What is angina pectoris

Angina pectoris is also called stable angina, is the medical term for chest pain or discomfort that occurs when your heart doesn’t get as much blood and oxygen as it needs due to coronary heart disease. Angina pectoris occurs when the heart muscle doesn’t get as much blood as it needs that is relieved by rest, nitroglycerin or both ¹. This usually happens because one or more of the heart’s coronary arteries is narrowed or blocked, also called ischemia. Over time, the coronary arteries that supply blood to your heart can become clogged with plaque. If one or more arteries are partly clogged, not enough blood can flow through, and you can feel chest pain or discomfort. Reversible (stable) angina occurs when the heart works harder and needs more oxygen, and goes away when heart demand is decreased. Progressive (unstable) angina occurs when a plaque in one or more of your coronary arteries ruptures (bursts). If the plaque buildup (atherosclerosis) happens rapidly, you are at risk for a heart attack.

Angina (chest pain) is a warning sign of heart disease, and recognizing it and getting treated early may prevent a heart attack.

Heart disease occurs when fatty build-up in your coronary arteries, called plaque, prevents blood flow that’s needed to provide oxygen to your heart muscle.

As heart disease progresses, you may have tightness, pressure or discomfort in your chest during physical activity or when stressed. But it goes away shortly after you stop the activity or get rid of the stress.

Angina pectoris usually causes uncomfortable pressure, fullness, squeezing or pain in the center of the chest. You may also feel the discomfort in your neck, jaw, shoulder, back or arm. Many types of chest discomfort — like heartburn, lung infection or inflammation — aren‘t related to angina. Angina in women can be different than in men.

Angina pectoris symptoms in women can also include feeling out of breath, nausea, vomiting, abdominal pain or sharp chest pain. Once the extra demand for blood and oxygen stops, so do the symptoms.

Why would angina symptoms be different in women and men?

Heart disease in men is more often due to blockages in their coronary arteries, referred to as obstructive coronary artery disease (CAD). Women more frequently develop heart disease within the very small arteries that branch out from the coronary arteries. This is referred to as microvascular disease and occurs particularly in younger women. Up to 50 percent of women with anginal symptoms who undergo cardiac catheterization don’t have the obstructive type of coronary artery disease.

Cardiovascular disease is the No. 1 killer of women in the United States, affecting one out of every three in the United States ². Nearly half of African-American women have cardiovascular disease.

What is stable angina

Stable angina is also called reversible angina, is chest pain or discomfort that occurs with increased demand on your heart such as when you’re exercising. Stable angina often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low, such as when you’re sitting. But, with physical exertion—like walking up a hill or climbing stairs—the heart works harder and needs more oxygen.

Stable angina is less serious than unstable angina, but it can be very painful or uncomfortable.

Possible triggers of stable angina include:

• Emotional stress – learn stress management
• Exposure to very hot or cold temperatures – learn how cold and hot weather affect the heart.
• Heavy meals
• Smoking – learn more about quitting smoking.

Stable angina symptoms

Symptoms of stable angina are most often predictable. This means that the same amount of exercise or activity may cause your angina to occur. Your angina should improve or go away when you stop or slow down the exercise.

The most common symptom is chest pain that occurs behind the breastbone or slightly to the left of it. The pain of stable angina most often begins slowly and gets worse over the next few minutes before going away.

Typically, the chest pain feels like tightness, heavy pressure, squeezing, or a crushing feeling. It may spread to the:

• Arm (most often the left)
• Back
• Jaw
• Neck
• Shoulder

Some people say the pain feels like gas or indigestion.

Less common symptoms of angina may include:

• Fatigue
• Shortness of breath
• Weakness
• Dizziness or lightheadedness
• Nausea, vomiting, and sweating
• Palpitations

Pain from stable angina:

• Most often comes on with activity or stress such as when your heart must work harder, usually during physical exertion
• Lasts an average of 1 to 15 minutes. Usually lasts a short time (5 minutes or less)
• Is relieved with rest or a medicine called nitroglycerin or glyceryl trinitrate
• Doesn’t come as a surprise, and episodes of pain tend to be alike
• May feel like gas or indigestion
• May feel like chest pain that spreads to the arms, back, or other areas

Angina attacks can occur at any time during the day. Often, they occur between 6 a.m. and noon.

