Angina Pectoris Overview

If you are having pain or pressure in the middle of your chest, left neck, left shoulder, or left arm, go immediately to the nearest hospital emergency department. Do not drive yourself. Call 911 for emergency transport. Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the heart is not getting enough blood. The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries. Blood carries the oxygen and nutrients the heart muscle needs to keep pumping. When the heart does not get enough blood, it can no longer function at its full capacity. When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin. The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day. An episode of angina is not a heart attack. Having angina means you have an increased risk of having a heart attack. A heart attack is when the blood supply to part of the heart is cut off and that part of the muscle dies (infarction). Angina can be a helpful warning sign if it makes the patient seek timely medical help and avoid a heart attack. Prolonged or unchecked angina can lead to a heart attack or increase the risk of having a heart rhythm abnormality. Either of those could lead to sudden death. Time is very important in angina. The more time the heart is deprived of adequate blood flow (ischemia), and thus oxygen, the more the heart muscle is at risk of heart attack or heart rhythm abnormalities. The longer the patient experiences chest pain from angina, the more the heart muscle is at risk of dying or malfunctioning. Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to very serious. For example, chest pain can be caused by: acid reflux (gastroesophageal reflux disease, GERD), upper respiratory infection, asthma, or sore muscles and ligaments in the chest (chest wall pain) If chest pain is severe and/or recurrent, the patient should see a healthcare provider. Go to a hospital emergency department if the patient has any of the following with chest pain: o Other symptoms such as: sweating, weakness, faintness, numbness or tingling, or nausea o Pain that does not go away after a few minutes o Pain that is of concern in any way o o o o Angina is classified as one of the following two types: Stable Angina Stable angina is the most common angina, and the type most people mean when they refer to angina. People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a pattern and are predictable.

For most people, angina symptoms occur after short bursts of exertion. Stable angina symptoms usually last less than five minutes. They are usually relieved by rest or medication, such as nitroglycerin under the tongue. Unstable Angina Unstable angina is less common. Angina symptoms are unpredictable and often occur at rest. This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is already unstable. The symptoms are worse in unstable angina - the pains are more frequent, more severe, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue. Unstable angina is not the same as a heart attack, but it warrants an immediate visit to the healthcare provider or a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack. If the patient has stable angina, any of the following may indicate worsening of the condition: An angina episode that is different from the regular pattern Being awakened at night by angina symptoms More severe symptoms than usual Having angina symptoms more often than usual Angina symptoms lasting longer than usual Coronary Heart Disease The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery disease. In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged. They can no longer supply the heart with all of the blood it needs. Most cases of coronary heart disease are caused by atherosclerosis (hardening of the arteries). Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels. These buildups are called plaques, and they can block blood flow through the vessels partially or completely. Multiple risk factors, particularly: o diabetes, o high blood pressure, o smoking, o high cholesterol, and o genetic predisposition may accelerate this build up. Coronary Artery Spasm Another cause of unstable angina is coronary artery spasm. Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily. This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms. This is called variant angina or Prinzmetal angina. This is not the same as atherosclerosis, although some people have both conditions. The symptoms often come on at rest (or during sleep) and without apparent cause. Cocaine use/abuse can cause significant spasm of the coronary arteries and lead to a heart attack. Other Causes Other causes of angina symptoms include the following: Blockage of a coronary artery by a blood clot or by compression from something outside the artery Inflammation or infection of the coronary arteries Injury to one or more coronary arteries Poor functioning of the tiny blood vessels of the heart (microvascular angina) When a person has underlying atherosclerosis, spasm, or damage to the coronary arteries, angina symptoms usually are set off by one of the following triggers:

Physical exertion or exercise Emotional stress Exposure to cold Decreased oxygen content in the air you breathe (for example flying in an airplane or at high altitudes) 5. Using a stimulant such as caffeine or smoking cigarettes (which lowers the amount of oxygen in the blood) Risk Factors for Atherosclerosis and Angina Risk factors for atherosclerosis and angina include the following. Some of these are reversible. 1. 2. 3. 4. 5. 6. 7. 8. 9. High blood pressure (hypertension) High levels of cholesterol and other fats in the blood Diabetes Smoking Male gender Inactive (sedentary) lifestyle Family history of coronary heart disease Aging Regular use of stimulants, especially nicotine, cocaine, or amphetamines: Other stimulants include theophyllines, inhaled beta-agonists, caffeine, diet pills, and decongestants

1. 2. 3. 4.

