Angina Pectoris
Overview
Reduced blood flow to heart muscles causes chest pain called as angina pectoris. Angina is a symptom of coronary artery disease. A person may feel pain when insufficient oxygen-rich blood reaches the heart muscle. This reduced blood flow is caused by coronary artery disease. In coronary artery disease, there is an accumulation of plaque inside the coronary blood vessels. The pain associated with angina is typically described as squeezing, pressure, heaviness, tightness or pain in your chest. A common presentation as told by most patients is the feeling that ‘someone is standing on their chest’. The usual site of pain in angina is chest, but may also be felt in the shoulders, arms, neck, throat, jaw, or back.
Anginapectoriscan be a recurring problem or a sudden, acute health issue. Although angina is common, it can be hard to distinguish from other types of chest pain. Most common confounding factor is pain or discomfort of indigestion. Seek medical attention immediately if you have unexplained chest pain.
Angina can be of the following three types:
- Stable angina: In this type of angina, the pain is predictable and presents only during exertion or extreme emotional distress. It generally disappears with rest.
- Unstable angina: This type of angina could be an indication of a heart attack. Unstable angina is angina pain that is different from your regular angina pain or pain that occurs while at rest. The characteristic feature of this type of angina is that it may occur more frequently, more easily at rest, feel more severe, last longer, or come on with minimal activity. In most cases, this type of angina gets relieved with medication. But, it is unstable and may progress to a heart attack. Intensive medical or surgical treatment or a procedure is required for relief.
- Prinzmetal’s angina: Angina occurring at rest is called Prinzmetal’s angina. This may occur at rest, when sleeping, or when exposed to cold temperatures. The cause is mostly decreased blood flow to the heart muscle from a spasm of the coronary artery. This type of angina in most people is associated with coronary artery disease. These spasms occur close to the blockage.
Causes
Reduced blood flow to your heart muscles causes angina. Blood is a carrier of oxygen, which your heart muscle needs to survive. In situations where heart muscle isn’t getting enough oxygen, it causes a condition called ischemia. Coronary artery disease (CAD) is the most common cause of reduced blood flow to your heart muscles. The arteries of the heart (coronary arteries) can become narrowed by fatty deposits called plaques. This is called atherosclerosis.
Angina due to reduced blood flow is a supply problem, wherein the heart is not getting enough oxygen-rich blood. It might be interesting to note that a person may not always have angina if the heart arteries are narrowed due to fatty buildup. The reason is that during times of low oxygen demand — when you’re resting, for example — your heart muscle may be able to get by on the reduced amount of blood flow without triggering angina symptoms. When the demand for oxygen suddenly increases, like when you exercise, this can cause angina.
A positive family history of CAD or stroke indicates increased risk to develop unstable angina than in people whose families do not have these conditions. Other risks for unstable angina are related to lifestyle, including:
- Smoking
- High cholesterol
- Sedentary lifestyle
- High blood pressure
- Eating a high-fat, high-cholesterol diet
- Having diabetes
- Being more than 30 percent overweight
- Using cocaine or other recreational drugs
Symptoms
Symptoms of angina include:
- Chest pain or discomfort
- Pain in your arms, neck, jaw, shoulder or back accompanying chest pain
- Nausea
- Fatigue
- Shortness of breath
- Anxiety
- Sweating
- Dizziness
The typical features of chest pain and discomfort common with angina are a felling of pressure, squeezing, fullness or pain in the center of your chest. The feeling experienced by some people is of as if someone is squeezing their chest, or feeling like a heavy weight has been placed on their chest.
There are variations in the severity, duration and type of angina. In case somebody has a new or changing chest pain, immediate medical attention should be sought. New or different symptoms may signal a more dangerous form of angina (unstable angina) or a heart attack.
Most common form of angina is stable angina. It typically occurs with exertion and goes away with rest. When somebody previously healthy experiences a new onset chest pain, it’s important to see the doctor to find out what’s causing the chest pain and to get proper treatment. If your stable angina gets worse or changes, seek medical attention immediately.
Characteristics of stable angina
- Pain appears when your heart works harder, such as when you exercise or climb stairs
- A predictable angina and the pain is usually similar to previous types of chest pain you’ve had
- Duration is short, perhaps five minutes or less
- Disappears sooner if you rest or use your angina medication
- Could feel like indigestion
- Might spread to your arms, back or other areas
- Can be triggered by mental or emotional stress
Characteristics of unstable angina (a medical emergency)
- May occurs even at rest
- Is a deviation from usual pattern of angina
- Comes unexpectedly
- Severity is high and lasts longer than stable angina, maybe as long as 30 minutes
- May not disappear with rest or use of angina medication
- Might signal a heart attack
Characteristics of variant angina (Prinzmetal’s angina)
- Occurs during rest
- Is often severe
- Relieved by angina medication
- It is rare — only about 2 percent of angina cases are Prinzmetal’s angina. This type of angina is caused by a spasm in your heart’s arteries that temporarily reduces blood flow.
Angina in women
Symptoms of angina in women can be different from the classic angina symptoms. For example, a woman may have chest pain that feels like a stabbing, pulsating or sharp form of chest pain rather than the more typical vise-like pressure. Associated symptoms like nausea, shortness of breath or abdominal pain are more common in women. These differences may lead to delays in seeking treatment.
