Discomfort in the chest that can range from mild discomfort to severe pain is called angina. Although chest pain can have many origins, true angina is a symptom of inadequate blood and oxygen supply to the heart, a condition most often due to plaque in the arteries (also called ischemic or coronary heart disease).
The heart requires a steady supply of oxygen and nutrients from arteries on the surface of the heart muscle called coronary arteries. When deposits (plaques) build up within the arteries, the condition is called coronary atherosclerosis (also known as coronary heart disease or ischemic heart disease).
These plaques contain fats and inflammatory cells, and occur more frequently in smokers, older adults, males, and people with diabetes, high blood pressure, and high cholesterol. The plaques narrow the coronary arteries, reducing the arteries’ ability to supply the heart with blood. When the heart does not receive enough oxygen and nutrients, angina results.
Most people experience angina when the heart’s demand for oxygen increases; such as during exercise, while walking up stairs or hills, during stressful situations, or after eating a large meal.
However, a person can also experience angina while at rest, which may reflect a very serious form of the condition, or may be a warning sign of an impending heart attack.
“Angina is more common in men than in women.”
About 70% of people who have angina are men. The typical angina patient is a man older than age 50 or a woman older than age 60.
There are two main types of angina: stable angina and unstable angina. Stable angina occurs fairly predictably, and is usually triggered by certain activities or situations. Unstable angina is a worsening pattern of chest pain that occurs more frequently, more severely, and/or at lower levels of activity. If you are suffering from chest pain that is new (less than two months), or begins to occur more frequently, more severely, or at lower levels of activity, you may have unstable angina.
This can be a sign of an impending heart attack, and should be treated as a medical emergency. You can develop unstable angina suddenly, or you may feel a gradual worsening of your symptoms over days to weeks. Stable angina can develop into unstable angina; however, unstable angina can also occur without stable angina preceding it.
If you have been diagnosed with stable angina and you notice that the attacks are increasing in frequency and severity, or that they occur while you are resting or after exerting yourself less strenuously than normal, this may signal the onset of unstable angina or an impending heart attack. True unstable angina is a medical emergency.
It can be difficult to tell the difference between angina and a heart attack. Pain from a heart attack is usually more severe, and usually lasts longer (for example, longer than 10-15 minutes). However, angina can feel very similar to a heart attack.
Angina is heart pain that results from inadequate blood and oxygen flow to an area of heart muscle. While painful, angina does not permanently damage the heart muscle. A heart attack, on the other hand, does actual damage to a part of the heart muscle as a result of inadequate blood and oxygen flow. How much heart muscle is damaged by a heart attack depends on the size of the artery supplying the affected area of the heart and how quickly the heart attack is treated.
You can lower your risk of a heart attack with diet, exercise, medications, stopping smoking, and maintaining control of blood pressure, cholesterol, and diabetes. However, the risk can never be eliminated, so treat angina as a serious reminder to take care of your health.
“Medications are available to treat angina.”
When angina occurs, certain medications can be taken to dilate the heart arteries temporarily, allowing increased blood and oxygen flow to the heart. Other medications can be taken regularly to reduce or relieve the symptoms of angina before they even occur.
Whatever type of angina you have, you should take steps to reduce your heart disease risk factors by maintaining a proper weight, exercising regularly, and lowering cholesterol levels. If you are a smoker, it is essential that you quit. Your doctor may also recommend taking aspirin regularly.
In many cases, lifestyle changes, medications, and treating underlying conditions such as high blood pressure can be enough to ease stable angina without need for further procedures or surgery. Importantly, these measures also reduce the risk of future heart attacks and the risk of death from heart disease.
Procedures such as angioplasty (opening the narrowed part of the artery with a balloon) and coronary artery bypass grafting (bypassing the narrowed part of the artery with surgery) often can reduce angina that cannot be controlled by these measures.
