Angina Pectoris

If you are having pain or pressure in the middle of your chest, left neck, left shoulder, or left arm, go immediately to the nearest hospital emergency department. Do not drive yourself. Call 911 for emergency transport.

Angina, or angina pectoris, is the medical term used to describe temporary chest discomfort that occurs when the heart is not getting enough blood.

• The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries.
  
  
• The blood carries the oxygen and nutrients that the heart needs to keep pumping.
  
  
• When the heart does not get enough blood, it can no longer function at its full capacity.
  
  
• When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, the person feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin.
  
  
• The discomfort of angina is temporary, meaning a few seconds or minutes, not hours or all day.

An episode of angina is not a heart attack. Having angina means you have an increased risk of having a heart attack.

• A heart attack is when the blood supply to part of the heart is cut off and that part of the muscle dies.
  
  
• Angina can be a helpful warning sign if it makes you seek timely medical help and avoid a heart attack.
  
  
• Prolonged or unchecked angina can lead to a heart attack or increase your risk of having a heart rhythm abnormality. Either of those could lead to sudden death.

Time is very important in angina.

• The more time your heart is deprived of adequate blood flow (ischemia), and thus oxygen, the more your heart muscle is at risk of heart attack or heart rhythm abnormalities.
  
  
• The longer you have chest pain from angina, the more your heart muscle is at risk of dying or malfunctioning.

Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to very serious.

• It can be caused by acid reflux (gastroesophageal reflux disease, or GERD), an upper respiratory infection, or asthma. Chest pain is frequently due to muscles and ligaments in the chest being sore (chest wall pain).
  
  
• If pain in the chest is severe and/or recurrent, you should see your health care provider. 
  
  
• Go to a hospital emergency department if you have any of the following with chest pain:
  
  
  • Other symptoms such as sweating, weakness, faintness, numbness or tingling, or nausea
    
    
  • Pain that does not go away after a few minutes
    
    
  • Pain that concerns you in any way

Angina is classified as one of the following two types:

• Stable angina
  
  
• Unstable angina

Stable angina is the most common angina and the type most people mean when they say angina.

• People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a pattern and are predictable.
  
  
• For most people, this involves angina symptoms after exertion such as climbing the stairs or running to catch an elevator.
  
  
• Stable angina symptoms last less than 5 minutes.
  
  
• They are usually relieved by rest or medication, such as nitroglycerin under the tongue.

Unstable angina is a less common type. Angina symptoms are unpredictable and often occur at rest.

• This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is already unstable.
  
  
• The symptoms are worse in unstable angina, meaning the pains are more frequent, more severe, last longer, occur at rest, and not relieved by nitroglycerin under the tongue. 
  
  
• Unstable angina is not the same as a heart attack, but it warrants an immediate visit to your health care provider or a hospital emergency department. You may need to be hospitalized to prevent a heart attack.

If you have stable angina, any of the following may indicate worsening of your condition:

• An angina episode that is different from your regular pattern
  
  
• Being awakened at night by angina symptoms
  
  
• More severe symptoms than usual
  
  
• Having angina symptoms more often than usual
  
  
• Angina symptoms last longer than usual

The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery disease.

• In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged.
  
  
• They can no longer supply the heart with all of the blood it needs.

Most cases of coronary heart disease are caused by atherosclerosis, also called "hardening of the arteries."

• Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels.
  
  
• These buildups are called plaques, and they can block blood flow through the vessel partly or completely. Multiple risk factors, especially diabetes, high blood pressure, smoking, and high cholesterol, accelerate this build up.

Another cause of unstable angina is coronary artery spasm.

• Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily. This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms.
  
  
• This is called variant angina or Prinzmetal angina.
  
  
• This is not the same as atherosclerosis, although some people have both conditions.
  
  
• The symptoms often come on at rest (or during sleep) and without apparent cause.

