In this Article
Angina
What Is Angina?
Angina literally means “choking pain,” and angina pectoris refers to a painful or uncomfortable sensation in the chest that occurs when part of the heart does not receive enough oxygen due to disease in the coronary arteries that supply blood to the heart.
The coronary arteries supply the heart muscle with oxygen and nutrients. The word “coronary” means a crown and is the name given to the arteries that circle the heart like a crown.
Coronary heart disease develops when one or more of the coronary arteries that supply the blood to the heart become narrower than they used to be, due to the buildup of
Deposits of cholesterol and other fat-like substances can build up in the inner lining of these blood vessels and become coated with scar tissue, forming a cholesterol-rich bump in the blood vessel wall known as
Eventually these plaque deposits can build up to significantly reduce or block blood flow to the heart. A person may experience chest pain or discomfort from inadequate blood flow to the heart, especially during exercise when the heart needs more oxygen.
Angina is the body’s warning sign that the heart is being overworked. It can be experienced in a variety of ways.
- Angina usually manifests as a feeling of pain, pressure, or tightness in the middle chest, especially behind the sternum (breastbone).
- The sensation may spread to the left shoulder, arm, and hand, or to the neck, throat, and jaw.
- The attack typically lasts for only a few minutes
An attack of angina does not cause permanent damage to the heart muscle. This is the main difference between angina and a heart attack, during which part of the heart muscle suffers permanent damage (unless the new clot-busting drugs are given in time).
Stable versus unstable angina
It is very important to distinguish between two types of angina: stable angina and unstable angina. Both types result from problems within the coronary arteries.
- Stable angina results from a fixed obstruction of blood flow to the heart. It occurs when there is not enough blood for a fast-pumping heart, but sufficient blood can get through when the heart slows down and the individual is at rest. Stable angina typically is caused by widespread, irregular disease throughout the coronary arteries. The blockages that result may not seriously hinder the flow of blood, and they usually do not damage the heart unless a plaque (atheroma; fatty deposit within a blood vessel) suddenly ruptures.
- Unstable angina is due to a sudden interruption of blood flow to the heart due to a partial or complete blockage of the artery.Unstable angina comes on when a person is resting, asleep, or undergoes physical exertion (unlike stable angina, which usually comes on with a physical exertion). Symptoms of moderate or severe discomfort suddenly may develop in a person who has never experienced angina before, and attacks may become more frequent or increase in intensity.
Unstable angina can be dangerous, while stable
- Stable angina usually occurs during physical exertion or emotional stress or excitement. Stable angina doesn’t lead to a heart attack in most people.
- Unstable angina can occur during rest, can awaken a person from sleep, and can appear suddenly during physical exertion. Unstable angina may quickly progress to a heart attack.
Need To Know: About unstable angina
Unstable angina is a much more serious condition than stable angina because it may quickly progress to a heart attack. Some physicians regard unstable angina as a heart attack (until tests prove definitely that it is not a heart attack) because it is difficult to distinguish with early tests whether or not there has been damage to the heart muscle.
In unstable angina, cracks develop in the bulgingplaque inside the coronary artery. These cracks, or partial ruptures of the plaque, are called plaque fissuring. It sets off an inflammatory reaction that dissolves the layer of tissue separating the plaque from the flowing blood. When the blood comes into direct contact with the plaque, it begins to form a clot around the damaged plaque.
Three things can happen:
- The clot gets bigger. Depending on how much of the artery it blocks, it will either cause the pain of angina or develop into a heart attack if it completely blocks the artery.
- The clot moves to another part of the artery and blocks it, causing a heart attack.
- The clot may simply be washed away after the crack in the plaque has healed.
What was previously a reasonably “stable” narrowing of the coronary artery has become “unstable,” reducing the blood flow through the affected coronary artery and causing symptoms even at rest.
Some interesting facts about unstable angina:
- The plaques that develop the crack, or rupture, are usually not the same ones that cause the critical narrowing of the coronary arteries.
- We do not know why a plaque suddenly ruptures.
- Because the clot that forms is formed by
platelets , the treatment initially is to give antiplatelet treatments. This is a very different treatment from the “clot-busters” given for a heart attack. - Unstable angina is considered as part of a spectrum called “acute coronary syndrome,” which includes unstable angina and heart attack (known as myocardial infarction, either q-wave or non-q-wave types). What these conditions have in common is that symptoms result from rupture or erosion of a clot with obstruction of the coronary artery.
- A heart attack (known as a q-wave myocardial infarction) generally results from a more extensive rupture of a plaque, in which the whole clotting system, not just platelets, becomes involved. The treatment then uses “clot-busters” (called thrombolytics), which are very different drugs from antiplatelet drugs used for unstable angina.
It is vitally important for the doctor to make the distinction between stable angina, unstable angina, and a heart attack. This cannot always be done immediately.
Angina may occur during everyday activities such as:
- Rapid walking or running
- Lifting or carrying a weight
- Becoming angry or excited
- Shoveling snow
- Physical stress after eating (when food is still being digested)
- Sexual intercourse (rarely)
The sensation of stable angina usually wears off after the angina-causing activity ends. Attacks typically last for only a few minutes. Symptoms may be worse in cold weather.
Because the sensation of
Although angina therapy is better than ever before, successful treatment depends upon close cooperation between the individual and the healthcare team. The person with angina must assume a lifestyle that minimizes the risk of further heart trouble.
Facts about angina
- According to recent U.S. health statistics, more than six million Americans have angina.
- Each year, there are about 350,000 new cases of angina in the U.S.
