Angina

Angina is caused by reduced blood flow to the heart muscle. Blood carries oxygen, which the heart muscle needs to survive. When the heart muscle isn't getting enough oxygen, it causes a condition called ischemia.

The most common cause of reduced blood flow to the heart muscle is coronary artery disease (CAD). The heart (coronary) arteries can become narrowed by fatty deposits called plaques. This is called atherosclerosis.

If plaques in a blood vessel rupture or a blood clot forms, it can quickly block or reduce flow through a narrowed artery. This can suddenly and severely decrease blood flow to the heart muscle.

During times of low oxygen demand — when resting, for example — the heart muscle may still be able to work on the reduced amount of blood flow without triggering angina symptoms. But when the demand for oxygen goes up, such as when exercising, angina can result.

The following things may increase the risk of angina:

• Increasing age. Angina is most common in adults age 60 and older.
• Family history of heart disease. Tell your health care provider if your mother, father or any siblings have or had heart disease or a heart attack.
• Tobacco use. Smoking, chewing tobacco and long-term exposure to secondhand smoke can damage the lining of the arteries, allowing deposits of cholesterol to collect and block blood flow.
• Diabetes. Diabetes increases the risk of coronary artery disease, which leads to angina and heart attacks by speeding up atherosclerosis and increasing cholesterol levels.
• High blood pressure. Over time, high blood pressure damages arteries by accelerating hardening of the arteries.
• High cholesterol or triglycerides. Too much bad cholesterol — low-density lipoprotein (LDL) — in the blood can cause arteries to narrow. A high LDL increases the risk of angina and heart attacks. A high level of triglycerides in the blood also is unhealthy.
• Other health conditions. Chronic kidney disease, peripheral artery disease, metabolic syndrome or a history of stroke increases the risk of angina.
• Not enough exercise. An inactive lifestyle contributes to high cholesterol, high blood pressure, type 2 diabetes and obesity. Talk to your health care provider about the type and amount of exercise that's best for you.
• Obesity. Obesity is a risk factor for heart disease, which can cause angina. Being overweight makes the heart work harder to supply blood to the body.
• Emotional stress. Too much stress and anger can raise blood pressure. Surges of hormones produced during stress can narrow the arteries and worsen angina.
• Medications. Drugs that tighten blood vessels, such as some migraine drugs, may trigger Prinzmetal's angina.
• Drug misuse. Cocaine and other stimulants can cause blood vessel spasms and trigger angina.
• Cold temperatures. Exposure to cold temperatures can trigger Prinzmetal angina.

The chest pain that occurs with angina can make doing some activities, such as walking, uncomfortable. However, the most dangerous complication is a heart attack.

Warning signs and symptoms of a heart attack include:

• Pressure, fullness or a squeezing pain in the center of the chest that lasts for more than a few minutes
• Pain extending beyond the chest to the shoulder, arm, back, or even to the teeth and jaw
• Fainting
• Impending sense of doom
• Increasing episodes of chest pain
• Nausea and vomiting
• Continued pain in the upper belly area (abdomen)
• Shortness of breath
• Sweating

If you have any of these symptoms, seek emergency medical attention immediately.

You can help prevent angina by following the same lifestyle changes that are used to treat angina. These include:

• Not smoking.
• Eating a healthy diet.
• Avoiding or limiting alcohol.
• Exercising regularly.
• Maintaining a healthy weight.
• Managing other health conditions related to heart disease.
• Reducing stress.
• Getting recommended vaccines to avoid heart complications.

To diagnose angina, your health care provider will do a physical exam and ask questions about your symptoms. You'll also be asked about any risk factors, including whether you have a family history of heart disease.

