Angina attack or cardiac pain must be addressed in time for angina symptoms. Angina pectoris diagnosis and treatment can save lives by timely intervention.

Angina

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Iqra Mazhar

Overview

The prevalence of angina pectoris varies across populations, depending on age, gender, and ethnicity. A meta-analysis conducted across 31 countries found a prevalence of&nbsp; 0.7-14.4% in women and 0.8-15.1% in men<a href="#accordion">[2]</a>. Angina is more often the presenting symptom of coronary artery disease (CAD) in women. This was evident in the American Heart Association&rsquo;s latest report that reported a higher prevalence of angina pectoris in females (54.4%) than in males (45.6%)<a href="#accordion">[3]</a>.&nbsp;&nbsp;A Pakistani study conducted among hospitals in Punjab also demonstrated similar results with a higher incidence of angina pectoris among females (65%) than males (35%)<a href="#accordion">[4]</a>. Comparatively, men with newly diagnosed angina are at a higher risk of acute <a href="https://merisehat.pk/disease/myocardial-infarction">myocardial infarction</a> (MI) and death from <a href="https://merisehat.pk/disease/ischemic-heart-disease-63">ischemic heart disease</a><a href="#accordion">[5]</a>. 
&nbsp;

There are different types of angina, depending on the cause or severity.

&nbsp;

Stable Angina - This is the most common type. It occurs due to excessive pumping of the heart. For example, during exercise, chest pain appears during physical activity and gets better with rest or administration of sublingual nitroglycerin. It appears for a short while (1-5 minutes) and people experience it for months or years. Cold weather, stress, or eating heavy meals can also trigger stable angina.

 
Unstable Angina - An unstable angina is often the first sign of a heart attack or myocardial infarction. Unlike stable angina, it does not follow a regular pattern, occurs at rest, lasts longer than 5 minutes, and is not relieved by rest or sublingual nitroglycerin. Blockage of a coronary artery due to atherosclerosis is the most common cause of unstable angina. It is an emergency condition and requires immediate care.

 
Microvascular Angina - Coronary microvascular disease (MVD) affecting the small coronary arteries results in this type of angina. The pain is often accompanied by sleep disturbances, shortness of breath, and fatigue. It can appear during exercise or at rest and is often not relieved by medicines. Moreover, it&#39;s more painful and longer lasting than other types of angina.&nbsp;

 
Variant Angina Pectoris - Also called Prinzmetal angina, this is a rare type of angina. It occurs at rest, mostly between midnight and early morning. There is no history of physical activity preceding the chest pain. The extremely painful condition results from spasms of the coronary arteries. Triggers include cold weather, smoking, stress, certain medications, or cocaine use.

 
Refractory Angina - This is characterized by chronic angina-type chest pain (more than 3 months) despite medications, lifestyle modifications, and surgical interventions.&nbsp;&nbsp;

 
Post-Infarction Angina - Angina that occurs within 30 days of acute myocardial infarction. 
&nbsp;

Signs And Symptoms

Chest pain in angina is often described as a discomfort characterized by tightness, pressure, heaviness, squeezing, or a choking sensation in the chest. Moreover, the pain typically radiates to the jaw, neck, back, left shoulder, left arm, or the epigastrium.&nbsp;

 
Patients with angina may also complain of:

<ul>
	<li>Pain exacerbated by physical exertion, emotional stress, eating, or cold temperature</li>
	<li>Pain relieved by rest or nitroglycerin pills</li>
	<li>Pain lasting for 1-5 minutes</li>
	<li>A change in position, breathing, or coughing does not affect pain intensity</li>
	<li>Nausea and vomiting</li>
	<li>Shortness of breath</li>
	<li>Sweating</li>
	<li>Fatigue</li>
	<li>Dizziness</li>
</ul>

&nbsp;

In women, angina can also be present with abdominal pain, stabbing chest pain instead of chest pressure, nausea or vomiting, and discomfort in the teeth, jaw, neck, or back.&nbsp;

The chest pain in angina can also mimic that of indigestion; therefore, it is important to know the common symptoms of angina. However, if the above-mentioned symptoms last longer than a few minutes or keep recurring, it might be a myocardial infarction (MI). also called a heart attack. Therefore, any type of chest pain should be immediately evaluated by a healthcare professional and not be ignored. 
&nbsp;

Causes

Angina pectoris develops from an imbalance between myocardial oxygen demand and blood supply. It is often a warning sign of an underlying heart disease.&nbsp;

Coronary artery disease due to atherosclerosis is the most common cause of angina. A build-up of fatty deposits within the artery walls results in hardening and narrowing of the vessels. As a result of the reduced blood flow, heart muscles face an oxygen shortage. Thus, resulting in myocardial ischemia.