Other causes of angina symptoms include the following:

• Blockage of a coronary artery by a blood clot or by compression from something outside the artery
  
  
• Inflammation or infection of the coronary arteries
  
  
• Injury to one or more coronary arteries
  
  

• Poor functioning of the tiny blood vessels of the heart (microvascular angina)

When a person has underlying atherosclerosis, spasm, or damage to the coronary arteries, angina symptoms usually are set off by one of the following "triggers":

• Physical exertion or exercise
  
  
• Emotional stress
  
  

• Exposure to cold

• Decreased oxygen content in the air you breathe, as when flying in an airplane or being at high altitude)
  
  
• Using a stimulant, such as caffeine, or smoking a cigarette (which lowers the amount of oxygen in the blood)

Risk factors for atherosclerosis and angina include the following. Some of these are reversible.

• High blood pressure (hypertension)
  
  
• High levels of cholesterol and other fats in the blood
  
  

• Diabetes

• Smoking
  
  
• Male sex
  
  
• Inactive (sedentary) lifestyle
  
  
• Family history of coronary heart disease
  
  
• Aging
  
  
• Regular use of stimulants, especially nicotine, cocaine, or amphetamines: Other stimulants include theophyllines, inhaled beta-agonists, caffeine, diet pills, and decongestants.

Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:

• An uncomfortable pressure, fullness, squeezing, or pain in the center of your chest
  
  
• It may also feel like tightness, burning, or a heavy weight.
  
  
• The pain may spread to your shoulders, neck, or arms.
  
  
• It may be located in the upper abdomen, back, or jaw.
  
  
• The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack, as follows:

• Shortness of breath
  
  
• Light-headedness
  
  
• Fainting
  
  
• Anxiety or nervousness
  
  
• Sweating or cold, sweaty skin
  
  
• Nausea
  
  
• Rapid or irregular heart beat
  
  
• Pallor (pale skin)
  
  
• Feeling of impending doom

These symptoms are identical to the signs of an impending heart attack described by the American Heart Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a few minutes and heart attack pain does not go away.

• If you have never had symptoms like this before, sit down. If you are able, call your health care provider. If you cannot speak to him or her immediately, call 911 or go to the closest hospital emergency department.
  
  
• If you have had angina attacks before and this attack is similar to those, rest for a few minutes. Take your sublingual nitroglycerin. Your angina should be totally relieved in 5 minutes. If not, take a second nitroglycerin. If you still have no relief, call 911 or go to the nearest hospital emergency department.

If you have never had symptoms like this before, you can call your health care provider, especially if you are uncertain of your symptoms or what action you should take.

• Do not delay calling 911. Do not wait for a call back from the doctor. Do not "wait it out." To wait is to risk your life.
  
  
• Emergency personnel are trained to recognize angina and to treat it rapidly and safely.

If you have had angina before, you may not need to seek medical care if your symptoms are the same as they always are.

• If you have already been evaluated by your health care provider and received advice about how to react to these symptoms, follow that advice.
  
  
• This usually involves rest, removing the stressor, and taking sublingual nitroglycerin.

If you have angina before, go to the nearest hospital emergency department if any of the following situations occur:

• If your usual pattern of angina symptoms changes in any way
  
  
• If the symptoms are different than usual or more severe
  
  
• If the symptoms occur at rest or with less activity than usual
  
  
• If your symptoms do not get better with rest or sublingual nitroglycerin 
  
  
• If you are not certain about what to do

Any of these situations may be a medical emergency and requires a visit to a hospital emergency department.

• Don't delay or try to "wait it out."
  
  
• Do not drive yourself to the hospital.
  
  
• Call 911 for emergency medical transport.

If you believe you have risk factors for angina, but no symptoms, you should call your health care provider to arrange for an evaluation in the office. Don’t wait until you have symptoms.

Upon hearing about your symptoms, your primary care provider or the provider in the emergency department will immediately think of angina and other heart problems. Time is of the essence—your treatment will probably begin as the evaluation continues.

An electrocardiogram (ECG) will be done.

• This painless test checks for abnormalities in the beating of the heart.
  
  
• Electrodes are attached to your chest and other points on your body. These electrodes read the electrical impulses linked to the beating of the heart.
  
  
• The ECG looks for signs of a heart attack or of impaired blood flow to the heart.
  
  
• For many patients with angina, the ECG result is normal.

You may have a chest x-ray. This will show any fluid buildup in the lungs. It can also rule out some other causes of chest pain.

