Angina Pectoris

Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the heart is not getting enough blood.

• The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries.
  
• Blood carries the oxygen and nutrients the heart muscle needs to keep pumping.
  
• When the heart does not get enough blood, it can no longer function at its full capacity.
  
• When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin.
  
• The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day.

Causes

Angina is classified as one of the following two types:

• Stable angina
  
• Unstable angina

Stable Angina

Stable angina is the most common angina, and the type most people mean when they refer to angina.

• People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a pattern and are predictable.
  
• For most people, angina symptoms occur after short bursts of exertion.
  
• Stable angina symptoms usually last less than five minutes.
  
• They are usually relieved by rest or medication, such as nitroglycerin under the tongue.

Unstable Angina

Unstable angina is less common. Angina symptoms are unpredictable and often occur at rest.

• This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is already unstable.
  
• The symptoms are worse in unstable angina - the pains are more frequent, more severe, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue.
  
• Unstable angina is not the same as a heart attack, but it warrants an immediate visit to the healthcare provider or a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack.

If the patient has stable angina, any of the following may indicate worsening of the condition:

• An angina episode that is different from the regular pattern
  
• Being awakened at night by angina symptoms
  
• More severe symptoms than usual
  
• Having angina symptoms more often than usual
  
• Angina symptoms lasting longer than usual

Symptoms

Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:

• An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest
  
• It may also feel like tightness, burning, or a heavy weight.
  
• The pain may spread to the shoulders, neck, or arms.
  
• It may be located in the upper abdomen, back, or jaw.
  
• The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack, as follows:

• Shortness of breath
  
• Lightheadedness
  
• Fainting
  
• Anxiety or nervousness
  
• Sweating or cold, sweaty skin
  
• Nausea
  
• Rapid or irregular heart beat
  
• Pallor (pale skin)
  
• Feeling of impending doom

Self-Care at Home

Stop doing whatever it is that causes the symptoms and call 911. Immediate help and intervention is the best chance for survival if someone is having a heart attack or other serious problem.

• Lie down in a comfortable position with the head up.
  
• Chew a regular adult aspirin or its equivalent (as long as the patient is not allergic to aspirin). Chewing more than one will not do any good and may cause unwanted side effects.

If the patient has had angina before and been evaluated by a healthcare provider, follow his or her recommendations.

• This may mean rest and the immediate use of sublingual nitroglycerin.
  
• It may include a visit to the hospital emergency department.

Medical Treatment

If the patient has come to the hospital emergency department, they may be sent to another care area for further testing, treatment, or observation. On the basis of the provider's preliminary diagnosis, the patient may be sent to the following units:

• An observation unit pending test results or further testing
  
• A cardiac care unit
  
• A cardiac catheterization unit

Regardless of where the patient is sent, several basic treatments may be started. Which ones are given depends on the severity of the symptoms and the underlying disease.

• At least one IV line will be started. This line is used to give medication or fluids.
  
• Aspirin will probably be administered (unless the patient has already taken one)
  
• Oxygen will be administered through a face mask or a tube in the nose. This will help if the patient is having trouble breathing or feeling uncomfortably short of breath. The direct administration of oxygen raises the oxygen content of the blood.

Treatment will depend on the severity of the symptoms, severity of the underlying disease, and extent of damage to the heart muscle, if any.

• Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that the patient needs, if it is only angina.
  
• Medication may be administered to reduce anxiety.
  
• Medication may be administered to lower blood pressure or heart rate.
  
• Medication may be administered to reduce the risk of having a blood clot or to prevent further clotting.
  
• If the healthcare provider believes the chest pain actually represents a heart attack, the patient may be given a fibrinolytic (apowerful clot-buster medication).

After reviewing the patient's immediate test results, the hospital healthcare provider will make a decision about where the patient should be for the next hours and days.

• If the diagnosis of angina is made, and the patient is feeling better and their condition is stable they may be allowed to go home. The patient may be given medications to take. Follow-up with a primary healthcare provider within the next day or two will be recommended.
  
• The patient will be admitted o the hospital if the they are unstable with continuing symptoms. Further testing will be ordered, and if the arteries are critically blocked, the patient may undergo coronary angiography, coronary artery angioplasty, or even coronary artery bypass surgery.

Angioplasty is a treatment used for people whose angina does not get better with medication and/or who are at high risk of having a heart attack.

• Before angioplasty can be done, the area(s) of coronary artery narrowing is located with coronary arteriography.
  
• A thin plastic tube called a catheter is inserted into an artery in the arm or groin with local sedation. The catheter has a tiny balloon attached to the end.
  
• The catheter is threaded through the arteries and into the artery where the narrowing is.
  
• The balloon on the catheter is inflated, opening up the narrowing.
  
• Following ballon treatment, many patients require placement of a "stent," a small metal sleeve that is placed in the narrowed artery. The stent holds the artery open.

