ANGINA

What Is Angina?
Angina (an-JI-nuh or AN-juh-nuh) is chest pain or discomfort that occurs if an area of your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. The pain also can occur in your shoulders, arms, neck, jaw, or back. Angina pain may even feel like indigestion. Angina isn't a disease; it's a symptom of an underlying heart problem. Angina usually is a symptom of coronary heart disease (CHD). CHD is the most common type of heart disease in adults. It occurs if a waxy substance called plaque (plak) builds up on the inner walls of your coronary arteries. These arteries carry oxygen-rich blood to your heart.

Plaque Buildup in an Artery

Figure A shows a normal artery with normal blood flow. The inset image shows a cross-section of a normal artery. Figure B shows an artery with plaque buildup. The inset image shows a cross-section of an artery with plaque buildup. Plaque narrows and stiffens the coronary arteries. This reduces the flow of oxygen-rich blood to the heart muscle, causing chest pain. Plaque buildup also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow, which can cause a heart attack. Angina also can be a symptom of coronary microvascular disease (MVD). This is heart disease that affects the hearts smallest coronary arteries. In coronary MVD, plaque doesn't create blockages in the arteries like it does in CHD. Studies have shown that coronary MVD is more likely to affect women than men. Coronary MVD also is called cardiac syndrome X and nonobstructive CHD.

Types of Angina
The major types of angina are stable, unstable, variant (Prinzmetal's), and microvascular. Knowing how the types differ is important. This is because they have different symptoms and require different treatments.

Stable Angina
Stable angina is the most common type of angina. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. (Pattern refers to how often the angina occurs, how severe it is, and what factors trigger it.) If you have stable angina, you can learn its pattern and predict when the pain will occur. The pain usually goes away a few minutes after you rest or take your angina medicine. Stable angina isn't a heart attack, but it suggests that a heart attack is more likely to happen in the future.

Unstable Angina
Unstable angina doesn't follow a pattern. It may occur more often and be more severe than stable angina. Unstable angina also can occur with or without physical exertion, and rest or medicine may not relieve the pain. Unstable angina is very dangerous and requires emergency treatment. This type of angina is a sign that a heart attack may happen soon.

Variant (Prinzmetal's) Angina

Variant angina is rare. A spasm in a coronary artery causes this type of angina. Variant angina usually occurs while you're at rest, and the pain can be severe. It usually happens between midnight and early morning. Medicine can relieve this type of angina.

Microvascular Angina
Microvascular angina can be more severe and last longer than other types of angina. Medicine may not relieve this type of angina.

Overview

Experts believe that nearly 7 million people in the United States suffer from angina. The condition occurs equally among men and women. Angina can be a sign of CHD, even if initial tests don't point to the disease. However, not all chest pain or discomfort is a sign of CHD. Other conditions also can cause chest pain, such as:

Pulmonary embolism (a blockage in a lung artery) A lung infection Aortic dissection (tearing of a major artery) Aortic stenosis (narrowing of the hearts aortic valve) Hypertrophic cardiomyopathy (KAR-de-o-mi-OP-ah-thee; heart muscle disease) Pericarditis (inflammation in the tissues that surround the heart) A panic attack

All chest pain should be checked by a doctor.

Other Names for Angina

Acute coronary syndrome Angina pectoris Chest pain Coronary artery spasms Microvascular angina Prinzmetal's angina Stable or common angina Unstable angina Variant angina

What Causes Angina?

Underlying Causes
Angina usually is a symptom of coronary heart disease (CHD). This means that the underlying causes of angina generally are the same as the underlying causes of CHD. Research suggests that CHD starts when certain factors damage the inner layers of the coronary arteries. These factors include:

Smoking High amounts of certain fats and cholesterol in the blood

High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

Plaque may begin to build up where the arteries are damaged. When plaque builds up in the arteries, the condition is called atherosclerosis (ath-er-o-skler-O-sis). Plaque narrows or blocks the arteries, reducing blood flow to the heart muscle. Some plaque is hard and stable and causes the arteries to become narrow and stiff. This can greatly reduce blood flow to the heart and cause angina. Other plaque is soft and more likely to rupture (break open) and cause blood clots. Blood clots can partially or totally block the coronary arteries and cause angina or a heart attack.

Immediate Causes
Many factors can trigger angina pain, depending on the type of angina you have.

Stable Angina
Physical exertion is the most common trigger of stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low, such as when you're sitting. However, with physical exertionlike walking up a hill or climbing stairsthe heart works harder and needs more oxygen. Other triggers of stable angina include:

Emotional stress Exposure to very hot or cold temperatures Heavy meals Smoking

Unstable Angina
Blood clots that partially or totally block an artery cause unstable angina. If plaque in an artery ruptures, blood clots may form. This creates a blockage. A clot may grow large enough to completely block the artery and cause a heart attack. For more information, go to the animation in "What Causes a Heart Attack?" Blood clots may form, partially dissolve, and later form again. Angina can occur each time a clot blocks an artery.

Variant Angina
A spasm in a coronary artery causes variant angina. The spasm causes the walls of the artery to tighten and narrow. Blood flow to the heart slows or stops. Variant angina can occur in people who have CHD and in those who dont. The coronary arteries can spasm as a result of:

Exposure to cold Emotional stress Medicines that tighten or narrow blood vessels Smoking Cocaine use

Microvascular Angina
This type of angina may be a symptom of coronary microvascular disease (MVD). Coronary MVD is heart disease that affects the hearts smallest coronary arteries. Reduced blood flow in the small coronary arteries may cause microvascular angina. Plaque in the arteries, artery spasms, or damaged or diseased artery walls can reduce blood flow through the small coronary arteries.

