Angina

What Causes Angina

If you have angina, one or more of your coronary arteries is usually narrowed. This causes a reduced blood supply to a part, or parts, of your heart muscle.

The blood supply may be good enough when you are resting. When your heart works harder (when you walk fast or climb stairs and your heart rate increases) your heart muscle needs more blood and oxygen. If the extra blood that your heart needs cannot get past the narrowed coronary arteries, the heart responds with pain.

The narrowing of the arteries is caused by atheroma. Atheroma is like fatty patches or plaques that develop within the inside lining of arteries. (This is similar to water pipes that get furred up with limescale.)

Plaques of atheroma may gradually form over a number of years. They may be in one or more places in the coronary arteries. In time these can become bigger and cause enough narrowing of one or more of the arteries to cause symptoms. The diagram shows three narrowed sections as an example, but atheroma can develop in any section of the coronary arteries.

What is angina?

Angina is a pain that comes from the heart. Each year about 20,000 people in the UK develop angina for the first time. It is more common in people over the age of 50 years. It is also more common in men than women. Sometimes it occurs in younger people.

This leaflet is about the common type of angina which is caused by narrowing in the coronary arteries of the heart. Sometimes angina can be caused by uncommon disorders of the heart valves or heart muscle.

What Are the Signs and Symptoms of Angina?

Pain and discomfort are the main symptoms of angina. Angina often is described as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort usually starts behind the breastbone.

Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion. Some people say that angina pain is hard to describe or that they can’t tell exactly where the pain is coming from.

Signs and symptoms such as nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, and weakness also may occur.

Women are more likely to feel discomfort in the neck, jaw, throat, abdomen, or back. Shortness of breath is more common in older people and those who have diabetes. Weakness, dizziness, and confusion can mask the signs and symptoms of angina in elderly people.

Symptoms also vary based on the type of angina you have.

Because angina has so many possible symptoms and causes, all chest pain should be checked by a doctor. Chest pain that lasts longer than a few minutes and isn’t relieved by rest or angina medicine may be a sign of a heart attack.

Triggers

There are two types of angina, called

stable and unstable angina.

Stable Angina

The symptoms of these two types are similar, but there are some important differences.

Attacks of stable angina usually occur when the heart is forced to work harder, for example during physical activity or emotional stress. In some cases, the pain can also develop after eating a meal or during cold weather. These are known as angina triggers. The symptoms of stable angina usually improve if you rest for a few minutes.

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

Unstable angina is more unpredictable. It can develop without any obvious triggers and can persist even when you are resting. Attacks of unstable angina may last longer than a few minutes and do not always respond to treatments used for stable angina.

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 uncommon — 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.

Symptoms of Anjaina

Angina symptoms include:

• Chest pain or discomfort

• Pain in your arms, neck, jaw, shoulder or back accompanying chest pain

• Nausea

• Fatigue

• Shortness of breath

• 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. For others, it may feel like indigestion.

The severity, duration and type of angina can vary. It’s important to recognize if you have new or changing chest discomfort. 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 discomfort 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.

Less typical symptoms that sometimes occur

Some people have nontypical pains – for example, pains that develop when bending or eating. If the symptoms are not typical then it is sometimes difficult to tell the difference between angina and other causes of chest pain, such as a pulled muscle in the chest or heartburn.

Some people with angina also become breathless when they exert themselves. Occasionally, this is the only symptom and there is no pain.

What tests will Patient have?

If you have suspected angina, tests are usually advised:

• A blood test to check for anaemia, thyroid problems, kidney problems, a high glucose level, and a high cholesterol level, as these may be linked with angina.

• A heart tracing called an electrocardiograph (ECG). This can be useful. However, a routine ECG may be normal if you have angina. In fact, more than half of people with angina have a normal resting ECG.

What can I do to help with angina?

Certain risk factors increase the risk of more atheroma forming, which can make angina worse. These are discussed in more detail in another leaflet called ‘Preventing Cardiovascular Diseases’.

Briefly, risk factors that can be modified and may help to prevent angina from getting worse include:

• Smoking. If you smoke, you should make every effort to stop.

• High blood pressure. Your blood pressure should be checked regularly, at least once a year, if you have angina. If it is high, it can be treated.

