Angina

What is Angina?

Angina describes chest pain and is often a sign of ischemic heart disease, a condition where the heart doesn’t get enough blood supply. This disease is a major health issue on a global scale. Remember, chest pain can come from either heart-related or non-heart-related causes. That’s why it’s important for doctors to take a careful history and perform a detailed check-up to figure out what might be causing the chest pain and to spot any early signs of a condition called acute coronary syndrome.

Acute coronary syndrome is a heart-related emergency and angina could be one of its symptoms. Angina can be split into two types: stable and unstable. Stable angina is when the chest pain only happens during physical activity. On the other hand, unstable angina, which is chest pain that happens even when you’re at rest, needs immediate assessment and treatment.

About 9 million people in the United States experience symptoms of angina. Knowing these symptoms are critical to improving the health outcomes of these patients.

What Causes Angina?

Chest pain can arise from a variety of sources. These include problems not related to the heart like acid reflux, lung diseases, muscle issues, or even stress and panic attacks. There are also heart-related issues that are not related to blockages in blood vessels, like diseases that affect the layer surrounding the heart.

The cause of chest pain related to a lack of blood supply to the heart is mostly thought to be due to hardening and narrowing of the coronary arteries and spasms in these same arteries. Essentially, this condition leads to an imbalance between the oxygen needed by the heart muscle and the oxygen it actually receives.

In the case of stable angina, increased oxygen demand happens only when the heart is working harder, like during exercise. However, in unstable angina, this can also occur when the person is at rest. This is mainly due to increased heart rate, high blood pressure, and increased work of the heart muscles among other factors.

Normally, when the heart is working harder, the coronary arteries expand to allow more blood flow. However, when these arteries are hardened due to atherosclerosis, this ability is reduced. As a result, blood supply decreases, causing chest pain.

There’s another type of chest pain – vasospastic angina, also known as variant or Prinzmetal angina. This type too, occurs while at rest. But this is not related to the hardening of arteries, rather it’s due to their spasms.

Risk Factors and Frequency for Angina

Chronic stable angina is a condition that impacts around 30,000 to 40,000 in every million people in Western countries. It becomes more common as people get older, affecting around 4% to 7% of men and women aged 45 to 64. The number goes up as you get older, with 14% to 15% of men and 10% to 12% of women aged 65 to 84 experiencing this condition.

There are certain risk factors for angina that can be changed or managed. These include high cholesterol levels, high blood pressure, smoking or a history of smoking, diabetes, obesity, and what is known as metabolic syndrome.

• High cholesterol levels
• High blood pressure
• Smoking or a history of smoking
• Diabetes
• Obesity
• Metabolic syndrome, which involves a combination of different health issues

Body Mass Index (BMI) is another independent risk factor for heart disease. But there are also factors that you can’t change that may increase your risk, like growing older, being a male, having a family history of heart disease, and your ethnic background.

• Increased age
• Being male
• Family history of heart disease
• Ethnic background

Signs and Symptoms of Angina

Acute coronary syndrome (ACS) primarily shows up as angina, which is best described as chest discomfort. Patients often report feeling pain, pressure, tightness, or weight in their chest, which can also be felt in the jaw or left arm. This may be paired with shortness of breath, excessive sweating, nausea or any mix of these. If it’s stable angina, physical activity might trigger the discomfort but rest or medicine (nitroglycerin) can often ease it. But for unstable angina or a type of heart attack called myocardial infarction, the chest discomfort is likely to persist, regardless of rest or medicine. In a stable angina case, symptoms might last for 5 minutes and typically go away with rest or nitroglycerin use.

It’s important to note that some patients, particularly those with diabetes, might not exhibit the typical symptoms of ACS. This means doctors need to be extra vigilant when dealing with patients who have a high risk of heart-related issues.

During a physical examination, the patient might appear normal. However, signs such as discomfort, anxiety, excessive sweating, or clutching of the chest might be observed. When it comes to vital signs, they may be normal or reveal increased heart and respiratory rates.

Testing for Angina

When a patient experiences chest discomfort, also known as angina, the doctor uses a range of tests to determine if it’s due to a condition called Acute Coronary Syndrome(ACS). ACS is a condition in which blood supply to the heart muscle suddenly becomes blocked. How likely this is to be the cause of the symptoms, known as ‘pretest probability’, is evaluated by considering the patient’s symptoms and their heart disease risk factors. If the chance of having ACS is very high or very low, additional tests might not change the treatment plan.

The initial testing includes three main components. First is a 12-lead electrocardiogram (ECG), a painless test to record the heart’s electrical activity. The second is a chest X-ray that allows the doctor to see the lungs, heart, and blood vessels in order to identify any issues. The third includes basic lab tests such as a Complete Blood Count (CBC), which checks for different blood cells in a sample, and a Basic Metabolic Profile (BMP), which measures the levels of certain substances in the blood, along with a blood test for a protein called troponin if ACS is suspected. Troponin is released into the blood when the heart muscle has been damaged.

Keep in mind, in cases of stable angina, unstable angina, or a type of heart attack called a non-ST segment elevation myocardial infarction (NSTEMI), the ECG may not show any abnormalities. However, it may show signs of lack of oxygen to the heart muscle, such as flattening or inverting T-waves, or depression of the ST-segment.

Further testing may include a stress test, where the doctor observes the heart while the patient exercises or takes certain medications, sometimes along with imaging of the blood flow within the heart muscle, and a diagnostic heart catheterization, which involves a flexible tube inserted into a blood vessel to examine the heart. Significant changes in the ECG readings will show up in a type of heart attack called ST-segment elevation myocardial infarction (STEMI) and need immediate treatment to restore the blood flow to the heart.

