Angina Pectoris

What is Angina pectoris?

Angina pectoris describes pain resulting from insufficient blood flow to the heart (myocardial ischemia). The pain is usually felt in the chest, and is typically described as an aching or crushing sensation. It is characteristically brought on by exertion or emotional stress. The most common cause of angina pectoris is coronary artery disease, obstruction of the coronary arteries due to atherosclerosis. However, any condition that interferes with blood flow to the heart may result in angina such as coronary artery spasm or severe narrowing of the aortic valve (aortic stenosis). Any condition that greatly increases the heart's need for oxygen, such as severe hyperthyroidism, or a very rapid heartbeat (tachycardia) from any cause, may cause angina pectoris. In addition, any condition that decreases the blood's oxygen content, like severe anemia, may be a contributing factor. So angina can result whenever there is insufficient blood and oxygen delivered to the heart to meet its need for oxygen. The following information pertains to coronary artery disease (CAD) except where otherwise specified.

In CAD, narrowing (stenosis) of the coronary arteries occurs gradually over years or decades. One or more of the coronary arteries may be affected, with stenosis occurring at one or more sites. Eventually, the stenosis may become severe enough to result in insufficient blood flow and oxygen supply (ischemia) to meet the needs of the heart. At rest, ischemia is usually absent, but during exertion or stress, the heart's need for oxygen increases. Angina results when the narrowed coronary arteries cannot accommodate the increased need for oxygen. Symptoms are usually associated when the artery is narrowed to less than 30% of normal. The pattern of angina may remain stable for months or years. But as the disease advances, the anginal episodes may increase in frequency or duration, become less responsive to medication, and/or be precipitated by less exertion. An increasing pattern of angina is referred to as unstable angina.

Angina Pectoris signs and symptoms

• Tightness, squeezing, pressure or ache in the chest.
• Sudden breathing difficulty (sometimes).
• Chest pain similar to indigestion.
• A choking feeling in the throat.
• Chest pain that radiates to the jaw, teeth or earlobes.
• Heaviness, numbness, tingling or ache in the chest, arm, shoulder, elbow or hand usually on the left side.
• Pain between the shoulder blades.

Causes

• Coronary-artery disease with partial blockage or spasm of arteries that supply blood to the heart.
• Anemia.
• Overactive thyroid gland.
• Heartbeat that is too fast.
• Heart-valve disease.

Risk increases with

• Smoking, obesity, diabetes mellitus.
• High blood pressure, high blood-cholesterol levels.
• Excess intake of fat or salt.
• Sedentary lifestyle, fatigue, overwork or stress.
• Family history of coronary-artery disease.
• Exposure to cold and wind.

Preventive measures

• Obtain medical treatment for underlying causes or risks.
• Don't smoke.
• Eat a diet that is low in fat and low in salt. Lose weight if you are overweight.
• Avoid the stressful physical or emotional factors that trigger angina attacks.
• Exercise regularly after consulting doctor.

Expected outcomes

Individuals with angina pectoris may remain stable for varying lengths of time, may develop worsening symptoms (unstable angina), or may progress to myocardial infarction or death. Prognosis depends on the severity and extent of ischemia, the presence or absence of complex cardiac arrhythmias, the site(s) of obstruction and number of vessels involved, how well the heart is functioning, and the extent to which risk factors can be modified. In some cases, the prognosis can be improved by revascularization. This is true for individuals with severe left main coronary artery disease or three-vessel disease, or impaired heart function, with evidence of ischemia on cardiac stress tests.

In stable angina, the prognosis is relatively good, as long as ventricular function is normal. After medical treatment has been optimized, or after revascularization, cardiac stress tests are performed to determine the individual's functional classification.

Possible complications

The same coronary artery disease that causes angina may progress to a heart attack, heart arrhythmias, or congestive heart failure.

How is Angina Pectoris treated?

At the onset of an anginal episode, the individual should stop activity immediately and a short-acting nitrate is taken under the tongue (sublingually). This will usually relieve the pain within several minutes. Failure to obtain relief after several doses suggests either unstable angina or possible heart attack.

For ongoing anti-anginal treatment, beta-blockers are taken on a regular basis. Long acting nitrates, taken orally or as a skin patch or paste (topically), can be added if necessary. Calcium channel blockers may also be useful in the management of angina. All of these drugs act by reducing the heart's need for oxygen. Nitrates and calcium channel blockers also dilate the coronary arteries, increasing the heart's blood supply. A small daily dose of an anti-platelet drug helps prevent a future heart attack by inhibiting blood clotting. To minimize progression of the disease, individuals with coronary artery disease will benefit by modification of their risk factors. Stopping smoking, getting adequate exercise, and correcting a high- fat diet are essential. Treatment may be required for high blood pressure, diabetes, and/or high cholesterol levels.

Some individuals may benefit from procedures to restore blood flow to the heart. This is most commonly done by coronary balloon angioplasty or coronary bypass surgery. Restoration of blood flow (revascularization) relieves symptoms in most cases and may greatly improve quality of life. Individuals who have had revascularization do not require antianginal medication unless residual ischemia is present. However, revascularization does not improve long-term survival since re-obstruction eventually occurs in a significant percentage of cases.

Angioplasty is less invasive and less risky than bypass surgery. However, it is not suitable for all individuals, particularly those with extensive disease or with stenoses that have certain characteristics. If revascularization of either type is being considered, coronary arteriography is performed to determine whether revascularization is possible and, if so, which procedure is most appropriate.

Medications

Coumadin (Warfarin), Tenormin (Atenolol)

Activity

• Learn to adjust activities to minimize attacks.
• Don't use angina as an excuse not to exercise. A regular moderate exercise routine (determined by the doctor) can help to control symptoms.

Diet

• Low-fat, low-salt diet is recommended.
• Weight loss diet if overweight.

Learn more about Angina pectoris

• Additional information available from the American Heart Association.

Last updated 10 May 2016