Angina (Chest Pain)

What is Angina?

Angina, commonly known as chest pain, is a discomfort or pain that arises when the heart muscle doesn’t receive an adequate blood supply. This pain may not be confined to the chest alone and could manifest as pressure in the chest, jaw, or arm.

Angina typically occurs due to the narrowing of coronary arteries, the blood vessels supplying blood to the heart, caused by atherosclerosis (plaque buildup) or a spasm of these arteries.

Types of Angina:

1. Stable Angina:
   1. Characterized by pain or tightness often triggered by consistent high levels of activity such as walking upstairs after emotional discussions or during stressful times.
   2. Typically predictable, and the pain can be relieved by resting, relaxing, or taking nitroglycerin.
2. Unstable Angina:
   1. Involves chest pain or tightness without a clear trigger or a sudden worsening of stable angina.
   2. Exercise may trigger chest pain, and the pain may be more intense or prolonged.
   3. Considered an emergency, requiring immediate medical attention, and may indicate a heart attack.
3. Variant Angina, also known as Prinzmetal’s angina or vasospastic angina.
   1. Occurs when a coronary artery undergoes sudden spasms or contractions, disrupting blood flow to the heart muscle.
   2. Not always associated with external triggers; can happen at rest.
   3. Temporary spasms can result in pain similar to a heart attack or coronary artery disease.
   4. Commonly relieved with nitroglycerin.
   5. Although substances like cocaine are linked to coronary artery spasm, it can also occur in individuals who have never used cocaine.

Variant angina may be slightly more frequent at night but can occur at any time of the day, typically lasting a few minutes before subsiding.

Signs and Symptoms

Angina typically manifests as chest pain or pressure, often radiating to the neck, jaw, or arm. However, some individuals may experience angina as shortness of breath, upper belly pain, indigestion, light-headedness, extreme weakness or fatigue, or a general sense of discomfort.

In the case of women, symptoms of angina might be accompanied by additional indicators beyond chest pain or pressure.

When to Seek Medical Attention: It’s crucial to be aware of your typical angina symptoms to recognize when to seek medical assistance. Don’t hesitate to call 911 if your angina becomes more severe, more frequent, or lasts longer than usual.

Seek immediate medical attention or call your healthcare professional if you experience any of the following:

• Your angina is worse than normal.
• Your chest pain occurs at rest, without exertion.

Prompt action in these situations is essential for appropriate evaluation and intervention.

Exams and Tests

Chest pain can arise from various causes, ranging from benign to serious. Distinguishing angina from other sources of chest pain can be challenging. When evaluating chest pain, your healthcare professional will conduct a thorough history and physical examination. They will inquire about the characteristics of the chest pain, including its location, accompanying symptoms, timing, duration, and aggravating or alleviating factors.

An electrocardiogram (ECG) may be performed to assess the heart’s rate and rhythm, identifying signs of prior heart attacks or reduced blood flow to the heart muscle, known as ischemia. This test also helps determine the appropriate type of stress test.

If coronary artery disease is suspected, a stress test, either with or without imaging, may be recommended. During a stress test, the heart is challenged to assess whether blood supply to the heart muscle meets the demands of increased activity. This test can reveal signs of reduced blood flow or identify areas of the heart muscle with insufficient blood supply. Some imaging stress tests use ultrasound to capture images of the heart muscle before and after exercise, revealing compromised heart muscle movement indicative of restricted blood flow.

Additional tests, such as coronary calcium scoring and coronary computed tomography, can detect atherosclerosis or narrowing of the coronary arteries. In cases where blood flow assessment is crucial, a stress cardiac MRI might be employed.

If a heart attack is a concern, blood work may be conducted, and immediate referral to the emergency department may be recommended. Early and accurate diagnosis is vital for appropriate intervention and management.

Treatment

Effectively managing stable angina involves adopting a healthy lifestyle, including staying physically active, abstaining from smoking, and adopting a nutritious diet. Medications are often prescribed to control risk factors and alleviate symptoms. Your healthcare professional will work with you to determine the most suitable combination of medications and treatments.

Medications:

1. Beta Blockers: These medications reduce the heart’s workload by slowing the heart rate and lowering blood pressure, preventing subsequent heart attacks.
2. Nitroglycerin and Nitrates: These medications increase blood flow to the heart by dilating blood vessels, easing the workload on the heart. Long-acting versions are also utilized.
3. Calcium Channel Blockers: Similar to beta blockers, they reduce heart workload by slowing the heart rate and lowering blood pressure. They are beneficial in lowering high blood pressure and are avoided if the heart is weak.
4. Ranolazine: This medication acts directly on the heart, helping it relax and reducing its workload without affecting blood pressure or heart rate.

Procedures/Surgery:

1. Angioplasty (PCI) with Stent or Balloon Procedure: This procedure opens narrowed coronary arteries, restoring blood flow to the affected heart muscle area.
2. Coronary Artery Bypass Graft (CABG) Surgery: Also known as open-heart surgery, this procedure involves creating a bypass around blocked arteries to enhance blood flow.

Cardiac Rehabilitation: Cardiac rehab is a 12-week program that includes supervised exercise, heart-healthy eating guidance, stress management, and smoking cessation counseling. An intensive cardiac rehab option with extended sessions may provide even better outcomes.

Enhanced External Counterpulsation Therapy (EECP): EECP therapy may be recommended if angina persists despite standard treatments. It involves inflatable cuffs placed on the calves, thighs, and buttocks, enhancing blood flow to the heart. EECP may stimulate the formation of small blood vessels, creating a natural bypass around blocked arteries and improving exercise duration while reducing angina.

Prevention

To prevent angina related to atherosclerosis, it’s crucial to reduce risk factors for coronary artery disease. Medications and lifestyle changes play key roles in this prevention.

Medications to Lower Heart Risk Factors:

1. Aspirin: A daily “baby” aspirin may be recommended to enhance blood flow through blood vessels, if you have atherosclerosis. It helps prevent heart attacks and strokes, potentially extending life.
   Important Note: Consult your healthcare team before stopping or starting any medication.
2. Statins: These medications reduce levels of low-density lipoprotein (LDL), known as “bad” cholesterol, decreasing the risk of cholesterol buildup in blood vessels. Statins are beneficial for preventing heart attacks and strokes, promoting longevity. They may also reduce the likelihood of cardiac events in individuals with angina.

Preventing Angina Through Lifestyle Changes:

1. Control Blood Pressure: Maintain healthy blood pressure levels through lifestyle adjustments and, if necessary, medications.
2. Quit Smoking: Smoking cessation is a paramount step in preventing heart disease, as smoking is the leading cause of preventable death.
3. Exercise: Engage in regular physical activity, such as brisk walking, running, or biking, for at least 30 minutes five times a week. Exercise contributes to lower blood pressure, increased high-density lipoprotein (HDL) cholesterol, and better blood glucose control.
4. Healthy Diet: Adopt a well-balanced diet rich in fruits, vegetables, whole grains, fish, and lean meats. Avoid sugary beverages, refined grains, and processed or red meats.
5. Stress Reduction: Chronic high levels of stress can contribute to heart disease and angina. Balancing stress through a well-rounded life is vital for heart health. If stress exacerbates angina symptoms, discuss this with your healthcare professional.

Combining medications with these lifestyle changes forms a comprehensive approach to preventing angina and reducing the risk of cardiovascular events.