- Many people believe angina to be a “man’s disease.” Yet angina actually affects more women than men (13.9% versus 9.4%), and it is most widespread among women who are black (5.2%) or Mexican-American (4.6%).
What Causes Angina?
The coronary arteries are small arteries that carry blood to the heart muscle. This blood flow provides the oxygen and nutrients needed by the heart itself so that it can keep pumping. If the heart has to speed up (for example, during exercise or periods of excitement) and cannot get the blood it needs, it will send out a signal in the form of angina.
The three major coronary arteries are the:
- Left anterior descending artery
- Left circumflex artery
- Right
coronary artery
Most people with angina have blockages in one or more of these arteries and/or their branches. A cardiologist (heart specialist) will perform various tests to determine the location and extent of the blockage.
The two major causes of angina are:
- Coronary artery disease (CAD)
- Coronary artery spasm
In almost all cases, the underlying cause of angina is the critical narrowing of one or more of the coronary arteries that supply blood to the heart.
Coronary artery disease – also known as coronary heart disease (CHD) or ischemic heart disease (IHD) – affects most people as they age. The coronary arteries become constricted or blocked by atheromas – bulging masses or “plaques” that form within the walls lining the arteries.
Nice To Know:
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The more atheromas that line the coronary arteries, the narrower the pathway for blood. Atherosclerosis often restricts as much as 70% of the blood that flows through the coronary arteries. Although the heart muscle receives enough blood for routine activities like walking or sitting,
Need To Know
Stable angina itself is not dangerous, but it does indicate the presence of underlying coronary heart disease. The plaques and narrowed coronary arteries that cause angina significantly increase the risk of a heart attack.
A heart attack occurs if a clot sticks in the narrowed part of a coronary artery and no blood can get through at all. Part of the heart muscle will die since it will not be supplied with the necessary oxygen to survive.
The exact cause(s) of coronary artery disease remains unknown. Yet experts have identified some of the risk factors that increase a person’s chance of getting this disease. They include:
- Aging
- High blood pressure (hypertension)
- Cigarette smoking
- High blood
cholesterol - Being overweight
- Lack of exercise
- Family history of angina or heart attack at a young age
- Diabetes
Certain individuals, though, develop angina without having any of the above common risk factors for CAD.
Coronary artery spasm
A more unusual type of angina is caused by spasm (sudden contraction [squeezing response]) of the smooth muscle within the coronary arteries. This condition is called
variant angina pectoris
(also known as “Prinzmetal’s angina” or angina inversa).
Variant angina pectoris does not occur when the heart has been overworked. Instead, variant angina comes on almost exclusively when a person is at rest or asleep, often between the hours of midnight and 8 a.m. The attacks can be extremely painful.
Variant angina is associated with coronary artery disease (CAD). About 65% of all sufferers have atherosclerosis in at least one major vessel of the heart. The coronary artery spasm that causes this form of angina typically occurs very near the atherosclerotic blockage.
People with variant angina often experience an active phase of the disease in which they are at particular risk for:
- Serious cardiac arrhythmias (heart rhythm disturbances), such as
ventricular tachycardia (rapid rate of the left, pumping chamber of the heart) andfibrillation (rapid, uncoordinated contraction [squeezing] of the heart muscle) - Myocardial infarction (MI; a heart attack)
- Sudden death
During this phase – which can last three to six months or more – an individual may experience frequent attacks of angina and
What Are The Symptoms Of Angina?
Chest pain is the major symptom of angina. This is usually felt as pain in the chest described as:
- Crushing pain,
- “Heaviness,” or
- Tightness in the middle of the chest.
The pain may spread to the left shoulder, arm and hand or to the neck, throat and jaw
It may feel as if someone is squeezing or pressing on the chest, or it may feel like a stabbing pain or numbness.
The pain may last from one to 10 minutes
It is usually associated with overexertion (or in some people when they get over excited)
Sometimes there are additional symptoms such as:
- Sweating
- Nausea
- Breathing difficulties
Sometimes the pain is low grade, not very painful, more of a discomfort in the chest.
The features of a heart attack – which include chest pain, sweating, and nausea – resemble those of angina, although there are major differences between the two conditions.
In angina the pain lasts from 1 minute to 10 minutes and then stops. The pain should also stop with rest.
Heart attack lasts much longer than angina, and the pain of a heart attack generally continue even after a person rests.
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What is the difference between a heart attack and angina? |
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ANGINA |
HEART ATTACK |
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Partial narrowing of the artery |
Partial or total blockage of the artery from a blood clot |
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No permanent heart muscle damage |
Permanent damage of the heart muscle, unless the blockage can be removed quickly by “clot-buster” medicine or other means |
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Lasts one to 10 minutes |
Lasts at least 20 minutes |
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Goes away with rest |
May continue after rest |
Does chest pain always mean a heart problem?
Chest pain does not always mean that there is a problem with the heart. Other conditions can be confused with angina. For example:
- Anxiety and tension are common causes of sharp chest pain, especially in the area under the left breast. These sensations differ from those of angina, which seldom is concentrated in this region. Anxiety-related chest pain may be accompanied by tenderness or made worse by movement.
- Gallbladder disease or indigestion also can cause pain in the chest, although such pain is associated with food rather than exercise.
When is angina an emergency?
Usually there are specific signs that angina is very serious or, indeed, an emergency. Whether or not a person has stable or unstable angina, it is important to go to the hospital IMMEDIATELY if anginal pain or discomfort is:
- More severe than previously experienced
- Getting worse or lasting longer than 20 minutes
- Accompanied by weakness, nausea, or fainting
- Unchanged after taking three nitroglycerin tablets
- Happening at an unusual time (for example, during rest)
If ambulance service is not available locally, a person should be driven to the nearest hospital and should NOT attempt to drive there alone. The individual’s family or friends should be made aware of the location and names of any angina medicines that are being used. They also should be familiar with warning signs of an anginal emergency.