Who Is at Risk for Angina?

Angina is a symptom of an underlying heart problem. Its usually a symptom ofcoronary heart disease (CHD), but it also can be a symptom of coronary microvascular disease (MVD). So, if youre at risk for CHD or coronary MVD, youre also at risk for angina. The major risk factors for CHD and coronary MVD include:

Unhealthy cholesterol levels. High blood pressure. Smoking. Insulin resistance or diabetes . Overweight or obesity. Metabolic syndrome. Lack of physical activity. Unhealthy diet. Older age. (The risk increases for men after 45 years of age and for women after 55 years of age.) Family history of early heart disease.

For more detailed information about CHD and coronary MVD risk factors, visit the Health Topics Coronary Heart Disease, Coronary Heart Disease Risk Factors, andCoronary Microvascular Disease articles. People sometimes think that because men have more heart attacks than women, men also suffer from angina more often. In fact, overall, angina occurs equally among men and women. Microvascular angina, however, occurs more often in women. About 70 percent of the cases of microvascular angina occur in women around the time of menopause.

Unstable angina occurs more often in older adults. Variant angina is rare; it accounts for only about 2 out of 100 cases of angina. People who have variant angina often are younger than those who have other forms of angina.

What Are the Signs and Symptoms of Angina?

Pain and discomfort are the main symptoms of angina. Angina often is described as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort usually starts behind the breastbone. Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion. Some people say that angina pain is hard to describe or that they can't tell exactly where the pain is coming from. Signs and symptoms such as nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, and weakness also may occur. Women are more likely to feel discomfort in the neck, jaw, throat, abdomen, or back. Shortness of breath is more common in older people and those who havediabetes . Weakness, dizziness, and confusion can mask the signs and symptoms of angina in elderly people. Symptoms also vary based on the type of angina you have. Because angina has so many possible symptoms and causes, all chest pain should be checked by a doctor. Chest pain that lasts longer than a few minutes and isn't relieved by rest or angina medicine may be a sign of a heart attack. Call 911 right away.

Stable Angina
The pain or discomfort:

Occurs when the heart must work harder, usually during physical exertion Doesn't come as a surprise, and episodes of pain tend to be alike Usually lasts a short time (5 minutes or less) Is relieved by rest or medicine May feel like gas or indigestion May feel like chest pain that spreads to the arms, back, or other areas

Unstable Angina
The pain or discomfort:

Often occurs at rest, while sleeping at night, or with little physical exertion Comes as a surprise Is more severe and lasts longer than stable angina (as long as 30 minutes) Usually isnt relieved by rest or medicine

May get worse over time May mean that a heart attack will happen soon

Variant Angina
The pain or discomfort:

Usually occurs at rest and during the night or early morning hours Tends to be severe Is relieved by medicine

Microvascular Angina
The pain or discomfort:

May be more severe and last longer than other types of angina pain May occur with shortness of breath, sleep problems, fatigue, and lack of energy Often is first noticed during routine daily activities and times of mental stress

How Is Angina Diagnosed?

The most important issues to address when you go to the doctor with chest pain are:

What's causing the chest pain Whether you're having or are about to have a heart attack

Angina is a symptom of an underlying heart problem, usually coronary heart disease (CHD). The type of angina pain you have can be a sign of how severe the CHD is and whether it's likely to cause a heart attack. If you have chest pain, your doctor will want to find out whether it's angina. He or she also will want to know whether the angina is stable or unstable. If it's unstable, you may need emergency medical treatment to try to prevent a heart attack. To diagnose chest pain as stable or unstable angina, your doctor will do a physical exam, ask about your symptoms, and ask about your risk factors for and your family history of CHD or other heart diseases. Your doctor also may ask questions about your symptoms, such as:

What brings on the pain or discomfort and what relieves it? What does the pain or discomfort feel like (for example, heaviness or tightness)? How often does the pain occur? Where do you feel the pain or discomfort? How severe is the pain or discomfort? How long does the pain or discomfort last?

Diagnostic Tests and Procedures

If your doctor thinks that you have unstable angina or that your angina is related to a serious heart condition, he or she may recommend one or more tests.

EKG (Electrocardiogram)
An EKG is a simple, painless test that detects and records the hearts electrical activity. The test shows how fast the heart is beating and its rhythm (steady or irregular). An EKG also records the strength and timing of electrical signals as they pass through the heart. An EKG can show signs of heart damage due to CHD and signs of a previous or current heart attack. However, some people who have angina have normal EKGs.

Stress Testing
During stress testing, you exercise to make your heart work hard and beat fast while heart tests are done. If you cant exercise, you may be given medicine to make your heart work hard and beat fast. When your heart is working hard and beating fast, it needs more blood and oxygen. Plaque-narrowed arteries can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs and symptoms of CHD, such as:

Abnormal changes in your heart rate or blood pressure Shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

As part of some stress tests, pictures are taken of your heart while you exercise and while you rest. These imaging stress tests can show how well blood is flowing in various parts of your heart. They also can show how well your heart pumps blood when it beats.

Chest X Ray
A chest x ray takes pictures of the organs and structures inside your chest, such as your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure. It also can show signs of lung disorders and other causes of symptoms not related to CHD. However, a chestx ray alone is not enough to diagnose angina or CHD.

Coronary Angiography and Cardiac Catheterization

Your doctor may recommend coronary angiography (an-jee-OG-ra-fee) if he or she suspects you have CHD. This test uses dye and special x rays to show the inside of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure calledcardiac catheterization (KATH-e-ter-ih-ZA-shun). A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is threaded into your coronary arteries, and the dye is released into your bloodstream.