Tests used to diagnose and confirm angina include:

• Electrocardiogram (ECG or EKG). This quick and painless test measures the electrical activity of the heart. Sticky patches (electrodes) are placed on the chest and sometimes the arms and legs. Wires connect the electrodes to a computer, which displays the test results. An ECG can show if the heart is beating too fast, too slow or not at all. Your health care provider also can look for patterns in the heart rhythm to see if blood flow through the heart has been slowed or interrupted.
• Chest X-ray. A chest X-ray shows the condition of the heart and lungs. A chest X-ray may be done to determine if other conditions are causing chest pain symptoms and to see if the heart is enlarged.
• Blood tests. Certain heart enzymes enter the bloodstream when the heart muscle is damaged, such as from a heart attack. A cardiac enzyme blood test can help detect these substances.
• Stress test. Sometimes angina is easier to diagnose when the heart is working harder. A stress test typically involves walking on a treadmill or riding a stationary bike while the heart is monitored. Other tests may be done at the same time as a stress test. If you can't exercise, you may be given drugs that mimic the effect of exercise on the heart.
• Echocardiogram. An echocardiogram uses sound waves to create images of the heart in motion. These images can show how blood flows through the heart. An echocardiogram may be done during a stress test.
• Nuclear stress test. A nuclear stress test helps measure blood flow to the heart muscle at rest and during stress. It is similar to a routine stress test, but during a nuclear stress test, a radioactive tracer is injected into the bloodstream. A special scanner shows how the tracer moves through the heart arteries. Areas that have little or no amounts of the tracer suggest poor blood flow.
• Cardiac computerized tomography (CT). For this test, you typically lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around the body and collects images of the heart and chest. A cardiac CT scan can show if the heart is enlarged or if any heart's arteries are narrowed.
• Cardiac magnetic resonance imaging (MRI). This test uses magnetic fields and radio waves to create detailed images of the heart. You typically lie on a table inside a long, tubelike machine that produces detailed images of the heart's structure and blood vessels.

• Coronary angiography. Coronary angiography uses X-ray imaging to examine the inside of the heart's blood vessels. It's part of a general group of procedures known as cardiac catheterization.

  A health care provider threads a thin tube (catheter) through a blood vessel in the arm or groin to an artery in the heart and injects dye through the catheter. The dye makes the heart arteries show up more clearly on an X-ray. Your health care provider might call this type of X-ray an angiogram.

Options for angina treatment include:

• Lifestyle changes
• Medications
• Angioplasty and stenting
• Open-heart surgery (coronary bypass surgery)

The goals of angina treatment are to reduce the frequency and severity of the symptoms and to lower the risk of a heart attack and death.

You will need immediate treatment if you have unstable angina or angina pain that's different from what you usually have.

Medications

If lifestyle changes — such as eating healthy and exercising — don't improve heart health and relieve angina pain, medications may be needed. Medications to treat angina may include:

• Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen the blood vessels so more blood flows to the heart. The most common form of nitrate used to treat angina is nitroglycerin. The nitroglycerin pill is placed under the tongue. Your health care provider might recommend taking a nitrate before activities that typically trigger angina (such as exercise) or on a long-term preventive basis.
• Aspirin. Aspirin reduces blood clotting, making it easier for blood to flow through narrowed heart arteries. Preventing blood clots can reduce the risk of a heart attack. Don't start taking a daily aspirin without talking to your health care provider first.
• Clot-preventing drugs. Certain medications such as clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta) make blood platelets less likely to stick together, so blood doesn't clot. One of these medications may be recommended if you can't take aspirin.
• Beta blockers. Beta blockers cause the heart to beat more slowly and with less force, which lowers blood pressure. These medicines also relax blood vessels, which improves blood flow.
• Statins. Statins are drugs used to lower blood cholesterol. High cholesterol is a risk factor for heart disease and angina. Statins block a substance that the body needs to make cholesterol. They help prevent blockages in the blood vessels.
• Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels to improve blood flow.
• Other blood pressure medications. Other drugs to lower blood pressure include angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). If you have high blood pressure, diabetes, signs of heart failure or chronic kidney disease, your health care provider may prescribe one of these types of medications.
• Ranolazine (Ranexa). This medication may be prescribed for chronic stable angina that doesn't get better with other medications. It may be used alone or with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.

