Angina

Overview

Angina (an-JIE-nuh or AN-juh-nuh) is a type of chest pain caused by reduced blood flow to the heart. Angina is a symptom of coronary artery disease.

Angina also is called angina pectoris.

Angina is often described as squeezing, pressure, heaviness, tightness or pain in the chest. It may feel like a heavy weight lying on the chest. Angina may be a new pain that needs to be checked by a healthcare professional, or it may be recurring pain that goes away with treatment.

Angina is relatively common. But some people may not be able to tell it apart from other types of chest pain, such as heartburn. If you have unexplained chest pain, get medical help right away.

Types

There are different types of angina. The type depends on the cause and whether rest or medicine eases symptoms.

• Stable angina. Stable angina is the most common form of angina. It usually happens during activity, also called exertion. It goes away with rest or angina medicine. Pain that starts when you're walking uphill or in the cold weather may be angina.

  Stable angina is predictable. It is usually similar to previous episodes of chest pain. The chest pain typically lasts a short time, perhaps five minutes or less.

• Unstable angina, which is a medical emergency. Unstable angina is unpredictable and occurs at rest. Or the pain is worsening and occurs with less physical effort. Unstable angina is typically severe and lasts longer than stable angina, maybe 20 minutes or longer. The pain doesn't go away with rest or the usual angina medicines. If the blood flow doesn't improve, the heart doesn't get enough oxygen. A heart attack occurs. Unstable angina is dangerous and needs emergency treatment.
• Variant angina, also called Prinzmetal angina. This type of angina isn't due to coronary artery disease. It's caused by a spasm in the heart's arteries. The spasm temporarily reduces blood flow. Severe chest pain is the main symptom of variant angina. It most often occurs in cycles, typically at rest and overnight. The pain may be relieved by angina medicine.
• Refractory angina. Angina episodes are frequent despite a combination of medicines and lifestyle changes.

Symptoms

Angina symptoms include chest pain and discomfort. The chest pain or discomfort may feel like:

• Burning.
• Fullness.
• Pressure.
• Squeezing.

Pain also may be felt in the arms, neck, jaw, shoulder or back.

Other symptoms of angina include:

• Dizziness.
• Fatigue.
• Nausea.
• Shortness of breath.
• Sweating.

The severity, duration and type of angina can vary. New or different symptoms may signal unstable angina or a heart attack.

Any new or worsening angina symptoms need to be checked immediately by a healthcare professional. The healthcare team can determine whether you have stable or unstable angina.

Angina in women

Symptoms of angina in women can be different from the classic angina symptoms. These differences may lead to delays in seeking treatment. For example, chest pain may not be the only symptom or the most common symptom. Other symptoms of angina in women may include:

• Discomfort in the neck, jaw, teeth or back.
• Nausea.
• Shortness of breath.
• Stabbing pain instead of chest pressure.
• Stomach pain.

When to see a doctor

Chest pain that lasts longer than a few minutes and doesn't go away with rest or angina medicines may be due to a heart attack. Call 911 or emergency medical help. Only drive yourself to the hospital if there is no other way to get there.

If chest discomfort is a new symptom for you, see a healthcare professional to determine the cause and to get proper treatment. If you have stable angina and it gets worse or changes, seek medical help immediately.

Causes

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

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

Plaque in a blood vessel may rupture or cause a blood clot. These events can quickly block or reduce flow through a narrowed artery. This can suddenly and severely decrease blood flow to the heart muscle.

The heart muscle may still be able to work during times of low oxygen demand without triggering angina symptoms. An example is when resting. But when the demand for oxygen goes up, such as when exercising, angina can result.

