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Angina


What is Angina ?
Angina is short for the term Angina Pectoris which means "chest cramp" in Latin. It is a discomfort you experience when your heart cannot get enough blood. The discomfort does not damage your heart but is a warning symptom that there is a problem with the blood supply to your heart.

What are the symptoms of Angina ?
The symptoms of Angina vary among individuals. The discomfort ranges from a tightness in the chest to severe pain. It may occur anywhere from the belly button up to the top of your jaw and down both arms. The discomfort often starts in the chest and spreads to the arms and even up to the neck and jaw. Sometimes it spreads around the back. The pain or discomfort is usually continuous. Sharp, stabbing pains are usually not angina. Angina usually happens when people are walking or doing something that takes some effort. It lasts longer than a few seconds and eases off when exertion stops. It may also occur if you become very stressed and eases off as you become more relaxed. The pain does not usually vary with breathing or with changing your posture which occurs with lung and chest wall problems. Pains from the food passage are often precipitated after eating or when one lies flat at night however angina may also be precipitated by a large meal. Angina usually gets worse if one continues to do exercise. Chest pain that allows one to run around and do physical activity is unlikely to be angina.

Angina Graphic

What causes Angina ?
Our heart is basically a muscular bag which squeezes and pumps blood around our bodies. Like all muscles, it requires its own blood supply to provide it with oxygen and energy nutrients. The blood supply to the heart is through the coronary arteries. These arteries can normally adapt when the heart needs more blood during exercise. However, if the arteries are narrowed due to plaques, then the artery may not be able to provide enough blood for the heart during exercise. Therefore the portion of the heart muscle supplied by the narrowed artery would not have enough oxygen. To protect itself from further lack of oxygen, the heart produces angina to stop one from doing more exercise.

Some conditions make angina occur more often such as high blood pressure, lack of blood (anaemia), cold weather, heavy meals, smoking, being overweight and carrying heavy loads. The reason for this is that these conditions cause the heart to need more blood or that the supply of blood is reduced. Simple measures to reduce angina, include avoiding exercise after meals for 2 hours, reducing weight, quitting smoking, covering one's face with a scarf in cold weather. Many patients need to take medicines called "anti-anginal drugs" . The more severe the narrowing in the coronary arteries the lower the amount of exercise required to produce angina. If the artery is almost completely blocked, angina may occur at rest and if the block persists for a long time the heart muscle would die which is what occurs with a heart attack.

What narrows our arteries ?
Except for a few rare exceptions, the condition that narrows our coronary arteries is called atherosclerosis which is translated as hardened gruel (atheroma or “lump of porridge” from the word Athera for porridge and sclerosis means “hardening” in Greek). This is purely a descriptive term to denote the appearance of hard yellow white plaques which lie beneath the inner lining layer of our arteries. These plaques grow with time on the inner lining of arteries. The rate at which the plaques grow depends on a number of factors particularly ones genetic make up or family history but also one's sex, cholesterol level, smoking habits, blood pressure and presence of diabetes. Although coronary arteries adapt initially to plaques, they eventually narrow the artery and reduce its ability to provide blood to the heart. In addition to continual growth, plaques may also become more fragile and break. When this occurs, the inner lining of the artery tears and in an effort to seal this tear, blood clots at this site which can result in narrowing of the artery so that it is less able to transport blood to the heart muscle. Thus growth of plaques and their occasional tearing leads to progressive narrowing and possibly complete blockage of the coronary arteries resulting in unstable angina or a possible heart attack. 

 Blood FlowDamaged Heart

 

What factors contribute to narrowing our arteries ?
In most instances our coronary arteries are narrowed due to atherosclerosis, an inflammatory process resulting in build up of cholesterol in the arteries. This condition is brought about by many factors but some of the key factors include your family history, having a high cholesterol, smoking, diabetes, high blood pressure, being overweight and inactivity.

CHOLESTEROL: Cholesterol is a fatty substance. Many people have too much cholesterol in their blood. The cholesterol helps to coat the insides of the arteries, clogging them up. Most people can reduce the amount of cholesterol in their blood by eating less fatty foods. If you have high cholesterol, bringing it down will help to reduce your chances of getting a heart attack.

