Angina Pectoris

A sign of trouble

Simply stated, angina (angina pectoris) is chest discomfort or pain -- but not just any chest pain. Angina is a symptom of a condition called myocardial ischemia that occurs when the heart muscle (myocardium) doesn't get as much blood (and therefore as much oxygen) as it needs. Insufficient blood supply is called ischemia.

Although the blood flow to your heart may be adequate for normal needs, when the heart demands increased oxygen, the arteries supplying blood to the heart may not be able to meet the demand because they are narrowed or blocked. When this situation occurs -- typically during or after physical exertion or during periods of extreme stress -- you'll feel the discomfort or pain of angina.

Angina is a warning sign of coronary artery disease and requires medical attention.

Pronunciation

an-JYE-nah

Synonyms

  • Angina pectoris
  • Unstable angina
  • Prinzmetal's angina/variant angina pectoris (angina that occurs almost exclusively when a person is at rest)
  • Chest pain

Detailed Description

Angina is often described as a squeezing, feeling of pressure, heaviness, tightening, or aching across the chest, especially behind the breastbone. It can range from a vague ache to an intense crushing sensation. You may feel short of breath. The pain can radiate to the left shoulder and down the inside of the left arm and into the fingers, and can travel to the back, throat, jaws, and teeth. Some people even feel pain in the abdomen.

Angina is typically triggered by physical activity and usually lasts for no more than a few minutes. The pain begins to subside with rest. Angina gets worse when exertion follows a meal, and cold weather is also a culprit. Walking into the wind or getting a blast of cold air when you leave a warm room can also cause angina.

Once you experience angina, subsequent attacks generally follow the same pattern. Any changes in this pattern -- increased intensity, less stimulus required, longer duration, or occurrence during periods of rest -- may signal that your angina has become "unstable." Unstable angina is a medical emergency that requires immediate hospital care.

Some people experience angina even when they're not stressed out or physically active. This type of angina is called variant angina pectoris, or Prinzmetal's angina. It is caused by a spasm in one of the coronary arteries, and is often seen in conjunction with plaque deposits on the inner lining of a coronary artery (coronary atherosclerosis). Variant angina pectoris occurs almost exclusively when a person is at rest -- often between midnight and 8 a.m. -- and it can be quite painful. With proper medical care, the condition can be often stabilized within three to six months and the symptoms tend to diminish over time.

During angina, the lack of oxygen to the heart muscle is temporary and reversible, and the chest pain disappears with rest. However, if angina is followed by a heart attack, the resulting cardiac muscle damage is permanent.

The numerous effective treatments for angina range from lifestyle modifications to drugs to surgery.

How Common Is Angina?

The American Heart Association estimates that 6,200,000 people in the United States suffer from angina, and that 350,000 new cases occur each year. The likelihood of angina increases with age. In females, angina becomes more apparent after menopause.

The estimated prevalence of angina is 3.4% for non-Hispanic white men, 2.6% for non-Hispanic black men, and 3.4% for Mexican-American men. The estimated prevalence of angina is 4.1% for non-Hispanic white women, 5.2% for non-Hispanic black women, and 4.6% for Mexican-American women.


Established Causes

The most common cause of angina is coronary artery disease. Coronary arteries supply oxygen to the heart muscle. Coronary artery disease develops when cholesterol is deposited on the artery wall. The accumulation of cholesterol over time causes narrowing of the coronary arteries, a process called atherosclerosis. The prognosis for angina depends on the stage of this narrowing process. If caught at a relatively early stage, medical treatments should be able to halt and, in some cases, even reverse the narrowing of the coronary arteries. In advanced stages, surgery has proven successful.

