What is Angina?
Stable angina is another term for chest pain that occurs with activity and improves with rest or a medication called nitroglycerine. This is an extremely common condition that typically affects older individuals with high blood pressure, diabetes, and elevated cholesterol. People with angina are at increased risk for cardiovascular conditions such as heart attack, peripheral vascular disease, and stroke. As opposed to stable angina, unstable angina is an emergency that can lead to heart attack very quickly.
Since stable angina is so important, it is critical that patients be educated about the causes and treatment of this condition.
What Causes Angina?
Angina is caused by reduced blood flow and oxygen to the heart during physical activity. Conditions such as advanced age, smoking, elevated cholesterol, high blood pressure, and diabetes promote the formation of plaques in the arteries of the heart. Plaque buildup in these arteries leads to blockages and reduced blood flow to heart tissue.
When you exercise, your heart is using more energy and requires more blood supply and oxygen. Plaques in the arteries of the heart restrict blood flow to the heart muscles, leading to chest pain, difficulty breathing, and exercise intolerance.
How Common is Angina?
Angina is extremely common - In fact, approximately 9.8 million Americans currently suffer from angina and about 500,000 new cases of angina occur each year.
As mentioned, people with angina are generally older adults with other risk factors such as smoking history, elevated blood pressure, high cholesterol, and diabetes. This collection of risk factors is exceedingly common in Western society due to our diet and lack of physical activity.
Signs and Symptoms
By definition, angina is chest pain that occurs with activity and improves with rest or nitroglycerine. Other symptoms that may occur during angina attacks include:
- Difficulty breathing
- Low energy
- Exercise intolerance
- Profuse sweating
- Nausea or vomiting
There are no specific signs on physical examination that can diagnose angina.
Angina is suspected based on symptoms and the diagnosis is typically confirmed with a stress test. There are various types of stress tests. Your doctor may have you exercise on a treadmill while monitoring your symptoms, blood pressure, heart rate, and electrocardiogram (stress EKG). If you have an abnormal EKG at baseline, they might not be able to interpret the EKG during exercise, so they may perform other tests that provide similar information - a stress echocardiogram or nuclear stress test.
During a stress echocardiogram, your doctor will look at an ultrasound of your heart before and after exercise. Similarly, during a nuclear stress test, you doctor will evaluate your heart before and after exercise using nuclear imaging. If your heart pumps abnormally with exercise, this can suggest that it is not receiving enough blood during physical activity.
Sometimes, individuals might not be able to use a treadmill due to severe arthritis in the hips or knees, or because they are paraplegic or unable to walk. During these circumstances, your doctor can administer an intravenous medication (e.g., adenosine, dobutamine) to mimic physical activity. In other words, your doctor will administer medications that activate your heart as if you were exercising. They can then perform any one of the imaging studies mentioned above (eg, echocardiogram, nuclear study) to evaluate your heart function before and after the intravenous medication is given.
If your stress test results come back positive - meaning you most likely have a significant blockage in the arteries of the heart - you cardiologist will likely recommend angiography.
Angiography is a procedure by which your cardiologist accesses the arteries of your heart by advancing a catheter through an artery in your groin or arm. They then inject a dye into the heart blood vessels to evaluate for any blockages. If they see blockages in the heart arteries, they can deploy a stent to open up these blockages.
Angina Medication and Treatment
The first step in reducing angina and cardiovascular risk involves lifestyle modification such as diet and exercise. Patients are usually encouraged to have a diet low in sodium and saturated fat, and high in fruits and vegetables. Always consult your cardiologist for their recommendations in regards to exercise as your activity level may need to be modified depending on various factors – too much physical exertion can actually be dangerous.
Angina can be treated with several classes of medications including:
- isosorbide mononitrate,
- isosorbide dinitrate
- Coreg (carvedilol)
- Lopressor (metoprolol)
- Calcium channel blockers
Your doctor may also prescribe low-dose aspirin, cholesterol-lowering medication (eg, Lipitor (atorvastatin), Pravachol (pravastatin)), and other blood pressure reducing medications (eg, diuretics). If you have diabetes, they may also recommend oral antidiabetic agents (eg, metformin, glipizide) and sometimes insulin. Smoking is the number one cause of preventable death, so if you smoke, tobacco cessation is always encouraged.
Besides medications, your cardiologist may recommend interventional procedures such as stent placement in the narrowed arteries of the heart. These can be drug-eluting stents or non-drug-eluting stents. Depending on the type of stent you receive, you may have to take a medication called Plavix (clopidogrel), which acts similarly to aspirin.
- Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 1999 Jun;33(7):2092-197. - https://www.ahajournals.org/doi/full/10.1161/01.cir.99.21.2829
- Wee Y, Burns K, Bett N. Medical management of chronic stable angina. Aust Prescr. 2015 Aug;38(4):131-6 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653970/
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.