha, kantakari, gokshura, dwaya bala, riddhi, ela,
amalaki, kapikakacchu, meda, mahameda, madhuka, salaparni, satavari, jivaka
and prsnaparni.

वऩप्ऩल्मेरावचाहहङ्गुमवबस्त्भातन सैन्धवभ ् |
सौवचूरभथो शुण्िीभजभोदाां च चर्ू णूतभ ् ||
परधान्माम्रकौर्थदचधभद्मासवाहदलब् |
ऩाममेत ववशुद्धां च स्त्नेहेनान्मतभेन वा ||
बोजमेज्जीणूशाल्मन्नां जाङ्गरै् सघत
ृ ै यसै् ||
( Su. Utt. 43/12-14/1 )
ͻ Take powders of Pippali, ela, vacha, hingu, yavakshara, saindhava, sauvarchala,
sunthi, ajamoda with madanphala, dhanyamla, kulattha, dadhi, madya or sneha.
ͻ Give Jirna shalyanna with jangala animal mamsa and ghrta.
ह्रद्रोगे वातजे तैरां भस्त्तुसौवीयतक्रवत ् |
वऩफेत ् सुखोष्णां सत्रफडभ ् गुल्भानाहाततूस्जच्चतत ् ||
तैरां च रवणै् लस्धां सभूराम्रां तथागुणभ ् ||
( A.H.Chi. 6/25/2-26 )( A.S.Chi. 8/31-32/1 )
ͻ Give warm oil prepared with mastu, sauviraka, takra mixed with bida.
ͻ Give medicated oil prepared with lavanas, gomutra and amla.

त्रफल्वां यास्त्नाां मवान ् कोरां दे वदारु ऩन

ु नूवाभ ् ||
कुर्थान ् ऩञ्चभर
ू ां च ऩक््वा तस्स्त्भन ् जरे ऩचेत ् |
तैरां तन्नावने ऩानेफस्त्तौ च ववतनमोजमेत ् ||
( A.H.6/27-28/1 )( A.S.8/32/2-33 )
ͻ Do nasya, pana, basti with medicated oil prepared with decoction of bilwa,
rasna, yava, kola, devadaru, punarnava, kulattha and panchmula.

शण्
ु िीवमस्त्थारवणकामस्त्थाहहङ्गऩ
ु ौष्कयै ् |
ऩथ्ममा च श्रत
ु ां ऩाश्वूह्र्दद्रज
ु ागल्
ु भस्जद्धृतभ ् ||
( A.H.6/28/2-29/1 )( A.S.8/34 )
ͻ Give medicated ghrta prepared with decoction of sunthi, amalaki, lavana,
haritaki, hingu, pauskara, pathya.
 सौवचूरस्त्म द्ववऩरे ऩथ्माऩञ्चाशदस्न्वते |
घत
ृ स्त्म साचधत् प्रस्त्थो ह्रदोगश्वासगल्
ु भनतु ् ||
( A.H.6/29/2-30/1 )( A.S.8/35 )
ͻ Give medicated ghrita prepared with 2 pala of sauvarcala, 50 pala of pathya
and 1 prastha of ghrita.
दाडडभां कृष्णरवणभ ् हहङ्गुशुण्िम्लम्रवेतसां |
अऩतन्रकह्रद्रोगश्वासघ्नभ ् चण
ू भ
ू ुतभभ ् ||
( A.H.6/30/2-31/1 )( A.S.8/36 )
ͻ Take churna of dadima, krsnalavana, hingu, sunthi and amlavetasa.

ऩुष्कयाह्मशिीशुण्िीफीजऩूयजटाबमा् |
ऩीता् कल्कीकृता् ऺायघत
ृ ाम्ररवणैमुताू् ||
ववकततूकाशूरहया् क्वाथ् कोष्णश्चतदगुण् |
( A.H.6/31/2-32 )( A.S.8/37 )
ͻ Take kalka of puskarahwa, sathi, sunthi, bijapuramula and abhaya mixed with
kshara, ghrta, amla and lavana.