The following conditions can also decrease oxygenation of the heart or prevent it from pumping blood effectively:

  • Severe anemia
  • Heart valve disease
  • Fast heartbeat (tachycardia)
  • Spasms of the coronary arteries

Risk Factors

Risk factors for angina include:

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

Signs and symptoms of angina include:

  • Paleness
  • Perspiration
  • Pain between shoulder blades
  • Difficulty breathing
  • Aching due to feeling of chest constriction, brought on by exertion or stress
  • Choking feeling in throat
  • Chest pain similar to indigestion
  • Heaviness or tingling sensation in neck, arm, shoulder, elbow (typically on left side)

Conditions That May Be Mistaken for Angina

Conditions that may confuse the diagnosis of angina include:

  • Gastrointestinal disorders such as peptic ulcer, indigestion, hiatus hernia, gallbladder disease, and spasms or inflammation of the esophagus
  • Aortic aneurysm: injury of the tissue in the wall of aorta (the major artery carrying blood out of the heart)
  • Chronic shortness of breath (dyspnea)
  • Blood clot in the lung, pneumonia, or pleurisy
  • Inflammation of the membrane around the heart (pericarditis)
  • Inflammation of or damage to the ribs
  • Disease of the spinal nerve roots (radiculopathy)
  • Psychological disorders due to panic or anxiety
  • Cervical or thoracic spine disease

How Is Angina Diagnosed?

Specific Tests

Your doctor will likely order an exercise stress test that will show your heart activity via electrocardiogram (ECG) and monitor your symptoms as you exercise to a predetermined level.

Although not usually used for diagnosis, continuous ECG monitoring with a Holter monitor (a portable, battery-powered ECG recorder) shows abnormalities indicating silent ischemia in some patients. The American Heart Association estimates that as many as 3 to 4 million Americans may have ischemic episodes without knowing it because they experience no pain or discomfort (silent ischemia). Continuous ECG monitoring also helps diagnose variant angina by detecting certain changes that occur when angina develops during rest.

Imaging

If your doctor wants to determine the condition of your coronary arteries, you may undergo some type of imaging procedure:

  • Coronary arteriography: A doctor guides a thin plastic tube through an artery in your arm or leg and into the coronary arteries, and then injects a liquid dye visible in X-rays through the catheter. High-speed X-ray movies show the liquid as it flows through the arteries. Doctors can identify blockages in the arteries by tracing the liquid's flow.
  • Stress echocardiography: A diagnostic procedure that studies the structure and motion of the heart.
  • Stress thalium: An imaging test to measure cardiac function and blood flow.

Laboratory work to determine risk factors includes a blood test to determine your cholesterol levels.


Goals of Treatment

The specific and immediate goal of treating angina is to either the decrease oxygen demand of the heart or increase oxygen supply to the heart. The longer-term goal is to address the underlying cause and halt the progression of coronary artery disease. Minor angina can be managed effectively with rest and use of nitroglycerin and other medications, while lifestyle changes can help address the underlying coronary heart disease. In more severe cases, surgery may be necessary to clear or circumvent arterial blockages.

Treatment Overview

Angina is a no-nonsense condition that requires medical treatment and monitoring. In severe cases and in the initial stages of mild to moderate cases, medication is usually necessary. Over time, you should be able to control angina with lifestyle changes and natural approaches. However, if you have significant blockage of the coronary artery, surgery in the form of angioplasty or coronary artery bypass may be appropriate.

Drug Therapy

Drugs most commonly prescribed

The drugs of choice include:

  • Aspirin for its anticoagulation properties
  • Beta-blockers like Inderal (propanolol) or Tenormin (atenolol) to reduce heart rate
  • Nitroglycerin to treat acute angina attacks by widening blood vessels
  • Nitrates like Ismo (isosorbide mononitrate) or Dilitrate-SR, Isonae, or Isordil (isosorbide dinitrate) to dilate coronary arteries
  • Calcium-channel blocking agents like Calan or Isoptin (verapamil) and Cardizem (diltiazem) prevent angina by reducing heart rate, thus reducing the heart's oxygen needs. Furthermore, these agents dilate the coronary arteries, preventing constricted blood flow.
  • HMG-CoA reductase inhibitors like Pravacol (pravastatin), Mevacor (lovastatin), Lipitor (atorvastatin), Baycol (cerivastatin), Lescol (fluvastatin), and Zocor (simvastatin) to decrease elevated cholesterol levels

Patients who are not responsive to one antianginal medication are often responsive to others. Efforts to find alternative medications are more useful before turning to therapies involving combinations of drugs.

