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Angina

What Is Angina? (an-JI-nuh or AN-juh-nuh)

Angina is chest pain or discomfort that occurs when your heart muscle does not get enough blood. Angina may feel like pressure or a squeezing pain in your chest. The pain may also occur in your shoulders, arms, neck, jaw, or back. It may also feel like indigestion.

Angina is a symptom of coronary artery disease (CAD), the most common type of heart disease. CAD occurs when plaque builds up in the coronary arteries. This buildup of plaque is called atherosclerosis. As plaque builds up, the coronary arteries become narrow and stiff. Blood flow to the heart is reduced. This decreases the oxygen supply to the heart muscle.

Types of Angina

There are 3 types of angina-stable, unstable, and variant (Prinzmetal's). It is very important to know the differences among the types.

Stable angina. Stable angina is the most common type. It occurs when the heart is working harder than usual.

• There is a regular pattern to stable angina.
• After several episodes, you learn to recognize the pattern and can predict when it will occur.
• The pain usually goes away in a few minutes when you rest or take your angina medicine.
• Stable angina is not a heart attack but makes it more likely that you will have a heart attack in the future.

Unstable angina. Unstable angina is a very dangerous condition that requires emergency treatment. It is a sign that a heart attack could occur soon. Unlike stable angina, it does not follow a pattern. It can occur without physical exertion and is not relieved by rest or medicine.

Variant angina. Variant angina is rare. It usually occurs at rest. The pain can be severe and usually occurs between midnight and early morning. It is relieved by medication.

Not all chest pain or discomfort is angina. Chest pain or discomfort can be caused by a heart attack, lung problems (such as an infection or a blood clot), heartburn, or a panic attack. However, all chest pain should be checked by a doctor.

What Causes Angina?

Angina is caused by reduced blood flow to an area of the heart. This is most often due to coronary artery disease (CAD). Sometimes, other types of heart disease or uncontrolled high blood pressure can cause angina.

In CAD, the arteries that carry oxygen-rich blood to the heart muscle are narrowed due to the buildup of fatty deposits called plaque. This is called atherosclerosis. Some plaque is hard and stable and leads to narrowed and hardened arteries. Other plaque is soft and is more likely to break open and cause blood clots. The buildup of plaque on the inner walls of the arteries can cause angina in two ways:

• By narrowing the artery to the point where the flow of blood is greatly reduced
• By forming blood clots that partially or totally block the artery.

Stable Angina

Physical exertion is the most common cause of pain and discomfort from stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low (such as when you are sitting). But with exertion like walking up a hill or climbing stairs, the heart works harder and needs more oxygen. Other causes include:

• Emotional stress
• Exposure to very hot or cold temperature
• Heavy meals
• Smoking.

Unstable Angina

Unstable angina is caused by blood clots that partially or totally block an artery. If plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. The clot may grow large enough to completely block the artery and cause a heart attack. Blood clots may form, partly dissolve, and later form again. Chest pain can occur each time a clot blocks an artery.

Variant Angina

Variant angina is caused by a spasm in a coronary artery. The spasm causes the walls of the artery to tighten. This narrows the artery, causing the blood flow to the heart to slow or stop. Variant angina may occur in persons with and without CAD. Other causes of spasms in the arteries that supply the heart with blood are:

• Exposure to cold
• Emotional stress
• Medications (vasoconstricting) that constrict or narrow blood vessels
• Cigarette smoking
• Cocaine use

The pain or discomfort of angina:

• Is often described as pressure, squeezing, burning, or tightness in the chest
• Usually starts in the chest behind the breastbone
• May also occur in the arms, shoulders, neck, jaw, throat, or back
• May feel like indigestion.

Some people say that angina discomfort is hard to describe or that they can't tell exactly where the pain is coming from. Symptoms such as nausea, fatigue, shortness of breath, sweating, light-headedness, or weakness may also occur.

Symptoms vary based on the type of angina.

Stable Angina

The pain or discomfort:

• Occurs when the heart must work harder, usually during physical exertion
• Is expected, and episodes of pain tend to be alike
• Usually lasts a short time (5 minutes or less)
• Is relieved by rest or angina medicine
• May feel like gas or indigestion
• May feel like chest pain that spreads to the arms, back, or other areas.

Unstable Angina

The pain or discomfort:

• Often occurs at rest, while sleeping at night, or with little physical exertion
• Is unexpected
• Is more severe and lasts longer (as long as 30 minutes) than stable angina episodes
• Is usually not relieved with rest or angina medicine
• May get continuously worse
• May signal that a heart attack will happen soon.

Variant Angina

The pain or discomfort:

• Usually occurs at rest and during the night or early morning hours
• Tends to be severe
• Is relieved by angina medicine.