• If you are overweight, losing some weight is advised. Losing weight will reduce the amount of workload on your heart and also help to lower your blood pressure.

• High cholesterol. This should be treated if it is high.

• Inactivity. You should aim to do some moderate physical activity on most days of the week for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, gardening, etc. (Occasionally, angina is due to a heart valve problem where physical activity may not be so good. Ask your doctor to confirm that you can undertake regular physical activity.)

• Diet. You should aim to eat a healthy diet. A healthy diet means:Alcohol. Some research suggests that drinking a small amount of alcohol may be beneficial for the heart. The exact amount is not clear, but it is a small amount. So, do not exceed the recommended amount of alcohol as more than the recommended upper limits can be harmful. That is, men should drink no more than 21 units of alcohol per week, no more than four units in any one day, and have at least two alcohol-free days a week. Women should drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two alcohol-free days a week. Pregnant women, and women trying to become pregnant, should not drink alcohol at all. One unit is in about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits.

  • At least five portions (and ideally 7-9 portions) of a variety of fruit and vegetables per day.

  • You should not eat much fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Ideally you should use low-fat, monounsaturated or polyunsaturated spreads.

  • Try to include 2-3 portions of fish per week, at least one of which should be oily (such as herring, mackerel, sardines, kippers, salmon, or fresh tuna).

  • If you eat red meat, it is best to eat lean red meat, or eat poultry such as chicken.

  • If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive.

  • Try not to add salt to food, and limit foods which are salty.

What are the aims of treatment if you have angina?Doctors and patients can use Decision Aids together to help choose th

The main aims of treatment are:

• To prevent angina pains as much as possible and to ease pain quickly if it occurs.

• To limit further deposits of atheroma as much as possible. This prevents or delays the condition from worsening.

• To reduce the risk of having a heart attack.

Treatments that are advised in most cases

Lifestyle measures to reduce risk factors

These are discussed above.

Glyceryl trinitrate (GTN)

This medicine comes as tablets or sprays. You take a dose under your tongue as required when your angina pain develops. GTN is absorbed quickly into the bloodstream, from under the tongue. A dose works to ease the pain within a minute or so.

You should always carry your GTN spray or tablets with you. Some people take a GTN tablet or a spray before any exercise – for example, before climbing stairs. If the first dose does not work, take a second dose after five minutes. If the pain persists for 10 minutes despite taking GTN, then call an ambulance.

GTN works by relaxing the blood vessels. This reduces the workload on the heart, and also helps to widen the coronary arteries and increase the flow of blood to the heart muscle.

GTN tablets go off after a few weeks, so you need a fresh supply every eight weeks and should return any unused tablets to the pharmacist. You may prefer to use a GTN spray which has a longer shelf life than tablets.

A dose of GTN may cause a headache and/or flushing for a short while. This side-effect often improves, or goes, with continued use.

A statin medicine to lower your cholesterol level

Cholesterol is a chemical that is made in the liver from fatty foods that you eat. Cholesterol is involved in forming atheroma. As a rule, the higher the blood cholesterol level, the greater the risk of developing atheroma. However, whatever your cholesterol level, a reduction in the level is usually advised if you have angina.

Statin medicines lower the blood cholesterol level by blocking an enzyme which is needed to make cholesterol in the liver. There are several different statin medicines to choose from.

Aspirin or another antiplatelet medicine

Aspirin reduces the stickiness of platelets. Platelets are tiny particles in the blood that help the blood to clot after cuts. If lots of platelets become stuck on to a patch of atheroma inside an artery they can form a clot (thrombosis). Therefore, taking aspirin reduces the risk of a heart attack, which is caused by a blood clot forming in a coronary artery.

The usual dose of aspirin is 75 mg daily. This is a much smaller dose than that used for pains and headaches. Side-effects are unusual with low-dose aspirin. If you have a stomach or duodenal ulcer, or asthma, you may not be able to take aspirin. Options then include taking an additional medicine to protect the gut, or using another antiplatelet medicine such as clopidogrel. See leaflet called ‘Aspirin and Other Antiplatelet Medicines’ for details.

A beta-blocker medicine

Beta-blockers block the action of certain hormones such as adrenaline, which increase the rate and force of the heartbeat when you exert yourself or are anxious. Therefore, when taking a beta-blocker, less oxygen is needed by the heart and angina pains are prevented, or occur less often.

