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| Angina pectoris (chest pain) |
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Reviewed by Dr Neal Uren, consultant cardiologist, Dr Patrick Davey, cardiologist and Dr Stephen Collins, GP
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What is angina?
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| Angina causes crushing pain in the centre of the
chest. |
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Angina pectoris is a phrase that comes from Latin and
translates as 'tight chest'.
People with angina experience pain in the centre of the chest.
The chest can feel constricted and tight, but the pain can also be oppressive,
as if something is crushing your chest.
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:
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physical exercise
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stress
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extreme cold
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a heavy meal.
Once these trigger factors stop, the pain tends to fade away
quickly, usually within 10 minutes.
What causes 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.
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.
Are there any other causes?
Angina can be aggravated by other illnesses,
including:
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a sustained fast heartbeat
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anaemia (thin blood)
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heart valve diseases such as severe aortic stenosis - a
narrowing of the outflow valve of the heart
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thickening of the heart muscle (hypertrophy), which can be a
result of high blood pressure over several years.
In rare cases, a severe spasm of a coronary artery can happen
when there is relatively little narrowing from fatty deposits. The artery
appears to be working normally, but is not. This is known as variant or
Prinzmetal angina.
Types of angina
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Stable angina: chest pain is brought on when
the heart has to work harder.
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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.
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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.
What are the risk factors?
All of us have fatty deposits in our arteries to some degree.
Atherosclerosis can start as early as our 20s and increases with
age.
But there are risk factors that are known to increase the
development of fatty deposits that can cause your arteries to narrow.
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A family history of atherosclerosis.
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High levels of
LDL cholesterol in
the blood.
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High blood
pressure.
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Smoking.
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Being male.
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Diabetes.
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Obesity.
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Stress.
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Lack of regular exercise.
What are the 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.
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A squeezing or heavy pressing sensation on the
chest.
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Increased shortness of breath on exercise.
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A sense of heaviness or numbness in the arm, shoulder, elbow or
hand, usually on the left side.
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A constricting sensation in the throat.
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The discomfort can radiate into both arms, the jaw, teeth,
ears, stomach and in rare cases between the shoulder blades.
Unstable angina is associated with the same symptoms at
rest.
In some cases the fatty deposits that restrict blood flow can
rupture.
Blood then clots around the rupture, and the clot may be large
enough to block the artery and seal off the blood supply. This may cause
unstable angina or a
heart attack.
How does a doctor diagnose angina?
Diagnosis is based on:
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the presence of typical symptoms
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medical history
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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's done in
hospital as a day-case procedure.
What can the doctor do?
Your GP can:
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help identify and reduce risk factors, eg by treating high
cholesterol and high blood pressure that are not responding to lifestyle
changes
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prescribe medicines for relief of angina
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refer you for further examinations by a cardiologist (heart
specialist).
How is angina treated?
You may need to take several medicines to control symptoms and
improve your angina.
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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.
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Glyceryl trinitrate relaxes the arteries of the heart and
relieves angina attacks. GTN comes in
sublingual tablet
or
spray
form.
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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.
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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.
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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.
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The potassium-channel activator
nicorandil
(Ikorel) 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.
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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.
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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.
What can be done to prevent angina?
Many of the risk factors for angina can be tackled by lifestyle
changes.
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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.
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Stop smoking. Your
doctor or pharmacist will be able to provide advice about stop-smoking
programmes and
medicines that can help you
quit.
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Lose weight if you are
overweight.
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Exercise more: aim for a half-hour walk each day.
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If you have
diabetes or
high blood pressure,
maintain treatment for these conditions.
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Based on a text by Dr Sabine Gill and Dr Steen Dalby Kristensen
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Last updated 04.07.2008
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