Special x rays are taken while the dye is flowing through your coronary arteries. The dye lets your doctor study the flow of blood through your heart and blood vessels. Cardiac catheterization usually is done in a hospital. You're awake during the procedure. It usually causes little or no pain, although you may feel some soreness in the blood vessel where your doctor inserts the catheter.

Computed Tomography Angiography

Computed tomography (to-MOG-rah-fee) angiography (CTA) uses dye and special x rays to show blood flow through the coronary arteries. This test is less invasive than coronary angiography with cardiac catheterization. For CTA, a needle connected to an intravenous (IV) line is put into a vein in your hand or arm. Dye is injected through the IV line during the scan. You may have a warm feeling when this happens. The dye highlights your blood vessels on the CT scan pictures. Sticky patches called electrodes are put on your chest. The patches are attached to an EKG machine to record your heart's electrical activity during the scan. The CT scanner is a large machine that has a hollow, circular tube in the middle. You lie on your back on a sliding table. The table slowly slides into the opening of the machine. Inside the scanner, an x-ray tube moves around your body to take pictures of different parts of your heart. A computer puts the pictures together to make a three-dimensional (3D) picture of the whole heart.

Blood Tests
Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CHD. Your doctor may recommend a blood test to check the level of a protein calledC-reactive protein (CRP) in your blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CHD and heart attack. Your doctor also may recommend a blood test to check for low levels of hemoglobin (HEE-muh-glowbin) in your blood. Hemoglobin is an iron-rich protein in red blood cells. It helps the blood cells carry oxygen from the lungs to all parts of your body. If your hemoglobin level is low, you may have a condition called anemia.

How Is Angina Treated?

Treatments for angina include lifestyle changes, medicines, medical procedures,cardiac rehabilitation (rehab), and other therapies. The main goals of treatment are to:

Reduce pain and discomfort and how often it occurs Prevent or lower your risk for heart attack and death by treating your underlying heart condition

Lifestyle changes and medicines may be the only treatments needed if your symptoms are mild and aren't getting worse. If lifestyle changes and medicines don't control angina, you may need medical procedures or cardiac rehab. Unstable angina is an emergency condition that requires treatment in a hospital.

Lifestyle Changes
Making lifestyle changes can help prevent episodes of angina. You can:

Slow down or take rest breaks if physical exertion triggers angina. Avoid large meals and rich foods that leave you feeling stuffed if heavy meals trigger angina. Try to avoid situations that make you upset or stressed if emotional stress triggers angina. Learn ways to handle stress that can't be avoided.

You also can make lifestyle changes that help lower your risk for coronary heart disease. One of the most important changes is to quit smoking. Smoking can damage and tighten blood vessels and raise your risk for CHD. Talk with your doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke. If you have trouble quitting smoking on your own, consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking. For more information about how to quit smoking, go to the Health Topics Smoking and Your Heart article and the National Heart, Lung, and Blood Institutes (NHLBIs) "Your Guide to a Healthy Heart." Following a healthy diet is another important lifestyle change. A healthy diet can prevent or reduce high blood pressure and high blood cholesterol and help you maintain a healthy weight. A healthy diet includes a variety of fruits and vegetables (including beans and peas). It also includes whole grains, lean meats, poultry without skin, seafood, and fat-free or low-fat milk and dairy products. A healthy diet also is low in sodium (salt), added sugars, solid fats, and refined grains. For more information about following a healthy diet, go to the NHLBIs Your Guide to Lowering Your Blood Pressure With DASH and the U.S. Department of Agricultures ChooseMyPlate.gov Web site. Both resources provide general information about healthy eating. Other important lifestyle changes include:

Being physically active. Check with your doctor to find out how much and what kinds of activity are safe for you. For more information, go to the Health Topics Physical Activity and Your Heart article. Maintaining a healthy weight. If youre overweight or obese, work with your doctor to create a reasonable weight-loss plan. Controlling your weight helps you control CHD risk factors. Taking all medicines as your doctor prescribes, especially if you havediabetes .

Medicines

Nitrates are the medicines most commonly used to treat angina. They relax and widen blood vessels. This allows more blood to flow to the heart, while reducing the hearts workload. Nitroglycerin (NI-tro-GLIS-er-in) is the most commonly used nitrate for angina. Nitroglycerin that dissolves under your tongue or between your cheek and gum is used to relieve angina episodes. Nitroglycerin pills and skin patches are used to prevent angina episodes. However, pills and skin patches act too slowly to relieve pain during an angina attack. Other medicines also are used to treat angina, such as beta blockers, calcium channel blockers, ACE inhibitors, oral antiplatelet medicines, or anticoagulants (blood thinners). These medicines can help:

Lower blood pressure and cholesterol levels Slow the heart rate Relax blood vessels Reduce strain on the heart Prevent blood clots from forming

People who have stable angina may be advised to get annual flu shots.

Medical Procedures
If lifestyle changes and medicines don't control angina, you may need a medical procedure to treat the underlying heart disease. Both angioplasty (AN-jee-oh-plas-tee) and coronary artery bypass grafting (CABG) are commonly used to treat heart disease. Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores blood flow. Angioplasty can improve blood flow to your heart and relieve chest pain. A small mesh tube called a stent usually is placed in the artery to help keep it open after the procedure. During CABG, healthy arteries or veins taken from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. Bypass surgery can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. You will work with your doctor to decide which treatment is better for you.