Beta-blockers are also thought to have some protective effect on the heart muscle, which may reduce the risk of developing complications.

An angiotensin-converting enzyme (ACE) inhibitor medicine

There are several types and brands of ACE inhibitors. These medicines prevent a build-up of fluid by interfering with the enzyme angiotensin which is involved in regulating body fluid. ACE inhibitors also have a protective effect on the heart and may slow down the progression of heart failure.

An ACE inhibitor is usually prescribed to people with angina who are shown to have a reduced function of the left ventricle of the heart or who have had a heart attack (myocardial infarction). In these situations there is good evidence that an ACE inhibitor improves the outlook. However, it is uncertain whether an ACE inhibitor should be taken routinely by people with angina who do not have these other heart problems. It is hoped that research will clarify this issue. In the meantime, some doctors do prescribe an ACE inhibitor to all their patients with angina.

Other treatments that may be advised

Other medicines to prevent angina pains

A beta-blocker (described above) may be sufficient to prevent angina pains but other medicines are available if required. They fall into three main groups:

• Calcium-channel blockers relax the coronary arteries to increase blood flow. Some of these medicines also reduce the heart rate at rest, and the rate of rise in the heart rate when you exert yourself.

• Nitrate medicines work in a similar way to GTN but last for longer in the body.

• Potassium-channel activators work in a similar way to nitrates. They relax the blood vessels supplying the heart.

There are several types and brands in each group. They are all good at preventing angina pains. If the pains are not well controlled by taking one medicine, then another medicine can be added from another group. As the different groups of medicines work in different ways, combinations of these medicines complement each other. It is quite common to take a combination therapy of two or three medicines to prevent angina pains.

The possible side-effects vary between the different medicines. Therefore, if a particular medicine does not suit, you may find that a different one is fine. The aim is to find a medicine, or combination of medicines, to prevent your pains, but with minimal side-effects.

Note: even when taking regular medication to prevent angina pains, you can still take GTN for breakthrough angina pains that may still occur from time to time.

The treatment of angina is a developing area of medicine. New treatments continue to be developed and are likely to be introduced in the near future.

Non-medicine treatments

These are called angioplasty and coronary artery bypass graft (CABG) surgery. You may be offered one of these procedures if:

• You have pains not controlled by medicines. OR,

• The site and severity of the atheroma deposits are particularly suited to one of these treatments. In some cases this may even be if you have few or no pains, as the overall outlook may be improved in certain circumstances.

Your doctor will advise if angioplasty or CABG is worth considering. You may like to see the guidelines doctors follow regarding this issue which are at the end of this article.

• Angioplasty – in this procedure a tiny wire with a balloon at the end is put into a large artery in your groin or arm. It is then passed up to your heart and into the narrowed section of a coronary artery, using X-ray guidance. The balloon is then blown up inside the narrowed part of the artery to open it wide again. A stent may be inserted which works to keep the artery open. This is like a small coiled spring which expands and holds the artery open. This procedure is only suitable in some cases, as only arteries with short narrowed sections can be treated this way. See separate leaflet called ‘Coronary Angioplasty’ for details.

• Surgery – this involves an operation (CABG surgery) to bypass the narrowed sections of arteries with healthy blood vessel segments (grafts) which are taken from other parts of the body. More blood can then get past into the heart muscle. Not all people with angina are suitable for this operation, as it depends on where the narrowed arteries are.

Some common worries about angina

Straining the heart by exertion is a common worry. On the contrary, more physical activity is usually advised. You will normally be encouraged to exercise regularly. Physical activity helps to get the heart fitter and improves the blood supply to the heart muscle.

Sex. Some people with angina worry that the physical effort of having sex will damage the heart. This is wrong and you do not need to stop having sex. If sex does bring on an angina pain, it may be helpful to take some GTN beforehand.

Driving and flying. There is usually no restriction for driving your own car unless pains occur at rest, with emotion or while driving. But, you must inform your insurance company if you have angina. People with PCV or LGV licences, who have angina, must stop driving and contact the DVLA. As regards flying, in general, if you can climb 12 stairs and walk 100 metres on the level without pain or getting very breathless, you are fit to fly as a passenger. People with frequent angina pains or unstable angina should avoid flying.

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