Angina Pectoris Symptoms

Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina: 1. An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest 2. It may also feel like tightness, burning, or a heavy weight. 3. The pain may spread to the shoulders, neck, or arms. 4. It may be located in the upper abdomen, back, or jaw. 5. The pain may be of any intensity from mild to severe. Other symptoms may occur with an angina attack, as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. Shortness of breath Lightheadedness Fainting Anxiety or nervousness Sweating or cold, sweaty skin Nausea Rapid or irregular heart beat Pallor (pale skin) Feeling of impending doom

These symptoms are identical to the signs of an impending heart attack described by the American Heart Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a few minutes and heart attack pain does not go away. If you have never had symptoms like this before, sit down. If you are able, call your healthcare provider, call 911, or go to the closest hospital emergency department. If you have had angina attacks before and this attack is similar to those, rest for a few minutes. Take your sublingual nitroglycerin. Your angina should be totally relieved in five minutes. If not, you may repeat the nitroglycerin dose and wait another five minutes. A third dose may be tried but if you still have no relief, call 911 or go to the nearest hospital emergency department

Exams and Tests

Upon hearing about the patient's symptoms, the primary healthcare provider or the provider in the emergency department will immediately think of angina and other heart problems. Time is of the essence - treatment will probably begin as the evaluation continues. An electrocardiogram (ECG) will be done. 1. This painless test checks for abnormalities in the beating of the heart. 2. Electrodes are attached to the chest and other points on the body. The electrodes read the electrical impulses linked to the beating of the heart. 3. The ECG looks for signs of a heart attack or of impaired blood flow to the heart. 4. For many patients with angina, the ECG result is normal.

The patient may have a chest x-ray. This will show any fluid buildup in the lungs. It can also rule out some other causes of chest pain. There is no blood lab test that can tell with certainty that someone is having angina. There are certain blood tests that suggest that a person may be having a heart attack. These tests may be done if a heart attack is suspected. While these tests are going on, the healthcare provider will be asking questions to help with the diagnosis. The questions will be about the symptoms and about the patient's medical history: o o o o previous operations, medications, allergies, and habits and lifestyle.

The physical exam will include listening to the heart and lungs and feeling the heart through the chest. If, after these tests, the healthcare provider suspects the patient may have coronary heart disease, additional tests will be performed to confirm the possibility. Exercise stress test: An ECG is taken before, during, and after exercise (usually walking on a treadmill) to detect inadequate blood flow to the heart muscle indirectly by changes on the ECG. This usually is done only for stable angina. Thallium stress test: This is a more complex and expensive test that injects a radioisotope into the circulation and indirectly detects parts of the heart that may not be getting enough blood during "stress" (usually walking on a treadmill, or after administration of a drug that mimics exercise in those unable to walk on the treadmill). This information indicates more accurately whether any of the coronary arteries may be narrowed, causing inadequate blood flow to the heart muscle or ventricle. Again, this is usually done only for stable angina. Dobutamine echocardiogram stress test: This is done for people who cannot walk on a treadmill. A drug called dobutamine stimulates and speeds up the heart, creating an increased

demand or need for blood flow tot he left ventricle or muscle. If the muscle shows a slowing of function on the ultrasound image of the heart muscle, then it indirectly indicates inadequate blood flow to the muscle. Coronary angiogram (or arteriogram): This test of the coronary arteries is the most accurate but also the most invasive. It is a type of x-ray. A thin, plastic tube called a catheter is threaded through an artery in the arm or groin to one of the main coronary arteries. A contrast, or harmless dye is injected into the arteries. The dye depicts the arteries directly and shows any blockage more accurately than the above or more noninvasive procedures. The healthcare provider will make the decision about whether these tests or any treatment need to be done on an urgent basis. If so, the patient will be admitted to the hospital. If not, the tests will be scheduled for the next few days, and the patient may be allowed to go home.

Medical Treatment
If the patient has come to the hospital emergency department, they may be sent to another care area for further testing, treatment, or observation. On the basis of the provider's preliminary diagnosis, the patient may be sent to the following units: An observation unit pending test results or further testing A cardiac care unit A cardiac catheterization unit Regardless of where the patient is sent, several basic treatments may be started. Which ones are given depends on the severity of the symptoms and the underlying disease. At least one IV line will be started. This line is used to give medication or fluids. Aspirin will probably be administered (unless the patient has already taken one) Oxygen will be administered through a face mask or a tube in the nose. This will help if the patient is having trouble breathing or feeling uncomfortably short of breath. The direct administration of oxygen raises the oxygen content of the blood. Treatment will depend on the severity of the symptoms, severity of the underlying disease, and extent of damage to the heart muscle, if any. Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that the patient needs, if it is only angina. Medication may be administered to reduce anxiety. Medication may be administered to lower blood pressure or heart rate. Medication may be administered to reduce the risk of having a blood clot or to prevent further clotting. If the healthcare provider believes the chest pain actually represents a heart attack, the patient may be given a fibrinolytic (apowerful clot-buster medication).

