Angina

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Dr. Sachin Shelke
Internal Medicine

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Angina, known as angina pectoris, is used to describe chest pain or a feeling of tightness, heaviness and discomfort in the chest because of inadequate blood oxygen supply to heart muscles. The insufficient supply of oxygen is primarily attributed to the narrowing of arteries carrying blood to the heart (coronary arteries). It is the primary symptom of coronary heart disease and is commonly mistaken as an indigestion-related symptom. Angina often occurs when a person is under emotional or physical stress. Although pain is commonly felt in the chest, often pain in the shoulders, arms, neck, throat, jaw, abdomen or back is experienced. There are different types of angina. Stable angina is the most common type of angina, which suggests the possibility of getting a heart attack in the near future. Unstable angina is severe compared to stable angina and requires emergency treatment. In this section, you will find articles, including the risk of a heart attack in night-shift workers; angioplasty and tips to keep your heart healthy.

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Types

Depending on the type of pain and duration for which it lasts, angina is classified into four different types:


  1. Stable angina: It occurs when the heart muscle has to work harder to pump blood. Situations such as emotional stress, physical exertion and cold temperature may cause angina by interrupting blood flow to the heart. This type of angina lasts for a short time period and is relieved with medicines and rest.

  2. Unstable angina: It can occur without any exertion while you are at rest. Usually, for causing unstable angina, building plaque and obstruction of main coronary arteries is the primary reason. The pain may last for 10-15 min.

  3. Prinzmetal angina/Variant angina: It occurs because of spasms in coronary arteries. Pain occurs at rest, particularly between midnight and early morning.

  4. Microvascular angina: It is mild pain that usually lasts for >10 min and may continue for 30 min or more. It occurs because of interrupted blood flow through the smallest coronary arteries.

Symptoms

There are a few features of angina that differentiate it from regular chest pain because of other reasons not originating from the heart.

‘Angina is usually felt as pressure, heaviness, tightening, squeezing or aching across the chest, particularly behind the breastbone. This pain often radiates to the neck, jaw, arms, back or even the teeth. Patients may suffer from indigestion, heartburn, weakness, sweating, nausea and shortness of breath.’
‘Any chest pain or discomfort that occurs at rest and continues for >10 min requires medical attention if it is associated with:


  1. Profuse sweating

  2. Giddiness

  3. Weakness

  4. Nausea

  5. Lightheadedness


The threshold to consult a doctor should be low if the subject has risk factors for atherosclerosis (fat accumulation in arteries) such as advanced age, smoking, diabetes, hypertension, family history of heart disease and obesity/sedentary life style.

Causes And Risk Factors

Causes


Angina is chest discomfort caused by decreased oxygen supply to a part of the heart muscle. It is caused by partial or complete obstruction to arteries supplying the heart.

Risk Factors


Coronary arteries narrow down because of fat deposition (plaque) in the arteries’ inner linings. The narrowing of arteries is referred to as atherosclerosis, and this build-up occurs because of various factors such as

  1. Unhealthy diet

  2. Obesity or being overweight

  3. Smoking

  4. Inactive lifestyle

  5. High cholesterol

  6. High blood pressure

  7. Uncontrolled diabetes mellitus

  8. Age

  9. Males are more prone to coronary artery disease

  10. Genetic factors or family history

  11. Postmenopausal women are more inclined toward a heart attack

  12. Mental illness

Prevention

Because heart disease is the underlying cause of angina, preventative measures include controlling risk factors that could lead to heart disease.


  1. Eating healthy food, and avoiding junk is the mainstay for controlling cholesterol levels and maintaining a good lipid profile.

  2. Exercising regularly, at least 30 min every day, will help you lose weight, increase your good cholesterol levels and improve your heart function.

  3. Smoking is the primary cause of atherosclerosis that can lead to angina. So, if you smoke, you should now quit.

Diagnosis

Angina can be difficult to differentiate from chest pain arising from other systems of the body. Therefore, it is best for you to let the doctor determine the cause of chest pain because self-diagnosis could be misleading and may result in complications.
‘Chest pain can occur from almost any organ in the chest other than the heart such as lungs, ribs, oesophagus (swallowing tube), aorta (the largest artery of the body) and pericardium (layers of the heart). Any chest pain that typically precipitates on exertion and gets relieved on rest favours the heart. A well-localised pain, varying with phases of respiration or posture and any chest pain that is reproducible on palpation is unlikely to be from the heart.
Depending on your explanation of chest pain and physical examination, your doctor may recommend you the following tests to confirm angina and its underlying cause.


  1. Blood tests: Certain blood markers such as troponin T or I and creatine phosphokinase myocardial band (CPK MB) can help identify changes of artery blockage and plaque formation, thus causing angina

  2. ECG: Electrocardiograms are used to verify the electrical activity of your heart using an ECG device

  3. Echocardiography: It is a test that helps doctors visualise the heart real time to analyse how effectively it works

  4. Coronary angiography: In this test, a specific dye is injected into the bloodstream to verify the rate at which blood flows via the arteries. It is an important test for identifying CHD.

