Angina (Angina Pectoris)

Basic Information

When the heart does not have an adequate oxygen supply in the blood, pain may be felt in the chest, back, shoulder, jaw or upper arms. Angina pectoris is the name of this heart-related pain or discomfort which has been described in different ways including:

• constricting
• crushing
• knife-like
• smothering
• choking
• squeezing

The pain or discomfort can be dull or sharp and may last anywhere from just a few moments to 15 minutes.

Blood is supplied to the heart muscle by the coronary arteries. Angina may occur if there is coronary artery disease from fatty deposits in the blood (atherosclerosis) or from vessel spasms. Abnormal heart valves or arrhythmias (abnormal heart rhythm) can stop the heart from moving blood in an effective manner. The heart may have to pump harder during exercise, periods of stress or illness and an attack of angina can occur.

When lack of blood causes part of the heart muscle to die it is called ryocardial infarction. In other words demand exceeds the supply. This damage of the heart muscle (from disease or heart attack) is a cause of angina.

There are different classifications of angina. They include:

1. Stable angina -- the most common type. It is referred to as typical angina pectoris and usually follows what is called a precipitating event such as physical exertion, climbing stairs, engaging in sex, cold weather, a full or heavy meal or a stressful event.
2. Unstable angina -- attacks can follow with greater frequency increasing in severity and/or duration and can occur at rest or with even slight exercise.
3. Prinzmetal's variant -- angina occurs while at rest and is caused by coronary artery spasms. Those patients diagnosed with this type of angina are more prone to develop ventricular arrhythmias.
4. Syndrome X -- microvascular angina. There is a very good prognosis for patients with this type of angina who have normal coronary angiograms and have no coronary spasms.

Increased age is a risk factor in cases of angina; most diagnosed patients are middle-aged and elderly males. Three percent of the U.S. population over 30 years of age are diagnosed with angina pectoris. There may be a genetic predisposition for angina and males are more likely than females to develop it. When females do develop it, it is most likely to be after menopause, especially if estrogen replacements are not taken.

Other risk factors which can be modified include:

• Smoking (twice the risk of non-smokers)
• Diabetes
• Obesity
• Hypertension
• Hyperthyroidism
• Cocaine use
• Glucose intolerance
• Sedentary life-style
• High cholesterol
• Oral contraceptive use

Symptoms

As noted above, patients generally complain of chest pain, which they can describe differently, i.e.,

• tightness
• heaviness
• sharp, knife-like pain
• pressure
• heartburn

The pain generally lasts from a few moments to 15 minutes but some patients experience pain up to half an hour. It can be accompanied by dizziness, sweating, nausea, shortness of breath and pain (or numbness) in the jaw, left arm or shoulder.

Diagnosis/Treatment

The patient is usually diagnosed by symptoms and medical history in an office setting. Your health care provider may find few clues in a physical exam which may be quite normal. But your health care provider may need to rule out GI disorders or pulmonary diseases whose pain may mimic angina. An exercise tolerance test is a diagnostic tool. Laboratory tests can be useful in ruling out MI and in evaluating patients with unstable angina. They also may reveal other conditions such as high cholesterol, diabetes, hyperthyroidism and anemia. Imaging studies may be useful in certain evaluations. Electrocardiograms (ECGs) may also be recommended.

The goal in treating angina is to better the flow of blood to the heart muscle, thereby lessening the work of the heart itself. In this way the pain becomes more controllable.

Usually non-pharmacological therapy is recommended as the first treatment to try. This consists of getting more rest and lessening activity in general.

For those patients whose risk factors can be modified, behavioral changes are an essential part of treatment, i.e., stopping smoking, losing weight if obese, going on a low cholesterol diet if your cholesterol is high, and estrogen replacement following menopause.

Aerobic exercise has been found to be beneficial for many patients, not only improving symptoms but giving them a new lease on life with a better ability to work and enjoy leisure time. But remember not every patient with heart disease is able to tolerate exercise. If you have been diagnosed with heart disease, before engaging in an exercise program you must undergo an exercise test and your physician must approve any strenuous activities on your part.

Your health care provider will want to treat and manage underlying medical problems or aggravating conditions that contribute to angina or heart disease. These conditions would include hypertension, diabetes, high blood cholesterol, thyroid disease and arrhythmias.

In some angina patients the use of nitrates (such as nitroglycerin) -- a little pill that is placed beneath the tongue -- causes a better blood flow to the heart and reduces symptoms.

Beta blockers or calcium channel blockers may be recommended to those patients with hypertension.

Your health care provider will be able to prescribe the treatment or treatments that are best for your needs after evaluating the underlying causes of your angina. But whatever the cause, aspirin taken daily (unless your health care provider directs otherwise) is recommended.

It is important to remember to take your medications as scheduled and directed. And if you have cardiac symptoms not controlled by your medication (such as sweating, shortness of breath, faintness) seek medical care immediately.

Also if you are taking nitrates for relief of symptoms but do not get relief after taking them three times you should get to an emergency room as soon as possible or call 911.

If you are concerned about the effect of sexual activity, have a discussion with your health care provider. Usually -- though not always -- sexual activity is considered safe and about on the same level of risk as exercise done in moderation.

If you feel you have angina or have questions about it, please see your health care provider.

Additional Resource(s):

• American Heart Association 1-800-242-8721