Angina

Angina is chest pain or discomfort that occurs when your heart muscle doesn't receive enough oxygen-rich blood. It's a symptom of an underlying heart problem, typically coronary artery disease, and serves as a warning sign that requires medical attention.

Overview

Angina, also known as angina pectoris, is a clinical syndrome characterized by chest discomfort or pain resulting from inadequate blood supply to the heart muscle (myocardial ischemia). This occurs when the heart's demand for oxygen exceeds the supply delivered through the coronary arteries. Angina is not a disease itself but rather a symptom of underlying cardiovascular conditions, most commonly coronary artery disease (CAD).

The experience of angina varies among individuals but typically manifests as pressure, squeezing, burning, or tightness in the chest. Some describe it as feeling like a heavy weight on the chest or like indigestion. The discomfort may radiate to the shoulders, arms, neck, jaw, or back. Angina episodes are often triggered by physical exertion, emotional stress, extreme temperatures, or heavy meals – situations that increase the heart's workload and oxygen demand.

Understanding angina is crucial because it often represents the first warning sign of heart disease. While angina itself isn't life-threatening, it indicates an increased risk of heart attack and other cardiac events. There are several types of angina, each with different characteristics and implications for treatment. Stable angina follows a predictable pattern and improves with rest or medication, while unstable angina is unpredictable and constitutes a medical emergency. Proper diagnosis and management of angina can significantly improve quality of life and prevent serious cardiovascular complications.

Symptoms

Angina symptoms can vary significantly between individuals, and some people, particularly women, diabetics, and elderly patients, may experience atypical presentations. Recognizing these symptoms is crucial for timely medical intervention.

Classic Chest Symptoms

  • Chest pain or discomfort (pressure, squeezing, burning)
  • Chest tightness or heaviness
  • Pain typically behind the breastbone
  • Discomfort lasting 2-10 minutes
  • Pain triggered by exertion or stress
  • Relief with rest or nitroglycerin

Radiating Symptoms

Associated Symptoms

Types of Angina Patterns

  • Stable Angina: Predictable pattern, triggered by exertion, relieved by rest
  • Unstable Angina: Unpredictable, occurs at rest, increasing frequency/severity
  • Variant (Prinzmetal's) Angina: Occurs at rest, often at night, due to coronary spasm
  • Microvascular Angina: Chest pain without major coronary blockages

Atypical Presentations

Certain groups may experience angina differently:

  • Women: More likely to have non-chest symptoms like nausea, jaw pain, or back pain
  • Elderly: May present with only dyspnea, fatigue, or confusion
  • Diabetics: May have silent ischemia due to neuropathy
  • Post-surgical patients: May have altered pain perception

Causes

Angina occurs when there's an imbalance between the heart's oxygen supply and demand. Understanding the underlying causes helps in proper management and treatment of this condition.

Primary Cause: Coronary Artery Disease

The most common cause of angina is coronary artery disease (CAD), where the coronary arteries become narrowed or blocked by atherosclerotic plaques. This process involves:

  • Atherosclerosis: Buildup of cholesterol, fat, and other substances in artery walls
  • Plaque formation: Hard deposits that narrow arteries and reduce blood flow
  • Inflammation: Contributes to plaque instability and progression
  • Endothelial dysfunction: Impaired ability of blood vessels to dilate

Other Cardiac Causes

  • Coronary artery spasm: Temporary tightening of coronary arteries
  • Microvascular disease: Dysfunction of small coronary arteries
  • Aortic stenosis: Narrowing of the heart's aortic valve
  • Hypertrophic cardiomyopathy: Thickened heart muscle
  • Coronary artery anomalies: Congenital abnormalities

Triggers That Increase Oxygen Demand

Physical Triggers

  • Physical exertion or exercise
  • Sexual activity
  • Walking uphill or against wind
  • Lifting heavy objects

Emotional/Psychological Triggers

  • Emotional stress or anxiety
  • Anger or excitement
  • Fear or panic
  • Mental stress at work

Environmental Triggers

  • Extreme cold or hot weather
  • High altitude
  • Air pollution
  • Sudden temperature changes

Physiological Triggers

  • Large meals
  • Smoking
  • Stimulant use (caffeine, cocaine)
  • Severe anemia
  • Hyperthyroidism
  • Tachyarrhythmias

Pathophysiology

The mechanism of angina involves:

  1. Increased demand: Heart requires more oxygen during stress or exertion
  2. Limited supply: Narrowed arteries can't deliver adequate blood flow
  3. Ischemia: Temporary oxygen shortage in heart muscle
  4. Pain signals: Nerve fibers detect ischemia and transmit pain
  5. Resolution: Rest reduces demand, allowing supply to catch up

Risk Factors

Multiple factors increase the risk of developing angina by promoting coronary artery disease or increasing cardiac workload. Some risk factors are modifiable through lifestyle changes and medical treatment.

Age and Gender

Risk increases with age. Men typically develop angina earlier than women, but women's risk increases significantly after menopause. Women may have more atypical symptoms.

Family History

Genetic predisposition plays a significant role. Having a first-degree relative with premature heart disease (men <55 years, women <65 years) increases risk substantially.

Smoking

Major modifiable risk factor. Damages blood vessel lining, reduces oxygen in blood, increases clot risk, and accelerates atherosclerosis. Secondhand smoke also increases risk.

High Blood Pressure

Hypertension damages artery walls and accelerates atherosclerosis. Also increases heart's workload, raising oxygen demand.

High Cholesterol

Elevated LDL ("bad") cholesterol and low HDL ("good") cholesterol promote plaque buildup. Triglycerides also contribute to atherosclerosis.

Diabetes

Diabetes significantly increases risk through multiple mechanisms: accelerated atherosclerosis, endothelial dysfunction, and increased clotting tendency.

Obesity

Excess weight strains the heart and is associated with other risk factors like diabetes, hypertension, and high cholesterol. Central obesity is particularly harmful.

Physical Inactivity

Sedentary lifestyle contributes to obesity, high blood pressure, and poor cholesterol levels. Regular exercise strengthens the heart and improves circulation.

Stress

Chronic stress may damage arteries and worsen other risk factors. Acute stress can trigger angina episodes through increased heart rate and blood pressure.

Other Risk Factors

  • Sleep apnea: Drops in oxygen levels strain the cardiovascular system
  • Chronic kidney disease: Accelerates atherosclerosis
  • Autoimmune conditions: Rheumatoid arthritis, lupus increase risk
  • Preeclampsia history: Doubles lifetime cardiovascular risk
  • Radiation therapy: To chest area can damage coronary arteries
  • Recreational drugs: Cocaine, amphetamines can trigger spasm

Diagnosis

Accurate diagnosis of angina involves comprehensive evaluation to confirm the presence of coronary artery disease, assess severity, and rule out other causes of chest pain.

Medical History and Physical Examination

  • Symptom characterization: Quality, location, duration, triggers, and relieving factors
  • Risk factor assessment: Family history, lifestyle factors, medical conditions
  • Physical examination: Blood pressure, heart sounds, signs of heart failure
  • Differential diagnosis: Rule out non-cardiac causes of chest pain

Diagnostic Tests

Electrocardiogram (ECG/EKG)

Records heart's electrical activity. May be normal at rest in stable angina. Changes during symptoms suggest ischemia. Continuous monitoring may capture episodes.

Exercise Stress Test

ECG monitoring during treadmill or bicycle exercise. Reveals ischemia provoked by exertion. Helps determine exercise capacity and prognosis.

Stress Echocardiography

Ultrasound imaging before and after exercise or medication-induced stress. Shows wall motion abnormalities indicating ischemia. More sensitive than ECG alone.

Nuclear Stress Test

Radiotracer injection shows blood flow to heart muscle. Images at rest and stress reveal perfusion defects. Quantifies extent and severity of ischemia.

Coronary Angiography

Gold standard for visualizing coronary arteries. Contrast dye and X-rays show blockages. Can proceed directly to intervention if needed.

CT Coronary Angiography

Non-invasive visualization of coronary arteries. High-resolution CT with contrast. Useful for ruling out significant disease in low-intermediate risk patients.

Blood Tests

  • Cardiac biomarkers: Troponin to rule out heart attack
  • Lipid profile: Cholesterol and triglyceride levels
  • Blood glucose: Screen for diabetes
  • Complete blood count: Check for anemia
  • Thyroid function: Rule out hyperthyroidism
  • Inflammatory markers: hs-CRP for cardiovascular risk

Risk Stratification

Based on diagnostic findings, patients are stratified into risk categories:

  • Low risk: Normal ECG, good exercise capacity, no high-risk features
  • Intermediate risk: Mild ischemia, moderate symptoms
  • High risk: Severe ischemia, left main disease, reduced heart function

Treatment Options

Angina treatment aims to reduce symptoms, prevent heart attacks, and improve quality of life. The approach combines lifestyle modifications, medications, and sometimes procedures to restore blood flow.