Procedure

The two most commonly performed procedures to unblock the blood vessels leading to the heart are angioplasty and coronary bypass surgery, but a relatively new treatment called transmyocardial revascularization also shows promise for certain patients. The location and severity of the disease in the coronary arteries determine which procedure is chosen.

Angioplasty: A catheter with a balloon tip is inserted into the coronary arteries. When the catheter reaches a narrowed segment, the balloon is inflated to flatten the plaque and widen the artery. In one newer variation, a rotating blade shaves the plaque into tiny particles, and in another, a laser beam vaporizes the plaque. In some cases, a wire stent may be inserted into the narrowed vessel to help keep it open and clear.

Coronary bypass surgery: This is reserved for severe cases of coronary blockage that cannot be addressed by any other means. Segments of healthy blood vessels, either from the chest or leg, are used to bypass the severely narrowed parts of the coronary arteries. The result is greatly increased blood flow to the heart muscle, reducing angina and risk of a heart attack.

Transmyocardial revascularization: In this procedure, a laser cuts a series of channels in the heart muscle to increase blood flow. A surgeon makes an incision on the left side of the chest and inserts a laser into the chest cavity. With the laser, the surgeon shoots from 15 to 30 holes, each a millimeter in diameter, through the heart's left ventricle, in between heartbeats. (The laser is fired when the chamber is full of blood so the blood can protect the inside of the heart.) Then the surgeon seals the outer openings but lets the inner channels stay open, allowing oxygen-rich blood to flow through the heart muscle. This is a new and still experimental procedure.

Appropriate Healthcare Setting

If you experience characteristic mild angina (discomfort or pain brought about by physical exertion that goes away with rest), make an appointment to see your doctor for evaluation. More severe attacks and unstable angina require immediate medical attention and inpatient hospitalization.

Healthcare Professionals Who May Be Involved in Treatment

Healthcare professionals who participate in managing this disorder include:

  • Family physicians
  • Internists
  • Geriatricians
  • Critical care physicians
  • Radiologists
  • Cardiac surgeons
  • Cardiologists
  • Thoracic surgeons
  • Psychiatrists

Activity & Diet Recommendations

Because angina can be triggered by physical overexertion, avoid sudden bursts of activity and wait to exercise at least one hour after eating. Also, eat smaller meals over the course of the day. Large meals place more strain on the circulatory system. Because exposure to cold temperatures can constrict blood vessels, avoid going outside in cold, windy weather. However, exercise of moderate intensity can be very beneficial.

The importance of diet in heart disease is well established and many experts recommend a low-fat, high-fiber diet for patients with coronary artery disease. Here are some general guidelines:

  • Avoid foods high in saturated fats, such as meats, eggs, cheeses, and other dairy products
  • Eat plenty of whole grains, breads, and cereals instead of white and refined grains
  • Eat lots of fresh fruits and vegetables with meals and as snacks
  • Eat legumes such as beans, peas, and lentils in soups and salads

Quality of Life

Depending on the severity of your angina and the stage of the related coronary artery disease, available treatments range from lifestyle adjustments to major surgery. Which treatment is right for you will depend on your individual situation. Making lifestyle changes such as improving your diet, quitting smoking, gradually increasing exercise, and reducing stress can improve your overall quality of life as well as reduce your risk for a future heart attack.

Possible Complications

Angina is a symptom of coronary artery disease. The major complication of coronary artery disease is heart attack (myocardial infaction).

Considerations for Women

Pregnancy

Other causes of chest pain besides angina should be ruled out. The additional demands of pregnancy can make symptoms worse and interfere with treatment.

Considerations for Older People

The frequency of angina increases with age. Also, older patients can be especially sensitive to the side effects of medication. For example, beta-blockers can cause depression. And stress from any emotional cause, such as loneliness, affects all illnesses.

Significant activity restrictions for older people are recommended when angina attacks begin suddenly or increase in severity or frequency. Rest at first and then resume activity slowly, gradually increasing exercise. Avoid situations that increase demands on the heart, such as anger, temperature extremes, or sudden bursts of activity.