SMOKING: Smoking brings on anginal attacks and increases ones risk of a heart attack. Smokers get almost three times as many heart attacks as people who do not smoke. People who go on smoking after a heart attack are twice as likely to die as people who stop smoking. No matter how long you have been smoking, your health will benefit if you stop. There is no such thing as "too late to stop now".Smokingcessation however is optimally done under guidance to improve the chance od success, so ask yoru nurse or doctor for advice.

HIGH BLOOD PRESSURE: If your blood pressure is high you have a greater risk of heart attack and stroke. The risk is magnified in those who smoke and have high cholesterol. Anyone can have high blood pressure. It does not cause any discomfort. Many people have high blood pressure without realising it. If you have high blood pressure, your doctor can give you tablets to help to bring it back to normal. There are also a lot of things you can do to bring down your own blood pressure. Cutting down on the amount of salt you eat, and reducing your weight (if you are overweight) will help. Exercise reduces blood pressure over time.Your should have your blood pressure checked from 40 years onwards or earlier if there is a family history

Many people find that their angina is worse when their blood pressure is high. Remember that it increases the hearts work. Having your blood pressure controlled will reduce the amount of angina you have.

What brings on an anginal attack ?
An anginal attack is brought on when your heart is not getting enough oxygen for its needs. This can occur if you ask your heart to do a lot of extra work and the coronary arteries do not bring in enough blood to the heart muscle. An example of extra work is when you ask your heart to beat faster and also to work against a higher blood pressure. Think of your heart muscle trying to pump blood out through the aortic valve to the main artery the aorta. To open the valve and let the blood out is like asking your heart to push open a door. If you have high blood pressure there is a big weight on the other side of the door pushing against you as you open the door. This pressure is a bit like the amount of weight you ask a weight lifter to lift. Now the second part of the work is how often he has to lift the weight every minute. If you have a very fast heart rate, this means the weight lifter (your heart) has to push up a weight many times every minute which makes the heart's work load greater.

Now just in case you think this is a lot to ask your heart, remember this is what our hearts are designed to do and they do their job very effectively. The problem arises when you ask your heart to do a lot of work but at the same time you do not give it enough fuel to do the work. The fuel (oxygen and energy source) is brought into your heart muscle through the coronary arteries. If these arteries are narrowed or if the amount of fuel in the blood is not enough (due to lack of oxygen or the red cells that carry it around), your heart muscle would not have enough energy to do its work. It would then complain by giving you angina.

An example of bringing on angina would be a person who has a narrowed coronary artery who decides to walk up a hill. Going up the hill would make the persons heart go faster and the blood pressure to increase. You may find that it is easier to bring on angina in the cold weather or by exercising soon after a meal. The reason for this is that cold weather particularly on the face makes the coronary arteries tighten up and thus less blood can get to the heart muscle. After a meal a lot of blood goes to the stomach which means that your heart has to do more work in pumping the blood around the body. Its like running on the outside lanes of a tract rather than on the inside lanes.

Have I mild or severe angina ?
Although you may feel that having angina is the same for everyone, there are certain differences that are important to know. For some individuals, they only get angina if they do a lot of strenuous activities. In such individuals, it is likely that the narrowing in their arteries is not very severe or that the narrowing is in a place that supplies only a small amount of heart muscle. In other individuals, angina may come on when they do very little activity. Such people may have a severe narrowing in one or more of their coronary arteries or the narrowing is in an area that supplies a very large amount of heart muscle.

This is a typical example but in many situations, there is more to getting mild or severe angina than just how narrow the artery has become. As mentioned above, it all depends on the balance between blood supply and the demands of your heart. In some individuals, when their angina has become worse it is not because there was a change in the narrowing in their arteries but because there is an increased demand for oxygen or a reduced supply of blood. This can occur for example, if you develop a very high blood pressure which puts a big demand on your heart. Another example would be a person who has become anaemic or has a chest infection that leaves them with less oxygen in their blood. In this situation they may get angina more easily because of less oxygen carrying blood to meet the needs of the heart. Correcting the blood pressure, anaemia or chest infection may get rid of the angina in this instance.

What is Unstable Angina ?
Unstable angina is when the anginal symptoms occur at rest or with very little exertion. In someone with previous anginal symptoms, who now finds that they are occuring much more frequently and with less and less activity, unstable angina is present.

