Angina

Definition

Angina is a type of chest pain caused by reduced blood flow to the heart muscle. Angina is a symptom of coronary artery disease. Angina is typically described as squeezing, pressure, heaviness, tightness or pain in your chest. Many people with angina say it feels like someone is standing on their chest.

Angina, also called angina pectoris, can be a recurring problem or a sudden, acute health concern.

Angina is relatively common, but can be hard to distinguish from other types of chest pain, such as the pain or discomfort of indigestion. If you have unexplained chest pain, seek medical attention right away.

Symptoms

Angina symptoms 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 chest pain and discomfort common with angina may be described as pressure, squeezing, fullness or pain in the center of your chest. Some people with angina symptoms describe angina as feeling like a vise is squeezing their chest, or feeling like a heavy weight has been placed on their chest.

The severity, duration and type of angina can vary. It's important to recognize if you have new or changing chest pain. New or different symptoms may signal a more dangerous form of angina (unstable angina) or a heart attack.

Stable angina is the most common form of angina and typically occurs with exertion and goes away with rest. If chest pain is a new symptom for you, it's important to see your doctor to find out what's causing your chest pain and to get proper treatment. If your stable angina gets worse or changes, seek medical attention immediately.

Characteristics of stable angina

• Develops when your heart works harder, such as when you exercise or climb stairs
• Can usually be predicted and the pain is usually similar to previous types of chest pain you've had
• Lasts a short time, 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)

• Occurs even at rest
• Is a change in your usual pattern of angina
• Is unexpected
• Is usually more severe 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)

• Usually happens when you're resting
• Is often severe
• May be relieved by angina medication

Prinzmetal's angina 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
A woman's angina symptoms 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. Women are also more likely to experience symptoms, such as nausea, shortness of breath or abdominal pain. These differences may lead to delays in seeking treatment.

When to see a doctor
If your chest pain lasts longer than a few minutes and doesn't go away when you rest or take your angina medications, it may be a sign you're having a heart attack. Call 911 or emergency medical help. Arrange for transportation. Only drive yourself to the hospital as a last resort.

Causes

Angina is caused by reduced blood flow to your heart muscle. Your blood carries oxygen, which your heart muscle needs to survive. When your heart muscle isn't getting enough oxygen, it causes a condition called ischemia.

The most common cause of reduced blood flow to your heart muscle is coronary artery disease (CAD). Your heart (coronary) arteries can become narrowed by fatty deposits called plaques. This is called atherosclerosis.

This reduced blood flow is a supply problem — your heart is not getting enough oxygen-rich blood. You may wonder why you don't always have angina if your heart arteries are narrowed due to fatty buildup. This is because 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 ithout triggering angina symptoms. But when you increase the demand for oxygen, such as when you exercise, this can cause angina.

• Stable angina. Stable angina is usually triggered by physical exertion. When you climb stairs, exercise or walk, your heart demands more blood, but it's harder for the muscle to get enough blood when your arteries are narrowed. Besides physical activity, factors such as emotional stress, cold temperatures, heavy meals and smoking also can narrow arteries and trigger angina.
• Unstable angina. If fatty deposits (plaques) in a blood vessel rupture or a blood clot forms, it can quickly block or reduce flow through a narrowed artery, suddenly and severely decreasing blood flow to your heart muscle. Unstable angina can also be caused by conditions such as severe anemia, especially if you already have narrowed coronary arteries.
  Unstable angina worsens and is not relieved by rest or your usual medications. If the blood flow doesn't improve, heart muscle deprived of oxygen dies — a heart attack. Unstable angina is dangerous and requires emergency treatment.
  
• Variant angina. Variant angina, also called Prinzmetal's angina, is caused by a spasm in a coronary artery in which the artery temporarily  narrows. This narrowing reduces blood flow to your heart, causing chest pain. Variant angina accounts for about 2 percent of angina cases.

Risk factors

The following risk factors increase your risk of coronary artery disease and angina:

• Tobacco use. Chewing tobacco, smoking and long-term exposure to secondhand smoke damage the interior walls of arteries — including arteries to your heart — allowing deposits of cholesterol to collect and block blood flow.
• Diabetes. Diabetes is the inability of your body to produce or respond to insulin properly. Insulin, a hormone secreted by your pancreas, allows your body to use glucose, which is a form of sugar from foods. Diabetes greatly increases the risk of coronary artery disease, which leads to angina and heart attacks by speeding up atherosclerosis and increasing your cholesterol levels
• High blood pressure. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. Over time, high blood pressure damages arteries by accelerating atherosclerosis. High blood pressure can be an inherited problem. The risk of high blood pressure increases as you age, but the main causes are eating a diet too high in salt, stress, inadequate exercise and being overweight.
• High blood cholesterol or triglyceride levels. Cholesterol is a major part of the deposits that can narrow arteries throughout your body, including those that supply your heart. A high level of the wrong kind of cholesterol in your blood increases your risk of angina and heart attacks. Low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries. A high LDL level is undesirable and is often a byproduct of a diet high in saturated fats and cholesterol. A high level of triglycerides, a type of blood fat related to your diet, also is undesirable.
• Personal or family history of heart disease. If you have coronary artery disease or if you've had a heart attack, you're at a greater risk of developing angina.
• Older age. Men older than 45 and women older than 55 have a greater risk than younger adults.
• Lack of exercise. An inactive lifestyle contributes to high blood cholesterol levels and obesity. Exercise is beneficial in lowering high blood pressure. However, it is important to consult with your doctor before starting an exercise program.
• Obesity. Obesity raises the risk of angina and heart disease because it's associated with high blood cholesterol levels, high blood pressure and diabetes. Also, your heart has to work harder to supply blood to the excess tissue.
• Stress. You may respond to stress in ways that can increase your risk of angina and heart attacks. If you're under stress, you may overeat or smoke from nervous tension. Too much stress, as well as anger, can also raise your blood pressure. Surges of hormones produced during stress can narrow your arteries and worsen angina.

Complications

The chest pain that can occur with angina can make doing some normal activities, such as walking, uncomfortable. However, the most dangerous complication to be concerned about with angina is a heart attack.
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
• Prolonged pain in the upper abdomen
• Shortness of breath
• Sweating
• Impending sense of doom
• Fainting
• Nausea and vomiting

If you have any of these symptoms, seek emergency medical attention immediately.

Preparing for your appointment

If you think you may have recurring angina or are worried about your angina risk because of a strong family history, make an appointment with your family doctor. If angina is found early, your treatment may be easier and more effective. If you're having sudden chest pain (unstable angina), seek emergency medical attention immediately.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. For a blood test to check your cholesterol or other indicators of heart disease, for example, you may need to fast for a period of time beforehand.
• Write down any symptoms you're experiencing, including any that may seem unrelated to angina.
• Write down key personal information, including any family history of angina, chest pain, heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you're taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For angina, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What kinds of tests will I need?
• What's the best treatment?
• What foods should I eat or avoid?
• What's an appropriate level of physical activity?
• What are the alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist?
• Is there a generic alternative to the medicine you're prescribing me?
• Are there any brochures or other printed material that I can take home with me?
• What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

The doctor will also ask you to describe your discomfort or pain:

• Is it pain? Discomfort? Tightness? Pressure? Sharp? Stabbing?
• Where is the pain located? Is it in a specific area or more generalized?
• Does the pain spread to your neck and arms? How and when did the pain start? Did something specific seem to trigger the pain? Does it start gradually and build up? Or start suddenly?
• How long does it last?
• What makes it worse? Activity? Breathing? Body movement?
• What makes it feel better? Rest? Deep breath? Sitting up?
• Do you have other symptoms with the pain, such as nausea or dizziness?
• Do you have trouble swallowing?
• Do you often have heartburn? (Heartburn can mimic the feeling of angina.)

What you can do in the meantime
It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense against angina and its complications, including heart attack and stroke.

Tests and diagnosis

To diagnose angina, your doctor will start by doing a physical exam 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). Each beat of your heart is triggered by an electrical impulse generated from special cells in your heart. An electrocardiogram — also called an ECG or EKG — records these electrical signals as they travel through your heart. Your doctor can look for patterns among these heartbeats to see if the blood flow through your heart has been slowed or interrupted or if you are having a heart attack.
• Stress test. Sometimes angina is easier to diagnose when your heart is working harder. During a stress test, you exercise by walking on a treadmill or pedaling a stationary bicycle. While exercising, your blood pressure is monitored and your ECG readings are watched. Other tests also may be conducted while you're undergoing stress testing. If you're unable to exercise, you may be given drugs that cause your heart to work harder to simulate exercising.
• Chest X-ray. This test takes images of your heart and lungs. This is to look for other conditions that might explain your symptoms and to see if you have an enlarged heart.
• Echocardiogram. An echocardiogram uses sound waves to produce images of the heart. Your doctor can use these images 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. An echocardiogram is sometimes given during a stress test.
• Nuclear stress test. A nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It is similar to a routine stress test, but during a nuclear stress test, a radioactive substance is injected into your bloodstream. This substance mixes with your blood and travels to your heart. A special scanner — which detects the radioactive material in your heart — creates images of your heart muscle. Inadequate blood flow to any part of your heart will show up as a light spot on the images — because not as much of the radioactive substance is getting there.
• Coronary angiography. Coronary angiography uses X-ray imaging to examine the inside of your heart's blood vessels. It's part of a general group of procedures known as cardiac catheterization. During coronary angiography, a type of dye that's visible by X-ray machine is injected into the blood vessels of your heart. The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at the inside of your blood vessels.
• Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Samples of your blood can be tested for the presence of these enzymes.
• Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest, which can show if any of your heart's arteries are narrowed or if your heart is enlarged.