Causes of Chest Pain
Stable angina is caused by partial obstruction of the blood vessels of the heart (coronary arteries)Figure 01. Deposits (plaques) in the walls of the coronary arteries narrow the area inside the artery available for carrying blood. This reduces the capacity of the artery to supply the heart muscle with oxygen and nutrients.
Angina occurs when the heart’s need for oxygen is greater than what the blood vessels are able to supply. Exercise, cold weather, stressful situations, and large meals can all trigger an attack.
Unstable angina is believed to occur when a plaque in a coronary artery splits or breaks open (ruptures), releasing materials contained within the plaque into the bloodstream. The causes of plaque rupture are not well understood. When a plaque ruptures, clot-forming cells (platelets) and inflammatory cells gather at the site to attempt to repair the damage, similar to what occurs when you cut your skin.
These cells may form a blood clot and release chemicals that narrow the blood vessel further. The clot and the narrowing of the blood vessel (spasm) may act to partially or completely block blood flow very quickly–within hours or even minutes.
This sudden decrease in blood flow often causes severe, prolonged pain, and may lead to a heart attack. If you suspect unstable angina, this is a medical emergency, and you should immediately go to a hospital via ambulance.
Symptoms of Chest Pain
A feeling of tightness or pressure in the mid-chest, which may radiate to one or both shoulders, arms, or hands, or to the jaw or more rarely the back or abdomen, is the typical symptom of angina Figure 02. Stable angina typically occurs with activity or stress, lasts one to five minutes, and then eases with rest.
The sensation may occur suddenly and then gradually ease. People often do not experience angina as pain, but rather a sensation of tightness, heaviness, or pressure in the chest. Nausea, shortness of breath, sweats, and sense of anxiety and fear may also accompany an angina attack.
Women and persons with diabetes may have unusual or atypical angina symptoms, such as shortness of breath or nausea without chest pain.
Risk Factors of Chest Pain
The risk factors for angina are the same as those for coronary artery disease: cigarette smoking, lack of exercise, high blood pressure, high cholesterol, diabetes, male gender, older age, and a family history of premature heart disease.
A family history of premature heart disease may be defined as having a close relative (such as a parent, brother or sister, uncle or aunt, or grandparent) who has been diagnosed with coronary heart disease before the age of 55.
Treatment of Chest Pain
Unstable angina–chest pain that occurs more severely, more frequently, and/or at lower levels of activity or at rest–may be a warning sign of a potential heart attack, and may require emergency treatment. Indeed, any chest pain can be the sign of a serious problem. If you experience such symptoms, you should consult a doctor immediately. If you experience such symptoms, take an aspirin (unless you are allergic to aspirin) and immediately seek emergency medical treatment..
If you are diagnosed with unstable angina, you can expect to stay in the hospital for at least 24 hours.
You will be placed on a monitor to follow your heart rhythm. Blood tests will be drawn to look for signs of heart damage (heart attack). You will be treated with medications that will usually include aspirin and heparin (a clot-preventing medication) until you are pain-free for 24 to 48 hours. Your doctor will then decide if further tests are needed, such as a stress test or cardiac catheterization.
An important part of treating stable angina treatment involves improving other conditions that may worsen it, such as obesity, high blood pressure, diabetes, and high cholesterol. Your doctor can help you with treatment of these conditions.
Smoking cigars or cigarettes is one of the major causes of heart disease. Quitting smoking can ease symptoms and save your life. Talk to your doctor about smoking cessation medications and techniques. This is one of the most important things you can do for your health.
Making adjustments to your activities may also help ease the symptoms of angina. Monitor your symptoms and determine what seems to make your angina worse. For example, you may notice that you suffer from angina if you exert yourself early in the day, but then may be able to exercise without chest discomfort in the afternoon.
If your angina tends to flare up after eating, avoid exertion immediately after mealtime. Performing certain activities at a slower pace can also make them more tolerable. However, if you find that you are limiting your lifestyle to the point where you are unable to do the things that you enjoy, you should contact your doctor. Adjustments in medications and other treatments can significantly relieve or reduce many people’s angina.
A physician-approved exercise regimen is a great way to strengthen the heart and improve high blood pressure and diabetes. Consult with your doctor before starting an exercise program. He or she can help you understand your limitations and will design something specifically for you. Gentle, steady, aerobic activity, such as walking or bicycling, are usually the best for the heart.
Your doctor can also help you determine when and how to gradually increase the intensity of your workouts over time, and you can monitor your progress together.
Learning to manage and reduce emotional stress can also be an important part of controlling chest pain from angina. Exercise, stretching, and relaxation techniques may help manage stress. It is also important to try to avoid situations that are excessively stressful. Talk to your health professional for ideas on how to manage your stress. Your doctor is the best source of information on the drug treatment choices available to you.
If you have angina or have had a heart attack, your doctor may recommend fish oil tablets, which may reduce your risk of dying from a heart attack in the future.
If unstable angina continues after you have received aspirin, heparin, and other medications in the hospital or emergency room, a procedure called cardiac catheterization (angiogram) may be required. An angiogram allows the doctor to view the outlines of the coronary arteries to identify blockages and to determine the severity of the blockages.
During cardiac catheterization, the skin over one of the large leg arteries (femoral artery) is treated with local anesthetic, and then a hollow tube called a “sheath” is placed into the artery. Through this sheath, the doctor can pass thinner, longer hollow tubes called catheters up to your heart.
The catheters deliver a liquid (known as contrast) to the coronary arteries that can be seen with x-rays. As the liquid is injected, an x-ray camera outside the body takes pictures of the heart.
The images show the liquid moving through the arteries of your heart, and allow the doctor to determine if narrowing has occurred in your heart’s arteries. You are awake during this procedure, as there is little discomfort once the leg artery is anesthetized. You may be given a sedative to make you more comfortable.
During cardiac catheterization, your doctor may be able to treat a blockage by using a balloon to press open the plaque (balloon angioplasty)Figure 03. Through the sheath in the leg, a miniature balloon attached to a catheter is passed through the leg artery until it reaches the heart.
It is then passed into the diseased heart artery and positioned at the site of the blockage (plaque) requiring treatment. Once in position, it is temporarily inflated, which compresses the plaque against the walls of the artery, reducing the blockage and allowing more blood flow to the heart.
Small metal coils (stents) may also be placed at the site of the blockage to help keep the artery open. If a stent is placed, you may be treated with a medication such as the anti-clot medication clopidogrel (Plavix) for four to six weeks to help prevent re-occurrence of the blockage.
In general, angioplasty requires relatively short hospital stays (for example, one to two days), is less invasive than open heart surgery, and allows most patients to return to normal life quickly, usually within a week or so.
However, not all blockages can be treated with angioplasty, and some blockages can reoccur after treatment: up to 30% of blockages treated with angioplasty might worsen again and cause symptoms within the first 6-12 months. On the other hand, blockages that do not worsen within the first 6-12 months after angioplasty might remain open for many years.
Continued smoking is one of the main risks for re-closure of an artery treated with angioplasty and stenting, and therefore quitting smoking is essential.
Cardiac catheterization may also be done on a non-emergency basis for diagnosis of coronary heart disease if you have stable angina and are being considered for major surgery, or if your angina continues to be significant despite the use of medications.
You may be considered for open heart surgery, called coronary artery bypass grafting (CABG), to detour blood flow around the blockages in your heart arteries Figure 04. If you have severe disease of your heart arteries, or if your angina cannot be sufficiently treated with lifestyle changes, medications, and/or angioplasty, surgery may be recommended. Also, in some patients with unstable angina, surgery may be recommended to help prevent a heart attack.
Heart artery blockages are bypassed using a vein from the leg or an artery within the chest, creating an alternate route for blood flow to the heart muscle. CABG usually requires that the breastbone be cut and that the patient be placed on a machine to supply the body with blood during the surgery.
In come cases, CABG can be performed without the breastbone being cut or without placing the patient on bypass, but this depends on the clinical situation, the patient, the surgeon, and the operating team.