Cardiac Rehabilitation
Your doctor may recommend cardiac rehab for angina or after angioplasty, CABG, or a heart attack. Cardiac rehab is a medically supervised program that can help improve the health and well-being of people who have heart problems. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians or nutritionists, and psychologists or other mental health specialists.

Rehab has two parts:

Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your personal abilities, needs, and interests. Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk for future heart problems. The rehab team will help you learn how to adjust to a new lifestyle and deal with your fears about the future.

For more information about cardiac rehab, go to the Health Topics Cardiac Rehabilitation article.

Enhanced External Counterpulsation Therapy

Enhanced external counterpulsation (EECP) therapy is helpful for some people who have angina. Large cuffs, similar to blood pressure cuffs, are put on your legs. The cuffs are inflated and deflated in sync with your heartbeat. EECP therapy improves the flow of oxygen-rich blood to your heart muscle and helps relieve angina. You typically get 35 1-hour treatments over 7 weeks.

How Can Angina Be Prevented?

You can prevent or lower your risk for angina and heart disease by making lifestyle changes and treating related conditions.

Making Lifestyle Changes

Healthy lifestyle choices can help prevent or delay angina and heart disease. To adopt a healthy lifestyle, you can:

Quit smoking and avoid secondhand smoke Avoid angina triggers Follow a healthy diet Be physically active Maintain a healthy weight Learn ways to handle stress and relax Take your medicines as your doctor prescribes

For more information about these lifestyle changes, go to How Is Angina Treated? For more information about preventing and controlling heart disease risk factors, visit the Health Topics Coronary Heart Disease, Coronary Heart Disease Risk Factors, and Coronary Microvascular Disease articles.

Treating Related Conditions

You also can help prevent or delay angina and heart disease by treating related conditions, such as high blood cholesterol, high blood pressure, diabetes , andoverweight or obesity. If you have one or more of these conditions, talk with your doctor about how to control them. Follow your treatment plan and take all of your medicines as your doctor prescribes.

Living With Angina

Angina isn't a heart attack, but it does increase your risk of having a heart attack. The risk is even higher if you have unstable angina. For these reasons, it's important that you know:

The usual pattern of your angina, if you have it regularly. What medicines you take (keep a list) and how to take them. Make sure your medicines are readily available. How to control your angina. The limits of your physical activity. How and when to seek medical attention.

Know the Pattern of Your Angina

Stable angina usually occurs in a pattern. You should know:

What causes the pain to occur What the pain feels like How long the pain usually lasts Whether rest or medicine relieves the pain

After several episodes, youll learn the pattern of your angina. Youll want to pay attention to whether the pattern changes. Pattern changes may include angina that occurs more often, lasts longer, is more severe, occurs without physical exertion, or doesn't go away with rest or medicines. These changes may be a sign that your symptoms are getting worse or becoming unstable. You should seek medical help. Unstable angina suggests that you're at high risk for a heart attack very soon.

Know Your Medicines

You should know what medicines you're taking, the purpose of each, how and when to take them, and possible side effects. Know exactly when and how to take fast-acting nitroglycerin or other nitrates to relieve chest pain. Correctly storing your angina medicines and knowing when to replace them also is important. Your doctor can advise you about this. If you have side effects from your medicines, let your doctor know. You should never stop taking your medicines without your doctor's approval.

Talk with your doctor if you have any questions or concerns about taking your angina medicines. Tell him or her about any other medicines youre taking. Some medicines can cause serious problems if they're taken with nitrates or other angina medicines.

Know How To Control Your Angina

After several angina episodes, youll know the level of activity, stress, and other factors that trigger your angina. By knowing this, you can take steps to prevent or lessen the severity of episodes.

Physical Exertion
Know what level of physical exertion triggers your angina and try to stop and rest before chest pain starts. For example, if walking up a flight of stairs leads to chest pain, stop halfway and rest before continuing. If chest pain occurs during physical exertion, stop and rest or take your angina medicine. The pain should go away in a few minutes. If the pain doesn't go away or lasts longer than usual, call 9 11 for emergency care.

Emotional Stress
Anger, arguing, and worrying are examples of emotional stress that can trigger angina. Try to avoid or limit situations that cause these emotions. Exercise and relaxation can help relieve stress. Alcohol and drug use play a part in causing stress and don't relieve it. If stress is a problem for you, talk with your doctor about getting help for it.

Eating Large Meals

If large meals lead to chest pain, eat smaller meals. Also, avoid eating rich foods.

Know the Limits of Your Physical Activity

Most people who have stable angina can continue their normal activities. This includes work, hobbies, and sexual relations. However, if you do very strenuous activities or have a stressful job, talk with your doctor.

Know How and When To Seek Medical Attention

Angina increases your risk for a heart attack. Its important that you and your family know how and when to seek medical attention. Talk with your doctor about making an emergency action plan. The plan should include making sure you and your family members know:

The signs and symptoms of a heart attack How to use aspirin and nitroglycerin when needed How to access emergency medical services in your community The location of the nearest hospital that offers 24-hour emergency heart care

Discuss your emergency plan with your family members. Take action quickly if your chest pain becomes severe, lasts longer than a few minutes, or isn't relieved by rest or medicine. Sometimes its hard to tell the difference between unstable angina and a heart attack. Both are emergencies, so you should call 911 right away.

http://www.nhlbi.nih.gov/health/health-topics/topics/angina/

Heart Disease and Angina (Chest Pain)

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The most common symptom of coronary artery disease is angina or "angina pectoris," also known simply as chest pain. Angina can be described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing, or painful feeling due to coronary heart disease. Often, it can be mistaken for indigestion. Angina is usually felt in the chest, but may also be felt in the shoulders, arms, neck, throat, jaw, or back.
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If you experience these symptoms, take notice. If you've never been diagnosed with heart disease, you should seek treatment immediately. If you've had angina before, use your angina medications as directed by your doctor and try to determine if this is your regular pattern of angina or if the symptoms are worse. What Causes Angina? Angina is caused when blood flow to an area of the heart is decreased, impairing the delivery of oxygen and vital nutrients to the heart muscle cells. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body. The byproduct of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes pain. Some medications used to treat angina work by inhibiting the use of this fuel source.