Risk factors

The following things may increase the risk of angina:

• Increasing age. Angina is most common in adults age 60 and older.
• Family history of heart disease. Tell your healthcare team if your mother, father or any siblings have or had heart disease or a heart attack.
• Tobacco use. Smoking, chewing tobacco and long-term exposure to secondhand smoke can damage the lining of the arteries. Artery damage can let deposits of cholesterol collect and block blood flow.
• Diabetes. Diabetes increases the risk of coronary artery disease. Coronary artery disease can cause angina.
• High blood pressure. Over time, high blood pressure damages arteries by speeding up the hardening of the arteries.
• High cholesterol or triglycerides. Too much bad cholesterol, called low-density lipoprotein (LDL), in the blood can cause arteries to narrow. A high LDL level increases the risk of angina and heart attack. A high level of triglycerides in the blood also is unhealthy.
• Other health conditions. Chronic kidney disease, peripheral artery disease, metabolic syndrome or a history of stroke increases the risk of angina.
• Not enough exercise. An inactive lifestyle raises the risk of high cholesterol, high blood pressure, type 2 diabetes and obesity. Talk with your healthcare team about the type and amount of exercise that's best for you.
• Obesity. Obesity is a risk factor for heart disease, which can cause angina. Being overweight makes the heart work harder to supply blood to the body.
• Emotional stress. Too much stress and anger can raise blood pressure. Rushes of hormones made by the body during stress can narrow the arteries and worsen angina.
• Medicines. Some medicines tighten blood vessels, which may trigger Prinzmetal angina. An example is certain migraine medicines.
• Drug misuse. Cocaine and other stimulants can cause blood vessel spasms and trigger angina.
• Cold temperatures. Exposure to cold temperatures can trigger Prinzmetal angina.

Complications

The chest pain that occurs with angina can make doing some activities, such as walking, uncomfortable. However, the most dangerous complication is a heart attack.

Warning symptoms of a heart attack include:

• Pressure, fullness or a squeezing pain in the center of the chest that lasts for more than a few minutes.
• Pain extending beyond the chest to the shoulder, arm or back, or even to the teeth and jaw.
• Fainting.
• Threatening sense of doom.
• Increasing episodes of chest pain.
• Nausea and vomiting.
• Continued pain in the upper belly area.
• Shortness of breath.
• Sweating.

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

Prevention

You can help prevent angina by following the same lifestyle changes that are used to treat angina:

• Avoid or limit alcohol.
• Don't smoke.
• Eat a healthy diet.
• Exercise regularly.
• Maintain a healthy weight.
• Manage other health conditions related to heart disease.
• Reduce stress.
• Get 7 to 9 hours of sleep a day.

Also get recommended vaccines to avoid heart complications.

Diagnosis

To diagnose angina, a healthcare professional examines you and asks questions about your symptoms. You are usually asked about any risk factors, including whether you have a family history of heart disease.

Tests

Tests used to diagnose and confirm angina include:

• Electrocardiogram (ECG or EKG). This quick and painless test measures the electrical activity of the heart. Sticky patches called electrodes are placed on the chest and sometimes the arms and legs. Wires connect the electrodes to a computer, which displays the test results. An ECG can show if the heart is beating too fast or too slow. The test can show if you are having or have had a heart attack.
• Chest X-ray. A chest X-ray shows the condition of the heart and lungs. A chest X-ray may be done to determine if other conditions are causing chest pain symptoms and to see if the heart is enlarged.
• Blood tests. Certain heart proteins slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these proteins, called cardiac enzymes.
• Stress test. Sometimes angina is easier to diagnose when the heart is working harder. A stress test typically involves walking on a treadmill or riding a stationary bike while the heart is checked. Other tests may be done at the same time as a stress test. If you can't exercise, you might get medicines that affect the heart like exercise does.
• Echocardiogram. This test uses sound waves to create images of the heart in motion. These images can show how blood flows through the heart. An echocardiogram may be done during a stress test.
• Nuclear stress test. A nuclear stress test helps measure blood flow to the heart muscle at rest and during stress. It is similar to a routine stress test, but during a nuclear stress test, a radioactive tracer is injected into the bloodstream. A special scanner shows how the tracer moves through the heart arteries. Areas that have small amounts or none of the tracer are likely to have poor blood flow.
• Cardiac computed tomography (CT) or magnetic resonance imaging (MRI). These tests create images of the heart and chest. Cardiac CT scans use X-rays. Cardiac MRI uses a magnetic field and radio waves to create images of the heart. For both tests, you usually lie on a table that slides inside a long tubelike machine. Each test can be used to diagnose heart problems. The tests can help show the severity of heart damage.

