Angina Pectoris

Angina pectoris in Latin means 'tight chest'.

People with angina experience severe crushing pain in the centre of the chest. The chest can feel constricted and tight, like tightened with a band.

Pain starts in the centre of the chest behind the breast bone (sternum) or on the left side of the front of the chest. It can spread out to other parts of your body like your arms and stomach.

Angina is often brought on by:

  • Physical exercise such as walking uphill
  • Stress.
  • Extreme cold
  • A heavy meal.


Once these trigger factors stop, the pain tends to fade away quickly, usually within 10 minutes.

Causes of Angina

In most cases, the cause of angina is coronary atherosclerosis, the thickening of arteries that supply blood, oxygen and nutrients to the heart. This happens when fatty deposits, called plaques or atheroma, narrow the arteries over time and reduce blood flow to the heart.
In some instances the arteries that supply the heart can go into spasm impeding blood supply to the heart.
Symptoms may only appear at times when your heart needs more blood supply, such as when you're stressed, exercising or climbing stairs.
As your heart tries to pump faster to meet your body's increased demands, the narrowed arteries struggle to keep up. The heart then receives too little oxygen, which causes pain in the heart that is felt as chest pain.
In severe cases this can also happen when the heart is at rest when the arteries are severely narrowed down.
Angina can be aggravated by

  • A sustained fast heartbeat
  • Anaemia (reduced oxygen carrying capacity of blood)
  • Heart valve diseases such as severe aortic stenosis - a narrowing of the outflow valve of the heart
  • Thickening of the heart muscle (hypertrophy), which can be a result of high blood pressure over several years.


Types of angina

Stable angina: chest pain is brought on when the heart has to work harder.

Unstable angina: there is no pattern to chest pain and it can happen when the heart is resting. Symptoms are more severe than stable angina and pain tends to last longer.

Variant angina: chest pain is caused by sudden artery spasm. This means pain can happen when the heart is at rest, more often in the early morning.

Risk factors

Narrowing of arteries can start at an early age and if the following risk factors exist can aggravate the process.

  • A family history of atherosclerosis.
  • High levels of LDL cholesterol in the blood.
  • High blood pressure.
  • Cigarette smoking.
  • Males.
  • Diabetes.
  • Obesity.
  • Stress.
  • Lack of regular exercise.


Weak associations
  • Contraceptive pill
  • Heavy alcohol consumption
  • Gout


Symptoms of angina

Symptoms typically start during physical exertion or emotional stress. They are often worse in cold or windy weather and sometimes after big meals.

  • A squeezing or heavy pressing sensation on the chest.
  • Increased shortness of breath on exercise.
  • A sense of heaviness or numbness in the arm, shoulder, elbow or hand, usually on the left side.
  • A constricting sensation in the throat.
  • The discomfort can radiate into arms, the jaw, teeth, ears, stomach and in rare cases between the shoulder blades.


Unstable angina is associated with the same symptoms at rest.

Symptoms of Angina are a strong indicator of impending Myocardial infarction or heart attack.

Diagnosis of angina
Diagnosis is based on:

  • The presence of typical symptoms
  • Medical history
  • Whether Glyceryl trinitrate relieves the pain.


An electrocardiogram (ECG) is a test that measures the electrical activity of the heart and can help diagnosis if done during an episode of pain.

In addition, you may be given an ECG exercise test on a treadmill or exercise bike (a stress test) to determine if the heart muscle is the source of the pain. This test is usually done by a specialist in a hospital.

In many cases, a coronary angiogram will be needed. This is a test that uses an injection of liquid dye to make the coronary arteries easily visible under x ray. It is done in hospital as a day-case procedure.

Treatment

Your doctor can:
  • Help identify and reduce risk factors, e.g. by treating high cholesterol and high blood pressure that are not responding to lifestyle changes
  • Prescribe medicines for relief of angina
  • Refer you for further examinations by a cardiologist (heart specialist).


You may need to take several medicines to control symptoms and improve your angina.

  • Aspirin in low doses reduces the tendency of small blood cells called platelets to stick together, which helps prevent the formation of a blood clots.
  • Glyceryl trinitrate relaxes the arteries of the heart and relieves angina attacks. GTN comes in sublingual tablet or spray form.
  • Long acting nitrates reduce the frequency of angina attacks. These can be in the form of tablets or patches and are very effective. Their main side-effect is headache, but this often disappears once the nitrate has been taken for some weeks.
  • Beta blockers block the effect of the hormone adrenaline so that the pulse is slowed and blood pressure lowered. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle. They are also important in protecting the heart after heart attacks.
  • Calcium channel blockers reduce the muscle tension in the coronary arteries, expanding them and creating more room. They also slightly relax the heart muscle, reducing the heart's need for oxygen and reducing blood pressure.
  • The potassium-channel activator Nicorandil reduces muscle tension in the blood vessel walls, expanding them and improving the flow of blood and the supply of oxygen.


Surgery

If you have severe angina that is not responding to medication, a cardiologist may decide you need surgery to restore heart function to an adequate level and reduce the likelihood of a heart attack.

This can be done by one of the following operations.

  • Angioplasty: the narrowed coronary artery is dilated (opened up) with a balloon. A small tube called a stent may also be inserted into the artery at this time to help prevent it narrowing down again in the future.
  • Bypass operation: a superficial blood vessel is taken from another part of your body, usually the leg, and joined to the coronary artery to bypass the obstruction to blood flow.


Prevention

Many of the risk factors for angina can be tackled by lifestyle changes.

  • Eat a varied and healthy diet with plenty of leafy vegetables. Avoid sugary foods and saturated fats found in meat and full-fat dairy products.
  • Stop smoking.
  • Drink alcohol in moderation
  • If you are overweight, try to reduce weight.
  • Exercise more: aim for a half-hour walk each day.
  • If you have diabetes or high blood pressure, proper control of diabetes and blood pressure.


Please consult online doctor for bespoke, evidence based and confidential medical advice.