There is no lab test that can tell with certainty that you are having angina. There are certain blood tests that suggest that you may be having a heart attack. These tests may be done if a heart attack is suspected.

While these tests are going on, your health care provider will be asking you and your companion questions to help with the diagnosis.

• The questions will be about your symptoms and about your medical history, any operations you have had, your medications, your allergies, and your habits and lifestyle.
  
  
• Your physical exam will include listening to your heart and lungs and feeling your heart through your chest.

If, after these tests, your health care provider thinks you may have coronary heart disease, you will undergo additional tests to confirm that.

• Exercise tolerance test: An ECG is taken before, during, and after exercise (usually walking on a treadmill) to detect inadequate blood flow to the heart muscle indirectly by changes on the ECG. This usually is done only for stable angina.
  
  
• Thallium stress test: This is a more complex and expensive test that injects a radioisotope into the circulation and indirectly detects parts of the heart that may not be getting enough blood during "stress" (usually walking on a treadmill). This information indicates more accurately whether any of the coronary arteries may be narrowed, causing inadequate blood flow to your heart muscle or ventricle. Again, this is usually done only for stable angina.
  
  
• Dobutamine echocardiogram stress test: This is done for people who cannot walk on a treadmill. A drug called dobutamine stimulates and speeds up the heart, creating an increased demand or need for blood flow tot he left ventricle or muscle. If the muscle shows a slowing of function on the ultrasound picture of the heart muscle, then it indirectly indicates inadequate blood flow to the muscle.
  
  
• Coronary angiogram (or arteriogram): This test of the coronary arteries is the most accurate but also the most invasive. It is a type of x-ray. A thin, plastic tube called a catheter is threaded through an artery in the arm or groin to one of the main coronary arteries. A contrast, or x-ray, dye harmless dye is injected into the arteries. The dye depicts the arteries directly and shows any blockage more accurately than the above or more noninvasive procedures.

The health care provider will make the decision about whether these tests or any treatment need to be done on an urgent basis. If so, you will be admitted to the hospital. If not, the tests will be scheduled for the next few days, and you probably will be allowed to be at home.

The treatment for angina depends on the severity of the symptoms and the results of tests that are done to find the underlying cause.

|Self-Care at Home|

Stop doing whatever it is that causes your symptoms and call 911. Immediate help and intervention is your best chance for survival if you are having a heart attack or other serious problem.

• Lie down in a comfortable position with your head up.
  
  
• If you have regular adult aspirin or its equivalent, chew one (as long as you are not allergic to aspirin). Chewing more than one will not do any good and may cause unwanted side effects.

If you have had angina before and been evaluated by your health care provider, follow his or her recommendations.

• This may mean rest, and the immediate use of sublingual nitroglycerin.
  
  
• It may include a visit to the hospital emergency department.

|Medical Treatment|

If you have come to the hospital emergency department, you may be sent to another care area for further testing, treatment, or observation. On the basis of your provider's preliminary diagnosis, you may be sent to the following units:

• An observation unit pending test results or further testing
  
  
• A cardiac care unit
  
  
• A cardiac catheterization unit
  
  
• The operating room for emergency cardiac bypass surgery

Regardless of where you are sent, several basic treatments may be started. Which are given to you depends on the severity of your symptoms and the underlying disease.

• You will have at least one IV line started. This line is used to give medication or fluids.
  
  
• You will probably be given an aspirin if you haven't already taken one.
  
  
• You may be given oxygen through a face mask or a tube in your nose. This will help you feel better if you are having trouble breathing or feeling uncomfortably short of breath by raising the oxygen content of your blood.

Treatment will depend on the severity of your symptoms, severity of the underlying disease, and extent of damage to the heart muscle, if any.

• Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that you need, if it is only angina.
  
  

• You may be given medication to reduce anxiety.

• You may be given medication to lower your blood pressure or your heart rate.
  
  
• You may be given medication to reduce your risk of having a blood clot or to prevent further clotting.
  
  
• If the health care provider believes your chest pain actually represents a heart attack, you may be given a powerful "clot-buster" medication called a fibrinolytic.

After reviewing your immediate test results, the hospital health care provider will make a decision about where you should be for the next hours and days.