After reviewing the patient's immediate test results, the hospital healthcare provider will make a decision about where the patient should be for the next hours and days. If the diagnosis of angina is made, and the patient is feeling better and their condition is stable they may be allowed to go home. The patient may be given medications to take. Follow-up with a primary healthcare provider within the next day or two will be recommended. The patient will be admitted to the hospital if the they are unstable with continuing symptoms. Further testing will be ordered, and if the arteries are critically blocked, the patient may undergo coronary angiography, coronary artery angioplasty, or even coronary artery bypass surgery. Angioplasty is a treatment used for people whose angina does not get better with medication and/or who are at high risk of having a heart attack. 1. Before angioplasty can be done, the area(s) of coronary artery narrowing is located with coronary arteriography. 2. A thin plastic tube called a catheter is inserted into an artery in the arm or groin with local sedation. The catheter has a tiny balloon attached to the end. 3. The catheter is threaded through the arteries and into the artery where the narrowing is. 4. The balloon on the catheter is inflated, opening up the narrowing. 5. Following ballon treatment, many patients require placement of a "stent," a small metal sleeve that is placed in the narrowed artery. The stent holds the artery open.

If the patient has had angina symptoms and is visiting their primary healthcare provider for evaluation, he or she will make a decision about how to proceed with the evaluation. The choices include going ahead with the evaluation on an outpatient basis, referring the patient to a specialist in heart disorders (cardiologist), or admitting the patient to the hospital for further workup. Nitroglycerin is a sublingual (under the tongue) medication relieves angina symptoms by expanding blood vessels and decreasing the muscle's need for oxygen. This allows more blood to flow through the coronary arteries. Nitroglycerin is taken only when the patient actually has symptoms or expect to have them. Slow - or long-acting nitroglycerin can be used as a preventative treatment for angina but not until beta blockers are tried first. Beta blockers: Beta blockers lessen the heart's workload. They slow the heart rate, decrease blood pressure, and lessen the force of contraction of the heart muscle. This decreases the heart's need for oxygen and thus decreases angina symptoms. Beta blockers are taken every day, regardless of whether the patient is having symptoms, because they are proven to prevent heart attacks and sudden death. Calcium channel blockers (CCBs): Calcium channel blockers are used primarily when beta blockers cannot be used and/or the patient is still having angina with beta blockers. Calcium channel blockers also lower blood pressure and certain ones slow heart rate. Calcium channel blockers have to be taken every day. Aspirin: Daily aspirin therapy is mandatory to decrease the possibility of sticky platelets in the blood starting a blood clot. Statins: Statins lower cholesterol and have been shown to stabilize the fatty plaque on the inner lining of the coronary artery, even when the blood cholesterol is normal or minimally increased. Low density lipoprotein (LDL) or "bad cholesterol" levels should be less than 70

mg/dL for those at high risk of heart disease. Every person with angina needs to know exactly what his or her blood lipids/fats are. Miscellaneous anti-anginal drugs: New drugs are being studied to treat angina. In 2006, the FDA approved ranolazine (Ranexa). Because of its side effects (potential to cause abnormal heart rhythm), ranolazine is indicated only after other conventional drug treatments are found to be ineffective.

Surgery
Like angioplasty, surgery is an option for people whose angina does not improve with medications and others who are at high risk of having a heart attack. Surgery is usually reserved for people with very severe narrowing or blockage in several coronary arteries. In almost all cases, the operation used for severely narrowed coronary arteries is coronary artery bypass grafting. Coronary Artery Bypass Surgery The chest and rib cage are opened up (open heart surgery) The narrowed part of the artery is bypassed by a piece of vein removed from the leg, or with a piece of artery behind the sternum (internal mammary artery), or a portion of the radial artery taken from the lower arm or forearm. Several arteries can be bypassed in one operation. This is a very safe operation, with a mortality rate of less than 1%, in people whose heart muscle is not severely damaged irreversibly and who have normal lungs, kidneys, liver, and other organs. Because the chest is opened, the recovery time can be quite long, especially if the patient is older and has multiple other health problems. Transmyocardial Revascularization Transmyocardial revascularization is a procedure for people who cannot undergo angioplasty or surgery. A simple incision is made in the chest, and a laser is used to "drill" small holes through the outside wall of the heart into the left ventricle. About 20-40 holes are made. Bleeding from these holes is minimal and usually stops after a few minutes of pressure. It is not clear why this helps relieve angina. One theory is that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect. Current research is focusing on trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels.