Angina (Chest Pain)

What is angina?

Angina is a feeling of tightness, squeezing, or pain in the chest. It happens when the heart does not get enough oxygen-rich blood.

Men and women of any age can have angina, but it is more common among middle-aged and older adults.

There are 2 types of angina: stable angina and unstable angina.

• Stable angina is chest discomfort that is usually predictable. It happens with exercise or increased activity.
• Unstable angina is unexpected chest discomfort that can happen at any time. Little or no exercise is needed to cause symptoms. You may even have symptoms when you are resting.

What is the cause?

Angina may be caused by any condition that affects the blood flow to your heart, such as:

• Coronary artery disease: The walls of the arteries that carry blood to the heart can develop atherosclerosis (fatty deposits). The passageway for blood through the arteries gets narrower and less blood can flow through the arteries. This means that less oxygen reaches the heart muscle. This is the most common cause of angina.
• Coronary artery spasm: Muscles in the wall of the coronary artery can go into spasm. This narrows the artery and causes blood to slow or stop flowing through it. When the spasm stops, the artery and blood flow return to normal.
• Abnormal heart valves that cause the heart muscle to get too thick.
• Abnormal heart rhythms.
• Anemia: The levels of red blood cells or hemoglobin are too low. (Hemoglobin is the oxygen-carrying chemical in the blood.)
• Polycythemia: The blood has too many red blood cells. This causes the blood to thicken.
• A thyroid problem.
• Uncontrolled high blood pressure.

You are more likely to have angina when your heart is working harder, for example, when:

• You are exercising or doing heavy physical labor.
• You are upset.
• You are in cold air.
• You are digesting a big meal.

However, you can also have angina when you are resting or sleeping.

What are the symptoms?

The symptoms of angina may vary from person to person. Symptoms may include:

• a feeling of tightness or heaviness in the chest
• squeezing, pressure, or burning in the chest
• discomfort that may spread to one or both arms, neck, back, or jaw
• numbness or tingling in shoulders, arms, or wrists
• a feeling of having gas or indigestion

Angina symptoms usually:

• Last for only a few minutes (5 minutes or less).
• Go away with rest or medicine (nitroglycerin).
• Don’t come as a surprise. Many people know when they are more likely to have angina.
• Happen when the heart has to work harder—for example, during physical activity or emotional stress

Symptoms of stable angina are uncomfortable, but if you have the symptoms only with activities that you know trigger angina, they are not dangerous. If you have unstable angina and don’t get treatment, you are at high risk of a heart attack or death. Recognizing unstable angina and treating it right away greatly lowers these risks.

How is it diagnosed?

Your healthcare provider will ask about your symptoms and medical history. You will have a physical exam. You may have one or more of the following tests:

• Electrocardiogram (ECG) and exercise treadmill test (ETT): These tests show electrical changes in the heart muscle if it is getting too little oxygen.
• Nuclear heart scan: This scan measures blood flow in the heart.
• Stress echocardiogram: This test shows how a lack of blood oxygen affects the heart's ability to squeeze (contract).

How is it treated?

Lifestyle:
When angina is caused by coronary artery disease, treatment often involves changes in your lifestyle. This may include:

• quitting smoking
• losing weight
• reducing stress
• getting more regular exercise, as prescribed by your healthcare provider

You may also need to:

• Lower your blood pressure if it is high.
• Lower your blood cholesterol if it is high.
• Lower your blood sugar if it is high.

Your healthcare provider may prescribe medicines to help you do this.

Medicine for angina:
Often the symptoms of angina can be controlled with medicine.

• Nitrates such as nitroglycerin increase the blood flow to the heart. They reduce the workload on the heart by dilating (expanding) the coronary blood vessels and lowering blood pressure slightly.
• Drugs called beta blockers and calcium channel blockers are also effective.
• Other medicines your healthcare provider may prescribe are ACE (angiotensin-converting enzyme) inhibitors, aspirin, and cholesterol-lowering medicines.

Your provider will determine which type of medicine is right for you based on your test results and any other medical problems you have.

Surgery and other procedures:
Angina caused by blocked arteries can be treated with surgical procedures.

• Coronary artery bypass graft surgery is one of the procedures that may be done. Blood vessels are taken from other parts of your body and attached to the blocked coronary arteries on either side of the blockage. The blood is then able to flow around, or bypass, the blockages. You will likely stay in the hospital about 1 week and then recover at home for several weeks.
• Percutaneous coronary intervention (PCI) is a simpler procedure than coronary bypass surgery. Your healthcare provider inserts a balloon catheter (a flexible tube) into a blocked artery in your heart to unblock it. The balloon at the tip of the catheter is inflated. The balloon opens the artery enough to let blood flow normally. The catheter is removed, but a metal mesh device called a stent is usually left in the artery. The stent helps keep the blood vessel open. You may need to stay at the hospital a day or two after the procedure. This procedure may also be called angioplasty.

How can I take care of myself and prevent angina?

Follow the treatment prescribed by your healthcare provider.

If your provider has prescribed nitroglycerin, take it if:

• stopping an activity doesn't help your pain, or
• the pain happens when you are resting

It may be more comfortable to sit in a chair when you take the medicine. Some people help prevent symptoms by taking nitroglycerin (nitro) before any activity that usually causes angina.

Find out from your healthcare provider how many doses of nitro you should take for chest pain before you need to call 911. Remember to make sure your nitroglycerin is still good. Renew the prescription before the expiration date on the bottle.

It may also help to:

• Slow down or take rest breaks if angina comes on with exertion.
• Avoid rich foods or large meals if angina comes on after a heavy meal.

In addition, follow these guidelines:

• Keep a healthy weight. If you are overweight, ask your provider about the best way to lose weight.
• Eat a healthy diet. Avoid foods high in cholesterol, saturated fat, and trans fat.
• Be as physically active as you can. Check with your provider about what kind of exercise is right for you. Aim for 30 minutes of moderate physical activity every day unless recommends something else.
• If you are a smoker, get help to quit smoking now and stay away from others who are smoking.
• Have your blood pressure checked regularly. High blood pressure increases your risk for heart disease.
• Do things to help your mood and emotions. If you start to feel depressed or anxious, talk to your provider about your feelings.
• Learn how to cope with and reduce stress.
• Always carry your medicine with you. Take it exactly as prescribed by your healthcare provider.
• Pay attention to your symptoms and call your provider at the first sign of trouble.

Call your healthcare provider if:

• The chest pains or symptoms:
  • Are stronger.
  • Last longer.
  • Happen when you are resting
  • Happen more often, at new times of day, or with activities that did not cause angina before.
• You need to use more nitro before the pain or discomfort goes away.

Sometimes it's hard to tell a severe attack of angina from the beginning of a true heart attack. You need to call 911 for emergency help right away if:

• You have chest discomfort that lasts for more than 5 minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness, or burning.
• You have chest discomfort and are feeling faint.
• You have chest pain that goes beyond your chest to one or both arms, neck, jaw, shoulder, or stomach.
• You have significant trouble breathing, with or without chest pain.
• You have chest discomfort along with sweating, indigestion, vomiting, or feeling sick to your stomach.
• You still have pain after taking your nitroglycerin tablets as directed by your healthcare provider.

If you are having these symptoms, do not drive yourself to the hospital. You could pass out if the angina is severe.