Alternative name:
Angina Pectoris

What is angina?
What are the signs of angina?
What causes angina?
How does my doctor tell if I have angina?
How is angina treated?

What is angina?

Angina, also called "angina pectoris," is a pain or a sense of discomfort in the chest arising from the heart. Although most often a consequence of inadequate oxygen delivery to the heart due to a narrowing of the heart arteries, angina may also be caused by heart valve disease, cardiac rhythm disturbances, and diseases of the muscular portion of the heart. In virtually all situations, the presense of angina indicates that the demands of the heart are outstripping the arterial blood supply.

Symptoms can vary dramatically from person to person. Typically, angina is described as a pressure or squeezing in the central chest, sometimes accompanied by discomfort in the neck, jaw, shoulders, and arms. Others say it feels like a vice is compressing their chest. Still others complain of an aching or burning sensation. Some people feel pain in areas outside of the chest. Many complain of other symptoms at the same time, such as shortness of breath, sweating, nausea and lightheadedness. Angina typically comes on with exercise or stress, and recedes with rest and relaxation.

While angina itself does not lead to permanent damage of the heart muscle, it does suggest the presence of heart disease, which can lead to heart attack and death. Angina affects more than five million people in the U.S., according to the National Institutes of Health.

Angina may occur in one of a number of patterns. Among them:

• Chronic stable angina is characterized by a long-term pattern of exercise-induced angina occurring very predictably over months to years.
  
  
• Unstable angina occurs at rest. Or, it may refer to a sudden worsening of symptoms in a person who had been experiencing stable angina. Unstable angina often is seen days, hours or weeks before a heart attack.
  
  
• Variant angina is a unique form that results not from progressive narrowing of the heart arteries or other underlying heart disease, but from transient and reversible spasm of the heart arteries. Variant angina tends to occur without any particular pattern and isn’t linked to exercise or exertion.

Microvascular angina is a unique form of angina in which the patient has symptoms virtually identical to those of stable angina yet appears to have normal coronary arteries. Microvascular angina is thought to be due to an inability of the coronary arteries to dilate during exercise. There is much debate in the medical community about microvascular angina, which is dubbed Syndrome X. Some doctors question whether the symptoms can be linked to vascular irregularities during exercise.

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What are the signs of angina?

People who have angina describe a wide variety of symptoms. For some, angina feels like a mild discomfort near the center of the chest. Other people have a burning sensation like heartburn or indigestion. Angina is also described as a tightening, heaviness, cramping, squeezing or sharp pain or discomfort behind the breastbone. Sometimes, the sensation spreads to the neck, jaw, throat, shoulder, upper back or arms. Others say the pain seems to start in those places. Angina does not always cause pain. Some people feel sweaty, weak and breathless instead, as if they are suffocating.

Symptoms of angina tend to occur most often during physical exertion, that is, when the heart is working harder than usual. A heavy meal, intense emotion, running for a bus or even walking outdoors in very cold weather can trigger symptoms. Usually, resting allows the symptoms to subside. But that isn't true for everyone. Some report symptoms while resting. Still others are even wakened from sleep by angina. Angina at rest is likely to represent unstable angina.

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What causes angina?

As a muscular pump responsible for moving up to thirty quarts of blood a minute during exercise, the heart has huge needs for blood, oxygen and nutrients. In fact, as blood is pumped out of the heart and into the aorta, a portion is channeled back to the heart via the coronary arteries. These arteries – three separate vessels – travel across the surface of the heart, dividing, branching and ultimately penetrating the heart to supply it with needed oxygen and nutrients. As the workload of the heart increases with exertion and other stresses, so, too, does its need for oxygen. A healthy heart can handle this increased oxygen demand. But a heart with either a compromised blood supply or disease leading to excessive demands simply cannot. Angina occurs whenever the oxygen demands of the heart outstrip the supply.

In the U.S. and Europe, the most common cause of angina is artherosclerosis. Atherosclerosis is a progressive process in which cholesterol, inflammatory cells and other substances are deposited in the arterial wall over a period of years or even decades. As a result, the arteries grow narrower and their ability to carry blood is reduced. Moreover, atherosclerosis leads to a loss of the normal dilating capacity of the arteries in response to exercise. Researchers are investigating the exact mechanisms of atherosclerosis, but it is known to be linked to many factors, most notably hypertension, diabetes, smoking, high cholesterol, certain hereditary factors and elevated levels of homocysteine. Less potent risk factors include obesity, physical inactivity, and a stressful lifestyle.