Diagnosis
To diagnose angina, your doctor will start by doing a physical examination and asking about your symptoms. You’ll also be asked about any risk factors, including whether you have a family history of heart disease.
There are several tests your doctor may order to help confirm whether you have angina:
- Electrocardiogram (ECG): It is an electrical recording of the signals as they travel through your heart. Evidence of a previous heart attack can be revealed by an ECG. If the signs and symptoms of your atherosclerosis is more evident during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG.
- Stress test: Stress test is also an exercise stress test. IT is used to gather information about how well your heart works during physical activity. By doing exercise on bike or treadmill your heart pump harder and faster than it does during most daily activities. Testing of the heart during and after exercise can reveal problems within your heart that might not be noticeable otherwise. The procedure usually involves walking on a treadmill or riding a stationary bike while your heart rhythm and blood pressure and breathing are monitored. In some types of stress tests, pictures will be taken of your heart, such as during a stress echocardiogram (ultrasound) or nuclear stress test. In patients who are unable to exercise due to some or other reason, a medication that mimics the effect of exercise on heart is used to make it pump harder.
- Chest X-ray: Images of your heart and lungs is displayed by this test. Also, other conditions can be looked into that might explain your symptoms and to see if you have an enlarged heart.
- Echocardiogram: It is a type of ultrasound examination of your heart to produce images of the heart. These images are seen by the doctor to identify angina-related problems, including whether there are areas of your heart not getting enough blood or heart muscle that’s been damaged by poor blood flow. Sometimes, an echocardiogram is performed during a stress test.
- Nuclear stress test: This test is performed to assess blood flow to your heart muscle at rest and during stress. It is similar to a routine stress test but uses a radioactive substance.
Coronary angiography. Narrowing or blockade in coronary arteries can be revealed by this test. The test involves injecting a liquid dye into the arteries of your heart through a long, thin tube (catheter) that’s fed through an artery, usually in your leg, to the arteries in your heart. The arteries become visible on X-ray, as the dye fills your arteries. Any area of blockage can then be revealed. - Blood tests: Blood is tested for elevation of certain heart enzymes that slowly leak out into your blood if your heart has been damaged by a heart attack.
- Cardiac computerized tomography (CT) scans: During performance of this test, you lie on a table inside a doughnut-shaped machine. Inside the machine there is an X-ray tube which rotates around your body and collects images of your heart and chest. These images can show if any of your heart’s arteries are narrowed or if your heart is enlarged.
Complications
Heart attack is the most dangerous complication to be concerned about with angina. Common symptoms of a heart attack include:
- Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes
- Pain extending beyond your chest to your shoulder, arm, back, or even to your teeth and jaw
- Increasing episodes of chest pain
- Seek emergency medical consultation if you have any of these symptoms.
- Prolonged pain in the upper abdomen
- Shortness of breath
- Sweating
- Impending sense of doom
- Fainting
- Nausea and vomiting
Treatment
Angina treatment options are many, including lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery. Treatment aims to reduce the frequency and severity of your symptoms and to lower your risk of heart attack and death.
Lifestyle changes
- Stop smoking
- Exercise most days of the week
- Eat healthy foods
- Avoid large meals
- Lose extra pounds and maintain a healthy weight
- Manage stress
- If you have high cholesterol, high blood pressure, diabetes or another chronic disease, work with your doctor to manage the condition and promote overall health.
- Pace yourself and take breaks as angina is often brought on by exertion.
Medications
Medications are required if lifestyle changes alone don’t help your angina. Medications may include:
Aspirin: It reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries.
Nitrates: This class of drugs relaxes and widens your blood vessels, which allows more blood to flow to your heart muscle: Angina related chest discomfort gets relieved with taking a nitrate tablet under the tongue.
Beta blockers: These drugs block the effects of the hormone epinephrine, and slow down the heart beats, thereby reducing blood pressure. Beta
Statins: These drugs are used to lower cholesterol.
Calcium channel blockers: These drugs relax and widen blood vessels by affecting the muscle cells in the arterial walls.
Angiotensin-converting enzyme (ACE) inhibitors: These drugs are also used to relax blood vessels.
Ranolazine: This drug used alone or with other angina medications, works specifically to treat angina.
Medical procedures and surgery
- Angioplasty and stenting: These are used when unstable angina or lifestyle changes and medications don’t effectively treat your chronic, stable angina.
- Coronary artery bypass surgery: This is recommended in patients with several blockades or in instances where the blockade is in a position that cannot be treated by stenting. It is a major surgery on heart arteries and involves creating a graft bypass using a vessel from another part of your body or a tube made of synthetic fabric. With this procedure, blood flow is maintained around the blocked or narrowed artery.
Prevention
Lifestyle changes can help you prevent angina. These include:
- Stop smoking
- Exercise most days of the week
- Eat healthy foods
- Avoid large meals
- Lose extra pounds and maintain a healthy weight.
- Manage stress
If you have high cholesterol, high blood pressure, diabetes or another chronic disease, work with your doctor to manage the condition and promote overall health.