• If you are feeling better, your condition is stable, and this was only an angina attack, you may be allowed to go home. You may be given medications to take. You will be told to follow up with your primary care provider within the next day or two.
  
  
• If you keep having symptoms or your condition is unstable, you will be admitted to the hospital. You will probably undergo further tests and possibly coronary angiography, coronary artery angioplasty, or even coronary artery bypass surgery, if all your arteries are critically blocked. 

Angioplasty is a treatment used for people whose angina does not get better with medication and/or who are at high risk of having a heart attack.

• Before angioplasty can be done, the area(s) of coronary artery narrowing is located with coronary arteriography.
  
  
• A thin plastic tube called a catheter is inserted into an artery in the arm or groin with local sedation. The catheter has a tiny balloon attached to the end.
  
  
• The catheter is threaded through the arteries and into the artery where the narrowing is.
  
  
• The balloon is inflated, opening up the narrowing.
  
  
• This is not a permanent solution for most people. Many require placement of a "stent," a small metal sleeve that is placed in the narrowed artery. The stent holds the artery open.

If you have had angina symptoms and are visiting your primary care provider for evaluation, he or she will make a decision about how to proceed with the evaluation. The choices include going ahead with the evaluation on an outpatient basis, referring you to a specialist in heart disorders (cardiologist), or admitting you to the hospital for further workup.

|Medications|

Nitroglycerin: This sublingual medication relieves angina symptoms by expanding blood vessels and decreasing the muscle's need for oxygen. This allows more blood to flow through the coronary arteries. Nitroglycerin is taken only when you actually have symptoms or expect to have them. Slow- or long-acting nitroglycerin can be used as a preventative of angina but not until beta-blockers are tried first. 

Beta-blockers: These drugs lessen the heart's workload. They slow the heart rate, decrease blood pressure, and lessen the force of contraction of the heart muscle. This decreases the heart's need for oxygen and thus angina symptoms. They are taken every day regardless of whether you are having symptoms, since they are proven to prevent heart attacks and sudden death.

Calcium channel blockers: These drugs are used primarily when beta-blockers can't be used and/or you are still having angina with beta-blockers. They also lower blood pressure and certain ones slow heart rate. They have to be taken every day.

Aspirin: A daily aspirin is mandatory to decrease the possibility of sticky platelets in the blood starting a blood clot.

Statin: A cholesterol-lowering drug that has now been shown to stabilize the fatty plaque on the inner lining of the coronary artery, even when the blood cholesterol is normal or minimally increased. New data suggest your "bad cholesterol" or LDL (low density lipoprotein) should be less than 70. Every person with angina needs to know exactly what his or her blood lipids/fats are.

|Surgery|

Like angioplasty, surgery is an option for people whose angina does not get better with medications and others who are at high risk of having a heart attack. Surgery is usually reserved for people with very severe narrowing or blockage in several coronary arteries.

In almost all cases, the operation used for severely narrowed coronary arteries is coronary artery bypass grafting.

• This is open heart surgery, meaning the chest and rib cage are opened up.
  
  
• The narrowed part of the artery is bypassed by a piece of vein removed from your leg, or with a piece of artery behind your sternum (internal mammary artery), or a portion of your radial artery taken from your lower arm or forearm. 
  
  
• Several arteries can be bypassed in one operation.
  
  
• This is a very safe operation, with a mortality rate of less than 1%, in people whose heart muscle is not severely damaged irreversibly and who have normal lungs, kidneys, liver, and other organs of the body.
  
  
• Because the chest is opened, the recovery time can be quite long, especially if you are older and have multiple other health problems.

Transmyocardial revascularization is a procedure for people who cannot undergo angioplasty or surgery.

• A simple incision is made in the chest, and a laser is used to "drill" small holes through the outside wall of the heart into the left ventricle.
  
  
• About 20-40 holes are made.
  
  
• Bleeding from these holes is minimal and usually stops after a few minutes of pressure.
  
  
• We are not really sure why this helps relieve angina. One theory is that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect.

Research focus now is trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels. 

|Follow-up|

If you have stable angina, your health care provider will probably see you regularly to monitor your angina episodes and how well you are reducing your risk factors.

Your health care provider will probably test your heart function periodically and assess your underlying disease. These tests will probably include the following:

• ECG
  
  
• Exercise tolerance tests
  
  
• Thallium stress test
  
  
• Repeat cardiac catheterization to see if the dilated artery or stent is still open and/or a surgical bypass graft is still open or closed. This is the key downside of both angioplasty and surgery: arteries, stents, and grafts restenose or occlude with the same disease process of atherosclerosis. None of these procedures are a cure. The patient has to be very compulsive in correcting the so-called risk factors, or they will return with the same blockages they started with.

|Prevention|

Your best action is to reduce risk factors early in your life. The goal is to not have angina, a heart attack, or sudden death in the first place. Although you cannot escape aging, inherited risk, or your sex, certain risk factors are in your control.

• Stop smoking and using nicotine in any form.
  
  
• Treat high blood pressure.
  
  
• Lower your blood fats (through diet, exercise, and medications).
  
  
• Keep your weight at a healthy level.
  
  
• Get better control of your blood sugar if you have diabetes.
  
  
• Do not use stimulants such as cocaine or amphetamines.

If you already have atherosclerosis and angina, you can learn to take precautions to avoid having symptoms. Avoiding the "triggers" will help keep you comfortable and free of symptoms.

• Quit smoking.
  
  
• Do not use caffeine, cocaine, amphetamines, or other stimulants.
  
  
• Drink alcohol moderately (no more than 1-2 drinks daily).
  
  
• Avoid large and heavy meals that leave you feeling "stuffed."
  
  
• Avoid extremes of emotions.
  
  
• Exercise sensibly after talking with your health care provider.

The question of exercise for a person with angina is important. Exercise is recommended.

• If you have been exercising strenuously, you may need to cut back to avoid symptoms.
  
  
• If you have not been exercising, or have been exercising moderately, talk to your health care provider first about physical activity that will be safe and comfortable for you.

Your health care provider may recommend that you take an aspirin every day.

• Aspirin has been shown to reduce the risk of a second heart attack in people who have already had one and may reduce the risk of a first heart attack.
  
  
• Taking aspirin is not without risks, especially in elderly people, people with digestive diseases or blood clotting disorders, and people who take certain types of medications.
  
  
• Allergy to aspirin is not uncommon. Tell your health care provider if you are allergic to aspirin or have a reaction to aspirin.

|Outlook|

The most common and serious complications of coronary heart disease are heart attack and sudden death from cardiac arrest.

Your future depends on the severity of your condition, any heart muscle injury you have incurred, and your risk of heart rhythm abnormalities.

• If you had no heart muscle injury and your angina is relieved by rest, then your outlook is good.
  
  
• Reversing your risk factors will raise your long-term chances of avoiding a heart attack.
  
  
• Many authorities believe that some people can actually reverse plaque buildup through diet and exercise and reversing other risk factors.

|Support Groups and Counseling|

American Heart Association
National Center
7272 Greenville Avenue
Dallas, TX 75231
(800) 242-8721

National Heart, Lung, and Blood Institute
Information Office
P.O. Box 30105
Bethesda, MD 20892-0105
(301) 592-8573

|Web Links|

American Heart Association

National Institutes of Health, National Heart, Lung, and Blood Institute

angina pectoris, angiogram, angiography, angioplasty, arteriogram, arteriography, aspirin, atherosclerosis, chest pain, coronary artery bypass graft, coronary artery disease, CAD, coronary heart disease, CHD, coronary insufficiency, coronary spasm, exercise, heart pain, heartburn, myocardial ischemia, myocardium, Prinzmetal angina, stable angina, unstable angina, variant angina, vasospasm

Author: George Woodward, DO, FAAEM, Medical Director, St Johns County Fire Rescue: Medical Director, First Coast Technical Institute, Baptist Medical Center.

Coauthor(s): Kathryn L Hale, MS, PA-C, Medical Writer, .com, Inc.

Editors: Alan D Forker, MD, Program Director of Cardiovascular Fellowship, Professor of Medicine, Department of Internal Medicine, University of Missouri at Kansas City School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.