मवानीरवणऺायवचाजाज्मौषधै्कृत् ||
सऩीतदारुफीजाह्मऩराशशहिऩौष्कयै ् |
ऩञ्चकोरशिीऩथ्मागुडफीजाह्मऩुष्कयभ ् ||
वारुणीकस्ल्कतां बष्ृ टां मभके रवणास्न्वतां |
ह्र्द्ऩाश्वूमोतनशूरेषु खादे त ् गुल्भोदये षु च ||
( A.H.6/33-35/1 )( A.S.8/38-40/1 )
ͻ Take recipe – kalka of yavani, lavana, kshara, vacha, ajaji, ausadha, pitadaru,
bijahvapalash, sathi, pauskara or panchakola, sathi, pathya, guda, puskrabija
with varuni in yamaka.

रघुना ऩञ्चभूरेन शुण्िमा वा साचधतां जरां ||

वारुणीदचधभण्डां वा धान्माम्रां वा वऩफेतवृ ष |
सामाभस्त्तम्बशर
ू ाभे ह्रहद भारुतदवू षते ||
कक्रमैषा सद्रवामाभप्रभोहे तु हहता यसा् |
स्त्नेहाढमास्स्त्तततरयक्रौञ्चलशर्खवतूकदऺजा् ||
फरातैरां सहद्रोग् वऩफेद्रा सक
ु ु भायकभ ् |
मष्ट्माह्वशतऩाकां वा भहास्त्नेहां तथोतभभ ् ||
यास्त्नाजीवकजीवन्तीफराव्माघ्रीऩन
ु नूवै् |
बागीस्स्त्थूयावचाव्मोषैभह
ू ास्त्नेहां ववऩाचमेत ् ||
दचधऩादां तथाम्रैस्त्च राबत् स तनषेववत् |
तऩूणो फांह
ृ णो फल्मो वातह्रद्रोगनाशन् ||
( A.H.6/35/2-41/1 )( A.S.8/41-45 )
ͻ If patient feels thirst – take jala boiled with laghu panchmula or sunthi or
varuni or dadhi or dhanyamla.
ͻ Take Mamsarasa of titira, kaunch, sikhi, vartaka, daksa with ghrta.
ͻ Drink balataila, sukumara taila, yasti taila or mahasneha which are cooked with
rasna, jivaka, jivanti, bala, vyaghri, punarnava, bhrangi, sthira, vacha, vyosa
mixed with amla, ¼ part of dadhi.

्मूषणत्ररपराऩािाभधक
ू ां भधक
ु ां रट
ु व |
ऩञ्चभूरां रघु फरे भेदे ऋवद्ध् शतावयव ||
कण्डूकयव ताभरकी जीवकांचाऺसांलभतै् |
तै् ऩचेत ् सवऩूष् प्रस्त्थां दन्ध् प्रस्त्थेन भाहहषात ् ||
मक्
ु तां लसद्धां च भधन
ु ा तस्न्नहस्न्त तनषेववतभ ् |
ह्र्दतऩाण्डुरहणीदोषकासश्वासहरवभकान ् ||
( A.S.8/46-48 )
ͻ Tryushanadi ghrita - Specially mentioned in astanga samgraha.
ͻ Take medicated ghrta prepared with decoction of 1 aksa each of tryusana,
triphala, patha, madhuka, madhooka, truti, laghu panchmula, dwaya bala, dwaya
bala, rddhi, shatavari, kantakari, tamalaki, jivaka, mixed with 1 prastha each of
ghrta and mahish dadhi.

दवप्ते अग्नौ सद्रवामाभे ह्रद्रोगे वाततके हहतभ ् |

ऺीयां दचध गुड् सवऩूयौदकानूऩभालभषां ||
एतान्मेव च वज्माूतन ह्रद्रोगेषु चतुष्ववऩू |
शेषेषु स्त्तम्बजाड्माभसांमुक्ते अवऩ च वाततके ||
कपानुफन्धे तस्स्त्भांस्त्तु रुऺोष्णाभाचये त ् कक्रमाभ ् |
( A.H.6/41/2-43 )( A.S.8/49-50 )
ͻ If patient has increased heart rate, expanding type of pain and has strong
digestive power, give kshira, dadhi, guda, ghrita, anupa mamsa.
ͻ Remaining other four type of hrdroga and rigidity, inactivity, ama in vatajaroga
– these pathyas are avoided.
If there are kaphanubandh, ruksha and ushna therapies are adopted.
 ANGINA PECTORIS

 Angina pectoris is a clinical syndrome of IHD resulting from transient

myocardial ischaemia.
 It is characterised by paroxysmal pain in the substernal or precordial region of
the chest which is aggravated by an increase in the demand of the heart and
relieved by a decrease in the work of the heart.
 Often, the pain radiates to the left arm, neck, jaw or right arm. It is more
common in men past 5th decade of life.