Triggers such as exposure to cold and smoking can also induce chest pain by causing vasoconstriction and reducing blood supply to the muscles. Other rare causes of angina are congenital cardiac anomalies, severe anemia, and hypertrophic cardiac myopathy. 
&nbsp;

Diagnosis

Since chest pain can also occur from other causes such as indigestion or peptic ulcers, it is important to differentiate angina from other causes of chest pain. Therefore, doctors might conduct a variety of tests to diagnose angina.&nbsp;

Along with a complete history and a physical exam, the following tests can help confirm the person&#39;s diagnosis: 
&nbsp;

<ul>
	<li>Blood Tests - A blood test for troponin levels can help differentiate unstable angina from a heart attack. Other tests may also be conducted to check the person&#39;s lipid, blood glucose, and protein levels. This can identify the presence of any chronic disease such as diabetes mellitus or hypercholesterolemia.&nbsp; 
	&nbsp;</li>
	<li>Chest X-Ray - This provides doctors with an image of the heart and lungs. Therefore, helping doctors rule out other causes of chest pain. In patients with previous MI or a history of heart disease, an enlarged heart may be seen.&nbsp; 
	&nbsp;</li>
	<li>Electrocardiogram (ECG) - An ECG measures the electrical activity of the heart. It provides information on the heart&#39;s rate, rhythm, and whether blood flow to any part of the heart was obstructed (ischemia) or slowed. Certain patterns on the ECG can also point to unstable or variant angina. Moreover, an ECG is often done as part of the stress test.&nbsp; 
	&nbsp;</li>
	<li>Stress Test - During a stress test, a patient may be required to perform physical exercise such as walking or running on a treadmill. An ECG is recorded during this period of exertion to evaluate for any obstruction to blood flow&nbsp;through the heart. When combined with echocardiography tests, it can help diagnose the cause of angina. Patients who can&#39;t exercise are given a drug that mimics the effect of strenuous exertion on the heart.&nbsp; 
	&nbsp;</li>
	<li>Nuclear Stress Test - This allows a measurement of the blood flow through the heart at rest and during stress. A radioactive tracer that can be tracked using a special sensor is injected into the blood. If there is little or no amount of tracer seen in certain areas, that indicates poor blood flow to the heart region.&nbsp; 
	&nbsp;</li>
	<li>Echocardiogram - Using soundwaves, the test helps create a moving picture of the heart as it pumps blood. Thus, any valve leaks, obstruction to blood flow, and the strength of the heartbeat can be evaluated. An echocardiogram is often conducted during a stress test.&nbsp; 
	&nbsp;</li>
	<li>Coronary Angiography With Catheterization - Coronary angiography is often conducted in symptomatic patients with inconclusive results from other tests. It is the definitive diagnostic test for evaluating the severity of CAD. A thin, flexible tube (catheter) is placed in a blood vessel in the neck, arm, groin, or thigh. The catheter is then guided through a wire, to the coronary arteries. Using X-rays, the flow of blood through the blood vessels can be captured and evaluated for obstructions or narrowing of the arteries. This test helps determine whether coronary artery disease is causing angina. Moreover, narrowed areas can then be reopened using stents or balloons.&nbsp; 
	&nbsp;</li>
	<li>CT Angiography - A computed tomography (CT) scan allows visualization of the blood flow through the coronary arteries. Wiring an invasive catheter through the arteries and into the heart is not needed. Instead, the contrast material is injected through a small line in the vein or arm.&nbsp; 
	&nbsp;</li>
	<li>CT Scan - This allows visualization of any narrowing of the arteries, location of blood clots, and presence of cardiomegaly.&nbsp; 
	&nbsp;</li>
	<li>Magnetic Resonance Imaging (MRI) Scan - An MRI scan can give detailed images of the heart&#39;s structures and even the small blood vessels of the heart. 
	&nbsp;</li>
	<li>Provocation Test - Doctors administer a medicine such as acetylcholine to the patients during coronary angiography. This can help detect if the coronary arteries spasm and confirm a diagnosis of variant angina.</li>
</ul>

<h4>&nbsp;</h4>

<h5>Staging</h5>

The severity of angina can be classified using the Canadian Cardiovascular Society (CCS) Angina Grading Scale<a href="http://#accordion">[6]</a>.&nbsp;

&nbsp;

Class I (Angina With Strenuous Exertion): Angina only occurs with strenuous or prolonged exertion, and not from ordinary physical activity (e.g., walking and climbing stairs).&nbsp;

Class II (Angina With Moderate Exertion): Angina occurs with physical exertion and there&#39;s a slight limitation with ordinary physical activity.

Class III (Angina With Mild Exertion): There is a marked limitation of ordinary physical activity. For example, walking at a normal pace or climbing one flight of stairs.