The risks and benefits of CABG vary depending on the severity of the heart condition, the patient’s overall health, and the skill and experience of the surgical team. Patients are generally in the hospital for a week or more, and recovery time at home is usually another six to eight weeks. Following recovery, most patients are able to have better, more active lives, usually with mild or no angina for many years.
Whether angioplasty or CABG can be performed depends on the nature of the blockages in the heart arteries and on the patient’s overall health and lifestyle.
Intake of fatty fish or fish oil tablets may reduce the risk of dying from a heart attack. Patients who are using nitroglycerin should not take the anti-impotence drugs Viagra, Cialis, or Levitra. The two drugs together can cause death by suddenly lowering the blood pressure.
The prognosis, or future risk of death or a heart attack, in a person with angina depends on several factors. These factors include the condition of the left ventricle, the heart muscle chamber that pumps blood through the body, and the location and severity of blockages in the heart arteries.
Smoking also increases the risk of death or a heart attack, and it is critical that you stop smoking if you have heart disease. Taking aspirin, beta-blockers, ACE inhibitors, cholesterol-lowering medication, and fish oil may also reduce the risk of death or a heart attack. In some patients, CABG surgery may also be recommended. Most people with stable angina can live productively for many years.
Patients who have had an episode of unstable angina are at increased risk for major heart problems (such as a heart attack or death) over the next 6-12 months. Close attention to your doctor’s recommendations is critical during this time.
Regular visits to your doctor are important so that your symptoms can be followed, to make sure you are tolerating your medications, and to treat your high blood pressure, high cholesterol, and diabetes, if you have these conditions. Stress tests may also be performed during your follow-up.
Diagnosis of Chest Pain
Discomfort in the chest that can range from mild discomfort to severe pain is called angina. Although chest pain can have many origins, true angina is a symptom of inadequate blood and oxygen supply to the heart, a condition most often due to plaque in the arteries (also called ischemic or coronary heart disease).
The heart requires a steady supply of oxygen and nutrients from arteries on the surface of the heart muscle called coronary arteries. When deposits (plaques) build up within the arteries, the condition is called coronary atherosclerosis (also known as coronary heart disease or ischemic heart disease).
These plaques contain fats and inflammatory cells, and occur more frequently in smokers, older adults, males, and people with diabetes, high blood pressure, and high cholesterol. The plaques narrow the coronary arteries, reducing the arteries’ ability to supply the heart with blood. When the heart does not receive enough oxygen and nutrients, angina results.
Most people experience angina when the heart’s demand for oxygen increases; such as during exercise, while walking up stairs or hills, during stressful situations, or after eating a large meal.
However, a person can also experience angina while at rest, which may reflect a very serious form of the condition, or may be a warning sign of an impending heart attack.
About 70% of people who have angina are men. The typical angina patient is a man older than age 50 or a woman older than age 60.
There are two main types of angina: stable angina and unstable angina. Stable angina occurs fairly predictably, and is usually triggered by certain activities or situations. Unstable angina is a worsening pattern of chest pain that occurs more frequently, more severely, and/or at lower levels of activity.
If you are suffering from chest pain that is new (less than two months), or begins to occur more frequently, more severely, or at lower levels of activity, you may have unstable angina. This can be a sign of an impending heart attack, and should be treated as a medical emergency.
You can develop unstable angina suddenly, or you may feel a gradual worsening of your symptoms over days to weeks. Stable angina can develop into unstable angina; however, unstable angina can also occur without stable angina preceding it.
If you have been diagnosed with stable angina and you notice that the attacks are increasing in frequency and severity, or that they occur while you are resting or after exerting yourself less strenuously than normal, this may signal the onset of unstable angina or an impending heart attack. True unstable angina is a medical emergency.
It can be difficult to tell the difference between angina and a heart attack. Pain from a heart attack is usually more severe, and usually lasts longer (for example, longer than 10-15 minutes). However, angina can feel very similar to a heart attack. Angina is heart pain that results from inadequate blood and oxygen flow to an area of heart muscle.