What Are the Types of Angina? The types of angina are:

Stable angina. The pain is predictable and present only during exertion or extreme emotional distress, and it disappears with rest. Unstable angina. This may signal an impending heart attack. Unstable angina is angina pain that is different from your regular angina pain or pain that occurs while at rest. The angina may occur more frequently, more easily at rest, feel more severe, last longer, or come on with minimal activity. Although this type of angina can often be relieved with medication, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure is required. Prinzmetal's angina. This is when angina occurs at rest, when sleeping, or when exposed to cold temperatures. In these cases, the symptoms are caused by decreased blood flow to the heart muscle from a spasm of the coronary artery. The majority of people with this type of angina also have coronary artery disease. These spasms occur close to the blockage.

Can Angina Occur Without Coronary Disease? Angina can occur in the absence of any coronary disease. Up to 30% of people with angina with a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart. People with severe anemia may have angina because their blood doesn't carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don't get enough.

How Is Angina Evaluated? To evaluate your angina, your doctor will first ask you a series of questions to determine what your symptoms are and what triggers them. After examining you, your doctor will order one or more of a series of tests to determine the underlying cause of the angina and the extent of coronary artery disease, if present. These tests include:

Exercise stress test Electrocardiogram (ECG or EKG) Stress imaging tests, such as nuclear tests or stress echocardiography, to accurately localize the part of the heart that has decreased blood flow Echocardiogram Cardiac catheterization

How Is Angina Treated?

Your angina treatment depends on the severity of the underlying problem, namely, the amount of damage to the heart. For most people with mild angina, a combination of drugs and lifestyle changes can control the symptoms. Lifestyle changes include: eating a hearthealthy diet, lowering cholesterol, getting regularexercise, quitting smoking, and controlling diabetes and high blood pressure. Some drugs used to treat angina work by either increasing the amount of oxygen delivered to the heart muscle or reducing the heart's need for oxygen. These medicines include:

Beta-blockers Nitrates Calcium channel blockers Ranolazine Others angina drugs work to prevent the formation of blood clots, which can further block blood flow to the heart muscle. These medicines include:

Antiplatelet medications For people with more serious or worsening angina, your doctor may recommend treatment to open blocked arteries. These include:

Angioplasty Stenting Coronary artery bypass grafting (CABG) surgery Enhanced External Counterpulsation (EECP) What Should I Do if I Have Angina? With any type of angina, stop what you are doing and rest. If you have been prescribed a medication called nitroglycerin to treat your angina, take one tablet and let it dissolve under your tongue. If using the spray form, spray it under your tongue. Wait five minutes. If you still have angina after five minutes, take another dose of nitroglycerin. Wait another five minutes and if angina is still present, take a third dose. If you still have angina after taking a third dose of nitroglycerin and resting for 15 minutes, call for emergency help (dial 911 in most areas) or have someone take you to the local emergency room. If you think you are having a heart attack, do not delay. Call for emergency help right away. Do not drive yourself to the hospital. Consider taking an aspirin. Quick treatment of a heart attack is very important to lessen the amount of damage to your heart. Why Shouldn't I Drive Myself or Have Someone Drive Me to the Hospital?

When the ambulance arrives, the emergency personnel can begin to give you heart-saving care right away. They can start an IV to give you important drugs and give you oxygen to help improve the flow of oxygen-rich blood to your heart. Should problems occur, they are there to provide life-saving help as well. Something to Remember About Angina If you have angina, carry nitroglycerin with you at all times; you never know when you will need it. Nitroglycerin must be kept in a dark container. Keep it away from heat or moisture. Check the expiration date on the container. Once the container of nitroglycerin tablets is opened, it must be replaced every three months. The spray form has a longer shelf life and should be replaced every 2 years.
http://www.webmd.com/heart-disease/guide/heart-disease-angina

Angina is a pain or discomfort felt in the chest, and usually caused by coronary heart disease. However, in some cases the pain may affect some people in only the arm, neck, stomach or jaw.

What does angina feel like?

Angina often feels like a heaviness or tightness in your chest, but this may spread to your arms, neck, jaw, back or stomach as well. Some people describe the feeling of severe tightness, while others say its more of a dull ache. Symptoms of experiencing shortness of breath have been reported too. Angina is often brought on by physical activity, an emotional upset, cold weather or after a meal. Symptoms usually subside after a few minutes. If your symptom pattern changes, you should speak to your doctor immediately.

Can I prevent angina?

Unfortunately you cant reverse coronary heart disease, but you can help prevent your angina and the condition from getting worse by keeping your heart healthy. It is 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. Some medications can also be used to help prevent angina episodes.

How is angina diagnosed and treated?

Your doctor may be able to diagnose whether you have angina from the symptoms that you describe. Alternatively, they may want to carry out a health check or send you for some tests. There is medication available too that can help control your symptoms, whereas some people requiretreatments such as angioplasty or heart bypass surgery. Living a healthy lifestyle is a very important part of your treatment too.

Everyday life with angina

Many people with 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.

What should I do if I get chest pain?