Class IV: Inability to perform any physical activity without angina; angina occurs at rest. 
&nbsp;

Unstable angina is usually classified as a class III angina or one that occurs at rest.&nbsp; 
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Treatment

In angina, the aim is to reduce the severity of symptoms, slow disease progression, and reduce the risk of myocardial infarction. A combination of lifestyle changes and medications is often prescribed. However, in severe cases, stent placement and coronary bypass might be the only option.

&nbsp;

<h5>Lifestyle Changes</h5>

Since heart disease is a common cause of angina, lifestyle changes help to improve heart health and prevent the risk of any future episodes. The following lifestyle modifications can help manage angina:

<ul>
	<li>Eating a healthy, well-balanced diet consisting of low salt and saturated fats, and more whole grains, fruits, and vegetables.</li>
	<li>Increase physical activity with the advice of a doctor. Since physical exertion is a trigger of angina, some people may be advised to keep it at a slow pace.</li>
	<li>Maintain weight within a healthy range</li>
	<li>Practice stress-relieving techniques to keep emotional stress under control</li>
	<li>Manage health conditions such as diabetes, hypertension, and hypercholesterolemia</li>
	<li>Reduce alcohol intake</li>
	<li>Quit smoking</li>
</ul>

<h5>&nbsp;</h5>

<h5>Medications</h5>

Medicines used to treat angina include:

<ul>
	<li>Nitrates - Nitrates work by widening and relaxing the blood vessels. Thus, increasing the blood flow to the heart. Nitroglycerin is the most common form of nitrate used for treating angina. Sublingual nitroglycerin can often provide immediate pain relief during an angina episode. In hospitals, intravenous nitrates are given for the relief of angina.&nbsp;</li>
	<li>Aspirin - Antiplatelet medicines such as aspirin can prevent blood clot formation. They can be prescribed for both stable and unstable angina. In Pakistan, aspirin is the most frequently prescribed drug for the treatment of stable angina, and it is used across healthcare sectors<a href="http://#accordion">[7]</a>.</li>
	<li>Beta Blockers - These slow down the heart rate and lower blood pressure by causing the heart to beat with less force. Moreover, they can also relax blood vessels, improving blood flow to the heart. People unable to use beta blockers are prescribed long-acting nitroglycerin.</li>
	<li>Statins - Statins lower blood cholesterol levels and prevent plaque formation in the arteries. Thus, reducing the risk of a heart attack.&nbsp;</li>
	<li>Calcium Channel Blockers - These drugs prevent calcium&#39;s entry into the muscle cells of the heart and blood vessels. Thus, helping the blood vessel relax and widen. It is most commonly prescribed for variant angina as beta blockers are contraindicated in those patients.&nbsp;</li>
	<li>Angiotensin-converting Enzyme (ACE) Inhibitors - ACE inhibitors help lower blood pressure and reduce the risk of an MI.&nbsp;&nbsp;</li>
	<li>Anticoagulants - Blood thinners, such as heparin, prevent blood clots and the risk of complications.</li>
	<li>Ranolazine - It is often prescribed with other medications, such as beta-blockers or nitroglycerin, for treating chronic stable angina.&nbsp;&nbsp;</li>
	<li>Morphine - If other medicines are unable to provide relief, morphine can be given to relieve pain and relax the blood vessels.&nbsp;</li>
</ul>

&nbsp;

Any medication should be started or stopped after consultation with a doctor.&nbsp;

&nbsp;

<h5>Medical Procedures And Surgery</h5>

If lifestyle changes and medications are unable to control an individual&#39;s angina, the following surgical procedures may be conducted:

<ul>
	<li>Percutaneous Coronary Intervention (PCI) - Also called coronary angioplasty, the procedure involves cardiac catheterization. During the procedure, a balloon is inserted into the narrowed artery and then inflated to widen the lumen of the vessel. A small wire mesh coil (stent) is often inserted to keep the artery open. Angioplasty with stenting is an effective option for patients with unstable angina. Or, in patients with chronic stable angina that is not getting better from medications and lifestyle changes.</li>
	<li>Coronary Artery Bypass Grafting (CABG) - CABG involves using a vein or artery from any part of the body and placing it near the blocked vessel. The new vessel then bypasses the blood flow from the narrowed or blocked vessel, providing an alternate route to the blood. Thus, the blood flow through the heart is increased. The open-heart surgery is a good option for patients with stable and unstable angina not responding to other treatments.&nbsp;</li>
</ul>

<h5>&nbsp;</h5>

<h5>Others</h5>

If despite all the interventions, angina does not improve, the following therapies may be recommended:

<ul>
	<li>Enhanced External Counterpulsation Therapy (EECP) - Large cuffs, similar to those used for measuring blood pressure, are placed on the legs, calves, and thighs. Through timely inflation and deflation, these cuffs can improve the blood flow to the heart muscle and help relieve angina. Multiple weekly sessions are often required. EECP can be used to treat refractory angina.</li>
	<li>Spinal Cord Stimulators - This is an emerging technology that works by blocking pain sensation.&nbsp;</li>
	<li>Transmyocardial Laser Therapy - This laser-based treatment is either done during open-heart surgery or through cardiac catheterization. The procedure improves blood flow through the heart by stimulating the growth of new blood vessels.&nbsp;</li>
</ul>