 Cause
 Major risk factors
 Age (≥ 45 years for men, ≥ 55 for women)
 Smoking
 Diabetes mellitus
 Dyslipidemia
 Family history of premature cardiovascular disease (men <55 years,
female <65 years old)
 Hypertension
 Kidney disease (microalbuminuria or GFR<60 mL/min)
 Obesity (BMI ≥ 30 kg/m2)
 Physical inactivity
  Prolonged psychosocial stres
 Conditions that exacerbate or provoke angina
 Medications
 Vasodilators
 Excessive thyroid hormone replacement
 Vasoconstrictors
 Polycythemia, which thickens the blood, slowing its flow through the
heart muscle
 Hypothermia
 Hypervolemia
 Hypovolemia

 Other medical problems

 Esophageal disorders
 Gastroesophageal reflux disease (GERD)
 Hyperthyroidism
 Hypoxemia
 Profound anemia
 Uncontrolled hypertension
 Other cardiac problems
 Bradyarrhythmia
 Hypertrophic cardiomyopathy
 Tachyarrhythmia
 Valvular heart disease

TYPE
 There are 3 overlapping clinical patterns of angina pectoris with some
differences in their pathogenesis:
i) Stable or typical angina
ii) Prinzmetal’s variant angina
iii) Unstable or crescendo angina
1) STABLE OR TYPICAL ANGINA.

 Pathogenesis :-
 This is the most common pattern. Stable or typical angina is
characterised by attacks of pain following physical exertion or emotional
excitement and is relieved by rest.
 The pathogenesis of condition lies in chronic stenosing coronary
atherosclerosis that cannot perfuse the myocardium adequately when
the workload on the heart increases.
 During the attacks, there is depression of ST segment in the ECG due to
poor perfusion of the subendocardial region of the left ventricle but
there is no elevation of enzymes in the blood as there is no irreversible
myocardial injury.

 Symptoms :-
1. Typical Anginal Pain or Distress :
(a) Site – Most often over middle or lower sternum or over left precordium,
at times in epigastrium. Sometimes discomfort is located only in left shoul
der or left upper arm, occasionally in lower jaw, rarely in interscapular area.
(b) Radiation – May spread to right or left arm or both, neck or jaw.
Occasionally pain starts in the wrists, upper arms or face and then spreads to
the chest.
(c) Character – Vicelike constriction or choking. Sometimes only pressure or
burning pain, rarely mere weakness of one or both arms. An impor tant
characteristic is its constancy, the pain being steady while it lasts.
(d) Duration – most commonly 1 to 4 minutes. May force patient to stop
walking.
(e) Provocation – by effort specially like walking against the wind or up a
climb, hurrying after meals, or unaccustomed exercise. At times due to
excitement, anger, fear. In advanced cases, pain is provoked by lying down
(angina decubitus) or stooping.
(f) Relief – with sublingual nitroglycerine.
 2. Dyspnoea - if it occurs before the pain suggests severe ventricular disease.
3. Other Symptoms –
(a) Choking sensation in throat or feeling of impending doom.
(b) Belching or passage of flatus or polyuria after an attack.
(c) Dizziness, faint ness or rarely syncope.
(d) If pain is severe, sweating and nausea.