Angina can also occur in the setting of normal or minimally narrowed coronary arteries when the oxygen demands of the heart become excessive. The most common cause of this is heart valvular disease. Other potential causes include diseases of the heart muscle called cardiomyopathies, heart rhythm disturbances leading to excessively fast heart rates, and several non-cardiac conditions such as hyperthyroidism, and severe anemia.

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How does my doctor tell if I have angina?

The medical history: A detailed medical history is the single most useful means of diagnosing angina. Your doctor will take particular interest in your description of the character, location, and pattern of occurrence of symptoms. Often, tests will be necessary. Those tests will help the physician assess the extent of your coronary artery disease, including how many blood vessels are likely to be involved. Your medical history also will help the physician decide what treatment may be appropriate.

Blood tests: As part of the screening process, your doctor will likely test your lipid levels and also check for diabetes. Your doctor may also check your homocysteine level, which could give clues about your cardiac health. After a prolonged episode of chest discomfort, blood enzymes can be useful in helping the doctor decide whether you’ve had an episode of severe angina or a small heart attack.

Angiography: Cardiac catheterization remains the “gold standard” in diagnosing the coronary artery disease. It is generally performed on an outpatient basis. An angiogram is performed by inserting a long, thin and flexible tube, or catheter, through an artery in the groin or arm. The physician then threads it through the circulatory system until it reaches to the heart arteries. Next, a dye is injected, and the heart is photographed as the dye moves through the coronary arteries. Often cardiac catheterization is combined with a definitive therapy to fix a blocked artery, such as angioplasty and placement of a stent, which is a wire mesh tube placed at the site of the angioplasty to lessen the possibility of complications. While there are risks, including infection, allergic reaction stroke or even heart attack, the likelihood of a serious complication is quite low. Statistically, complications occur in one out of 1000 angiographs.

Electrocardiogram: One of the most useful tests for diagnosing coronary artery disease is the electrocardiogram, sometimes called an ECG or EKG. An electrocardiogram measures the heart's electrical activity and often shows characteristic patterns following heart attacks and during episodes of angina. Most doctors will recommend those patients who are beginning to experience angina take a baseline ECG. Periodically, ECGs will be ordered to see if your condition has worsened.

Treadmill Stress Tests: Since the heart shows characteristic changes on the electrocardiogram during angina, the use of continuous electrocardiographic monitoring while the patient walks on a treadmill is an effective test for coronary artery disease. In addition to studying the results of your ECG, your doctor will get important information from observing your blood pressure, your maximum exercise level, and whether you have any symptoms during the test. Still, so-called “stress tests” are not completely accurate. Sometimes, your doctor will order a more specialized test.

Nuclear or Perfusion Stress Tests: In this procedure, radioactive substances are injected into a vein and observed as they make their way through the circulatory system to the heart. The test offers a look at blood flow to the heart. Often separate tests are done while the patient exercises and rests. That’s so your doctor can asses the presence, location, and extent of blood flow to the heart. Such tests, generally using substances such as thallium or sestamibi, are extremely useful in diagnosing coronary artery disease. These techniques are particularly helpful in the person with an abnormal baseline electrocardiogram and in whom a treadmill stress test alone often provides confusing information. In patients unable to walk on a treadmill, the use of a pharmacologic agent such as dipyridamole (Persantine? ) or adenosine are substituted for exercise and provide similarly useful information.

Echocardiography: A cardiac ultrasound or echocardiogram is useful in evaluating how effectively heart contracts, and it may show evidence of unrecognized heart attacks. Its ability to visualize heart valves make it particularly useful in diagnosing diseased valves. It often is performed during exercise on a treadmill or after stressing the heart in some other way.

Electron Beam CT Scan (EBCT): Since calcium is almost uniformly present in the plaque constituting the arterial build-up in disease coronary arteries, scans designed to detect calcium are increasingly used to diagnose coronary artery disease. Although a CT scan is considered a safe means of documenting calcium build -up in the arteries, the test is used to screen for coronary disease and not for diagnosing angina per se. But there is controversy over the use of this test. Because a lack of calcium does not rule out coronary artery disease, doctors are divided about the usefulness and cost-effectiveness of the test.

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How is angina treated?

Once your condition is diagnosed, you will learn there are a variety of approaches to treatment, ranging from simple lifestyle changes to major surgical procedures. The ideal approach depends on a number of factors including the extent and severity of your disease, your age, other diseases you may have, and perhaps most importantly, your feelings about the different options. In almost all situations, the disease can be treated in a variety of ways. Therefore, it is essential that you explore options with your physician and decide what works best for you.

Lifestyle changes:

Angina is not a death sentence, but rather an alarm. While your doctor may prescribe drugs, you should not underestimate how much lifestyle changes can improve your cardiac health. Some suggestions:

Keep active: Studies have shown that people who are physically active are healthier and live longer. Even people with coronary artery disease can benefit from starting an exercise program. Aim for at least twenty to thirty minutes of moderate activity daily or at least several times a week. Rapid walking, moderate weight-lifting, bicycling, or swimming are beneficial.

Because exercise may induce angina, you may need to modify the type of activity you choose and the way you approach it. In general, rapid, intense activity is more apt to bring on symptoms than gradually increasing activity. When exercise induces angina, you should slow or stop until the symptoms subside. Most doctors will agree it is safe to resume activity, though they might recommend a slower pace.

Keep in mind that digestion puts an added demand upon the heart, You will be more likely to get angina when exercising after a large meal. Weather, too, can be a factor. Many people find angina far more frequent when in cold weather.

Talk with your doctor about an ideal exercise program and determine a target heart rate. In some instances, your physician will choose to observe your response to exercise on a treadmill before prescribing a home exercise program. Most exercise programs shoot for a heart rate between 50 and 85% of the maximum rate for a person of your age.

Some medications, particularly beta blockers, will prevent your heart rate from increasing in a normal fashion. If you are taking such medications, your doctor will usually recommend a slower target heart rate. A quick formula for determining your maximal heart rate is to subtract your age from 220. A 50-year-old would have a predicted maximal heart rate of 170 beats a minute. Thus, the target heart rate during exercise should be between 85 and 144 beats per minute.

Manage stress: You may be upset to learn you have angina and coronary artery disease, and understandably so. But don’t let that worsen the situation. There is no reason to feel helpless or to give up. Learn about your disease, and put this knowledge to work for you.

Think about whether chronic stress is a factor in your life. Try to determine whether it may have contributed to the development of coronary disease. Remember that stress takes a toll on the body in insidious ways. It interferes with sleep, it leads to altered eating habits, it blunts our immune system, and, in many ways, it contributes to illness. Among the most detrimental forms of psychological stress are anger and hostility.

What can you do about stress? There are numerous methods to use on your own, and all of them can be learned through books and other commercially available material. Among these are meditation, self-hypnosis, exercise, and progressive muscular relaxation. For those patients with severe stress and anxiety, counseling with a professional may be helpful.

Eat well: Diet is an important component of health, especially cardiac health. The food you eat strongly affects other established risk factors such as hypertension, cholesterol, and diabetes. Altering your diet can substantially reduce your risk of angina or a heart attack.

Is there a perfect diet? No. In general, you should reduce the saturated fat and cholesterol in your diet. Keep in mind that animal products are the biggest sources of saturated fat and cholesterol. Select leaner cuts of meat if you’re a meat-eater. Remove all visible fat. Minimize your intake of eggs and dairy products, such as cream and cheese. As much as possible substitute fruits, vegetables and grains. Your doctor can help you set specific daily goals or refer you to a nutritionist to plan a comprehensive dietary program.

Here is what the American Heart Association recommends:

• Keep your total fat intake to less than 30% of total calories

• Limit saturated fat to less than 10% of total calories

• Limit your cholesterol intake to no more than 300 milligrams per day

Does a heart healthy diet mean tasteless food? No! There are dozens of books on nutrition and diet that can teach you on how to prepare interesting and delicious recipes. Keep in mind that long-term success in changing your eating habits will not come from following a structured and tasteless diet, but rather from changing your relationship to food. Think about the importance of your health and the joy you get from a fit, well-tuned body. Consider there may be some truth to the old axiom “we are what we eat”.

Alcohol in Moderation: Studies suggest the more you drink the less your likelihood of cardiac problems. This is probably due to the fact that wine and other alcoholic beverages raise the level of protective HDL cholesterol in the blood, although other factors may be important too. But drinking alcohol is associated with non-cardiac illness, and for that reason many doctors are reluctant to suggest their patients indulge in alcohol. For those who do enjoy a drink and who don’t suffering from any alcohol-related illness, doctors generally recommended no more than one or two drinks per day.

Don't smoke: Evidence indicates that smoking is a strong risk factor for angina and heart attack. The 1989 Surgeon General’s report concluded that smoking increases the risk of cardiovascular death by 50%. If you do smoke, you should realize that the risk of tobacco-related illness – including cardiovascular disease – falls rapidly after quitting.

What should you do if you are a smoker and you’ve been diagnosed with angina? Nicotine is highly addictive and quitting can be quite difficult, but people successfully quite all the time. Take advantage of the fact that your motivation may never be stronger. Talk with your doctor about which method might best suit you. Current approaches include nicotine replacement systems (patches, gum, and inhaled nicotine), antidepressant medications (Zyban?), behavioral techniques including hypnosis, and structured cessation programs.