• Coronary angiogram. This test uses X-ray imaging to check the inside of the heart's blood vessels. It's part of a general group of procedures known as cardiac catheterization.

  A healthcare professional inserts a flexible tube called a catheter into a blood vessel, usually in the groin. It's guided to the heart. Dye flows through the catheter. The dye makes the heart arteries show up more clearly on an X-ray. The X-ray is called an angiogram.

Treatment

Options for angina treatment include:

• Lifestyle changes such as eating a healthy diet and exercising.
• Medicines.
• Angioplasty and stenting.
• Open-heart surgery called coronary artery bypass grafting (CABG).

The goals of angina treatment are to:

• Reduce the number of angina episodes.
• Make symptoms less severe.
• Lower the risk of a heart attack and death.

You will need immediate treatment if you have unstable angina or chest pain that's different from what you usually have.

Medications

If lifestyle changes don't improve heart health and relieve angina, you may need medicines. Medicines to treat angina may include:

• Nitrates. These medicines are often used to treat angina. Nitrates relax and widen the blood vessels so more blood goes to the heart. The most common form of nitrate used to treat angina is nitroglycerin (Nitrostat). The nitroglycerin pill is placed under the tongue. Your healthcare team might recommend taking a nitrate before activities that typically trigger angina, such as exercise. Some people need to take nitrates on a long-term, preventive basis.
• Aspirin. Aspirin reduces blood clotting, making it easier for blood to go through narrowed heart arteries. Preventing blood clots can reduce the risk of a heart attack. Don't start taking a daily aspirin without talking to your care team first.
• Clot-preventing drugs. Certain medicines such as clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta) make blood platelets less likely to stick together so blood doesn't clot. One of these medicines may be recommended if you can't take aspirin.
• Beta blockers. Beta blockers slow the heartbeat. The heart beats with less force, which lowers blood pressure. These medicines also relax blood vessels, which improves blood flow.
• Statins. Statins are drugs used to lower blood cholesterol. High cholesterol is a risk factor for heart disease and angina. Statins block a substance that the body needs to make cholesterol. They help prevent blockages in the blood vessels.
• Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels to improve blood flow.
• Other blood pressure medicines. Other drugs to lower blood pressure include angiotensin-converting enzyme (ACE) inhibitors and angiotensin 2 receptor blockers (ARBs). If you have high blood pressure, diabetes, symptoms of heart failure or chronic kidney disease, your healthcare team may prescribe one of these types of medicines.
• Ranolazine. This treatment may be prescribed for chronic stable angina that doesn't get better with other medicines. It may be used alone or with other angina medicines.

Therapies

Sometimes, a nondrug option called enhanced external counterpulsation (EECP) may be done to increase blood flow to the heart. With EECP, blood pressure-type cuffs are placed around the calves, thighs and pelvis. EECP requires multiple treatment sessions. EECP may help reduce symptoms in people with frequent, uncontrolled angina, called refractory angina.

Surgery and procedures

If lifestyle changes, medicines or other therapies don't reduce angina pain, a catheter procedure or open-heart surgery may be needed.

Surgeries and procedures used to treat angina and coronary artery disease include:

• Angioplasty with stenting. This treatment also is called percutaneous coronary intervention. A tiny balloon is inserted into the narrowed artery. The balloon is inflated to widen the artery. Then a small wire mesh coil called a stent is usually inserted to keep the artery open.

  Angioplasty with stenting improves blood flow in the heart, reducing or eliminating angina. The treatment may be a good option for those with unstable angina or if lifestyle changes and medicines don't effectively treat chronic, stable angina.