Treatment Options for Angina

The treatment of chronic stable angina, a type of chest pain, focuses on managing symptoms and slowing the progression to heart events. The key components of this treatment involve changes in the patient’s lifestyle, managing risk factors, and medication.

Lifestyle changes include regular exercise, controlling weight, and quitting smoking. Managing risk factors involve controlling blood pressure, cholesterol levels, and blood sugar. Medications like aspirin, statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are often used to help manage these risk factors and slow the progression of the disease.

Medication can also help control symptoms and reduce the risk of atherosclerosis (hardening of the arteries) and heart events. Some drugs work by reducing the heart rate, which is a major factor causing chest pain. These include beta-blockers, ivabradine, and certain types of calcium channel blockers. However, calcium channel blockers should not be used in patients with a certain type of heart dysfunction.

Some medications can also help treat chest pain by causing the muscles in the walls of your arteries to relax, which helps your arteries to widen and improve blood flow. These include certain types of calcium channel blockers, nitrates, and nicorandil.

Another medication, called ranolazine, works differently by reducing a specific type of dysfunction in heart cells.

For patients with unstable angina, which is a more severe form of chest pain, treatment focuses on reducing pain, minimizing damage to the heart, and lowering the risk of severe outcomes. Treatments include the following:

– Nitrates: These drugs help relieve chest pain by causing your blood vessels to widen. However, they’re not suitable for some patients, including those with low blood pressure or who have taken certain other medications within the last 48 hours.

– Morphine: This powerful painkiller, used when nitrates aren’t providing enough relief, also causes some blood vessel widening.

– Beta-blockers: These drugs potentially reduce the risk of death by lowering heart rate, the force of heart contractions, and blood pressure, which in turn reduces the heart’s need for oxygen.

– Antiplatelet agents: Aspirin, clopidogrel, ticagrelor, or prasugrel are used in combination to decrease the risk of cardiovascular events.

– Anticoagulants: They’re used to lower the risk of repeated heart attacks and are typically received intravenously for acute treatment.

In high-risk patients, doctors may consider a procedure to open blocked or narrowed coronary arteries. This decision is based on an assessment of the patient’s risk level.

What else can Angina be?

When a patient experiences chest pain, or “angina,” doctors have a list of possible causes they need to rule out. These fall under various categories related to body systems:

• Gastrointestinal causes, such as acid reflux, a hiatal hernia, or a peptic ulcer
• Pulmonary (lung-related) causes, including a collapsed lung (pneumothorax), pneumonia, or a blood clot in the lung (pulmonary embolism)
• Musculoskeletal causes, such as costochondritis (inflammation of the cartilage in the rib cage), rib injury, muscle spasm, or injury to the chest wall
• Psychiatric reasons, like panic attacks or generalized anxiety
• Non-ischemic cardiac causes, which involve the heart but not due to blockages, for example, inflammation of the heart’s outer layer (pericarditis) or inflammation of the heart muscle (myocarditis)
• Vascular cause which involves the blood vessels such as aortic dissection

Each of these potential causes has to be considered and checked based on the patient’s symptoms, health history, and test results.

What to expect with Angina

The outlook for patients with chronic stable angina, a type of chest pain, can vary greatly, depending on several factors. The heart’s overall health, along with how well patients follow lifestyle changes and medical treatment plans, can all impact how the condition progresses.

Long-term outlook can also depend on things like the heart’s pumping ability (known as left ventricular systolic function), the patient’s level of physical activity, and the extent of coronary artery disease (CAD) present. CAD is a condition where the heart’s blood vessels are narrowed or blocked by plaque.

There are several risk factors that could lead to a worse prognosis. These include diabetes, a previous heart attack (MI), high blood pressure, increasing age, and being male. Additionally, using medication called nitrates can also indicate a poorer outlook. This might be because the use of these medications typically suggests that the disease is more advanced.

Possible Complications When Diagnosed with Angina

Angina often serves as the first sign of Coronary Artery Disease (CAD) and it can possibly lead to severe heart events like myocardial infarction (heart attack) in the future. According to one study, women who had been using nitrates as a treatment for chronic angina were observed to have a risk of heart attack higher than 10 percent in the next 10 years.

Chronic angina not only poses serious health risks, but it also has a significant impact on a patient’s quality of life and the society at large. For instance, it can affect a person’s ability to carry out daily tasks, leading to a lowered quality of life. At the societal level, chronic angina can cause increased indirect costs relating to early retirement or disability.

When treating angina, it’s important not only to aim at reducing the risks of mortality but also focus on controlling and minimizing the symptoms so that patients can enhance their physical activity levels.

Common Consequences:

• Potential heart events like heart attacks
• Reduction in the ability to perform daily activities
• Lowers quality of life
• May lead to early retirement or disability
• Increased societal costs

Preventing Angina

If you have heart disease risk factors, it’s important to keep an eye out for symptoms of angina – a type of chest discomfort caused by reduced blood flow to the heart. Also, you should learn about signs that your condition may be worsening, such as symptoms occurring even during rest, and discomfort that is no longer eased with nitrate medication.

It’s crucial to understand that changing certain lifestyle habits can play a huge role in slowing down the progression of your condition. This can include changes to your diet and exercise routine. If you’re a smoker, getting help to stop smoking can also be very beneficial.

One more key point is the importance of taking your prescribed medications as directed by your doctor. All these strategies are considered essential parts of your overall treatment.