Stable angina treatment

People with angina pectoris or sometimes referred to as stable angina have episodes of chest pain. The discomfort that are usually predictable and manageable. You might experience it while running or if you’re dealing with stress.

Normally stable angina type of chest discomfort is relieved with rest, nitroglycerin or both. Nitroglycerin relaxes the coronary arteries and other blood vessels, reducing the amount of blood that returns to the heart and easing the heart’s workload. By relaxing the coronary arteries, it increases the heart’s blood supply.

If you experience chest discomfort, be sure and visit your doctor for a complete evaluation and, possibly, tests. If you have stable angina and start getting chest pain more easily and more often, see your doctor immediately as you may be experiencing early signs of unstable angina.

Angina pectoris causes

Angina pectoris (stable angina) is not a disease. Angina pectoris (stable angina) is a symptom of an underlying heart problem, usually coronary heart disease (coronary artery disease). When the arteries that supply your heart muscle with blood and oxygen become narrowed, the blood supply to your heart muscle is restricted. This can cause the symptoms of angina.

Angina pectoris (stable angina) symptoms are often brought on by physical activity, an emotional upset, cold weather or after a meal. The episodes usually subside after a few minutes.

There are many risk factors for coronary artery disease. Some include:

• Diabetes
• High blood pressure
• High LDL cholesterol (bad cholesterol)
• Low HDL cholesterol (good cholesterol)
• Sedentary lifestyle
• Smoking
• Advancing age
• Male gender

Anything that makes the heart muscle need more oxygen or reduces the amount of oxygen it receives can cause an angina attack in someone with heart disease, including:

• Cold weather
• Exercise
• Emotional stress
• Large meals

Other causes of angina include:

• Abnormal heart rhythms (your heart beats very quickly or your heart rhythm is not regular)
• Anemia
• Coronary artery spasm (also called Prinzmetal angina)
• Heart failure
• Heart valve disease
• Hyperthyroidism (overactive thyroid)

Angina pectoris prevention

Unfortunately you can’t reverse coronary heart disease, which causes angina, but you can help delay your arteries narrowing. To do this it’s important to:

• stop smoking
• control high blood pressure
• reduce your cholesterol level
• be physically active
• achieve and maintain a healthy weight
• control your blood glucose if you have diabetes
• eat a healthy, balanced diet and only drink moderate amounts of alcohol.

Angina pectoris symptoms

Angina pectoris often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low, such as when you’re sitting. But, with physical exertion—like walking up a hill or climbing stairs—the heart works harder and needs more oxygen.

The most common symptom is chest pain that occurs behind the breastbone or slightly to the left of it. The pain of stable angina most often begins slowly and gets worse over the next few minutes before going away.

Typically, the chest pain feels like tightness, heavy pressure, squeezing, or a crushing feeling. It may spread to the:

• Arm (most often the left)
• Back
• Jaw
• Neck
• Shoulder

Some people say the pain feels like gas or indigestion.

Less common symptoms of angina may include:

• Fatigue
• Shortness of breath
• Weakness
• Dizziness or lightheadedness
• Nausea, vomiting, and sweating
• Palpitations

Pain from stable angina:

• Most often comes on with activity or stress such as when your heart must work harder, usually during physical exertion
• Lasts an average of 1 to 15 minutes. Usually lasts a short time (5 minutes or less)
• Is relieved with rest or a medicine called nitroglycerin
• Doesn’t come as a surprise, and episodes of pain tend to be alike
• May feel like gas or indigestion
• May feel like chest pain that spreads to the arms, back, or other areas

Angina attacks can occur at any time during the day. Often, they occur between 6 a.m. and noon.

How is angina pectoris diagnosed?

Your doctor may be able to tell whether you have angina pectoris (stable angina) from the symptoms that you describe.