How Is Angina Diagnosed?
A diagnosis of angina pectoris is based upon a number of factors, including the person’s symptoms, his or her medical history, and a physical examination. The physician will want to make sure that the individual’s chest pain is caused by angina and not some other condition, such as indigestion. In addition, the physician will want to determine how far coronary artery disease (CAD) has progressed.
Tests used to diagnose angina include:
Electrocardiography (EKG, ECG)
Electrocardiography (EKG, ECG) measures the electrical activity of the heart. To do this, a number of electrodes (small metal plates) are placed on the skin of the arms, legs, and chest. The electrodes detect the electrical signals that are produced by the heart muscle. The signals then are sent by wires to the EKG machine, which records them as “waves” that are printed out on paper.
The EKG provides information on new acute changes or damage to the heart muscle as well as clues to previous changes or damage to the heart muscle. It can reveal previous damage of the heart muscle, such as a mild heart attack that a person may have had without even knowing it. Unfortunately, the EKG does not reliably detect narrowing of the coronary arteries. For this information, the physician must perform additional tests, such as coronary angiography.
The EKG often is normal in people with angina when they are at rest, although it usually changes during an anginal attack. For this reason, EKG testing also may be conducted while the individual is exercising on a stationary bicycle or treadmill or while he or she performs daily activities over a 24-hour period (24-hour EKG).
Chest x-ray
A chest x-ray may be performed to rule out lung disease or other chest abnormalities that may be causing pain. In addition, a chest x-ray will reveal enlargement of the heart, which may be associated with heart muscle damage due to heart attack.
Chest x-ray, like an EKG, cannot identify narrowing within the coronary arteries.
Exercise (stress) test
The
- If a treadmill is used, the pace and steepness of the track will increase every few minutes so that the EKG can detect any changes in heart function during physical stress.
- If a fixed bicycle is used, the principle is exactly the same.
The physician or trained personnel will ask about angina symptoms during the test to ensure that the person does not overwork his or her heart.
In addition, the person may receive an injection of a radioisotope (a radioactive material) such as thallium, which makes the heart and its vessels visible to a special, computer-linked camera. The camera records how the heart moves and which parts of the heart muscle are short of blood during exercise.
The
Coronary angiography/cardiac catheterization
Coronary angiography – an outpatient procedure that is performed under local anesthesia by a cardiologist (heart specialist) – shows the precise size and location of blockages within the coronary arteries. The blood pressure within the heart can be measured at the same time.
- A catheter (fine tube) is inserted into an artery in the forearm or groin, and it is snaked through the blood vessels until it reaches the coronary arteries.
- Then, dye is pumped through the catheter, so that the heart itself and the coronary arteries are visible on a special video screen.
Coronary angiography can pinpoint narrowing, obstruction, and other abnormalities of the coronary arteries. It is an essential test if the cardiologist is considering
Coronary angiography takes about 30 minutes to perform, and it is quite safe. Most individuals are given antianxiety medication before the procedure, so that they feel calm throughout. Because of the anesthetic (painkiller) used during angiography, there is generally no discomfort.
Ergonovine test
The
- The artery-narrowing drug ergonovine (or, alternatively, acetylcholine) is injected to provoke coronary artery spasm.
- The person’s response to the ergonovine is then measured.
- If the individual experiences severe arterial spasm in response to ergonovine, he or she probably has variant angina.
Blood tests
The physician will order blood tests that gauge the amount of
The tests will create a “lipid profile” by measuring blood levels of
- high-density lipoproteins (HDL; “good
cholesterol “) - low-density lipoproteins (LDL; “bad cholesterol”)
- triglycerides
- other lipid markers
Recent research has shown that a blood test that measures the level ofC-reactive protein in the blood may be predictive of the mortality from heart disease. Other studies are also showing that the resting ESR (the “sedimentation rate” – how quickly the red blood cells settle to the bottom in a test tube) also has some predictive value about the mortality of heart disease.
Treatment of Angina?
The first step in angina treatment is to eliminate risk factors that are likely to hasten the progression of heart disease. This means that people with angina should stop smoking, lose excess weight, eat a “heart-healthy” diet, and exercise regularly, if possible.
Although physicians do not know everything about the causes of angina and atheroma (fatty deposits, or plaques, within the blood vessels), they do know enough to offer effective medical therapy. Such therapy will depend upon the results of exercise tolerance and other tests, the presence or absence of symptoms, and the individual’s personal preferences.
In general, most angina treatment involves medication, with or without an operative procedure such as
Angioplasty (blood vessel repair) orCoronary artery bypass surgery (surgically made arterial pathways that bypass [go around] diseased arteries in the heart)
Individuals with angina may consider:
- Smoking cessation
- Weight loss and proper nutrition
- Regular exercise
- Medication
- Surgery
Smoking cessation
If the person with angina is a smoker, the most important thing that he or she can do is to stop smoking. Smoking damages the heart in many ways. Tobacco smoke contains substances that speed up the heart, prevent oxygen from binding to the red blood cells, make the arteries tighten up, and hasten the development of
Research indicates that heart attack survivors who stop smoking live longer and have fewer complications than those who continue to smoke.Therefore, it is never too late to stop smoking!
All types of cigarettes are dangerous. There is no good evidence that low-tar products are any safer than those with high tar.
Anyone who wants to quit smoking should ask a physician for help. Nicotine gum and nicotine patches can be very beneficial, especially when the individual participates in other supportive measures, such as smoking cessation programs or counseling.
Weight loss and proper nutrition
Many people with angina are overweight. Weight loss is recommended, since it can:
- reduce symptoms
- improve a person’s overall sense of well-being
- decrease the likelihood of developing diabetes (which may lead to heart disease)
A nutritionist can help to develop a diet that is “heart-healthy,” but does not take all the pleasure out of food. Most nutritional programs have the objectives of cutting down on saturated fats, while increasing polyunsaturated fats in the diet.
Eating habits generally can be improved by following a few simple steps, such as:
Eat fewer portions of
- Fatty dairy products (such as butter, margarine, cream, cheese). These foods are rich in saturated fatty acids. Saturated fats are a type of fat that has been linked with high
cholesterol levels in the blood and also with the development of atheroma. Substitute low-fat dairy products (skim milk, low-fat cheese, etc.) whenever possible. - Red meat (such as beef, lamb)
Eat more portions of
- Unsaturated cooking fats (such as canola oil, sunflower oil, corn oil)
- White meat (such as chicken, turkey)
- Fish
- Grains, cereals, fruits and vegetables
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Nice To Know: Although fish contains fat, it is rich in polyunsaturated fatty acids known as |
Regular exercise
Many people with angina can and should exercise regularly, provided that exercise is not carried out to the point of exhaustion. Exercise helps to keep weight down, reduces clotting tendencies, improves heart function, and improves the blood lipid profile (fatty substances in the blood). Perhaps most importantly – exercise lessens depression and anxiety, since people feel better when they are fit.
Very inactive or sedentary individuals should begin to exercise slowly. To avoid injury, it is important to stretch the muscles before exercise.
The easiest form of exercise is simple: brisk walking. Other suitable activities include swimming, slow jogging, golf, or bicycling.
A typical cardiorespiratory (heart/lung) fitness program calls for 15 to 30 minutes of low-intensity
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Need To Know: Isometric exercise should be avoided, since it can cause decompensation (inability to maintain circulation) in the heart’s left ventricle (pumping chamber), as well as a sudden increase in blood pressure. |
Unfortunately, angina is so severe in some individuals that their ability to exercise is greatly limited. Specifically, people with severe
Medication
A variety of medicines now are available for the treatment of angina. There are five main types of medication, which help to control symptoms and increase blood flow to the heart muscle:
- Aspirin
- Nitrates
- Beta-blockers
- Calcium channel blockers
- Statin drugs
In addition, a physician may prescribe medicine for conditions such as high blood pressure (hypertension),
- Aspirin
Aspirin is used to prevent blood clots within the coronary arteries or other blood vessels. Physicians advise most people with angina to take a small dose of aspirin every day, unless they cannot tolerate it because of allergy or gastrointestinal (GI) complaints such as stomach ulcer. Such patients may be able to tolerate other medications such as clopidogrel (Plavix).
Note: Pain relievers like ibuprofen (Advil) and acetaminophen (Tylenol) donot have the same clot-preventing properties as aspirin and should not be taken for this purpose.
- Nitrates
Nitrates – such as nitroglycerin – have been used to treat angina for many years. Nitrates open up the arteries, improving blood flow to the heart and the rest of the body. This makes the heart’s work easier, since it can pump blood without as much resistance from narrow blood vessels. The reduced workload makes it less likely that angina will occur.
Nitrate medications comes in a variety of forms:
- Pills that dissolve under the tongue
- Pills that are swallowed
- Mouth sprays
- Ointments or creams
- Skin patches or plasters
Nitroglycerin (also known as glyceryl trinitrate, or “GTN”) often is administered as a pill that is placed under the tongue (for example,Nitrostat). The medication passes rapidly into the bloodstream and relieves angina symptoms within a few minutes. The individual may feel a “tingle” under the tongue and a slight “fullness” in the head, which indicates that the blood vessels are opening up.
Nitroglycerin is used for sudden attacks of
angina . It is also used as a preventive medicine to be taken before an individual engages in an activity known to bring on an attack. Longer-lasting sublingual (mouth-dissolving) pills are available for extended therapy (for example, Nitrogard).How To Information: How to take nitroglycerin tablets for sudden angina
- Take one tablet as soon as angina-related discomfort occurs.
- Wait five minutes. If discomfort does not go away, take a second tablet.
- Wait five minutes.
- If the discomfort persists, take a third tablet.
- Wait five minutes.
- If after taking three tablets in 15 minutes discomfort continues, go to the hospital immediately. Long-lasting discomfort that does not go away after 15 minutes may signal an approaching heart attack.
Isosorbide dinitrate and all mononitrates (Imdur, Isordil, Sorbitrate) are other nitrate medicines that come in tablet form to be swallowed whole or chewed for extended prevention of angina attacks.
Nitrate sprays (such as Nitrolingual) are fast-acting products that are used to relieve sudden angina attacks. The mouth should be closed after each dose, and care should be taken not to shake the container; it is flammable.
Ointments, like Nitro-Bid, are used for preventive therapy. They are not suitable for sudden attacks of angina.
Skin patches and plasters (for example, Transderm-Nitro, Minitran) slowly deliver medicine through the skin (the skin of the chest is the preferred site). These drug-delivery systems are used to prevent angina, especially in individuals who experience symptoms at night.
All nitrate products have a limited shelf life, after which they will no longer work effectively. A pharmacist can provide information about how long each product lasts and when it should be replaced.
Nitrates may cause headaches and faintness especially when first used, although these side effects usually diminish over time.