Control your blood pressure: Blood pressure has often been called the “silent killer” since it rarely announces itself with symptoms, but silently causes damage to various organs throughout the body. It is a potent risk factor for heart disease and angina. If you are already being treated for high blood pressure, take your medications and make sure your condition is well controlled. Remember that there are many non-pharmacological methods to lower blood pressure, including weight loss, limiting alcohol consumption, exercising regularly, reducing salt intake, increasing your intake of calcium and potassium, stopping smoking, and relaxation exercises.

Medicines:

Fortunately, there are a variety of medications that can relieve the symptoms of angina. In general they work by either decreasing the heart’s needs for oxygen or by improving blood flow to the heart. Others medicines, such as aspirin, do not actually reduce symptoms of angina but do reduce the risk of a heart attack. Unless you are allergic to aspirin, your doctor will almost certainly advise you to take one a day. Furthermore, the doctor may prescribe one or more medicines from the three categories of angina-fighting medicines available today: nitrates, calcium channel blockers, and beta blockers.

Be sure to keep track of what you are taking. You should know the name, dose and schedule of all your medication. Many doctors recommend their patients write down this basic information on a small card and carry in your wallet or purse. Often, in an emergency, people panic and find it difficult to remember the medication they are taking.

Aspirin: With rare exception, aspirin is recommended for virtually all people with angina or known to have coronary artery disease. Aspirin works by inhibiting platelets, which in turn are intimately involved in the process that leads to heart attacks. Several large clinical trials enrolling thousands of patients have shown that aspirin dramatically reduces the likelihood of heart attack. A baby aspirin, or 81 mg, is considered a minimum dose. Doctors recommend most people take a baby aspirin or a standard (325 mg) tablet daily.

For those allergic to aspirin or those who suffer gastrointestinal problems from taking it, there are alternative medications, including clopidogrel (Plavix) and ticlopidine (Ticlid). Neither of these have been studied as extensively as aspirin. Both are considerably more expensive. For some patients with aspirin sensitivity, the use of enteric coated aspirin may prevent problems.

Nitrates: These are the oldest and most commonly used drugs for angina. Nitrates act by relaxing the layer of muscle in the walls of both veins and arteries throughout the body. Thus, they improve flow through the coronary arteries. Nitrates can be taken in a variety of ways. Some doctors tell their patients to place a tablet under the tongue to speed its absorption into the bloodstream. Other suggest swallowing the tablets. Some prescribe skin patches. In general, the patches and the swallowed oral forms are designed to provide long-lasting effects. Tablets dissolved under the tongue are taken for immediate treatment of an angina episode. A spray form of the immediate acting nitrate is also available. One of its benefits is that it does not lose its potency over time, as the tablets do within six months after opening the bottle. Virtually everyone diagnosed with angina also is advised to carry nitroglycerine tablets or nitro-spray to relieve symptoms when an attack comes on.

In general, if angina is sparked by physical activity or emotional stress, you should rest and relax. If the symptoms persist for more than a few minutes, take the nitroglycerine. Likewise, if symptoms occurred without any provocation, take nitroglycerine. You should always be sitting or laying down when taking rapid-acting nitroglycerine; it can lower your blood pressure and could lead to some lightheadedness. Nitroglycerine is usually administered at five minutes intervals until symptoms are relieves. Most physicians recommend that you receive emergency medical attention if the angina persists after three or more sequential doses of nitroglycerine.

Side effects from nitrates, both the short and long-acting forms, include headaches and lightheadedness. Although relatively common the first few times you are exposed to nitrates, headaches are usually fleeting.

Beta blockers: This category of drug is used for a variety of conditions, including angina, hypertension, or arrhythmias, which are disturbances of the heartbeat. Beta blockers work by binding to sites on the heart normally reserved for the attachment of the hormone adrenaline, also called epinephrine. Since adrenaline increases the speed and force of the heart’s contraction, beta blockers will slow and relax the heart. The heart’s oxygen needs decrease and angina is less likely to occur. Beta blockers also prevent your blood pressure from rising during exercise. There are a variety of beta blockers available today.

Beta blockers can be effective, but are not for everyone. They have a tendency to aggravate asthma and other lung conditions. They may worsen some circulatory conditions in the legs, aggravate some dermatological conditions. For some patients, beta blockers lead to fatigue and cause depression. But the overwhelming majority of patients find beta blockers helpful and side effects minimal.