Treatments and drugs

There are many options for angina treatment, including lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery. The goals of treatment are to reduce the frequency and severity of your symptoms and to lower your risk of heart attack and death.
However, if you have unstable angina or angina pain that's different from what you usually have, such as occurring when you're at rest, you need immediate treatment in a hospital.

Lifestyle changes
If your angina is mild, lifestyle changes may be all you need to do. Even if your angina is severe, making lifestyle changes can still help. Changes include:

• If you smoke, stop smoking. Avoid exposure to secondhand smoke.
• If you're overweight, talk to your doctor about weight-loss options.
• If you have diabetes make sure that it is well controlled and that you are following an optimal diet and exercise plan.
• Because angina is often brought on by exertion, it's helpful to pace yourself and take rest breaks.
• Avoid large meals.
• Avoiding stress is easier said than done, but try to find ways to relax. Talk with your doctor about stress-reduction techniques.
• Eat a healthy diet with limited amounts of saturated fat, lots of whole grains, and many fruits and vegetables.
• Talk to your doctor about starting a safe exercise plan.

Medications
If lifestyle changes alone don't help your angina, you may need to take medications. These may include:

• Aspirin. Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clots can also reduce your risk of a heart attack. But don't start taking a daily aspirin without talking to your doctor first.
• Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, which allows more blood to flow to your heart muscle. You might take a nitrate when you have angina-related chest discomfort, before doing something that normally triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is with nitroglycerin tablets put under your tongue.
• Beta blockers. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, the heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina.
• Statins. Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in plaques in your artery walls, helping prevent further blockage in your blood vessels. Statins also have many other beneficial effects on your heart arteries.
• Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina.
• Angiotensin-converting enzyme (ACE) inhibitors. These drugs help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system in numerous ways, including narrowing your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder.
• Ranolazine (Ranexa). Ranexa can be used alone or with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin. Unlike some other angina medications, Ranexa can be used if you're taking oral erectile dysfunction medications.

Medical procedures and surgery
Lifestyle changes and medications are frequently used to treat stable angina. But medical procedures such as angioplasty, stenting and coronary artery bypass surgery are also used to treat angina.

• Angioplasty and stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — a tiny balloon is inserted into your narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open. This procedure improves blood flow in your heart, reducing or eliminating angina. Angioplasty and stenting is a good treatment option if you have unstable angina or if lifestyle changes and medications don't effectively treat your chronic, stable angina.
• Coronary artery bypass surgery. During coronary artery bypass surgery, a vein or artery from somewhere else in your body is used to bypass a blocked or narrowed heart artery. Bypass surgery increases blood flow to your heart and reduces or eliminates angina. It's a treatment option for both unstable angina as well as stable angina that has not responded to other treatments.

Lifestyle and home remedies

Because heart disease is often the cause of most forms of angina, you can reduce or prevent angina by working on reducing your heart disease risk factors. Making lifestyle changes is the most important step you can take.

• If you smoke, stop smoking.
• Eat a healthy diet with limited amounts of saturated fat, lots of whole grains, and many fruits and vegetables.
• Talk to your doctor about starting a safe exercise plan.
• If you're overweight, talk to your doctor about weight-loss options.
• Take anti-angina medications as prescribed and follow your doctor's directions.
• Treat diseases or conditions that can increase your risk of angina, such as diabetes, high blood pressure and high blood cholesterol.
• Because angina is often brought on by exertion, pace yourself and take rest breaks.
• Avoid large meals that make you feel overly full.
• Try to find ways to relax. Talk with your doctor about stress-reduction techniques.

Alternative medicine

Supplements that may help improve your angina treatment include:

• L-arginine
• L-carnitine

Both of these supplements may help reduce the swelling in your arteries that causes them to narrow, which contributes to high blood pressure and chest pain. Before adding either of these supplements to your treatment, talk to your doctor. Supplements can interact with other medications, causing dangerous side effects.

Prevention

You can help prevent angina by making the same lifestyle changes that might improve your symptoms if you already have angina. These include:

• Quit smoking.
• Monitor and control other health conditions, such as high blood pressure, high cholesterol and diabetes.
• Eat a healthy diet.
• Increase your physical activity, with your doctor's OK.
• Maintain a healthy weight.
• Reduce your stress level.