Need To Know:
Nitrate tolerance – the ineffectiveness of a nitrate drug after it has been used for a while – is a well-known hazard of angina therapy. Researchers suggest that nitrate tolerance is caused by the depletion of certain chemicals within the body’s cells. These chemicals are needed to convert the drug into its active form.
- Sublingual products (pills or sprays that dissolve under the tongue) are less likely to cause nitrate tolerance because of the limited length of time that they are active.
- By contrast, longer-acting products (such as pills that are swallowed, skin patches) may cause or provoke tolerance when used with sublingual preparations.
Nitrate tolerance usually can be prevented by intermittent delivery of the lowest effective dosage and is generally avoided by ensuring a 12-hour nitrate-free interval.
- Beta-blockers
Beta-blockers have been used for over 35 years to treat both angina and high blood pressure (hypertension). These medications act as a “brake” that slows down the heart rate. Beta-blockers reduce the heart’s work, so that it needs less oxygen and fuel.
When taken regularly, beta-blockers can reduce the frequency of angina attacks.
- “Combination therapy” with a beta-blocker and nitrate is a good choice for people who suffer from high blood pressure as well as angina.
- Beta-blockers also are a good choice for people who have tachycardia (rapid heart rate).
Sometimes beta-blockers cause side effects like cold hands, cold feet, or fatigue. About one in ten men may experience erectile dysfunction, or impotence (inability to achieve or maintain an erection), which sometimes is remedied by lowering the beta-blocker dose.
Because of their effects on the respiratory system, beta-blockers are unsuitable for angina sufferers who have asthma or bronchitis. Cardiologists (heart specialists) generally advise against beta-blocker use by people who have variant angina.
Beta-blockers are not to be used if the heart rate is excessively slow (or, if necessary, need to be used with great caution).
- Calcium channel blockers
Calcium channel blockers (CCBs), also known as calcium antagonists, are muscle relaxants that also relax arteries. They are particularly beneficial if angina is caused by arterial spasms rather than blockage.
Calcium channel blockers act like nitrates by opening up the arteries in the heart. They improve the blood supply in the heart muscle and relax the arteries within the body, making it easier for the heart to pump blood. Some calcium channel blockers also slow the heart like beta-blockers.
Calcium channel blockers, when combined with nitrates, provide excellent control of angina and hypertension. They also are useful in angina patients who have lung disease.
Certain calcium channel blockers are preferred when a person with angina experiences bradycardia – an abnormally slow heart beat.
- In such cases, calcium channel blockers like amlodipine (Norvasc) or nifedipine (Procardia) are preferred.
- The calcium channel blockers verapamil HCl (Calan, Isoptin) and diltiazem HCl (Cardizem) are not recommended when there is a slow heart rate (bradycardia)
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Statins are the newest and the most powerful of the prescription drugs used to lower cholesterol. They work by interrupting the final step in the chemical pathway that creates cholesterol in the liver.
Recent research shows statins can dramatically reduce the risk for a heart attack, stroke, or death, even in people who have normal cholesterol levels and do not have heart disease. In people with heart disease, statins prevent a first or second heart attack.
Statins are safe and well tolerated. Their mild side effects include headaches, abdominal pain, constipation, diarrhea, and gas. They occasionally can cause muscle or joint pain. In rare cases, they can cause liver damage.
Common statins are atorvastatin (Lipitor), fluvastatin (Lescol),lovastatin (Mevacor), pravastatin (Pravachol), and simvastatin (Zocor).
Surgery
Some people with angina have extensive narrowing of the heart’s blood vessels. If atheromas (plaques; fatty deposits within an artery) block an individual’s coronary arteries by more than 70%, the physician usually will recommend surgery to improve blood flow to the heart muscle. Surgical procedures relieve angina symptoms and also help to prevent heart attack.
The two main surgeries for angina are:
- Angioplasty
- Coronary artery bypass
- Angioplasty
Angioplasty is an interventional procedure to widen a blood vessel. It is commonly used for individuals who have short obstructions within one or two coronary arteries. People with three-vessel disease (obstructions in three coronary arteries) also may benefit from angioplasty if they do not have high-risk features such as severe impairment of the heart’s ventricle (pumping chamber).
To perform angioplasty, a physician makes an incision in a major artery of the forearm or leg and then threads a catheter (fine tube) through the blood vessels until it reaches the heart. A special dye is pumped into the bloodstream via the catheter, so that the coronary arteries are visible and the entire process can be watched on a video screen.
Once the catheter reaches the blocked coronary artery, the physician removes the obstruction or flattens it against the inside of the artery by different methods. These methods include:
- “
Balloon angioplasty ” (also known as percutaneous transluminal coronary angioplasty, or PTCA), in which a tiny balloon is attached to the end of a catheter. When the catheter reaches the blockage, the balloon is inflated, theplaque is flattened against the arterial lining, and the coronary artery is effectively widened. - Stent deployment, a newer technique being used to keep the coronary arteries open. A small, expandable metal sheath is slipped over the catheter and placed at the site where the artery has just been widened, to prevent it narrowing again.
- Microsurgery, in which tiny surgical instruments are used to cut through plaque.
- Laser surgery, in which a small laser (high-intensity, focused light beam) is used to clear out the obstruction. This procedure is known as transmyocardial revascularization, or TMR.
Both angioplasty and bypass surgery are designed to achieve the same goal – that is, to increase blood flow within the heart muscle. Depending upon the severity of angina, an individual may have the opportunity to choose between the two procedures.
Need To Know: Angioplasty or bypass surgery?
In comparison to coronary artery bypass, angioplasty:
- Is less invasive. Angioplasty is a much less complicated operation that involves comparatively small surgical incisions. Usually it is carried out under local anesthesia.