If you have not been diagnosed with heart disease and experience chest pains, call 999 immediately. The below information is for you if you have already been diagnosed with coronary heart disease and have a glyceryl trinitrate (GTN) spray or tablets. Sometimes you may experience pain or discomfort and often this will be angina that you can manage at home with your GTN. However, it could be a heart attack. Heres what to do if you feel:

A crushing pain, heaviness or tightness in your chest.

A pain in your arm, throat, neck, jaw, back or stomach. You may also become sweaty, feel light-headed, sick or become short of breath.

1. Stop what you are doing and sit down and rest. 2. Take your GTN spray and tablets, according to your doctor or nurses instructions. The pain should ease within a few minutes if it doesnt, take a second dose. 3. If the pain does not ease within a few minutes after your second dose, call 999 immediately. 4. If youre not allergic to aspirin, chew one adult tablet (300mg). If you dont have any aspirin or you are not sure if you're allergic to aspirin, you should rest until the ambulance arrives. Even if your symptoms dont match the above but you suspect youre having a heart attack, call 999 immediately.
http://www.bhf.org.uk/heart-health/conditions/angina.aspx

Angina
Angina (sometimes called angina pectoris) occurs when your heart doesn't get as much blood and oxygen as it needs because of a blockage of one or more of the heart's arteries (coronary arteries). This blockage causes pain in the chest. People who have angina describe the pain as a squeezing, suffocating or burning feeling.

What is angina?
Angina is not a heart attack. It is a warning signal that you are at increased risk of a heart attack, cardiac arrest or sudden cardiac death. Usually, the pain will go away with rest or medication, but it is your heart telling you that your body is working too hard and needs to slow down. Angina is a warning to you to stop what you are doing and rest. If you experience this kind of chest pain, see your doctor to determine the cause and get treatment if necessary.

What causes angina?

Angina is the pain you feel when one or more of your coronary arteries becomes damaged, blocked or narrowed and isn't able to bring enough oxygen-rich blood to your heart. The pain may occur

during physical activity, exercise, stress, periods of extreme cold or hot temperatures, after heavy meals or while drinking alcohol or smoking.Hide Angina is most often caused by:

Coronary artery disease as a result of atherosclerosis, a buildup of fatty deposits that block the flow of blood through the coronary arteries.

Coronary artery spasm, when one of the blood vessels supplying the heart muscle vigorously contracts, causing blood flow to the part of the heart supplied by the artery to decrease or even stop, resulting in a heart attack.

In some cases angina can be caused by uncontrolled high blood pressure, or other heart conditions such as narrowing of one of the valves in the heart (aortic stenosis) or an enlarged heart (hypertrophic cardiomyopathy). Sometimes, people can have chest pain that is the result of other health conditions such as lung problems, muscle problems or bone problems.

What are the symptoms of angina?

Angina is usually a symptom of coronary artery disease and puts you at risk of having a heart attack. Symptoms of angina are often experienced after exertion or emotional stress and are relieved with rest or medication. Symptoms of angina include:More

Pain that starts in the centre of your chest, but spreads to your left arm, neck, back, throat or jaw.

Tightness, pressure, squeezing and/or aching feeling in your chest or arm(s). Feeling of moderate to severe indigestion that is persistent. Sharp, burning or cramping pain. An ache starting in, or spreading to, your neck, jaw, throat, shoulder, back or arm(s). Discomfort in your neck or upper back, particularly between the shoulder blades. Numbness or a loss of feeling in your arms, shoulders or wrists.

If you experience one or more of these symptoms, see your doctor right away. If your pattern of angina changes, call your doctor as soon as possible.

What should I do?

Get immediate medical attention. Usually angina only lasts a few minutes, but if the pain lasts longer, it may mean that you have a sudden, total blockage of a coronary artery or that you may be having a heart attack and you need to get help immediately. If you are experiencing chest pain or pressure that is not relieved with rest or nitroglycerin after 15 minutes, you may be having a heart attack. Don't delay. Call 9-1-1 or your local emergency response number immediately.

What are the types of angina?

Stable angina usually follows a predictable pattern. The pain generally happens at about the same point when you are exercising or under emotional stress. The pain is usually relieved with rest or medication. If you have stable angina, try to track how long it lasts and what helps ease the pain. This will help you notice any change in the pattern, which could mean you have developed unstable angina.

Unstable angina causes chest pain that is unexpected and may happen when you are at rest or without stimulating activity. If you have chest pain that is new, worsening or constant, you are at greater risk of having a heart attack, an irregular heartbeat (arrhythmia), and even sudden death. See your doctor as soon as possible.

Variant angina Hide

, also called Prinzmetal's angina, usually happens

spontaneously, and unlike stable angina, it nearly always happens while you are at rest. It doesn't follow physical exertion or emotional stress. Attacks may be very painful and usually happen between midnight and 8 a.m. It is caused by coronary artery spasm. About two-thirds of people with variant angina have severe atherosclerosis in at least one major coronary artery and the spasm usually happens very close to the blockage.

Microvascular angina causes chest pain but without any apparent blockage in a coronary artery. The pain is caused by an improper functioning of the tiny blood vessels that feed your heart. (This condition may also be referred to as Cardiac Syndrome X, not to be confused with metabolic syndrome, which is also known as Syndrome X.)

Atypical angina is where you may not experience typical symptoms of angina and instead may feel a vague chest discomfort, shortness of breath, fatigue, nausea, back or neck pain or burning indigestion. Women are more likely to experience atypical symptoms such as vague chest discomfort.

How is angina diagnosed?

Your doctor will probably review your medical history and give you a complete physical exam. Then, he or she may want to run a few tests before recommending treatment. These tests may include:More

Angiography Electrocardiogram (ECG/ EKG) Echocardiogram Exercise electrocardiogram (Stress test) Thallium or cardiolite scan Transesophageal echocardiogram (TEE)

How is angina treated?

Lifestyle changes and medications are the most common ways to treat and control angina. Sometimes, surgery may be necessary.Hide Lifestyle changes Although exercise may bring on angina, you'll still need to stay physically active, as long as your doctor approves. You could live more comfortably and with fewer angina attacks by controlling yourrisk factors such as blood pressure, diabetes and high blood cholesterol, and by eating a healthy diet, being smoke-free, limiting alcohol use and reducing stress. Medications Certain medications may help prevent or relieve the symptoms of angina.

Anti-platelets

Beta-blockers Calcium channel blockers Nitroglycerin

Surgical and other procedures Angina can also be treated by widening or bypassing the narrowed artery to increase the blood flow to your heart. Procedures to treat angina might include:

Percutaneous coronary intervention (PCI or angioplasty with stent) Coronary artery bypass surgery

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484055/k.52CA/Heart_disease__Angina.htm

Angina
Introduction Angina is chest pain caused by restricted blood flow to the heart (called ischemia). It often occurs when you are under emotional or physical stress, such as exercise. When the heart doesn't get enough oxygen from the coronary arteries, you feel a squeezing chest pain or pressure across your chest that usually goes away after you stop the activity. The most common cause of angina is hardening of the arteries (atherosclerosis). Chest pain that is fairly predictable and usually occurs when you exercise is called stable angina. It is relieved with rest or nitroglycerin. Chest pain that occurs when you are resting, or at unpredictable times, is known as unstable angina. Because it can lead to a heart attack, you should immediately call 911 if you experience unstable angina. It can be difficult to determine whether your chest pain is something serious or a milder condition. For that reason, you should always see your doctor for a diagnosis and treatment. Angina can lead to a heart attack, so you should never try to diagnose or treat it on your own. Signs and Symptoms Chest pain from angina can feel like pain due to other causes, such as heartburn, a muscle strain, or asthma. When in doubt, assume that the pain is related to your heart until proven otherwise, especially if you are experiencing pain that you have never felt before. The classic chest pain from angina feels like significant pressure, squeezing, or tightness in the center of your chest. It has been described as feeling like a band across the chest or a

weight pressing down on the chest. You may also feel pain in your left arm and shoulder, neck, and jaw. Other possible sensations include indigestion, rapid or skipping heartbeat, or mild discomfort. Causes Coronary heart disease, which occurs when the arteries leading to the heart become narrowed or blocked by plaque, is almost always the cause of angina. Risk Factors The risk factors for angina are the same as the risk factors for developing heart disease, including: Age Male gender Menopause Family history of heart disease Diabetes Smoking or exposure to second hand smoke High cholesterol High blood pressure Obesity Sedentary lifestyle Stress Thyroid disease Diagnosis Your doctor may run several tests to determine the cause of your chest pain.

Electrocardiogram (ECG) -- Records heart activity through electrodes fastened to your chest. Stress test -- Measures how your heart performs when you exert yourself. You will be hooked up to an ECG machine and asked to exercise (usually on a treadmill or stationary bike) or receive a drug that causes your heart to act as it does when you exercise. The stress test also may be done with imaging (like thallium, sestimibi, or an echocardiogram) to look at the blood flow and muscle function of your heart. Coronary catheterization -- Examines arteries to see if they are narrowed or blocked and involves injecting a dye into your arteries through a thin catheter.

Other tests may include an electron beam computed tomography (EBCT) scan or cardiovascular magnetic resonance imaging (MRI). Preventive Care If you will be doing an activity that usually triggers your angina, your doctor may tell you to take nitroglycerin a few minutes in advance to prevent the pain. The best prevention for angina is to modify as many risk factors for heart disease as possible: Stop smoking Maintain a proper weight Control blood pressure, diabetes, and cholesterol Eat a diet low in saturated fats, and high in whole grains, fiber, fruits, and vegetables Exercise at least 30 minutes per day, 5 days per week Reduce stress Treatment Approach In treating angina, your doctor will treat the underlying heart disease to prevent it from getting worse. By doing this, blood flow to the heart improves and angina gets better. Lifestyle changes and certain medications can improve blood flow and make you feel better fairly quickly. Keep track of what causes your angina pain, what it feels like, how often you get it, and how long it lasts. If there's a change in your pattern for the worse (for example, if it happens more frequently or with less exertion), let your doctor know right away. Lifestyle Changing your diet, exercising regularly, and practicing relaxation techniques to reduce your response to stress can help improve blood flow to your heart and reduce angina. These steps can also help treat your risk factors for heart disease. Diet A diet low in saturated fat and high in whole grains, fruits, and vegetables will help your heart and also keep your weight under control. The American Heart Association recommends that you do the following to prevent or treat heart disease: Eat a variety of nutritious foods from all the food groups, especially whole grains, fruits and vegetables, and low fat dairy products. Eat at least 2 servings of fish per week, particularly fish high in Omega-3 fats, such as salmon, trout, and herring. Limit sodium intake to 1,500 mg per day. Limit alcohol intake to 2 drinks per day for men and 1 drink per day for women. Reduce your consumption of beverages and foods with added sugars.

Burn as many calories as you take in. Get at least 30 minutes of exercise most days (or, better still, every day). If you can't find a 30-minute block of time for exercise, aim for three 10-minute sessions during the course of the day. Relaxation Relaxation techniques may help you reduce stress -- which can be a contributing factor to heart disease -- and relieve chest pain. Such practices might include the use of meditation, progressive muscle relaxation, breathing exercises, yoga, self-hypnosis, or biofeedback. Medications For the treatment of stable angina, your doctor will likely recommend daily aspirin as well as a combination of the following prescription medications: Nitroglycerin and oral nitrates -- Temporarily dilate coronary arteries, allowing the heart to get more blood and oxygen. Beta-blockers -- Slow heart rate and blood pressure, reducing the heart's need for oxygen. You should never abruptly stop taking a beta-blocker, because serious side effects can occur. Talk to your doctor about how to slowly wean off of this drug. Beta-blockers include: Atenolol (Tenormin) Metoprolol (Lopressor, Toprol-XL) Propranolol (Inderal, Inderal LA) Calcium-channel blockers -- Slow heart rate and cause arteries to dilate. Calcium-channel blockers include: Nifedipine (Procardia) Amlodipine (Norvasc) Diltiazem (Cardizem) Statins -- Lower cholesterol, which is associated with a higher risk of heart attacks due to cardiovascular disease. Ranolazine (Ranexa) -- Used only when other anti angina drugs don't work, due to potential side effects. It is used with other anti-angina medications, such as beta-blockers or nitroglycerin. Surgery and Other Procedures If lifestyle changes and medications are not effective or if unstable angina develops, you may need coronary artery bypass graft surgery, angioplasty with stent placement, or another type of procedure to improve blood flow to your heart. Other procedures include transmyocardial laser revascularization (TMR), which is usually done along with coronary artery bypass; and, for those who are not candidates for standard treatments, a procedure called enhanced external counter pulsation (EECP).

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Nutrition and Dietary Supplements Eat a well balanced diet with plenty of whole grains, fruits, vegetables, and low fat dairy products. If approved by your physician, make sure you exercise at least 30 minutes a day most days of the week. There are many supplements that can help reduce your chances of developing heart disease and its consequences, including angina. A few supplements are being studied specifically to reduce the pain from angina. However, you should never try to treat angina on your own, and should only take supplements or herbs under your doctor's supervision. The doses given below are ones that have been used in studies; it is important to talk to your doctor about what dose might be best for you. L-carnitine (1 g 2 times per day), an amino acid, may help reduce symptoms of angina, according to several clinical trials. L-carnitine can potentially interact with blood-thining medications such as Coumadin (Warfarin) and thyroid hormone. Coenzyme Q10 or CoQ10 (150 mg per day) is important for heart health and several studies suggest that taking it may allow people with angina to exercise more without pain. High doses of CoQ10 may interfere with some blood thinners. If you take blood thinners, talk to your doctor before taking CoQ10. Arginine or l-arginine (2 g 3 times per day) is another amino acid that may improve blood flow and increase exercise tolerance in people with angina. L-argnine can increase bleeding and lower blood pressure. It can also interact with medications that treat erectile dysfunction and aggravate herpes symptoms. Magnesium (365 mg 2 times per day) acts similar to a calcium-channel blocker in the body, although it is much weaker. One study suggested it may help reduce chest pain caused by exercise. Magnesium can lower blood pressure and cause diarrhea, so talk to your doctor before taking it. Herbs The use of herbs is a time honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider. If you have angina, do not take any herbs without your doctor's supervision. There are several different herbs that may be helpful for the treatment and prevention of heart disease, including those that help you reduce your cholesterol, blood pressure, and other risk factors. Herbs that may be helpful for angina include: Hawthorn (Crataegus monogyna, 60 mg 3 times per day) has been used traditionally to treat heart disease. One small clinical trial suggested that people with angina who took hawthorn

improved blood flow to the heart and were better able to exercise without pain. However, the trial was small and more studies are needed. Hawthorn can cause side effects and interact with other drugs, so do not take it without your doctor's supervision. Kudzu (Pueria lobota, 30 mg - 120 mg per day) has been used in Chinese medicine for centuries to treat heart disease. A few clinical trials have indicated that kudzu may reduce the frequency of angina in people, but the trials were poorly designed. More research is needed. Kudzu can cause side effects and interact with other drugs, so do not take it without your doctor's supervision. Terminalia arjuna, an herb used in Ayurvedic medicine, was shown in one study to be as effective as isosorbide mononitrate (Imdur) in reducing the number of angina attacks and increasing exercise capacity. However, more studies are needed. Suxiao jiuxin wan is widely used in China for angina. One study found that suxiao jiuxin wan improved ECG measurements and reduced symptoms and frequency of acute angina attacks compared with nitroglycerin. Homeopathy Homeopathy should never be used instead of immediate medical attention for unstable angina, new onset chest pain, or chest pain that has changed in intensity, frequency, or other characteristics. Homeopathy may, however, be used to help reduce your risk of heart disease, along with other medications. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for you as an individual. Acupuncture Studies using acupuncture to treat angina have found mixed results. While some show no benefit, others have found that acupuncture may help reduce the frequency of angina attacks and the need to use nitroglycerin. One Chinese study found that pressing fingertips to an acupuncture point located at the sternum at nipple height during a stable angina incidents was as effective as taking nitroglycerin. It also worked faster than taking pills. Prognosis and Complications With the right treatment -- including eating proper diet, getting enough exercise, and taking medication -- blood flow to the heart can dramatically improve, lessening the likelihood of angina attacks.
Source: Angina | University of Maryland Medical Center http://umm.edu/health/medical/altmed/condition/angina#ixzz2mPFtYFaM

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