&nbsp;

After a diagnosis of angina, routine follow-up visits with the doctor are important to keep the symptoms at bay and prevent any complications or repeat episodes. 
&nbsp;

Myocardial infarction is a common complication of angina. If emergency care is not immediately sought, death may occur.&nbsp;

&nbsp;

The warning signs of a MI are: 
&nbsp;

<ul>
	<li>A squeezing pain or pressure in the centre of the chest, lasting more than a few minutes</li>
	<li>Pain radiates to the jaw, teeth, arm, back, or even shoulder</li>
	<li>Nausea and vomiting</li>
	<li>Sweating</li>
	<li>Shortness of breath</li>
	<li>Light-headedness or fainting 
	&nbsp;</li>
</ul>

The following factors increase the risk of angina: 
&nbsp;

<ul>
	<li>Family history of heart disease</li>
	<li>Increasing age</li>
	<li><a href="http://merisehat.pk/disease/anemia">Anemia</a>&nbsp;</li>
	<li><a href="http://merisehat.pk/disease/obesity">Obesity</a>&nbsp;or overweight</li>
	<li><a href="http://merisehat.pk/disease/diabetes-type-1-and-2">Diabetes</a>&nbsp;mellitus</li>
	<li><a href="http://merisehat.pk/disease/hypertension-57">Hypertension</a>&nbsp;</li>
	<li>Left ventricular hypertrophy</li>
	<li>Heart failure</li>
	<li>Elevated serum triglycerides or low high-density lipoprotein (HDL) levels</li>
	<li>Hypercholesterolemia</li>
	<li>Unhealthy diet</li>
	<li>Low physical activity</li>
	<li>Smoking</li>
	<li><a href="http://merisehat.pk/disease/depression">Stress</a> 
	&nbsp;</li>
</ul>

The following can help prevent angina: 
&nbsp;

<ul>
	<li>A healthy, well-balanced diet</li>
	<li>Regular exercise</li>
	<li>Quitting smoking</li>
	<li>Losing weight if obese or overweight</li>
	<li>Staying consistent with treatment for any diagnosed conditions such as high blood <a href="https://merisehat.pk/disease/cholesterol">cholesterol</a>, diabetes, or hypertension</li>
	<li>Learning to manage stress 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>The narrowing or blockage of the coronary arteries results in an imbalance between the myocardial oxygen demand and blood supply. As a result, the person experiences cardiac chest pain or angina. Common triggers include exercise, cold exposure, stress, and smoking.&nbsp;</li>
	<li>Angina is a common symptom of coronary artery disease and is characterized by chest pain that typically radiates to the jaw, neck, back, and shoulders. The chest pain is often accompanied by nausea, vomiting, shortness of breath, and fatigue.&nbsp;</li>
	<li>There are different types of angina: stable, unstable, microvascular, and variant. Unstable angina is a medical emergency as it increases the risk of a heart attack.&nbsp;</li>
	<li>Common diagnostic tests for angina include an ECG, echocardiogram, stress test, CT, and MRI scans. Invasive angiography provides a definitive diagnosis of angina.&nbsp;</li>
	<li>Treatment of angina involves a combination of medications (aspirin, beta-blockers, calcium channel blockers), lifestyle changes (diet, exercise, quitting smoking), and surgical interventions (angioplasty with stenting and CABG).&nbsp;</li>
	<li>If you experience any chest pain, seek medical help immediately.</li>
</ul>

&nbsp;

[1] Vos, T. et al., 2012. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859).

[2] Hemingway, H. et al., 2008. Prevalence of Angina in Women Versus Men: A Systematic Review and Meta-Analysis of International Variations Across 31 Countries. Circulation, 117(2), pp. 1526-1536.

[3] American Heart Association, 2020. Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association. Circulation, 141(9).

[4] Iqbal, M. N. et al., 2016. Prevalence of Angina Pectoris in Relation to Various Risk Factors. PSM Biological Research, 1(1), pp. 6-10.

[5] Buckley, B. S., McLernon, D. J. & Hannaford, P. C., 2009. Five year prognosis in patients with angina identified in primary care: incident cohort study. BMJ.

[6] Canadian Cardiovascular Society, 1976. Canadian Cardiovascular Society grading of angina pectoris. [Online]

[7] Ahmed, A., Tanveer, M., Bano, N. & Khan, G. M., 2016. Stable Angina Treatment Strategies and Current Practices in Lahore, Pakistan: A Cross-Sectional Analysis. International Current Pharmaceutical Journal, 6(1), pp. 1-5.