While painful, angina does not permanently damage the heart muscle. A heart attack, on the other hand, does actual damage to a part of the heart muscle as a result of inadequate blood and oxygen flow. How much heart muscle is damaged by a heart attack depends on the size of the artery supplying the affected area of the heart and how quickly the heart attack is treated.
You can lower your risk of a heart attack with diet, exercise, medications, stopping smoking, and maintaining control of blood pressure, cholesterol, and diabetes. However, the risk can never be eliminated, so treat angina as a serious reminder to take care of your health.
When angina occurs, certain medications can be taken to dilate the heart arteries temporarily, allowing increased blood and oxygen flow to the heart. Other medications can be taken regularly to reduce or relieve the symptoms of angina before they even occur.
Whatever type of angina you have, you should take steps to reduce your heart disease risk factors by maintaining a proper weight, exercising regularly, and lowering cholesterol levels. If you are a smoker, it is essential that you quit. Your doctor may also recommend taking aspirin regularly.
In many cases, lifestyle changes, medications, and treating underlying conditions such as high blood pressure can be enough to ease stable angina without need for further procedures or surgery. Importantly, these measures also reduce the risk of future heart attacks and the risk of death from heart disease.
Procedures such as angioplasty (opening the narrowed part of the artery with a balloon) and coronary artery bypass grafting (bypassing the narrowed part of the artery with surgery) often can reduce angina that cannot be controlled by these measures.
Stable angina is caused by partial obstruction of the blood vessels of the heart (coronary arteries)Figure 01. Deposits (plaques) in the walls of the coronary arteries narrow the area inside the artery available for carrying blood. This reduces the capacity of the artery to supply the heart muscle with oxygen and nutrients.
Angina occurs when the heart’s need for oxygen is greater than what the blood vessels are able to supply. Exercise, cold weather, stressful situations, and large meals can all trigger an attack.
Unstable angina is believed to occur when a plaque in a coronary artery splits or breaks open (ruptures), releasing materials contained within the plaque into the bloodstream. The causes of plaque rupture are not well understood. When a plaque ruptures, clot-forming cells (platelets) and inflammatory cells gather at the site to attempt to repair the damage, similar to what occurs when you cut your skin.
These cells may form a blood clot and release chemicals that narrow the blood vessel further. The clot and the narrowing of the blood vessel (spasm) may act to partially or completely block blood flow very quickly–within hours or even minutes.
This sudden decrease in blood flow often causes severe, prolonged pain, and may lead to a heart attack. If you suspect unstable angina, this is a medical emergency, and you should immediately go to a hospital via ambulance.
A feeling of tightness or pressure in the mid-chest, which may radiate to one or both shoulders, arms, or hands, or to the jaw or more rarely the back or abdomen, is the typical symptom of angina Figure 02. Stable angina typically occurs with activity or stress, lasts one to five minutes, and then eases with rest.
The sensation may occur suddenly and then gradually ease. People often do not experience angina as pain, but rather a sensation of tightness, heaviness, or pressure in the chest. Nausea, shortness of breath, sweats, and sense of anxiety and fear may also accompany an angina attack.
Women and persons with diabetes may have unusual or atypical angina symptoms, such as shortness of breath or nausea without chest pain.
The risk factors for angina are the same as those for coronary artery disease: cigarette smoking, lack of exercise, high blood pressure, high cholesterol, diabetes, male gender, older age, and a family history of premature heart disease.
A family history of premature heart disease may be defined as having a close relative (such as a parent, brother or sister, uncle or aunt, or grandparent) who has been diagnosed with coronary heart disease before the age of 55.
Your doctor will ask detailed questions about your episodes of chest discomfort and your past medical and family history, and will then conduct a physical examination. A series of laboratory tests may also be done to determine if you have diabetes or high cholesterol, both of which can worsen the buildup of plaque in the arteries (atherosclerosis).