- Requires a shorter hospital stay. The length of hospitalization for angioplasty is one to two days versus five to seven days for bypass surgery.
- Results in a quicker recovery. Most people are back at work within a week.
However, angioplasty:
- Does not work in about 5% of cases, and emergency bypass surgery is necessary.
- Must be repeated within six months in about 40% of cases. The coronary arteries become blocked again, and the individual must undergo another angioplasty or have bypass surgery.
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- Coronary artery bypass surgery
Coronary artery bypass surgery, like angioplasty, increases the amount of blood flow to the heart and eases discomfort. People with
angina usually are candidates for coronary artery bypass surgery if they have:- Widespread obstruction to the left main coronary artery
- “Three-vessel disease” (obstructions in three main coronary arteries)
- Obstruction that is more diffuse and not felt suitable for angioplasty.
Bypass surgery is especially recommended if the individual has significantly decreased heart function, or hazardous changes in the ECG (electrocardiogram).
During the bypass operation:
- A piece of blood vessel – usually a vein from the leg or an artery from the chest – is removed from the patient and is used to “bypass” the section of coronary artery that is blocked.
- One end of the graft (transplanted vessel) is connected below the blockage in the coronary artery.
- The other end is sewn into the
aorta (major artery that carries blood away from the heart and into the body). - The bypass procedure is repeated for each obstructed coronary artery (for example, “triple bypass” means that three grafts have been made to skirt arterial blockages).
- Increasingly, the artery from the chest (called the internal mammary artery) is being used, because this is easily accomplished and results are better.
Bypass operations are now commonplace, but some risks remain. A cardiologist (heart specialist) will be able to explain the possible risks and benefits in each particular case. In many people, the surgical risk is less than that for gallbladder removal.
After surgery, bypass patients need to spend a few days in intensive care, but they usually can go home in about a week. Most people can return to work after a few weeks, although the length of recovery is determined by factors such as age and the person’s overall health and fitness.
Bypass surgery does not completely cure angina, but most people experience total relief of discomfort for years. Also, specialists feel that the risk of a heart attack is reduced in many individuals.
Living With Angina
Most people can resume a normal or near-normal life after treatment of angina. Some lifestyle changes will be necessary, but life can still be good.
Simple angina can be kept under control by
- Following medical advice
- Taking necessary medication
- Keeping in good physical condition
- Eating well
Even if angina is complicated by other health problems, it should be controllable.
Angina is not a disease of the “fragile.” In fact, most angina sufferers lead extremely busy, stress-filled lives. Their disease provides a warning sign that they need to make adjustments in an otherwise full life.
Notify a physician if angina attacks become more frequent or more severe. This is especially important if angina comes on while a person is resting, or if nitrate tablets seem to become less effective.
Work
In spite of having angina, most people are able to continue working. Yet individuals with angina often have fast-paced schedules that could benefit from some improvement. A diagnosis of angina is a good reason to cut down on commitments and to examine one’s lifestyle. For example:
- Do you have to hurry to the train or bus in the morning?
- Would you be less harassed if you planned your work better?
- Do you do unnecessary things?
If “yes” is the answer to these questions, a slower, more efficient schedule should relieve stress and lessen the chance of an attack.
Intense physical labor is inappropriate, and special regulations apply to people who are licensed for heavy goods vehicles or public service vehicles. Driving a car is generally allowed, provided that angina does not occur while driving.
Sex
The combination of physical activity and sexual excitement may bring on an angina attack. But individuals need not avoid sexual activity, unless it produces angina. Attacks usually can be prevented by taking a nitrate or beta-blocker beforehand.
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Need To Know: Nitrates and Viagra If you are taking nitrate medication such as nitroglycerin, you should not take Viagra. The deaths that have been reported for people using Viagra are those with coronary heart disease who are also taking nitrates. |
Alcohol
In small amounts, alcohol does not harm the heart. In fact, it might help to relieve tension. But people must be careful to ensure that alcohol does not increase body weight.
Here are some recommended guidelines from the U.S. Department of Health and Human Services:
- Women – No more than one standard drink per day
- Men – No more than two standard drinks per day
A standard drink is the equivalent of:
- 12 oz. regular beer (5% alcohol), or
- 1.5 oz. 80% distilled spirits (40% alcohol), or
- 5 oz. wine (12% alcohol)
Eating habits
If the coronary arteries are partly blocked, the chances are that the individual has been eating too many fatty foods and has a high level of
People with high blood pressure (hypertension) should limit sodium (salt) intake (for example, aim for a target of under 1,500 milligrams of sodium a day) and learn to use other seasonings such as garlic, lemon, and onion.
Eat lean meats, use little or no butter, and switch to skimmed or semi-skimmed milk. Grill food rather than frying it. Eat plenty of fruit and fresh vegetables.
Weight gain
Avoid weight gain. Keeping close to the recommended weight for one’s height and age will keep blood pressure down and reduce the heart’s workload.
Stress
Avoid activities that cause mental and emotional turmoil. People with angina must learn to relax more. Some hobbies help people to relax, but it is most important to identify and eliminate unnecessary stresses at home and at work.
Exercise
Many people with angina can and should exercise regularly, provided that exercise is not carried out to the point of exhaustion.
Smoking
The most important thing that a smoker with angina can do is to stop smoking.
Vacations
Vacations and holidays are important and are recommended. But, when traveling, it is essential to organize trips and allow plenty of time. Also, avoid carrying heavy pieces of luggage.
Keep your
Air travel in a modern, pressurized aircraft should cause no problems. It is advisable to rest in the airport departure lounge so that an angina attack is less likely when walking to the departure gate. If angina is brought on by hectic activity, tell the airline staff in advance. They can provide help so that the flight is boarded with as little stress as possible.