The cause of unstable angina is the coronary arteries have become severely narrowed in a short time period. This is often due to the fact that a plaque in the artery tears and that a clot forms at this site which severely reduces the amount of blood supply to the heart. This is a serious condition and requires prompt medical attention.

What is variant angina pectoris (Prinzmetal's angina)?
This is an uncommon form of angina. Variant angina pectoris is also called Prinzmetal's angina. It differs from typical angina in that it occurs almost exclusively when a person is at rest. It usually doesn't follow a period of physical exertion or emotional stress. Attacks can be very painful. It's associated with

  • acute myocardial infarction (heart attack).
  • severe cardiac arrhythmias. These may include ventricular tachycardia and ventricular fibrillation .
  • sudden cardiac death.

Coronary artery spasm is the usual reason for variant angina. About two-thirds of people with variant angina pectoris have severe coronary atherosclerosis in at least one major vessel.

Many people with variant angina go through an acute, active phase. Anginal and cardiac events may occur frequently for 6 months or more. Heart attacks may occur in up to 20 percent of patients; death occurs in up to 10 percent. People who develop serious heart rhythm disturbances (arrhythmias) at this time are at greater risk of sudden death.

Most people who survive a heart attack or this initial three- to six-month period, stabilize and symptoms and cardiac events tend to diminish over time. Long-term survival is excellent, at 95 percent at five years. Patients who do not have severe coronary narowings have an excellent long-term outlook. Treatment of blood pressure and cholesterol can reduce the risk of coronary artery spasm. It is important to avoid drugs such a beta-blockers as they can aggravate coronary artery spasm. Calcium channel blockers are the preferred drugs in addition to nitrates.

Does angina mean I am going to get a heart attack ?
No !. It does not follow that if you have angina that you will definitely get a heart attack. Patients with stable exertional angina are at low risk of a cardiac event with only 1 in 100 such patients having a heart attack after 1 year. Remember angina is the way your heart tells you that it is lacking oxygen at the point in time you are doing an activity or are stressed. If you are having prolonged pain with minimal activity, you may be having unstable angina which could lead to a heart attack if not treated. Many individuals develop angina, but if this is recognised and the correct action is taken, it can be prevented. More importantly, the disease causing this symptom may be reversed or at least stabilised. It is therefore very important for all individuals with angina to not only have their symptoms relieved but also to be actively working towards reducing their risk of a heart attack.

What questions will my doctor ask me ?
Your doctor will ask you a lot of different questions as he or she tries to find out the cause of your chest pain. There are a whole lot of parts to your chest that can give rise to pain and it is often difficult to know exactly what part of your chest is causing the pain. Your doctor will ask you questions about the type, duration and severity of your pain. You will be asked what you are doing when the pain comes on or what you do when your pain is present. The doctor knows that it is difficult for you to describe the discomfort you feel but how you describe your discomfort is important to allow an accurate diagnosis to be made.  It is unusual for people with anginal pains to be able to carry on doing activities without the discomfort getting worse. Your doctor may also ask you questions about your use of medications, if you have lost blood or have symptoms of a chest infection.

What would my doctor look for on my examination ?
In many people with angina there is very little to find on examination. However, your doctor will look at your overall appearance to see if you are pale (anaemic), blue (cyanosed), have signs of being a smoker or if you are overweight. He will also look around your eyes for signs of having a high cholesterol level. Your pulse and blood pressure will be checked and he will listen to your heart. He may also listen to the Carotid arteries in your neck and feel the pulses in your legs.

What investigations are carried out ?
Angina is a sign that your heart cannot get enough blood to do its work. Your doctor will have to find out if this is happening. In many cases he will be able to find out by asking you about your symptoms. He may also arrange to do tests.

There are some tests which may help the doctor: you will have an electrocardiogram (ECG) done while you are resting. You may have one done while you are exercising to see how your heart reacts to exercise. An X-ray of the heart is also useful. These simple tests are often all that is needed. Sometimes more complicated tests are required. The most usual of these is an X-ray of the arteries of your heart. This is called a coronary angiogram. If you are having any of these tests, your doctor will explain them to you beforehand. If you need more information, just ask.