 Signs :-
1) No signs.
2) Signs of LV dysfunction – Atrial or third heart sound. If LV ejection time
is increased, the aortic valve closes late and second sound becomes
single, or splitting is reversed.
3) Dysfunction of papillary muscle – can lead to transient mitral
regurgitation in case of ischaemia.
4) Signs associated with risk factors – (a) Hypertension. (b)
Hyperlipidaemia–Arcus senilis, xanthelasma, or cholesterol deposits
along tendons and in skin of palms and buttocks. (c) Obesity. (d)
Diabetes and its accompaniments.
5) During the attack – Pallor and sweating with rise of BP Often
tachycardia. Pressure on carotid sinus may pro duce slowing of pulse and
cessation of pain

Grading of Effort Angina

1) Ordinary physical activity, e.g. walking, climbing stairs does not cause
angina. Angina with strenuous or rapid or prolonged exertion.
2) Slight limitation of ordinary activity. Walking or clim bing stairs
rapidly, walking uphill, walking or stair climbing after meals, or in cold or
against a wind, or under emotional stress, or only during the few hours
after awakening. Walking more than two blocks on the level and
climbing more than one flight of ordinary stairs in normal conditions and
at normal pace.
 3) Marked limitation of ordinary physical activity. Walk ing one to two
blocks on the level and climbing one f light of stairs in normal conditions
and at normal pace.
4) Inability to carry out any physical activity without dis comfort – anginal
syndrome may be present at rest.

Clinical Variations (Atypical Forms)

1) Site and character of pain – Pain may start in one of the sites of
radiation and may be confined to that area, e.g. only the left wrist, or
pain may be sharp and occur only in the left chest.
2) Dyspnoea – with or without angina, and exhaustion.
3) Episodic or chronic fatigue and exhaustion – due to reduced cardiac
output secondary to ischaemia induced depression of myocardial
contractility
4) Second wind angina – Pain occurs at beginning of exertion, subsequently
the patient is able to ‘walk off’ the pain.
5) Nocturnal angina – may develop after a period of angina of effort, or
may represent the initial pattern of angina. It may be related to dreams,
or latent LV failure.
6) Angina with syncope – may be caused by cardiac arrhythmia.
7) Sweating and nausea (or vomiting) because of severe pain.
8) Bradycardia angina – Angina results from inability of heart to
accelerate adequately in response to exercise or emotion.
9) Paroxysmal atrial fibrillation – may be the first evidence of ischaemic
heart disease particularly in middle aged patients.
 Diagnosis Tests :-
1) ECG at rest – may be normal or show STT changes suggestive of
ischaemia, or AV or intraventricular con duction defects.

2) Holter monitoring – is helpful in evaluating total ischaemic burden,

i.e. episodes of painful or painless myocardial ischaemia.
 3) Stress testing – Cardiovascular stress can be pro voked physically by
exercise, or pharmacologically (in patients who cannot exercise).
4) Exercise stress testing
5) Pharmacological stress – (Myocardial perfusion scintigraphy)
 Indications – (i) Patient unable to exercise or with limited capacity
to exercise. (ii) Patient with res ting or exerciseinduced LBBB.
6) Coronary angiography – remains the ‘gold standard’ technique for
diagnosis and planning treatment of IHD

 Differential Diagnosis :-

Anxiety States
  Dfferentiating myocardial infarction from anginaAngina
pectorisMyocardial infarction

 Investigations :-
 Echocardiography – 2D and Mmode echocardiography are valuable in
assessment of resting ventricular function and can identify areas of
segmentally reduced contraction corresponding to previous MI.

 Stress echocardiography – Continuous 2Dechocar diography is

performed at rest and during and after stress and image comparison is
used to determine the extent and distribution of wall motion
 abnormalities. Stress can be provoked by exercise or by pharmacolo
gical stimulation which can be used to predict the location and
severity of underlying coronary artery disease.

 Intravascular ultrasonography (IVUS) – defines completely the vessel

wall, plaque burden, morphology of the plaque, presence of
calcification in the lesion, and luminal dimensions.

 Intracoronary Doppler – Clinical applications include assessment of

functional significance of interme diate lesions by coronary
arteriography. With use of Dop pler wire the velocities and coronary
flow reserve across the lesion can be estimated.

 Management : -
1. Acute attack – Glyceryl trinitrate 0.6 mg or isosorbide dinitrate 5 mg
sublingually, or nitrite spray in a mea sured dose of 0.4 mg. Effect
starts in 3 to 5 minutes and its action lasts for 20 to 40 minutes.
Contraindicated in patients with glaucoma.