Your health care provider will examine you and check your blood pressure. Tests that may be done include:

• Coronary angiography
• Blood cholesterol profile
• Electrocardiogram (ECG) a test that records the electrical activity of the heart
• Exercise tolerance test (stress test or treadmill test)
• Nuclear medicine (thallium) stress test
• Stress echocardiogram
• Heart CT scan

In patients with stable coronary artery disease the risk of cardiovascular mortality may be predicted by clinical and demographic variables ¹. These include gender ³, left ventricular function ⁴, the provocation of myocardial ischemia with stress testing ⁵, and the severity of coronary artery disease seen on angiography ⁶. Patients at high risk of cardiovascular events may need revascularisation14,15 as well as medical therapy.

Echocardiography

Echocardiography provides information about left ventricular function, and regional wall motion abnormalities that may be related to infarction or ischemia. In patients with stable coronary artery disease, left ventricular ejection fraction is the strongest predictor of long-term survival. The 12-year survival of medically treated patients with ejection fractions greater than 50% is 73%, and 54% if the ejection fraction is between 35% and 49%. Survival is only 21% if the ejection fraction is less than 35% ⁴.

Stress testing

Stress testing on a treadmill or bicycle is recommended for patients with normal resting ECGs who can exercise ⁷. Symptoms such as chest discomfort and dyspnea, exercise workload, blood pressure response and ECG changes consistent with ischemia are recorded as the patient exercises ⁸. Abnormalities present at rest such as atrial fibrillation, left ventricular hypertrophy, intraventricular conduction abnormalities and ECG changes related to electrolyte imbalance or digoxin will result in more frequent false-positive results. Stress testing is also used to evaluate the efficacy of revascularisation and medical treatment, and to direct the prescription of exercise ⁶.

Exercise or pharmacological stress echocardiography may be necessary to demonstrate ischemic changes in left ventricular systolic function in patients whose resting ECGs are abnormal or unable to be interpreted (because of left bundle branch block, paced rhythm) ⁹. Exercise echocardiography provides information about cardiac structure and function, exercise workload, heart rate and rhythm and blood pressure response. Pharmacological testing may be necessary in patients who cannot exercise ¹⁰. Myocardial perfusion scintigraphy is an alternative for those with uninterpretable ECGs or inability to exercise ¹¹.

Imaging of coronary arteries

Computed tomography (CT) of the coronary arteries without contrast injection can show coronary calcification ¹², although correlation with the degree of luminal narrowing is poor.

Intravenous injection of a contrast agent allows visualisation of the vessel lumen. The severity and extent of the lesions determine the risk of a cardiovascular event (Table 1) ¹³. CT angiography exposes patients to radiation. It should be reserved for those who are not overweight, without excessive coronary calcium (Agatston score <400) and who are in sinus rhythm with resting heart rates of 65 beats/minute or less, with or without medication.

If patients have a high risk of cardiovascular events or if their symptoms are not adequately controlled, invasive coronary angiography may be indicated. It helps define prognosis ⁹ and options for revascularisation. The 12-year survival rate in medically treated patients is 74% for single-vessel disease, 59% for two-vessel disease and 50% for three-vessel coronary disease ¹³. Severe stenosis of the left main coronary artery or proximal left anterior descending artery has a poor prognosis if not revascularised ¹⁴. Conversely, the exclusion of significant obstructive disease on angiography is reassuring ¹⁵.

Table 1. Risk stratification by CT coronary angiography

Angina pectoris treatment

People with angina pectoris or sometimes referred to as stable angina have episodes of chest pain. The discomfort that are usually predictable and manageable. You might experience it while running or if you’re dealing with stress.

Treatment for angina pectoris may include:

• Lifestyle changes
• Medicines
• Procedures such as coronary angiography with stent placement
• Coronary artery bypass surgery

If you have angina pectoris, you and your doctor will develop a daily treatment plan. This plan should include:

• Medicines you regularly take to prevent angina
• Activities that you can do and those you should avoid
• Medicines you should take when you have angina pain
• Signs that mean your angina is getting worse
• When you should call the doctor or get emergency medical help

Medicines

You may need to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your provider’s directions closely to help prevent your angina from getting worse. The aim of medicines (see Table 2) is to minimize your symptoms and prevent progression of your coronary artery disease. Short-acting nitrates (e.g., nitroglycerin or glyceryl trinitrate) are prescribed to relieve acute symptoms or anticipated angina. Nitroglycerin pills or spray may be used to stop chest pain. Drug therapy aims to reduce myocardial oxygen demand or increase coronary blood supply. The choice of drugs is influenced by factors such as comorbidities, tolerance and adverse effects.