Medications

Nitroglycerin: Nitroglycerin is a sublingual (under the tongue) medication relieves angina symptoms by expanding blood vessels and decreasing the muscle's need for oxygen. This allows more blood to flow through the coronary arteries. Nitroglycerin is taken only when the patient actually has symptoms or expect to have them. Slow - or long-acting nitroglycerin can be used as a preventative treatment for angina but not until beta blockers are tried first.

Beta blockers: Beta blockers lessen the heart's workload. They slow the heart rate, decrease blood pressure, and lessen the force of contraction of the heart muscle. This decreases the heart's need for oxygen and thus decreases angina symptoms. Beta blockers are taken every day, regardless of whether the patient is having symptoms, because they are proven to prevent heart attacks and sudden death.

Calcium channel blockers (CCBs): Calcium channel blockers are used primarily when beta blockers cannot be used and/or the patient is still having angina with beta blockers. Calcium channel blockers also lower blood pressure and certain ones slow heart rate. Calcium channel blockers have to be taken every day.

Aspirin: Daily aspirin therapy is mandatory to decrease the possibility of sticky platelets in the blood starting a blood clot.

Statins: Statins lower cholesterol and have been shown to stabilize the fatty plaque on the inner lining of the coronary artery, even when the blood cholesterol is normal or minimally increased. Low density lipoprotein (LDL) or "bad cholesterol" levels should be less than 70 mg/dL for those at high risk of heart disease. Every person with angina needs to know exactly what his or her blood lipids/fats are.

Miscellaneous anti-anginal drugs: New drugs are being studied to treat angina. In 2006, the FDA approved ranolazine (Ranexa). Because of its side effects (potential to cause abnormal heart rhythm), ranolazine is indicated only after other conventional drug treatments are found to be ineffective.

Surgery

Like angioplasty, surgery is an option for people whose angina does not improve with medications and others who are at high risk of having a heart attack. Surgery is usually reserved for people with very severe narrowing or blockage in several coronary arteries.

In almost all cases, the operation used for severely narrowed coronary arteries is coronary artery bypass grafting.

Coronary Artery Bypass Surgery

• The chest and rib cage are opened up (open heart surgery)
  
  
• The narrowed part of the artery is bypassed by a piece of vein removed from the leg, or with a piece of artery behind the sternum (internal mammary artery), or a portion of the radial artery taken from the lower arm or forearm.
  
• Several arteries can be bypassed in one operation.
  
• This is a very safe operation, with a mortality rate of less than 1%, in people whose heart muscle is not severely damaged irreversibly and who have normal lungs, kidneys, liver, and other organs.
  
• Because the chest is opened, the recovery time can be quite long, especially if the patient is older and has multiple other health problems.

Transmyocardial Revascularization

Transmyocardial revascularization is a procedure for people who cannot undergo angioplasty or surgery.

• A simple incision is made in the chest, and a laser is used to "drill" small holes through the outside wall of the heart into the left ventricle.
  
• About 20-40 holes are made.
  
• Bleeding from these holes is minimal and usually stops after a few minutes of pressure.
  
• It is not clear why this helps relieve angina. One theory is that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect.

Current research is focusing on trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels.

Prevention

The best action is to reduce risk factors early in life. The goal is to not have angina, a heart attack, or sudden death in the first place. Although no one can escape aging, inherited risk, or gender, certain risk factors are in your control.

• Stop smoking and using nicotine in any form.
  
• Control high blood pressure.
  
• Lower blood fats (through diet, exercise, and medications).
  
• Maintain a healthy weight.
  
• Control diabetes and blood sugar
  
• Do not use stimulants such as cocaine or amphetamines.

If a person already has atherosclerosis and angina, they can learn to take precautions to avoid having symptoms. Avoiding the "triggers" will help keep the person comfortable and free of symptoms.

• Quit smoking
  
  
• Do not use caffeine, cocaine, amphetamines, or other stimulants
  
• Drink alcohol moderately (no more than 1-2 drinks daily)
  
• Avoid large and heavy meals that leave you feeling "stuffed"
  
• Decrease stress
  
• Establish a regular exercise routine (discuss the plan with your healthcare provider)

The question of exercise for a person with angina is important. Exercise is recommended.

• If the patient has been exercising strenuously, they may need to cut back to avoid symptoms.
  
• If the patient has not been exercising, or has been exercising moderately, talk to a healthcare provider first about physical activity that will be safe and comfortable. Sometimes a structured cardiac rehabilitation program is a beneficial way to begin an exercise program.

The healthcare provider may recommend taking an aspirin daily.

• Aspirin has been shown to reduce the risk of a second heart attack in people who have already had one, and may reduce the risk of a first heart attack.
  
• Taking aspirin is not without risks, especially in elderly people, people with digestive diseases or blood clotting disorders, and people who take certain types of medications.
  
• Allergy to aspirin is not uncommon. Tell your healthcare provider if you are allergic to aspirin or have a reaction to aspirin.