Your doctor may recommend an electrocardiogram (ECG), a test that monitors the electrical activity of the heart. This can be done at rest, and can also be performed before, during, and after you exercise on a treadmill. An ECG test done while you exercise is also known as an exercise stress test.
During an exercise stress test, your heart rate, blood pressure, and the electrical activity of the heart are monitored while your doctor tries to link your symptoms to your actual heart activity. This test can help determine your likelihood of having significant coronary artery disease, and can also help to judge its severity.
Your doctor may also recommend an exercise stress test that includes taking pictures of the heart. In some patients, these tests may be important for examining the blood supply to the heart. Images of the heart can be obtained using either a nuclear scan of the heart (called stress perfusion imaging) or using ultrasound (called stress echocardiography, or a “stress echo”). These images are usually obtained just after exercise, and are then compared to images obtained at rest.
In stress perfusion imaging, a chemical with a low level of radioactivity (such as thallium) is given to you during the exercise test, which is taken up by the heart muscle and can be measured after exercise using a scanner. If you are unable to exercise on a treadmill, these pictures may be taken using medication to speed up the heart rate (such as dobutamine) or to mimic the effects of exercise on the heart (such as dipyridamole or adenosine).
Your doctor may also recommend a procedure known as a cardiac catheterization or an angiogram, in which the arteries of the heart are evaluated more directly. Depending on your symptoms and risk factors, cardiac catheterization may be recommended as the first test to evaluate your heart, or it may be recommended after a stress test.
During cardiac catheterization, the skin over one of the large thigh arteries (the femoral artery) is treated with local anesthetic, and then a hollow tube called a “sheath” is placed into the artery. Through this sheath, the doctor passes thinner, longer hollow tubes called catheters up to your heart.
Through these catheters, a liquid (known as contrast) can be delivered to the coronary arteries, which can then be seen with x-rays. As the liquid is injected into the coronary arteries, an x-ray camera outside the body takes pictures of the heart; the pictures show the liquid moving through the heart arteries, and allow the doctor to determine if narrowing has occurred. You are awake during this procedure, as there is little discomfort once the leg artery is anesthetized. You may be given a sedative to make you more comfortable.
If you are admitted to the hospital with chest pain, your doctor may wish to see if you have had a heart attack. Sometimes this can be determined by your ECG alone. Usually, though, your doctor will order blood tests for substances called “troponin” or “creatinine kinase.”
When the heart is damaged from a heart attack, the damaged heart cells release substances into the bloodstream, such as “troponin” and “creatinine kinase.” In some cases these substances can be detected almost immediately after a heart attack, and in other cases it may take up to 24 hours to detect them. If there is worry about a heart attack, your doctor may keep you in the hospital overnight while your blood levels are checked for these substances.
Regular aerobic exercise, quitting smoking, eating a healthy diet (including fish, whole grains, fruits, and vegetables), and learning to cope with emotional stress effectively are all important ways to help angina. It is also important to control your diabetes, high blood pressure, and high cholesterol, if you have these conditions.
The steps to prevent angina are the same as those to guard against heart disease. Stopping smoking is essential. Eating a healthy diet, exercising, and maintaining a healthy weight are also very important. If you have high blood pressure, high blood cholesterol, or diabetes, you should work closely with your physician to control these conditions.
Your health care professional may recommend taking aspirin regularly because it discourages blood clots from forming, and may also reduce inflammation.
Prevention and Screening of Chest Pain
Regular aerobic exercise, quitting smoking, eating a healthy diet (including fish, whole grains, fruits, and vegetables), and learning to cope with emotional stress effectively are all important ways to help angina. It is also important to control your diabetes, high blood pressure, and high cholesterol, if you have these conditions.
The steps to prevent angina are the same as those to guard against heart disease. Stopping smoking is essential. Eating a healthy diet, exercising, and maintaining a healthy weight are also very important. If you have high blood pressure, high blood cholesterol, or diabetes, you should work closely with your physician to control these conditions.
Your health care professional may recommend taking aspirin regularly because it discourages blood clots from forming, and may also reduce inflammation.