Anti-clotting drugs such as aspirin and clopidogrel (Plavix), ticagrelor (Brilinta) or prasugrel (Effient) can help prevent blood clots from forming in your arteries, and reduce the risk of heart attack. Ask your provider if you should be taking these medicines.

You may need to take more medicines to help prevent you from having angina. These include:

• ACE inhibitors to lower blood pressure and protect your heart
• Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart
• Nitrates to help prevent angina e.g., nitroglycerin or glyceryl trinitrate
• Ranolazine (Ranexa) to treat chronic angina

Table 2. Medicines for angina

NEVER STOP TAKING ANY OF THESE DRUGS ON YOUR OWN. Always talk to your provider first. Stopping these drugs suddenly can make your angina worse or cause a heart attack. This is especially true for anti-clotting drugs (aspirin, clopidogrel, ticagrelor and prasugrel).

Your provider may recommend a cardiac rehabilitation program to help improve your heart’s fitness.

Prevention of cardiovascular events

Low-dose aspirin reduces major cardiac events by up to 30% and should be prescribed to patients with coronary artery disease ⁶. Clopidogrel is an alternative option for patients intolerant of aspirin. Patients with established coronary artery disease should be prescribed statin therapy irrespective of their lipid profile to slow the progression or even promote regression of coronary atherosclerosis ¹⁶.

Angiotensin converting enzyme (ACE) inhibitors should be prescribed for patients with stable angina, particularly those who have hypertension, left ventricular dysfunction, diabetes ¹⁷ or chronic kidney disease. Adverse effects include a persistent cough, hyperkalaemia and, rarely, angioedema. Angiotensin receptor antagonists may be used for those who do not tolerate ACE inhibitors ⁶.

Beta blockers

Beta blockers are first-line therapy to reduce angina and improve exercise tolerance by limiting the heart rate response to exercise ⁶. Although they reduce the risk of cardiovascular death and myocardial infarction by 30% in post-infarct patients, their benefits in those with stable coronary artery disease are less certain ¹⁸. The drugs most widely used for angina in the context of normal left ventricular function are the beta1-selective drugs such as metoprolol and atenolol.

Side effects include fatigue, altered glucose, bronchospasm, bradycardia, impotence and postural hypotension. Switching to a less lipophilic beta blocker such as atenolol may alleviate symptoms such as insomnia or nightmares. They are usually well tolerated in patients with emphysema who have predominantly fixed airways disease. Beta blockers should not be stopped abruptly due to the risk of rebound hypertension or ischaemia.

Calcium channel antagonists

Calcium channel antagonists improve symptoms of angina via coronary and peripheral vasodilation. They are indicated for those who cannot tolerate or have insufficient control of ischaemic symptoms on beta blockers alone.

Non-dihydropyridine drugs such as verapamil and diltiazem also reduce heart rate and contractility. Verapamil has comparable antianginal activity to metoprolol and can be useful for treatment of supraventricular arrhythmias and hypertension. However, verapamil should be avoided in patients taking beta blockers owing to the risk of heart block, and in those with heart failure because of its negative inotropic effect. Diltiazem has a low adverse effect profile with a modest negative inotropic effect. Care should be taken when prescribing in combination with a beta blocker and in patients with left ventricular dysfunction.

The dihydropyridines such as amlodipine, felodipine and lercanidipine have greater vascular selectivity and minimal negative inotropic properties. They are therefore safer in patients with left ventricular dysfunction. Amlodipine is an effective once-daily antianginal drug that can be used in combination with a beta blocker. Long-acting nifedipine is a proven antianginal drug and is most effective when used in conjunction with a beta blocker ¹⁹.