How we treat Angina.
There are three aims in treating angina:

1. To allow you to lead a normal, symptom free, healthy life

2. To stop your heart disease from getting worse.

3. To prevent a heart attack or sudden death

What medicines are used and how do they work ?
There are many drugs used in the treatment of angina. The main drugs used are called, beta-blockers, calcium channel blockers, nitrates, ACE inhibitors or angiotensin receptor blockers (ARBs) as well as drugs that prevent clots forming, such as aspirin or clopidogrel. 

Nitrates work to increase the size of the coronary arteries and thus allow more blood to flow through the coronary arteries to the heart muscle. They also open up other blood vessels in particular your veins which bring blood back to your heart. By reducing the amount of blood coming back to your heart it decreases the amount of work your heart has to do. The problem with taking these medicines is that they can give you a headache and flushing. Some people may also get light-headed. There are short acting and long acting types of nitrates. The short acting forms glycerine tri-nitrate (GTN) can be given in the form of a small tablet that you put under your tongue or a spray. You should spray this under your tongue. It is best to use these short acting forms of nitrates before you do any activity such as walking, climbing, having intercourse, carrying bags or before getting into what you know to be a stressful situation. Always check the expiry on both the GTN tablets and spray as they only last a few months so need to be replaced. The longer acting forms of nitrate are used to help you avoid angina during your daily activities. These are tablets which you may swallow or topical notrate patches that are stuck to the skin and worn for up to 16 hours a day. It is important to remove  the patch for up to 8 hours each day. It is not unusual to be taking both short and long acting forms of nitrates.

Betablockers are a class of anti-anginal drugs that work by making your heart go slower. They also lower your blood pressure and reduce the demands of your heart for oxygen. They are very effective in treating angina. However, some people taking betablockers may find that they get cold hands and feet. They may also find that they have less energy or in the case of men, that they may have difficulty maintaining erections. Betablockers can also worsen asthma or cause pain in the calves of people with diseased arteries in their legs. You should discuss these problems with your doctor. There are a number of different betablockers and your doctor will let you know which one is suitable for your needs. He will also adjust the dose of these drugs so that you have less problems.

Calcium channel blockers are also used to treat angina. They work to open up arteries and also slow the heart rate and reduce the blood pressure so reduce the work load of your heart. There are many different types of these drugs and they differ in their actions. Some are more potent at slowing heart rates and others work better in reducing blood pressure. Some people who take these medicines develop swelling in their feet. This is not a major problem but if it becomes bothersome, you should discuss this with your doctor.

Second Line Anti Anginal Drugs
These drugs are usually added on as part of your treatment if the other drugs mentioned above are not relieving your angina sufficiently well Some newer drugs used to treat angina act to help the heart muscle cells work better when the oxygen supply is poor.. Another class of drug slows your heart rate like beta blockers but does not affect the peripheral circulation and can be used in asthmatics.

Is it safe to have intercourse if you have angina ?
Intercourse with your partner does not necessarily cause excessive demands on your heart. You should not be afraid to engage in intercourse if you have angina. However, if you find that intercourse does produce anginal pains, you should stop and rest. You should use your GTN before making love as this will cause less angina. It is important to consult your doctor so that he can arrange for you to have a stress test to see how much activity your heart can cope with.

It is not uncommon for men to have impotence or some problems maintaining erections once they are diagnosed with heart disease. Often times this is due to emotional upset rather than having a medical problem. They may become depressed or anxious and this is the problem rather than true impotence. Sometimes the problem is related to the medicines they are taking. Beta-blockers often cause this problem and your doctor may adjust your medicines accordingly.

In some situations, you may need to use a drug to maintain an erection like Viagra or Cialis. These have been shown to be successful in many instances but there is some risk using these if taking nitrates. This is because both drugs when taken together can drop your blood pressure. This would be dangerous for your heart. It is therefore advisable to discuss the use of such erectile enhancing drugs with your doctor as it may be possible to alter your anti-anginal medicines so that you do not need to take nitrates.

What can I do to help myself ?
It is often very easy to think that your health is outside of your own control and that only your doctor and some magic drugs are going to keep you well. This is certainly not true. There are many things that you can do to reduce the amount of anginal attacks you may get. There are also important things to do to improve the state of your arteries.


Remember the reason we get angina is because our heart is not getting enough oxygen for its needs. There is a balance between supply and demand which has been upset. To reduce the demands of our heart you might think you should get into a cocoon and not move. However, there are simple things you can do to reduce the demands of your heart.

