Angina (Chest Pain)

Angina is chest pain or discomfort that occurs when 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 may occur in your shoulders, arms, neck, jaw, or back. It can feel like indigestion.

Not all chest pain or discomfort is angina. A heart attack, lung problems (such as an infection or a blood clot), heartburn, or a panic attack also can cause chest pain or discomfort. All chest pain should be checked by a doctor.

Angina itself isn't a disease. Rather, it's a symptom of an underlying heart problem. Angina is usually a symptom of coronary artery disease (CAD), the most common type of heart disease.

Angina - coronary artery narrowing
Figure A shows a normal artery with normal blood flow. Figure B shows an artery containing plaque buildup.

Plaque causes the coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to the heart muscle is reduced. This causes pain and can lead to a heart attack.

Types of Angina

The three types of angina are stable, unstable, and variant (Prinzmetal's). Knowing how the types are different is important. This is because they have different symptoms and require different treatment.

Stable angina

Stable angina is the most common type. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. If you know you have stable angina, you can learn to recognize the pattern and predict when the pain will occur.

The pain usually goes away in a few minutes after you rest or take your angina medicine.

Stable angina isn't a heart attack, but it makes a heart attack more likely in the future.

Unstable angina

Unstable angina doesn't follow a pattern. It can occur with or without physical exertion and isn't relieved by rest or medicine.

Unstable angina is very dangerous and needs emergency treatment. It's a sign that a heart attack may happen soon.

Variant (Prinzmetal's) angina

Variant angina is rare. It usually occurs while you're at rest. The pain can be severe. It usually happens between midnight and early morning. This type of angina is relieved by medicine.

Risk Factors for Angina

Angina is a symptom of an underlying heart condition, usually coronary artery disease (CAD). So if you're at risk for CAD, you're also at risk for angina.

Risk factors for CAD include:

  • Unhealthy cholesterol levels.
  • High blood pressure.
  • Cigarette smoking.
  • Insulin resistance or diabetes.
  • Overweight or obesity.
  • Metabolic syndrome.
  • Lack of physical activity.
  • 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.

Signs and Symptoms of Angina

Pain and discomfort are the main symptoms of angina. Angina is often described as pressure, squeezing, burning, or tightness in the chest. It usually starts in the chest behind the breastbone.

Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. It may feel like indigestion.

Some people say that angina discomfort is hard to describe or that they can't tell exactly where the pain is coming from.

Symptoms such as nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, or weakness also may occur. Women are more likely to feel discomfort in their back, shoulders, and abdomen.

Symptoms vary based on the type of angina.

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 (as long as 30 minutes) than episodes of stable angina
  • Is usually not relieved with rest or medicine
  • May get continually worse
  • 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

Lasting chest pain

Chest pain that lasts longer than a few minutes and isn't relieved by rest or angina medicine may mean you're having (or are about to have) a heart attack. Call 9–1–1 right away.

Causes of Angina

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). But with exertion, like walking up a hill or climbing stairs, the 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 or breaks open, blood clots may form. This creates a larger blockage. A clot may grow large enough to completely block the artery and cause a heart attack.

Blood clots may form, partly 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 may occur in people with or without CAD.

Other causes of spasms in the coronary arteries are:

  • Exposure to cold
  • Emotional stress
  • Medicines that tighten or narrow blood vessels
  • Smoking
  • Cocaine use
  • Lasting chest pain

Chest pain that lasts longer than a few minutes and isn't relieved by rest or angina medicine may mean you're having (or are about to have) a heart attack. Call 9–1–1 right away.

Diagnosis of Angina

Diagnostic tests and procedures

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

EKG (electrocardiogram)

An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart.

Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack.

However, some people with angina have a normal EKG.

Stress testing
 
During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate.

During exercise stress testing, your blood pressure and EKG readings are checked while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time.

If you're unable to exercise, a medicine can be injected into your bloodstream to make your heart work hard and beat fast. Nuclear heart scanning or echocardiography is then usually done.

When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs.

A stress test can show possible signs of CAD, such as:

  • Abnormal changes in your heart rate or blood pressure
  • Symptoms such as shortness of breath or chest pain
  • Abnormal changes in your heart rhythm or your heart's electrical activity

Chest X-ray

A chest X-ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest X-ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Coronary angiography and cardiac catheterization

Your doctor may ask you to have coronary angiography if other tests or factors show that you're likely to have CAD. This test uses dye and special X-rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special X-rays are taken while the dye is flowing through the coronary arteries.

Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

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 CAD.

Your doctor may order a blood test to check the level of C-reactive protein (CRP) in your blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CAD and heart attack.

Your doctor also may order a blood test to check for low hemoglobin in your blood. Hemoglobin is an iron-rich protein in the red blood cells that carries oxygen from the lungs to all parts of your body. If you have low hemoglobin, you may have a condition called anemia.

Treatment of Angina

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

  • Reduce pain and discomfort and how often it occurs
  • Prevent or lower the risk of heart attack and death by treating the underlying heart condition

Lifestyle changes and medicines may be the only treatments needed if your symptoms are mild and aren't getting worse. When 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 the hospital.

Lifestyle changes

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

  • Slow down or take rest breaks if angina comes on with exertion.
  • Avoid large meals and rich foods that leave you feeling stuffed if angina comes on after a heavy meal.
  • Try to avoid situations that make you upset or stressed if angina comes on with stress. Learn ways to handle stress that can't be avoided.

You also can make lifestyle changes that help lower your risk of heart disease. An important lifestyle change is adopting a healthy diet. This will help prevent or reduce high blood pressure, high blood cholesterol, and obesity.

Follow a heart healthy eating plan that focuses on fruits, vegetables, whole grains, low-fat or no-fat diary products, and lean meat and fish. The plan also should be low in salt, fat, saturated fat, trans fat, and cholesterol.

Other important lifestyle changes include:

  • Quitting smoking, if you smoke. Avoid secondhand smoke.
  • Being physically active. Check with your doctor to find out how much and what kinds of activity are safe for you.
  • Losing weight, if you're overweight or obese.
  • Taking all medicines as your doctor prescribes, especially if you have diabetes.

Medications for Angina

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 heart’s workload.

Nitroglycerin 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 for Angina

When medicines and other treatments don't control angina, you may need a medical procedure to treat the underlying heart disease. Angioplasty and coronary artery bypass grafting (CABG) are both commonly used to treat angina.

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, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to 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.

Your doctor will help decide which treatment is right for you.

Cardiac rehabilitation

Your doctor may prescribe cardiac rehabilitation for angina or after angioplasty, CABG, or a heart attack. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.

Rehabilitation 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 individual 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 of future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.

Prevention of Angina

You can prevent or lower your risk for angina and coronary artery disease (CAD) by making lifestyle changes and treating related conditions.

Make lifestyle changes

Healthy lifestyle choices can help prevent or delay angina and CAD. To make lifestyle changes, you can:

  • Follow a healthy eating plan.
  • Quit smoking, if you smoke. Avoid secondhand smoke.
  • Be physically active. Check with your doctor to find out how much and what kinds of activity are safe for you.
  • Learn ways to handle stress and relax.
  • Know the pattern of your angina

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

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

After several episodes, you will learn to recognize when you're having angina. It's important for you to notice if the pattern starts to change. Pattern changes may include angina that occurs more often, lasts longer, is more severe, occurs without 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. It's very important that you know exactly when and how to take fast-acting nitroglycerin or other nitrates to relieve chest pain.

It's also important to know how to correctly store your angina medicines and when to replace them. If you have side effects from your medicines, let your doctor know. You should never stop taking your medicines without your doctor's approval.

Know how to control your angina

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

Physical activity

Know what level of activity brings on 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, then stop halfway and rest before continuing.

When chest pain occurs during 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 9-1-1 for emergency care.

Emotional stress

Anger, arguing, and worrying are examples of emotional stress that can bring on an angina episode. 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 this leads to chest pain, eat smaller meals. Also, avoid eating rich foods.

Know the limits of your physical activity

Most people with 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 to your doctor.

Know how and when to seek medical attention

If you have angina, you're at a higher risk for a heart attack than someone who doesn't have angina. So it's very important that you and your family know how and when to seek medical attention.

Talk to 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

Be sure to 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, it may be difficult to tell the difference between unstable angina and a heart attack. Either way, it's an emergency situation, and you should call 9–1–1 right away.


© 2010 Vivacare. Last updated July 23, 2013.

Reference: The National Heart, Blood, and Lung Institute

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Additional Resources

Overview
Angina (link to CardioSmart® from the ACC)
Conditions
Tests
Medications
Surgical Procedures
Self Care
Angina Symptom Tracking Log (PDF) (link to American Heart Association)
En Espanol
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