 

Supplements

  • Vitamin E: Two landmark Harvard studies -- one involving men, the other, women -- showed that vitamin E (100 IU/day) substantially reduces the risk of heart attack. Compared with those who did not take the vitamin, the people who did suffered significantly percent fewer heart attacks -- 37% in men, 41% in women. [1, 2] Vitamin E is a powerful antioxidant that also helps treat heart disease.
  • Vitamin C: A major antioxidant, Vitamin C also helps prevent and treat heart disease.
  • B vitamins: The B vitamins help reduce blood levels of homocysteine, a recently identified risk factor for heart attack. Researchers in Northern Ireland gave supplemental B vitamins to 101 men with high homocysteine levels. Eight weeks later, their homocysteine levels had dropped 28%, significantly reducing their risk of heart attack. [3] Nutrition experts suggest 3 mg of vitamin B-6 and 400 mcg of folic acid.
  • Fish oil: you can get the omega-3 fatty acids found in cold-water fish without eating them if you take fish-oil supplements. In addition to preventing heart attack, fish oil also increases the effectiveness of angioplasty and coronary artery bypass surgery. [4, 5]

Relaxation

  • Meditation is a key element of the Ornish program, and other studies also show its value. At the State University of New York, at Buffalo, researchers tested the exercise ability of 21 people with heart disease, and then taught them Transcendental Meditation (TM). Eight months later, they could exercise 15% more strenuously before experiencing chest pain, indicating a decreased risk of heart disease. [6]

    A great deal of research shows that the broad range of relaxation therapies helps prevent and treat heart disease. Practice whatever appeals to you: meditation, deep breathing, massage, hot baths, imagery/visualizations, progressive muscle relaxation, or self-hypnosis.
  • Cherish your friends and family. The Ornish program includes a support group, since many studies show that social support helps prevent and treat heart disease. New York researchers followed more than 1,000 heart-attack survivors for four years. Among those who lived alone, 16 had a recurrence. But among those who lived with a spouse, the figure was only about half that. [7]

Herbs

  • Garlic: Some experts believe that garlic reduces cholesterol and blood pressure, and makes blood less likely to form the clots that can cause heart attacks. Commission E, the German panel of doctors, pharmacists, and herbalists that judges the safety and effectiveness of herbal medicines for the German government, recommends one to four garlic cloves a day.
  • Willow bark: Doctors recommend low-dose aspirin to prevent the internal blood clots that trigger heart attacks. [8] You can gain the same benefit from a cup of willow-bark tea. Willow bark contains salicin, aspirin's herbal precursor. A half-teaspoon of willow bark contains about 100 mg of salicin, enough to provide aspirin's benefits.

1 Rimm, E.B., et al. "Vitamin E Consumption and Risk of Coronary Heart Disease in Men," New England Journal of Medicine 328:1450, 1993.

2 Stampfer, M.J., et al. "Vitamin E Consumption and Risk of Coronary Disease in Women," New England Journal of Medicine 328:1444, 1993.

3 Woodside, J., et al. "Effect of Vitamin Supplementation on Cardiovascular Risk," Journal of Inheritable and Metabolic Diseases 19(Suppl 1):26, 1996.

4 Gapinski, J.P., et al. "Preventing Restenosis with Fish Oils Following Coronary Angioplasty: A Meta-Analysis," Archives of Internal Medicine 153;1595, 1993.

5 Eritsland, J., et al. "Effect of Dietary Supplementation with N-3 Fatty Acids on Coronary Artery Bypass Graft Patency," American Journal of Cardiology 77:31, 1996.

6 Zamarra J.W., et al. "Usefulness of TM in the Treatment of Patients with CAD," American Journal of Cardiology 77:867, 1996.

7 Case, R.B., et al. "Living Alone after MI: Impact on Prognosis," Journal of the American Medical Association 267:515, 1992.