• Coronary artery bypass grafting (CABG). This is a type of open-heart surgery. During CABG, a vein or artery from somewhere else in the body is used to bypass a blocked or narrowed heart artery. The surgery increases blood flow to the heart. It's a treatment option for both unstable angina and stable angina that has not improved with other treatments.

Lifestyle and home remedies

Heart disease is often the cause of angina. Making lifestyle changes to keep the heart healthy is an important part of angina treatment. Try these strategies:

• Don't smoke. Quitting smoking is the most important thing you can do to improve heart health. Also, avoid being around secondhand smoke. If you need to quit, ask your care team for help.
• Get regular exercise. Regular exercise helps improve heart health. As a general goal, aim for at least 30 minutes of moderate or vigorous physical activity five or more days a week. If you've had a heart attack or heart surgery, you may have activity limits. Ask your healthcare professional what's best for you.
• Manage weight. Too much weight strains the heart. Being overweight increases the risk of high cholesterol, high blood pressure and diabetes. Ask your healthcare team what the best weight is for you.
• Eat a healthy diet. Avoid or limit foods with saturated fat, trans fats, salt and sugar. Choose whole grains, fruits, vegetables, and lean protein, such as fish and beans.
• Manage other health conditions. Ask your care team how often you need to have your blood pressure, blood sugar and cholesterol levels checked.
• Control stress. Find ways to help reduce emotional stress. Getting more exercise, practicing mindfulness and connecting with others in support groups are some ways to ease stress.
• Avoid or limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
• Practice good sleep habits. Poor sleep may increase the risk of heart disease and other chronic conditions. Adults should aim to get 7 to 9 hours of sleep daily. Go to bed and wake at the same time every day, including on weekends. If you have trouble sleeping, talk with your care team about strategies that might help.

Preparing for an appointment

If you have sudden chest pain, call 911 or your local emergency number immediately.

If you have a strong family history of heart disease, make an appointment for a health checkup.

Appointments can be brief, and there's often a lot to discuss. So it's a good idea to take steps to prepare for your appointment. Here's some information to help you get ready and what to expect during your visit.

What you can do

• Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet. For example, you may be told not to eat or drink for a few hours before a cholesterol test.
• Write down any symptoms you're having, including any that may seem unrelated to angina. Note when they started and what you were doing when they started.
• Write down important personal information, including any family history of angina, chest pain, heart disease, stroke, high blood pressure or diabetes. Also note any major stresses or recent life changes.
• Make a list of all medicines, vitamins and supplements that you take. Include those you buy without a prescription. Also include the dosages.
• Take someone along, if possible. Someone who goes with you can help you remember information you're given.
• Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, talk with your care team about any challenges you might face in getting started.
• Write down questions to ask your healthcare team.

For angina, some basic questions to ask include:

• What's the most likely cause of my chest pain symptoms?
• What kinds of tests will I need? How do I need to prepare for these tests?
• What treatments do you recommend and why?
• What's the safest type and amount of physical activity for me?
• I have other health conditions. How can I best manage these conditions together?
• How often do I need to follow up with you about my angina?
• Are there any brochures or other printed materials that I can take home with me?
• What websites do you recommend visiting?

Don't hesitate to ask any other questions that you may have during your appointment.

What to expect from your doctor

Your healthcare team is likely to ask you many questions. Being ready to answer them may save time to go over any information you want to spend more time on. Your care team may ask:

• When did you first begin having symptoms?
• How would you describe the chest pain?
• Where is the pain located?
• Does the pain spread to other parts of the body, such as the neck and arms?
• How and when did the pain start?
• Did something specific seem to trigger the chest pain?
• Does the pain start gradually or suddenly?
• How long does the pain last?
• What makes the chest pain worse?
• What makes it feel better?
• Do you have other symptoms with the pain, such as nausea or dizziness?
• Do you have trouble swallowing?
• Do you have a history of heartburn? Heartburn can mimic the feeling of angina.

What you can do in the meantime

It's never too early to make heart-healthy lifestyle changes. Lifestyle changes can help prevent angina complications such as heart attack and stroke.