Chest pain that lasts longer than a few minutes and is not relieved by rest or angina medicine may mean you are having-or are about to have-a heart attack. Get emergency help right away.

How is Angina Treated?

Treatment for angina includes lifestyle changes, medication, surgery, and rehabilitation. The main goals of treatment are to:

• Reduce the frequency and severity of symptoms
• Prevent or lower the risk of heart attack and death.

Lifestyle changes and medication may be the only treatments needed if your symptoms are mild and are not getting worse. Unstable angina is an emergency condition that requires treatment in the hospital.

Lifestyle Changes

The first thing that you need to do is change your living habits to avoid bringing on an episode of angina. If angina comes on

• With exertion, slow down or take rest breaks.
• After a heavy meal, avoid large meals and rich foods that leave you feeling stuffed.
• With stress, try to avoid situations that make you upset or stressed. Learn techniques to handle stress that can't be avoided.

Other changes that you need to make include:

• Eat a healthy diet to prevent or reduce high blood pressure and high blood cholesterol, and obesity
• If you smoke, quit.
• Exercise as directed by your doctor.
• Lose weight if you are overweight.
• If you have diabetes, follow your doctor's orders and take all medications as directed.

Medications

Nitrates are the most commonly used medicines to treat angina. Fast-acting preparations are taken when angina occurs or is expected to occur. Nitrates relax and widen blood vessels, allowing more blood to flow to the heart while reducing its workload.

You can use nitrates in different forms to:

• Relieve an episode that is occurring by using the medicine when the pain begins
• Prevent episodes from occurring by using the medicine just before pain or discomfort is expected to occur
• Reduce the number of episodes that occur by using the medicine regularly on a long-term basis.

Nitroglycerin is the most commonly used nitrate for angina. Nitroglycerin that dissolves under your tongue or between your cheeks and gum is used to relieve an angina episode. Nitroglycerin in the form of pills and skin patches is used to prevent attacks of angina. (Nitroglycerin in these forms acts too slowly to relieve pain during an angina attack.)

Other medicines used to treat angina include:

• Beta blockers, which slow heart rate and lower blood pressure. They can delay or prevent the onset of angina.
• Calcium channel blockers, which relax blood vessels so that more blood flows to the heart, reducing pain from angina. Calcium channel blockers also lower blood pressure.
• ACE inhibitors lower blood pressure and reduce the strain on the heart. They also reduce the risk of a future heart attack and heart failure.

Medicines that may also be used by people with angina include:

• Medicines to lower cholesterol levels
• Medicines to lower high blood pressure
• Oral antiplatelet (an-ty-PLAYT-lit) medicines (such as aspirin and clopidigrel) taken daily to stop platelets from clumping together to form blood clots. Platelets are small blood cell fragments that circulate through your blood vessels and help stop bleeding by sticking together to seal small cuts or breaks in tiny blood vessels. Antiplatelet medicines may not be appropriate for some people because they increase the risk of bleeding. Discuss the benefits and risks with your doctor before starting therapy with aspirin or the other antiplatelet medicines.
• Glycoprotein IIb-IIIa inhibitors are potent antiplatelet medicines that prevent clots from forming in your arteries. They are given intravenously in hospitalized patients in the treatment of angina or during and after angioplasty.
• Anticoagulants (an-ty-ko-AG-u-lants) to prevent clots from forming in your arteries and blocking blood flow.

Special (Invasive) Procedures

When medicines and other treatments do not control angina, special procedures may be needed. Two commonly used procedures are:

• Angioplasty to open blocked or narrowed coronary arteries. It can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a stent is placed in the artery to keep it propped open after the procedure.
   
• Coronary artery bypass surgery, which uses arteries or veins from other areas in your body to bypass your blocked coronary arteries. Bypass surgery improves blood flow to your heart, relieves chest pain, and can prevent a heart attack.

Cardiac Rehabilitation (Rehab)

Your doctor may prescribe cardiac rehab for angina or after bypass surgery, angioplasty, or a heart attack.

The cardiac rehab team may include:

• Doctors
  • Your family doctor
  • A heart specialist
  • A surgeon
• Nurses
• Exercise specialists
• Physical therapists and occupational therapists
• Dietitians
• Psychologists or other behavior therapists.

Rehab has two parts:

• Exercise training to help you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual ability, needs, and interests.
  
   
• Education, counseling, and training to help you understand your heart condition and find ways to reduce your risk of future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.

Select the link below for more information on cardiac rehab:

"Recovering from Heart Problems Through Cardiac Rehabilitation: Patient Guide," from the U.S. Agency for Healthcare Quality and Research.

References:

National Institutes of Health (NIH)

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