2. Prophylaxis – In chronic stable angina. General measures

a) Control of risk factors – (a) Hypertension. (b) Cigarette smoking. (c)
Hyperlipidaemia. (d) Obesity. (e) Correc tion of disorders which increase
myocardial oxygen demand such as anaemia and hyperthyroidism if pre
sent.
b) Rest and exercise – Bed rest not essential unless frequent attacks.
Moderate exercise which does not cause pain or dyspnoea allowed.
c) Relaxation techniques and stress management.
d) Aspirin – 75–150 mg/day.
e) Sedatives – to relieve mental tension and control emotional factors.
 f) Antianginal agents

3. Myocardial Revascularization Techniques

a) Percutaneous transluminal coronary angioplasty(PTOA)
b) Minimally invasive coronary artery surgery (MICAS)
2) VARIANT (PRINZMETAL’S) ANGINA :-
 Pathogenesis :-
 This pattern of angina is characterised by pain at rest and has no
relationship with physical activity.
 The exact pathogenesis of Prinzmetal’s angina is not known.
 It may occur due to sudden vasospasm of a coronary trunk induced by
coronary atherosclerosis, or may be due to release of humoral
vasoconstrictors by mast cells in the coronary adventitia.
 ECG shows ST segment elevation due to transmural ischaemia.
 These patients respond well to vasodilators like nitroglycerin.

 Signs & symptoms :-

 Anginal attacks occur at rest.
 Attacks often worse in morning.
 ECG – shows transient ST elevation instead of depres sion during chest
pain or Holter monitoring. Pathogenesis: Coronary vasospasm accounts
for epi sodes. Majority of patients have associated atherosclerotic
coronary artery disease.

 Diagnostic Tests :-
 ECG – during episode of chest discomfort. Besides ST segment
elevation, transient abnormal Q waves, AV heart block, ventricular
arrhythmias may be detected.

Prinzmetal Angina
 Variant Angina

 Coronary angiography.

 Management :-
 Drugs – Nitrates and calcium antagonists. Beta bloc kers may
exacerbate.
 Avoidance of exposure to cold environments.
 Tobacco smoking to be discontinued.
 Coronary bypass surgery if coronary stenosis.
 Angioplasty – in selected patients if significant obstruc tion in one
coronary artery. Possibility of angioplasty induced coronary spasm
3) UNSTABLE OR CRESCENDO ANGINA.

 Pathogenesis :-
 Also referred to as ‘pre-infarction angina’ or ‘acute coronary
insufficiency’, this is the most serious pattern of angina.
 It is characterised by more frequent onset of pain of prolonged duration
and occurring often at rest. It is thus indicative of an impending acute
myocardial infarction.
 Distinction between unstable angina and acute MI is made by ST
segment changes on ECG - acute MI characterised by ST segment
elevation while unstable angina may have non-ST segment elevation MI.
 Multiple factors are involved in the pathogenesis of unstable angina
which include : stenosing coronary atherosclerosis, complicated
coronary plaques (e.g. superimposed thrombosis, haemorrhage,
rupture, ulceration etc), platelet thrombi over atherosclerotic plaques
and vasospasm of coronary arteries.
 More often, the lesions lie in a branch of the major coronary trunk so
that collaterals prevent infarction.

 Sign & symptoms :-

 Angina on effort of recent onset (one month).
 Angina of effort with increasing frequency and duration and provoked by
less than usual stimuli (accelerated or crescendo angina).
 Prolonged (>20 min) anginal pain at rest
 Angina in early (<1 month) post-infarction period.
 New onset (de novo) severe angina,
 Recent destabilization of previously stable angina with crescendo angina
 Diagnosis :-
1) E.C.G.

2) Engiography

 Management :-
 Statins and other drugs are recommended for all NSTE ACS patients
irrespective of cholesterol level with the aim of achieving LDLC levels
<70 mg/dL. ACE inhibi tor in patients with reduced LV systolic function.
ARBs in those who are intolerant.
 Coronary revascularization to relieve angina, ongoing myocardial
ischaemia and progression to MI death
 Epidemiology :-

 As of 2010, angina due to ischemic heart disease affects approximately

112 million people (1.6% of the population) being slightly more common
in men than women (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 is more often the presenting symptom of coronary artery disease

in women 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.

 Men 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 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 adoption of a rich, Westernized diet and subsequent increase of

smoking, obesity, and other risk factors has led to an increase in angina
and related diseases in countries such as China.