Avoid travel at high mountain altitudes, although people with mild or moderate angina should be unaffected at heights up to about 6,600 feet (2,000 meters).
Frequently Asked Questions: Angina
Here are some frequently asked questions related to angina.
Q: My doctor says that my chest pain may be angina, but more tests are needed. When my EKG was taken, it was normal. Do I really need to have a
A: Unfortunately, a simple EKG does not reliably detect angina. Therefore, the physician must perform additional tests, like an exercise stress test. The stress test is the only investigation needed for many people, since it is accurate most of the time. But even this test cannot identify exactly where or how severely the coronary arteries are blocked. So, in some people, additional tests like
Q: I am frightened by the idea of having to walk on a treadmill during my
A: Your physician or other trained personnel will ask about your angina symptoms during the test to make sure that you don’t overwork your heart or otherwise put it at risk. Although it may seem frightening, a treadmill is simply a machine with a band that continuously rotates during the test. Every few minutes, the band moves faster and becomes a little steeper. From your heart’s response to these stages, a lot of information is obtained on the EKG. If you are tested on a stationary bicycle, the principle is exactly the same.
Q: My wife is scheduled to have angiography. She was told that a plastic tube will be inserted through a blood vessel until it reaches her heart. Won’t that be painful – and dangerous?
A: No. Because of the anesthetic (painkiller) used during angiography, there generally is no discomfort. And people usually are given antianxiety medication before the procedure, so that they feel calm throughout. Coronary angiography only takes about 30 minutes to perform, and it is very safe. Your wife’s physician can explain any risks before the procedure.
Q: I’ve been told that I should exercise regularly for my angina. But aren’t some types of exercise dangerous?
A: Regular
Q: My nutritionist says that I should eat more fish and try to cook with vegetable oils like canola. Why?
A: Cold-water varieties of fish (such as salmon, herring, tuna) – as well as certain vegetable oils like canola oil and soybean oil – are rich in polyunsaturated fatty acids known as
Q: How do you tell the difference between angina and a heart attack?
A: Some angina symptoms – such as chest pain, sweating, and nausea – may seem like a heart attack. Yet there are significant differences between these two conditions. Heart attack lasts much longer than angina (more than 20 minutes versus 1 to 10 minutes), and, unlike angina, heart attack symptoms continue even after a person rests. Heart attack is a very serious condition that results when a
- Getting worse or lasts longer than 20 minutes,
- Severe than previously experienced,
- Accompanied by weakness, nausea, or fainting,
- Unchanged after taking three nitroglycerin tablets, or
- Happening at an unusual time (for example, during rest).
Q: What does “unstable” angina mean?
A: “Unstable” angina is a form of angina that is much more serious than stable angina. Unstable angina occurs when a person is resting, asleep, or undergoes physical exertion. Severe discomfort may come on suddenly in someone who has never had angina before. Attacks may intensify or happen more often. Unstable angina is caused by blood clots that form around damaged
Q: How do nitroglycerin pills stop angina?
A: Nitroglycerin tablets are “vasodilators” – that is, they increase the diameter of the arteries, improving blood flow to the heart and the rest of the body. They also dilate (open up) the veins and temporarily decrease the return of blood to the heart, and this eases the workload of the heart. Once enough blood returns to the heart muscle,
Q: I have high blood pressure as well as angina. Do any medications treat both problems?
A: To treat both high blood pressure and angina, physicians often rely on “combination therapy” consisting of nitrate medicine plus a beta-blocker, or nitrate medicine plus a calcium channel blocker (CCB).
Q: Isn’t bypass surgery less risky than it used to be?
A: Coronary artery bypass is now commonplace and even less risky than gallbladder surgery in most people. In addition, the recovery time for bypass surgery is much shorter than it was a decade ago. All bypass patients need to spend a few days in intensive care, but they usually are discharged home after about five to seven days. Most people can return to work within a few weeks. Of course, every form of heart surgery has risks, which can be explained by a cardiologist (heart specialist) for each individual.
Putting It All Together: Angina
Here is a summary of the important facts and information related to angina.
- Angina usually comes on as a feeling of pain, pressure, or tightness in the middle chest, especially behind the sternum (breastbone).
- The sensation may spread to the left shoulder, arm, and hand, or to the neck, throat, and jaw.
- Angina often occurs during everyday activities, such as rapid walking or running, lifting or carrying a weight, becoming angry or excited, shoveling snow, and physical stress after eating (when food is still being digested).
- In almost all cases, the underlying cause of angina is
coronary artery disease (CAD). - Spasm of a coronary artery can produce a condition known as
variant angina pectoris (also called “Prinzmetal’s angina” or angina inversa). - Angina itself is not dangerous, but the narrowed coronary arteries that cause angina can increase the risk of heart attack.
- Heart attack, in comparison to angina:
- Occurs when there is complete or partial blockage of a coronary artery
- Causes long-lasting chest pain (20 minutes or more) that continues even after a person rests
- May lead to permanent heart injury or death
- Other conditions can be confused with angina including anxiety and tension, gallbladder disease, and indigestion.
- If one or more plaques rupture and blood clots form in a coronary artery, the condition is known as unstable angina.
- Whether or not a person has stable or unstable angina, it is important to go to the hospital immediately if anginal pain or discomfort is:
- More severe than previously experienced
- Getting worse or lasting longer than 20 minutes
- Accompanied by weakness, nausea, or fainting
- Unchanged after taking three nitroglycerin tablets
- Happening at an unusual time (for example, during rest)
- The treatment of angina typically involves lifestyle changes and medication, with or without an operative procedure such as
angioplasty (blood vessel repair) or coronary artery bypass surgery (surgically made arterial pathways that bypass [go around] diseased arteries in the heart).