Calcium channel blockers: Combining some of the effects of both nitrates and beta blockers, this category of drug is commonly prescribed for angina. This diverse group of drugs tend to reduce the heart’s demand for oxygen and increase blood flow. Side effects are relatively uncommon. Several have a slight tendency to cause swelling in the legs and ankles, or edema. One drug in particular, verapamil, often causes fatigue. For that reason, doctors often recommend it be taken at bedtime.

Are there drugs that will prevent angina from progressing?

Lipid Lowering Drugs: Abnormalities of blood lipid levels are a known contributor to coronary artery disease and angina. In addition to total cholesterol, elevations of LDL or “bad cholesterol” low levels of the protective HDL cholesterol, and elevations of triglyceride levels have been found to be predictors of cardiovascular disease. In addition to changing your diet to lower fat and cholesterol, your doctor may recommend the use of lipid lowering drugs. This category of drugs has received a great deal of attention as a result of several large clinical trials comparing the use of cholesterol drugs versus placebo. Such studies have shown lipid lowering drugs can reduce heart attacks, reduce hospitalizations and even prolong life.

Vitamins: Your doctor may recommend vitamins thought to be helpful in preventing or halting the progress of coronary artery disease. Although there is some disagreement and some recent clinical trials have questioned its usefulness, some physicians recommend vitamin E. If you have elevated levels of homocysteine, your doctor may recommend supplements of folic acid and vitamins B6 and B12.

What about Procedures to Improve Heart Blood Flow?

In addition to drugs, there are many new surgical procedures that enlarge the coronary arteries and improve symptoms. Among are the most common:

Angioplasty: Balloon angioplasty – also called PTCA or percutaneous transluminal coronary angioplasty - is a procedure in which a catheter is inserted through an artery in the leg and guided up to the heart. Once inside the narrowed artery, a balloon at the tip of the catheter is inflated to widen the artery and improve blood flow. Some doctors use other devices, such as rotating blades, burrs, and lasers, to accomplish the same thing. All these devices offer a high success rate, a low complication rate, and an immediate and often dramatic improvement in symptoms.

On the downside, angioplasty often has to be to be re-done if the arteries become clogged again. For that reason, most doctors recommend placing a stent – a stainless steel wire mesh tube – at the site of angioplasty. Not only does a stent improve the safety and effectiveness of the initial procedure, but it also seems to reduce the need to re-do the procedure (see below).

Although angioplasty was originally used in patients with only a single blocked artery, several recent studies have shown it can also be effective in widening several blocked arteries. Such studies have shown this technique may be comparable to bypass surgery in terms of safety over the long term, although the need for repeat procedures was very common.

Recovery from an angioplasty is simple. Most patients are home within a day or two and back to work within a few days. If a stent has been inserted you will likely be put on a platelet-inhibiting drug such as clopidigral or ticlopidine for several weeks following the procedure in order to prevent blood clots.

Stents: Increasingly, angioplasty of heart arteries is accompanied by placement of “stents”. These are small stainless steel wire-mesh tubes which are inserted at the site of a blockage during heart catheterization. Stents are expanded into place using a balloon and are embedded into the inner wall of a diseased artery, thereafter serving as a frame or scaffold to prevent the artery from re-narrowing. Studies of shown that stents have the effect of reducing the likelihood of immediate complications at the time of arterial manipulation, and also – most importantly – reducing the likelihood of repeat blockage at the repair site during the months following the procedure.

The use of radiation, delivered at the site of a stent, is termed “brachytherapy” and has been shown to reduce the incidence of repeat blockage (“restenosis”). A additional technology, the use of drug-eluting stents, is now available at DHMC and has shown great promise in making results obtained at the time of the procedure virtually permanent.

Coronary artery bypass graft surgery: Developed more than 30 years ago and highly effective, this is a procedure in which a segment of vein from the leg or a natural artery from the chest wall is used to route blood around a site of narrowing in a heart artery. In general, this procedure is used in patients with many blocked arteries. Bypass surgery has become extremely widespread and generally very safe. It usually involves a hospitalization of about a week and a month-long recovery period. Most patients do not return to work until two to three months after surgery.

Which procedure is best for you? There is no easy answer. The choice of procedure is dependant upon a number of factors including the nature and extent of your coronary disease, the severity of your symptoms, the presence of other diseases, and – importantly – your preferences. Discuss your options in detail with your cardiologist or cardiac surgeon. Find out exactly what will be involved. Ask about the risks. Ask about the recovery. Ask about alternatives. Since there are so many potential approaches to coronary artery disease, your preferences will often be an important factor in the choice of treatment.

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