Contraindications to nifedipine use include severe aortic stenosis, obstructive cardiomyopathy and heart failure. Short-acting nifedipine is rarely used as monotherapy due to reflex tachycardia, which can worsen ischaemia and has been associated with a dose-related increase in mortality. It should therefore be avoided.

Nitrates

Sublingual glyceryl trinitrate tablets or nitroglycerin spray remain the treatment of choice for rapid relief of acute symptoms and anticipated angina. Sublingual glyceryl trinitrate tablets are absorbed in the sublingual mucosa and take effect within a couple of minutes. The tablet can be discarded with resolution of chest pain to minimise adverse effects such as headache. Glyceryl trinitrate spray is equally effective and, due to its longer shelf-life, is more convenient for those with infrequent symptoms of angina.

Isosorbide dinitrate undergoes hepatic conversion to mononitrate, resulting in an onset of action of 3–4 minutes. It can provide an antianginal effect for up to one hour. Less commonly it is used as a chronic antianginal drug but requires multiple dosing, and tolerance limits its usefulness. It is often used up to three times per day with a nitrate-free period of up to 14 hours to minimise tolerance.

Long-acting nitrates such as oral isosorbide mononitrate or transdermal patches are effective in relieving angina and can improve exercise tolerance. Chronic nitrate therapy is limited by the development of nitrate tolerance. A nitrate-free period of at least eight hours may reduce this problem. The mechanism of nitrate tolerance is not well established but involves attenuation of the vascular effect of the drug rather than altered pharmacokinetics ²⁰. A nitrate-free period restores the vascular reactivity of the vessel. Transdermal patches are generally used for 12 consecutive hours with a 12-hour nitrate-free period. There is no evidence that nitrates improve survival.

Common adverse effects include headache, hypotension and light-headedness. Nitrates should not be prescribed for patients taking phosphodiesterase-5 inhibitors such as sildenafil due to the risk of profound hypotension. Other contraindications include severe aortic stenosis and hypertrophic cardiomyopathy.

Nicorandil

Nicorandil is a potassium channel activator that improves coronary flow as a result of both arterial and venous dilation. It may be used in addition to beta blockers and calcium channel antagonists to control angina or in patients who are intolerant of nitrates. Nicorandil has been shown to reduce cardiovascular events by 14% in patients with chronic stable angina ²¹. Its use has been associated with headaches, hypotension, painful ulcers and genital and gastrointestinal fistulae ²¹.

Ivabradine

Ivabradine can be considered for patients intolerant of, or insufficiently responsive to, other drugs. It acts on If channels in the sinus node to lower the heart rate of patients in sinus rhythm without affecting blood pressure, conduction or myocardial contractility ²². Ivabradine has been shown to reduce a composite primary end point of cardiovascular death and hospitalisation with myocardial infarction or heart failure. However, a recent placebo-controlled trial involving 19,102 patients with stable coronary artery disease found that adding ivabradine to standard therapy did not improve a composite outcome of death from cardiovascular causes, or non-fatal myocardial infarction ²³. Ivabradine has been used in combination with beta blockers ²⁴.

Perhexiline

Perhexiline promotes anaerobic metabolism of glucose in active myocytes. Its use is limited by a narrow therapeutic window and high pharmacokinetic variability ²⁵. Given its potential for toxic effects such as peripheral neuropathy and hepatic damage, it is usually reserved for patients whose angina is refractory to other therapies. It may be used safely with conscientious monitoring of clinical effects and regular measurement of plasma drug concentrations ²⁶.

Surgical treatment

Some people will be able to control angina with medicines and not need surgery. Others will need a procedure called angioplasty and stent placement (also called percutaneous coronary intervention) to open blocked or narrowed arteries that supply blood to the heart.

Blockages that cannot be treated with angioplasty may need heart bypass surgery to redirect blood flow around the narrowed or blocked blood vessels.

Angina pectoris prognosis

Stable angina most often improves when taking medicines. Many people with stable angina have a good quality of life and continue with their normal daily activities. Your doctor or nurse will be able to advise you on your daily activity and any lifestyle changes you may need to make.

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