Glossary: Angina
Here are definitions of medical terms related to angina.
Aerobic exercise: Exercise that uses up oxygen in the blood by working large muscle groups and increasing the heart rate; endurance-building exercise.
Angina: Term for choking pain (LATIN, throat pain or choking). When coupled with the word “pectoris” (LATIN, of the chest), angina refers to a painful, constricting sensation in the chest. Angina is caused by coronary artery disease, which reduces the supply of blood to the heart muscle.
Angioplasty: An invasive procedure to enlarge a narrowed artery. Coronary angioplasty is an operation to enlarge a narrowed coronary artery.
Aorta: Great artery that arises from the left ventricle (pumping chamber) of the heart and is the starting point of the body’s arterial system.
Arrhythmia: Disturbance of the heart’s normal rhythm.
Arteriography: Procedure used to make an x-ray picture (arteriogram) of an artery or arterial system after injecting a contrasting dye into the bloodstream (see Coronary angiography).
Atheroma: Bulging yellow mass or “plaque” that forms within the walls lining the arteries. Atheromas (ITALIAN, porridge) contain a mix of fat, cholesterol, inflammatory cells, and fibrous scar tissue and, when deposited on the inner wall of an artery, reduce its inner diameter.
Atherosclerosis: Gradual buildup and hardening of atheromas within the arterial walls.
Balloon angioplasty: Angioplasty in which a tiny balloon is attached to the end of a catheter and is inflated against the arterial walls to flatten plaque (also known as percutaneous transluminal coronary angioplasty [PTCA]).
Cholesterol: A fat-like substance needed for the development body cells. Cholesterol is both produced by the body and found in animal foods. Although it is a necessary substance, if levels of cholesterol are too high it can be deposited on the artery wall, narrowing or blocking blood flow and leading to coronary heart disease.
Coronary angiography: Procedure used to make an x-ray picture (angiogram) of the heart’s blood vessels after injecting a contrasting dye into the bloodstream.
Coronary artery: The arteries that deliver blood to the heart itself. There are three major coronary arteries.
Coronary artery disease (CAD): Narrowing of the arteries that supply the heart (also known as coronary heart disease [CHD] and ischemic heart disease [IHD]). The coronary arteries become blocked by atheromas that form within the walls lining the arteries.
Electrocardiography (EKG, ECG): Procedure used to measure the electrical activity of the heart muscle. The record produced by EKG is known as an electrocardiogram.
Ergonovine test: Test performed if angina may be caused by coronary artery spasm (also known as a provocation test). The artery-narrowing drug ergonovine(or, alternatively, acetylcholine) is injected to provoke coronary artery spasm during coronary angiography. The person’s response to ergonovine is then measured.
Exercise tolerance test: Procedure used to measure the heart’s response to exercise (also known as a stress test). During exercise tolerance testing, the individual is asked to ride a stationary bicycle or walk on a treadmill while a physician takes an electrocardiogram.
Fibrillation: Rapid, uncoordinated contraction (squeezing) of the heart muscle.
Isometric exercise: Exercise in which the muscles are contracted (squeezed) against resistance over a period of time, for example, weight-lifting.
Lipids: Group of fatty substances that are stored in the body and can be measured in the blood; they include high-density lipoproteins (HDL; “good cholesterol”), low-density lipoproteins (LDL; “bad cholesterol”), and triglycerides, among other compounds.
Myocardial infarction (MI): Death of tissue in the heart muscle; a “heart attack.”
Myocardial ischemia: Lack of blood in the heart muscle.
Omega-3 fatty acids: Polyunsaturated fatty acids found in certain cold water fish and vegetable oils. Omega-3s may help to reduce the risk of heart attack by preventing blood from clotting and sticking to the artery walls.
Plaque: Bulging yellow mass (atheroma) that forms within the walls lining the arteries. Plaque contains a mix of fat, cholesterol, inflammatory cells, and fibrous scar tissue and, when deposited on the inner wall of an artery, reduces its inner diameter.
Platelets: The smallest cells in the blood; they are disk-shaped and are essential for blood to clot.
Stress test: Procedure used to measure the heart’s response to exercise (also known as an exercise tolerance test). During stress testing, the individual is asked to ride a stationary bicycle or walk on a treadmill while a physician takes an electrocardiogram.
Transmyocardial revascularization (TMR): Revascularization (artery-repair) procedure in which a laser is used to cut a series of channels into the heart muscle, thereby increasing its blood flow.
Variant angina pectoris: Angina caused by spasm (sudden contraction [squeezing response]) of the smooth muscle within the coronary arteries (also known as “Prinzmetal’s angina” or angina inversa). Variant angina occurs almost exclusively when a person is at rest or asleep, often between the hours of midnight and 8 a.m.
Ventricular tachycardia: Rapid rate of the left ventricle (pumping chamber) of the heart.
Additional Sources Of Information: Angina
Here are some reliable sources that can provide more information on angina.
American Heart Association
Phone: (800) AHA-USA1 Heart & stroke info
Phone: (888) MY HEART Women’s health info
http://www.americanheart.org
Heart Information Network
www.heartinfo.org
National Institute of Heart, Blood and Lung Diseases of the National Institutes of Health
www.nhlbi.nih.gov
Federal Consumer Information Center
www.pueblo.gsa.gov
Heart Beat – An organization providing new information about angina pectoris.
Phone: 800-455-3327, ext. 786