Angina

What is angina?

The most common symptom of coronary artery disease is angina or “angina pectoris,” also known as chest pain.

Angina can be described as a discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness or squeezing. Sometimes, it can be mistaken for indigestion or heartburn.

Angina symptoms last just a few minutes and are usually quickly relieved by rest and/or medications.

Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back or jaw.

Angina symptoms in women may include the pain as described above, but women’s symptoms may also include shortness of breath, nausea or fatigue, or an unusually rapid heart beat.

If you have symptoms, take notice. These are warning signs of heart disease. See your doctor right away for proper diagnosis and treatment, especially if the symptoms are new or have become more frequent or severe.

What causes angina?

When blood flow to an area of the heart is decreased, it impairs the delivery of oxygen and vital nutrients to the heart muscle cells. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body. The by-product of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes pain.

What are the types of angina?

• Stable angina: A type of angina brought on by an imbalance between the heart’s need for oxygen-rich blood and the amount of oxygen available. “Stable” means the same activities cause the angina symptoms; it feels the same way each time; and is relieved by rest and/or oral medications. Stable angina is a warning sign of heart disease and should be evaluated by a doctor. If the pattern of angina changes, it may progress to unstable angina.
• Unstable angina: This is considered an acute coronary syndrome and may signal an impending heart attack. It may be a new symptom or a change from stable angina. The angina may occur more frequently, more easily at rest, feel more severe, or last longer. Although this type of angina can often be relieved with oral medications (medicine taken by mouth), it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure is required to treat unstable angina. Unstable angina should be treated as an emergency.
• Variant angina (also called Prinzmetal’s angina or coronary spasm): A coronary arterycan spasm and disrupt blood flow to the heart muscle (ischemia). Variant angina can occur in people without significant coronary artery disease. However, two-thirds of people with variant angina have severe disease in at least one vessel and the spasm occurs at the site of the blockage. This type of angina is not common and usually occurs when a person is at rest or when sleeping. Underlying coronary artery disease, smoking, or using stimulants or illicit drugs (such as cocaine) can increase your risk for coronary artery spasm. If a coronary artery spasm is severe and occurs for a long period of time, a heart attack can occur.

Is all chest pain angina?

No. Not all chest pain originates from the heart. Non-cardiac chest pain usually occurs in the middle of the chest and is characterized by a dull, burning or pressure sensation. The pain usually does not radiate into the neck, shoulders or arms.

The most common cause of non-cardiac chest pain arises from a nearby organ, the esophagus.

Esophageal causes of non-cardiac chest pain include:

• Gastroesophageal reflux disease (GERD): A condition that occurs when stomach acid backs up into the esophagus, causing heartburn and chest pain.
• Gallstones.
• Esophageal spasm: Caused by chaotic muscle contractions of the lower esophagus and aggravated by acid reflux, stress or unknown factors.
• Esophageal rupture.
• Varicose veins, strictures or tumors of the esophagus.
• Other less common gastrointestinal problems.

Pulmonary (lung) causes of chest pain include:

• Pneumonia.
• Pulmonary embolus.
• Pneumothorax.
• Pleuritis.
• Bleb rupture.

Musculoskeletal causes of chest pain include:

• Back and spine problems.
• Musculoskeletal conditions including muscle strain, rib fracture and other conditions.
• Fibromyositis (muscle inflammation).

Psychological causes of chest pain include:

• Panic attacks.
• Anxiety.
• Stress.
• Mental duress.

Psychological causes of chest pain can produce symptoms that resemble the pain experienced during a heart attack.

Because non-cardiac chest pain resembles angina, it is important to see a physician for this problem to evaluate the cause of your chest pain.

Can angina occur in the absence of coronary disease?

Rarely, angina can occur in the absence of any coronary disease. People with a valve problem called aortic stenosis have decreased blood flow to the coronary arteries from the heart. People with severe anemia may have angina because their blood doesn’t carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don’t get enough oxygen.

How is angina diagnosed?

First, your doctor will ask you a series of questions to determine what your symptoms are and what brings them on. After examining you, your doctor will order one or more of a series of tests to determine the underlying cause of the angina and the extent of coronary artery disease, if present. These tests may include:

• Exercise stress test.
• Electrocardiogram (ECG or EKG).
• Nuclear imaging tests.
• Echocardiogram.
• Cardiac catheterization.
• Electron beam CT (ultrafast CT).

How is angina treated?

Your treatment will depend on the severity of the underlying problem, namely the amount of damage to the heart. For most people with mild angina, a combination of medications and lifestyle changes can control the symptoms.

Lifestyle changes include:

• Eating a heart-healthy diet.
• Lowering cholesterol.
• Getting regular exercise.
• Quitting smoking.
• Controlling diabetes.
• Managing high blood pressure.

Medications used to treat angina work by either increasing the amount of oxygen delivered to the heart muscle or reducing the heart’s need for oxygen. These medicines include:

• Beta-blockers.
• Nitrates.
• Calcium channel blockers.
• Antiplatelet medications.
• Blood thinners.
• Anticoagulants.

For people with more serious or worsening angina, your doctor may recommend treatment procedures to open blocked arteries. Treatment procedures include:

• Angioplasty.
• Stenting.
• Coronary artery bypass grafting (CABG) surgery.
• Transmyocardial revascularization (TMR).
• External counterpulsation (EECP).

What you should do if you have symptoms:

• If you or someone you are with has chest, left arm or back pain that lasts more than 5 minutes, call 911 to get emergency help. DO NOT WAIT. Quick treatment of a heart attack is very important to reduce the amount of damage to your heart. Aspirin: After calling 911, emergency personnel may tell you to chew one full (325 mg) aspirin slowly, if you do not have a history of aspirin allergy or bleeding. Aspirin is especially effective if taken within 30 minutes after the start of symptoms. Do NOT take an aspirin for symptoms of a stroke.
• If your symptoms stop completely in 5 minutes, still call your doctor to report your symptoms.
• Call your doctor if this is the first time you have experienced these symptoms so you can be evaluated.
• Learn to recognize your symptoms and the situations that cause them.
• Call your doctor if you have new symptoms or if they become more frequent or severe.

If you have been prescribed nitroglycerin

If you have been prescribed nitroglycerin and experience angina, stop what you are doing and rest. Take one nitroglycerin tablet and let it dissolve under your tongue, or if using the spray form, spray it under your tongue. Wait 5 minutes. If you still have angina after 5 minutes, call 911 to get emergency help.

Do not wait to get help

At the first signs of a heart attack, call for emergency treatment (911). Do not wait for your symptoms to “go away.” Early recognition and treatment of heart attack symptoms can reduce the risk of heart damage and allow treatment to be started immediately. Even if you’re not sure your symptoms are those of a heart attack, you should still be evaluated.

For patients diagnosed with chronic stable angina: If you experience angina, take one nitroglycerin tablet and let it dissolve under your tongue, repeating every 5 minutes for up to 3 tablets spanning 15 minutes. If you still have angina after taking 3 doses of nitroglycerin, call 911 to get emergency help.

Use of aspirin with unstable chest pain: After calling 911, emergency personnel may tell you to chew one full aspirin (325 mg) slowly, if you do not have a history of aspirin allergy or bleeding. Aspirin is especially effective if taken within 30 minutes after the start of symptoms. Do NOT take an aspirin for symptoms of stroke. Continue to take your nitroglycerin as prescribed.

Reference: ACC /AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology, 2007. 50(7):1-157.