Angina Pectoris

Angina (angina pectoris) is a type of temporary chest pain, pressure or discomfort. It is often described as a crushing, burning, heavy sensation, and it frequently radiates from the chest into other parts of the body, such as the neck, back, arms, jaw and abdomen. In women, angina may be experienced as abdominal pain. Typical episodes of angina can last anywhere from two to 15 minutes.

About 9.1 million Americans suffer from angina, according to the American Heart Association. In the United States, angina afflicts an estimated 3.9 percent of white women, 4.3 percent of black women, 3.3 percent of Mexican-American women, 4.8 percent of white men, 3.4 percent of black men and 2.3 percent of Mexican-American men.

Angina occurs when the heart is temporarily deprived of oxygen, a condition called cardiac ischemia. The most common cause of cardiac ischemia is coronary artery disease, a condition in which oxygen-rich blood cannot travel freely through coronary arteries that are severely hardened and narrowed (atherosclerotic) from plaque buildup and calcification.

If the angina occurs at predictable times, usually after exercise or exertion, it is called stable angina. If the angina occurs at unpredictable times, including at rest, and lasts longer than typical angina episodes, it is known as unstable angina. Unstable angina may signal an impending heart attack. People experiencing unstable angina should seek medical attention immediately.

Besides coronary artery disease, other causes of cardiac ischemia and angina include problems with:

• The heart’s aortic valve, such as regurgitation (leaking) or stenosis (narrowing).
• The heart muscle, as in hypertrophic subaortic stenosis (also known as hypertrophic cardiomyopathy).
• The capillaries, which could lead to a diagnosis of microvascular angina or cardiac syndrome X.
• Coronary artery spasms, which could lead to a diagnosis of variant or Prinzmetal angina. This type of angina is rare, and may be considered a form of unstable angina. It almost always occurs when patients are at rest, typically between midnight and early morning. It is common for these patients to have “active” periods of variant angina, with frequent anginal episodes over a period of months. Two-thirds of people with variant angina have severe blockage in at least one major vessel. There is also a greater risk of developing abnormal heart rhythms (arrhythmias), such as ventricular tachycardia and ventricular fibrillation.

• Arrhythmias, which can lead to either syncope (fainting) or sudden cardiac death.
• Heart disease patients whose episodes are triggered by stress (e.g., frustration, hostility) are more likely to die from their heart condition.
• Severe or lengthy episodes can trigger a heart attack.
• The small effects of minor episodes can eventually lead to permanent weakening of the heart muscle (cardiomyopathy).

There are two main types of angina pectoris. Stable (classical) angina is much more common. About 500,000 new cases of stable angina are reported annually in the United States, according to the American Heart Association.

Stable angina occurs while (or just after) the heart has a need for extra oxygen. The heart needs extra oxygen during a variety of situations that put extra stress on the heart, which include:

• Cigarette smoking
• Eating and digesting a heavy meal
• Physical exertion, especially after eating
• Strong emotions, such as anger or frustration – even during a dream
• Sudden changes in temperature or altitude

The most common symptom that people report when they have angina is chest pain, pressure or a vague chest discomfort. In fact, the term angina pectoris means "a choking sensation of the chest."

An angina attack may feel like a squeezing vise or crushing pressure deep in the chest behind the breastbone (sternum), and may radiate into the back, neck, jaw, shoulders, arms and even fingers or abdomen. People experiencing angina may also feel light-headed and have an abnormally fast or abnormal heartbeat (arrhythmia). Some people, especially women and individuals with diabetes, may have atypical, nonspecific or vague symptoms.

The pain is not necessarily severe. People experiencing angina often assume it is due to noncardiac causes such as indigestion, heartburn or costochondritis (an inflammation of cartilage in the ribcage).

From the patient’s description of symptoms, a physician can usually determine whether angina is present during a physical examination. Words used to describe angina include tightness, squeezing, crushing, burning, choking or aching. Because angina is not specific in location, patients may not be able to tell exactly where it comes from. Instead, they may make a fist in the middle of their chest to demonstrate chest pain. This is called a Levine sign and may cause the physician to suspect angina.

During an angina attack, a physician will assess a patient’s heartbeat, heart rate and blood pressure, which can be elevated. Various blood tests and/or a urine test may be ordered. From there, additional tests may be performed to determine the underlying cause of the angina, as well as the extent of any heart damage and coronary artery disease. These include:

The course of treatment for angina will depend on the physician's determination of its severity and the extent of underlying cardiovascular damage. The patient's family medical history, particularly for heart disease, will also play a role in planning treatment.

For most patients with mild, stable angina, a combination of medications and risk-reducing lifestyle changes is usually recommended.

Medications used to treat angina either increase the supply of oxygen to the heart muscle or reduce the heart's need for oxygen.

Individuals are encouraged to discuss with their physician any other medications or supplements they may be taking. For example, if a patient takes medication for erectile dysfunction in combination with nitrates it can provoke a dangerous drop in blood pressure.

In 2006 the U.S. Food and Drug Administration approved ranolazine (Ranexa), a treatment for chronic angina. Studies have shown that ranolazine is effective among patients with stable angina, but because it alters the heart rhythm, as a treatment for angina it is generally recommended only for patients who have failed other therapies.

For most patients with more serious or worsening angina, especially those in whom significant damage has already been found, further procedures may be performed, including:

After surgery, medications such as anti-clotting agents and/or antioxidants (both vitamins and drugs) may help to prevent re-blockage of the arteries (restenosis).

Physicians continue to debate whether medication or surgery is preferred for stable angina. In 2007 a major trial called the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) showed that drug therapy lowered patients' risk of heart attack and death. However, some physicians found that the data supported angioplasty as a first-line treatment. Angina may be treated case by case rather than according to one specific protocol because of the wide range of factors such as the patient's overall health, lifestyle and degree of atherosclerosis.

In addition to making healthy lifestyle changes, receiving regular medical care and taking all medication as prescribed, patients are encouraged to become familiar with their family's health histories. Although genetic factors such as disease history, ethnicity and gender cannot be changed, knowing them can help in measuring risk and creating an appropriate plan for making lifestyle changes.

Finally, any marked changes in symptoms, such as having more attacks or having more painful attacks, may be a sign of worsening health and increased risk of heart attack. These changes should be brought to the attention of a physician as soon as possible.