Things you can do to reduce angina

  • Do not exercise for at least 2 hours after a meal.
  • Avoid eating heavy meals.
  • Do not carry loads that are too heavy or wear heavy clothing.
  • If you are walking outdoors in cold weather, make sure to cover your face with a scarf. The reason for this is that cold air on your face tightens up your arteries.
  • Reduce your weight if you are overweight. A lower weight is not only less work for your heart to carry but it also allows you to exercise more.
  • Use your GTN spray before doing any moderate activities.
  • Regular walking will have a beneficial effect on your weight, blood pressure and cholesterol and may reduce your angina.
  • It is absolutely essential that you quit smoking. It causes your arteries to constrict after every cigarette and it reduces the amount of oxygen in your blood.
  • Eat a healthy diet containing fruits and vegetables and avoid high fat foods.
  • Reduce your salt intake if you are prone to high blood pressure.
  • Use alcohol in moderation.

 

How can I reduce my risk factors?
Quitting smoking is the single most effective thing you can do. You can save a small fortune, have the holiday you needed, feel healthier and have less angina. It is not easy to do. However, if you knew that smokers are more likely to have bigger heart attacks and die more often from heart attacks, you may be more determined to quit. There are many medicines available to help you quit. These include nicotine replacement therapy which allows you to get rid of your urge to smoke while you are learning to avoid the bad habit. However, these should be used with care when you have angina. You should consult your doctor before starting this treatment. There are also newer agents that work on your brain to switch off your desire to smoke and these have been shown to be effective in some smokers. They have not been shown to have a harmful effect in patients with angina. Again you should consult your doctor about this form of treatment.

Do I need to have an Angioplasty or Stent ?
Your doctor will advise you on the need for angioplasty or stent placement. The usual indication for such a procedure is when your angina is not controlled with medicines alone. However, in some situations your doctor may feel that the disease in your arteries is best managed by angioplasty and stenting although your angina may not be severe. An angioplasty involves inserting a balloon into the narrowed section in your artery and pushing the plaques outward so that the narrowing in the artery is removed. A stent is a little metal cage that can be expanded inside the artery to keep the plaque out of the central channel in the blood vessel so that blood can get to the heart muscle.

Angioplasty Procedure

Angioplasty Procedure

 

Do I need to have bypass surgery ?
Your doctor will advise you on the need for bypass surgery. The usual indication for such surgery is when your angina is not controlled with medicines alone. However, in some situations your doctor may feel that the disease in your arteries is best managed by surgery although your angina may not be severe. Bypass surgery involves taking veins from your legs or arteries from your arm or chest and using them as a new channel to bring blood around the narrowed areas in your artery

Coronary Artery Bypass Graft

If I have angina are my family at risk ?
One in three Irish people have a parent, brother or sister with heart disease. If you suffer from angina, it is very important that your close family relatives are checked for heart disease risk factors. These include high cholesterol, smoking, high blood pressure, diabetes and obesity.

Are there any new treatments for angina ?
In some patients it may not be possible to relieve their angina with drugs, bypass or angioplasty and stenting. This is a rare occurrence and occurs only in individuals with severe disease in their arteries or in people in whom it is not possible to do one of these procedures. This may be due to the fact the arteries are too small to fix or impossible for your doctor to reach to put in a bypass graft. In this situation, you may have to restrain your activities to reduce your angina or your doctor may consider alternative therapies with less proven benefit such as enhanced external counterpulsation, neurostimulation therapy or painkillers such as opiates. Rarely, uncontrollable angina is treated with heart transplantation in selected individuals.

Summary.
Angina is a message from your heart to tell you that it is suffering from a lack of blood carrying oxygen. This is usually due to a narrowing in the coronary arteries supplying blood to your heart muscle. There is an important balance between the amount of blood your heart muscle demands and the ability of the coronary arteries to supply that blood. The heart demands are increased by exercise, high blood pressure, exercise and infections. The blood supply is reduced by narrowed arteries, a low blood count (anaemia) or lack of oxygen. Correcting this imbalance allows patients to live their lives without pain. This is achieved through lifestyle changes and use of anti-anginal drugs. However, the other important aspect of treating angina is to prevent the disease in the arteries getting worse. This is the best long term strategy and is achieved through modifying risk factors such as cholesterol, blood pressure, smoking, weight and inactivity.


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