8 Duke, J. The Green Pharmacy,, Emmaus, PA: Rodale Press, 1997.


Preventing Angina Pectoris

The following strategies will specifically help prevent angina:

  • Eat four or five smaller meals spread evenly throughout the day. Eating heavy meals diverts blood to the digestive system, reducing oxygen flow to the heart.
  • Avoid exercise for at least one hour after eating.
  • Avoid excessive alcohol -- it can damage heart muscle.
  • Don't go out on cold, windy days. Cold weather constricts blood vessels.

Self-Care Measures

  • If you smoke, quit. Smoking is a major risk factor for heart disease, and quitting quickly reduces your risk.
  • An ultra low-fat diet is a key element of the only program ever shown to reverse heart disease. Pioneered by Dean Ornish, M.D., of the Preventive Medicine Research Institute in Sausalito, Calif., the program has five components:

    • Vegetarian diet containing just 10% fat (compared to the average American's 35%)
    • Daily exercise, like walking
    • Meditation
    • Yoga
    • Weekly support-group meetings

    In a series of three landmark studies, Ornish showed that people who embrace his program enjoy progressively increasing blood flow through their coronary arteries, a feat that drugs and surgery cannot match. As atherosclerosis decreases, so does risk of heart attack.
  • Eat more plant foods. Even if you don't adopt the entire Ornish program, it's a good idea to limit meats and eat more plant foods, which include fruits, vegetables, beans, and whole grains. In one study, Harvard researchers followed 44,000 middle-aged men for six years. As the men's plant-food consumption increased, their risk of atherosclerosis decreased. Compared with those who ate the fewest plant foods, those who ate the most enjoyed substantial protection from heart attacks. Plant foods are high in antioxidant nutrients, which prevent the cell damage at the root of atherosclerosis.

    Plant foods are central to the "Mediterranean diet" of people in Spain, Italy, and Greece. People there consume a good deal more fat than the Ornish-program limit, but it's mostly monounsaturated olive oil, the heart-healthiest fat, as opposed to the saturated fat found in meat, the kind that leads to heart disease. Several studies show that the Mediterranean diet helps prevent heart disease. And if you've survived a heart attack, this diet can prevent a recurrence. In one study, French researchers told 605 heart-attack survivors to eat either a diet heavier in saturated fat or a Mediterranean-style diet. During five years of follow-up, the Mediterranean group had 72% fewer second heart attacks.
  • Try drinking tea. Several recent studies have shown that, like plant foods, tea is high in the antioxidants that prevent heart disease.
  • Eating cold-water fish, notably salmon, may also help prevent and treat heart disease. Cold-water fish are high in omega-3 fatty acids, which help prevent the arterial damage that leads to heart attack.
  • Drink a little red wine. Many studies show that modest alcohol consumption raises HDL (or "good") cholesterol, the kind that reduces risk of atherosclerosis. In addition, red wine contains extra antioxidants that further reduce risk. Some people shouldn't drink at all, including current or former alcoholics, those with a family history of alcoholism, pregnant women, and people with liver disease. But if you can drink, a little alcohol, especially red wine, can help prevent atherosclerosis and heart attack.
  • Exercise moderately. An enormous amount of research shows that physical activity reduces the risk of heart disease. In one study, Harvard researchers analyzed the results of more than a dozen studies that correlated exercise and risk of death from heart disease. Compared with sedentary individuals, people who got regular exercise had just half the risk.

    The Ornish program encourages walking and yoga, but any regular, moderate exercise helps. Exercise is a standard part of post-heart-attack rehabilitation. It also reduces stress, a major contributor to high blood pressure and a risk factor for heart disease.

  • Websites & Organizations

    American Heart Association
    7320 Greenville Ave.
    Dallas TX 75231
    Phone: 214-750-5300

    Cardiac Health Web

    Heart Information Network

    Heartline
    9500 Euclid Ave., Room EE-37
    Cleveland, OH 44195
    Phone: 800-478-4255

    Heartmates, Inc.
    PO Box 16202
    Minneapolis, MN 55416
    Phone: 800-9HM-3331(800-946-3331)
    Email:heartmates@outtech.com

    National Heart, Lung, and Blood Institute, Information Office
    P.O. Box 30105
    Bethesda, MD 20892-0105
    Phone: 301-251-1222

    NOAH, New York Online Acess To Health

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