Therapies

Sometimes, a nondrug option called enhanced external counterpulsation (EECP) may be recommended to increase blood flow to the heart. With EECP, blood pressure-type cuffs are placed around the calves, thighs and pelvis. EECP requires multiple treatment sessions. EECP may help reduce symptoms in people with frequent, uncontrolled angina (refractory angina).

Surgery and procedures

If lifestyle changes, medications or other therapies don't reduce angina pain, a catheter procedure or open-heart surgery may be needed.

Surgeries and procedures used to treat angina and coronary artery disease include:

• Angioplasty with stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — a tiny balloon is inserted into the narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open.

  Angioplasty with stenting improves blood flow in the heart, reducing or eliminating angina. Angioplasty with stenting may be a good treatment option for those with unstable angina or if lifestyle changes and medications don't effectively treat chronic, stable angina.

• Open-heart surgery (coronary artery bypass surgery). During coronary artery bypass surgery, a vein or artery from somewhere else in the body is used to bypass a blocked or narrowed heart artery. Bypass surgery increases blood flow to the heart. It's a treatment option for both unstable angina and stable angina that has not responded to other treatments.

Heart disease is often the cause of angina. Making lifestyle changes to keep the heart healthy is an important part of angina treatment. Try these strategies:

• Don't smoke and avoid exposure to secondhand smoke. If you need help quitting, talk to your health care provider about smoking cessation treatment.
• Exercise and manage weight. As a general goal, aim to get at least 30 minutes of moderate physical activity every day. If you're overweight, talk to your health care provider about safe weight-loss options. Ask your health care provider what weight is best for you.
• Eat a healthy diet low in salt and saturated and trans fats and rich in whole grains, fruits and vegetables.
• Manage other health conditions. Diabetes, high blood pressure and high blood cholesterol can lead to angina.
• Practice stress relief. Getting more exercise, practicing mindfulness and connecting with others in support groups are some ways to reduce emotional stress.
• Avoid or limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.

If you have sudden chest pain (unstable angina), call 911 or your local emergency number immediately.

If you have a strong family history of heart disease, make an appointment with your health care provider.

Appointments can be brief, and there's often a lot to discuss. So it's a good idea to take steps to prepare for your appointment. Here's some information to help you get ready and what to expect from your health care provider.

What you can do

• Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet. For example, you may need to avoid eating or drinking for a period of time for a cholesterol blood test.
• Write down any symptoms you're having, including any that may seem unrelated to angina.
• Write down key personal information, including any family history of angina, chest pain, heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you're taking, and the dosages.
• Take a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, talk to your health care provider about any challenges you might face in getting started.
• Write down questions to ask your health care provider.

Your time with your health care provider is limited, so preparing a list of questions will help you make the most of your time together. For angina, some basic questions to ask your health care provider include:

• What's the most likely cause of my chest pain symptoms?
• What kinds of tests will I need? How do I need to prepare for these tests?
• What treatments do you recommend and why?
• What's the safest type and amount of physical activity for me?
• I have other health conditions. How can I best manage these conditions together?
• How often do I need to follow up with you about my angina?
• Are there any brochures or other printed materials that I can take home with me?
• What websites do you recommend visiting?

Don't hesitate to ask any other questions that you may have during your appointment.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions. Being ready to answer them may save time to go over any information you want to spend more time on. Your health care provider may ask:

• When did you first begin having symptoms?
• How would you describe the chest pain?
• Where is the pain located?
• Does the pain spread to other parts of the body, such as the neck and arms?
• How and when did the pain start?
• Did something specific seem to trigger the chest pain?
• Does the pain start gradually or suddenly?
• How long does the pain last?
• What makes the chest pain worse?
• What makes it feel better?
• Do you have other symptoms with the pain, such as nausea or dizziness?
• Do you have trouble swallowing?
• Do you have a history of heartburn? (Heartburn can mimic the feeling of angina.)

What you can do in the meantime

It's never too early to make healthy lifestyle changes. Try these steps:

• Quit smoking.
• Eat healthy foods.
• Get more exercise.