  5. Stress test: A simple exercise test can determine the electrical activity and functioning of your heart when exercising.

Treatment

Medicines for stable angina:


  1. Nitrates are given to prevent or reduce angina

  2. Nitroglycerin, aspirin and clopidogrel may be prescribed to prevent blood clotting and improve blood flow via the arteries

  3. Beta-blockers may be given to lower heart rate and help it smoothly work.

  4. Statins such as rosuvastatin and atorvastatin reduce cholesterol and hence atherosclerosis in the arteries.


Surgical procedures:

  1. Angioplasty: It is the most common surgery performed to open up blocked arteries using a small device called a stent.

  2. Bypass surgery: In this procedure, a healthy blood vessel (called a graft) taken from the leg, forearm or chest is used to bypass the affected artery.

  3. Untreated angina can result in a full-blown heart attack with severe damage to the heart muscle. It can result in a shock-like state, thus resulting in irreversible damage to the heart and abnormal heart rhythms.


Medicines for unstable angina:

  1. Blood-thinning agents such as heparin and nitroglycerin may be prescribed to improve blood flow via narrow arteries.

  2. Aspirin and clopidogrel may be prescribed to prevent blood clotting and reduce the chances of heart attack.

  3. Medicine to control blood pressure may be required if you are hypertensive.

  4. Statins may be prescribed to lower cholesterol.

  5. A bypass or another route may be made to supply blood to the heart.
    Stent placement: A stent is a small device that is placed in the blocked artery to open it up and improve blood flow.

Lifestyle/management

Lifestyle-related changes that might help in preventing angina are listed below:


  1. Reducing risk factors - Stop smoking, lose weight, lower blood pressure, high cholesterol and high blood sugar, which can help control angina.

  2. Modify daily activities - The heart is more at risk in the mornings or after meals; try to reduce the amount of physical activity at those times.

  3. Try to reduce stress and anger by meditating and joining programs that help reduce stress.

  4. Exercise can help reduce weight and improve angina-related symptoms.

  5. Eat healthily and include green leafy vegetables in your diet.

Prognosis And Complications

Prognosis


Note the patterns of your symptoms, e.g. you should pay attention to when your chest pains, what it feels like, how much time the episode lasts and how medicines affect the pain. Call the emergency number if your symptoms are sharply elevated. You need to treat the underlying causes of angina. If the angina is controlled, there is no reason to worry. People with angina can continue to perform normal activities.

Complications


Any long-lasting harm is not caused to heart muscles because of angina; however, the untreated disease may lead to a heart attack. If symptoms do not go away within 10 min of rest and taking the medication, you might be experiencing a heart attack. Immediately call your physician in that case.

References


  1. Better Health. Heart Condition - Angina. [Internet] [Updated on: 17 Sept, 2020] Available at: (https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/heart-conditions-angina)

  2. Health Harvard. Angina. [Internet] [Updated on: 6 July, 2018] Available at: https://www.health.harvard.edu/heart-health/angina-symptoms-diagnosis-and-treatments (https://www.health.harvard.edu/heart-health/angina-symptoms-diagnosis-and-treatments)

  3. Hopkins Medicine. Angina Pectoris. [Internet] [Updated on: 2020] Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/angina-pectoris (https://www.hopkinsmedicine.org/health/conditions-and-diseases/angina-pectoris)

  4. National Health System. Angina. [Internet] [Updated on: 2020] Available at: https://www.nhs.uk/conditions/angina/ (https://www.nhs.uk/conditions/angina/)

  5. Cleveland Clinic. Angina. [Internet][Updated on: 2021] Available at: https://my.clevelandclinic.org/health/diseases/21489-angina (https://my.clevelandclinic.org/health/diseases/21489-angina)

  6. Walker HK, et al. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. 1990; Butterworth Publishers: Boston. Chapter 32Creatine Kinase.

  7. MedlinePlus. Troponin Test. [Internet] Available at: https://medlineplus.gov/lab-tests/troponin-test/ (https://medlineplus.gov/lab-tests/troponin-test/)

  8. Heart UK. Statins. [Internet] Available at: https://www.heartuk.org.uk/getting-treatment/statins#:~:text=%20The%20first%20two%20are%20used%20most%20often%3A,4%20pravastatin%20%28Lipostat%29%205%20rosuvastatin%20%28Crestor%29.%20More%20 (https://www.heartuk.org.uk/getting-treatment/statins#:~:text=%20The%20first%20two%20are%20used%20most%20often%3A,4%20pravastatin%20%28Lipostat%29%205%20rosuvastatin%20%28Crestor%29.%20More%20)

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