Lifestyle Modifications

Essential Changes

  • Smoking cessation: Most important modifiable risk factor
  • Heart-healthy diet: Low saturated fat, high fiber, fruits and vegetables
  • Regular exercise: As prescribed by physician, usually 30 minutes daily
  • Weight management: Achieve and maintain healthy BMI
  • Stress management: Relaxation techniques, counseling if needed
  • Limit alcohol: Moderate consumption only

Medications

Anti-Anginal Medications

  • Nitrates:
    • Short-acting (nitroglycerin): For acute relief
    • Long-acting: For prevention
    • Dilate blood vessels, reduce heart workload
  • Beta-blockers:
    • Reduce heart rate and blood pressure
    • Decrease oxygen demand
    • First-line for stable angina
  • Calcium channel blockers:
    • Dilate coronary arteries
    • Reduce heart workload
    • Alternative when beta-blockers contraindicated
  • Ranolazine:
    • Newer anti-anginal drug
    • Doesn't affect heart rate or blood pressure
    • Add-on therapy for refractory symptoms

Preventive Medications

  • Antiplatelet therapy:
    • Aspirin: First-line for all patients
    • Clopidogrel: Alternative or addition
    • Prevents blood clots
  • Statins:
    • Lower cholesterol
    • Stabilize plaques
    • Reduce cardiovascular events
  • ACE inhibitors/ARBs:
    • Blood pressure control
    • Protect heart and kidneys
    • Especially for diabetics

Revascularization Procedures

Percutaneous Coronary Intervention (PCI)

  • Balloon angioplasty to open blocked arteries
  • Stent placement to keep arteries open
  • Drug-eluting stents reduce re-narrowing
  • Less invasive than surgery
  • Shorter recovery time

Coronary Artery Bypass Grafting (CABG)

  • Surgical creation of new routes around blockages
  • Uses vessels from leg, arm, or chest
  • Preferred for:
    • Left main coronary disease
    • Three-vessel disease
    • Diabetes with multi-vessel disease
    • Reduced heart function

Enhanced External Counterpulsation (EECP)

  • Non-invasive treatment for refractory angina
  • Inflatable cuffs improve blood flow
  • 35 one-hour sessions over 7 weeks
  • May stimulate collateral circulation

Cardiac Rehabilitation

  • Supervised exercise program
  • Education about heart-healthy living
  • Psychological support
  • Risk factor modification
  • Improves outcomes and quality of life

Prevention

Preventing angina involves reducing risk factors for coronary artery disease and managing existing heart conditions. Many preventive measures also help control angina in those already diagnosed.

Primary Prevention (Before Angina Develops)

  • Risk factor screening: Regular check-ups for blood pressure, cholesterol, diabetes
  • Healthy lifestyle adoption: Start heart-healthy habits early
  • Family history awareness: Earlier screening if genetic risk
  • Preventive medications: Statins for high-risk individuals

Dietary Modifications

  • Mediterranean diet: Proven cardiovascular benefits
  • Limit saturated fats: Less than 7% of daily calories
  • Increase omega-3 fatty acids: Fish twice weekly
  • Fiber intake: 25-35 grams daily
  • Sodium restriction: Less than 2,300mg daily
  • Plant sterols: Can help lower cholesterol

Physical Activity Guidelines

  • Aerobic exercise: 150 minutes moderate or 75 minutes vigorous weekly
  • Resistance training: 2 days per week
  • Start gradually: If sedentary, begin with short walks
  • Cardiac rehabilitation: Supervised program after diagnosis
  • Daily activities: Take stairs, park farther away

Secondary Prevention (After Angina Diagnosis)

  • Medication adherence: Take all prescribed medications
  • Regular monitoring: Follow-up appointments and tests
  • Symptom diary: Track triggers and patterns
  • Emergency plan: Know when to use nitroglycerin or seek help
  • Flu vaccination: Reduces cardiovascular events

Stress Management

  • Relaxation techniques: Deep breathing, meditation
  • Regular sleep: 7-9 hours nightly
  • Time management: Avoid overcommitment
  • Social support: Maintain relationships
  • Professional help: Counseling for anxiety or depression

When to See a Doctor

Recognizing when to seek medical attention for chest pain is crucial, as it could indicate a heart attack or unstable angina requiring immediate treatment.

Call 911 Immediately For

  • New or unfamiliar chest pain
  • Chest pain lasting more than 15 minutes
  • Chest pain not relieved by rest or nitroglycerin
  • Increasing frequency or severity of angina
  • Chest pain at rest (unstable angina)
  • Chest pain with:
    • Severe shortness of breath
    • Rapid or irregular heartbeat
    • Profuse sweating
    • Nausea or vomiting
    • Loss of consciousness

Schedule Urgent Appointment For

  • First episode of chest pain (even if resolved)
  • Change in usual angina pattern
  • Angina with less exertion than before
  • Need for more frequent nitroglycerin
  • Side effects from medications
  • Difficulty controlling risk factors

Regular Follow-up Needed For

  • Stable angina monitoring
  • Risk factor assessment
  • Medication adjustments
  • Preventive care planning
  • Cardiac testing as recommended

Related Conditions

Cardiac Conditions

Risk Factor Conditions

Related Symptoms

References

  1. Knuuti J, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-477.
  2. Fihn SD, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation. 2014;130(19):1749-1767.
  3. Jneid H, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. J Am Coll Cardiol. 2017;70(11):1415-1430.
  4. Boden WE, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.
  5. Task Force Members, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J. 2013;34(38):2949-3003.

Medical Disclaimer: This information is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.