Chest Pain/Angina

 
angina 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. When the heart does not get enough blood, it can no longer function at its full capacity.

When a person with angina eats, physically exerts himself or experiences strong emotions or extreme temperatures it increases the demand on his heart, causing angina.

Signs and symptoms of angina are temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back.

The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day.

An episode of angina can be relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin.

An episode of angina is not a heart attack; however, having angina does means you have an increased risk of having a heart attack. Angina can be a helpful warning sign if it makes a person seek timely medical help and avoid a heart attack.

Prolonged or unchecked angina can lead to a heart attack or increase the risk of having a heart rhythm abnormality. Either of those could lead to sudden death.

Time is very important in angina. The more time the heart is deprived of adequate blood flow (ischemia), and thus oxygen, the more the heart muscle is at risk of heart attack or heart rhythm abnormalities. The longer the person experiences chest pain from angina, the more the heart muscle is at risk of dying or malfunctioning.

If chest pain is severe and/or recurrent, the person should see a physician.

Call paramedics to take you to a hospital emergency department if you have any of the following symptoms along with chest pain:

  • Sweating
  • Weakness
  • Faintness
  • Numbness or tingling
  • Nausea
  • Pain that does not go away after a few minutes
  • Pain that is of concern in any way

Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to very serious. For example, chest pain can be caused by

  • acid reflux (gastroesophageal reflux disease, GERD),
  • asthma, or
  • sore muscles and ligaments in the chest (chest wall pain).

What causes angina?

Coronary heart disease
The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery disease. In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged. They can no longer supply the heart with all of the blood it needs. Most cases of coronary heart disease are caused by atherosclerosis (coronary plaque).
  • Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels.
  • These buildups are called plaques, and they can block blood flow through the vessels partially or completely. Multiple risk factors exist, particularly:
    • diabetes,
    • high blood pressure,
    • smoking,
    • high cholesterol, and
    • genetic predisposition may accelerate this build up.
Coronary artery spasm
Another cause of unstable angina is coronary artery spasm. Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily. This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms. This is called variant angina or Prinzmetal angina. This is not the same as atherosclerosis, although some people have both conditions.

The symptoms often come on at rest (or during sleep) and without apparent cause.

Cocaine use/abuse can cause significant spasm of the coronary arteries and lead to a heart attack.

Other causes of angina
Other causes of angina symptoms include the following:
  • Blockage of a coronary artery by a blood clot or by compression from something outside the artery
  • Inflammation of the coronary arteries
  • Injury to one or more coronary arteries
  • Poor functioning of the tiny blood vessels of the heart (microvascular angina)

When a person has underlying atherosclerosis (coronary plaque), spasm, or damage to the coronary arteries, angina symptoms usually are set off by one of the following triggers:

  • Physical exertion or exercise
  • Emotional stress
  • Exposure to cold
  • Decreased oxygen content in the air you breathe (for example flying in an airplane or at high altitudes)
  • Excessive use of caffeine
  • Ssmoking cigarettes/cigars (which lowers the amount of oxygen in the blood and can cause coronary spasms)

What are the signs and symptoms of angina?

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

These symptoms are identical to the signs of an impending heart attack described by the American Heart Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a few minutes and heart attack pain does not go away.

What are the types of angina?

Angina is classified as one of the following two types:
  1. Stable angina
  2. Unstable angina
1. 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.
2. 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.
  • Unstable angina is not the same as a heart attack, but it warrants a call to paramedics for an immediate visit to a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack.

If the person 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

How is angina diagnosed?

The physician will perform a complete physical exam, listening to the heart and lungs and feeling the heart through the chest. The physician will ask the patient questions about his symptoms and about his medical history.

There is no blood test that can tell with certainty that someone is having angina.

Imaging and other tests
An electrocardiogram (EKG/ECG) is a painless test that checks for abnormalities in the beating of the heart. Electrodes are attached to the chest and other points on the body. The electrodes read the electrical impulses linked to the beating of the heart. The ECG looks for signs of a heart attack or of impaired blood flow to the heart. For many patients with angina, the ECG result is normal.

A chest X-ray will show any fluid buildup in the lungs. It can also rule out some other causes of chest pain.

If the physician suspects the patient may have coronary heart disease, the physician will order additional tests. These may include:

  • Exercise stress test: An ECG is taken before, during, and after exercise (usually walking on a treadmill) to detect inadequate blood flow to the heart muscle indirectly by changes on the ECG. This usually is done only for stable angina.
  • Thallium stress test: This is a more complex and expensive test that injects a radioisotope into the circulation and indirectly detects parts of the heart that may not be getting enough blood during "stress" (usually walking on a treadmill, or after administration of a drug that mimics exercise in those unable to walk on the treadmill). This information indicates more accurately whether any of the coronary arteries may be narrowed, causing inadequate blood flow to the heart muscle or ventricle. Again, this is usually done only for stable angina.
  • Dobutamine echocardiogram stress test: This is done for people who cannot walk on a treadmill. A drug called dobutamine (Dobutrex) stimulates and speeds up the heart, creating an increased demand or need for blood flow to the left ventricle or muscle. If the muscle shows a slowing of function on the ultrasound image of the heart muscle, then it indirectly indicates inadequate blood flow to the muscle.
  • Coronary angiogram (or arteriogram): This test of the coronary arteries is the most accurate but also the most invasive. It is a type of X-ray. A thin, plastic tube called a catheter is threaded through an artery in the arm or groin to one of the main coronary arteries. A harmless contrast dye is injected into the arteries. The dye depicts the arteries directly and shows any blockage more accurately than the above or more noninvasive procedures.

What is the medical treatment for angina?

The treatment given depends on the severity of the symptoms and the underlying disease.
  • Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that the patient needs.
  • 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 physician believes the chest pain actually represents a heart attack, the patient may be given a fibrinolytic (a powerful clot-buster medication).

After reviewing the patient's immediate test results, the physician will make a decision about next steps:

  • If the diagnosis of angina is made, and the patient is feeling better and his condition is stable he may be allowed to go home. The patient may be given medications to take. Follow-up with a physician within the next day or two will be recommended.
  • The patient will be admitted to the hospital if he is 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 for people whose angina does not get better with medication 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 balloon 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.

If the patient has had angina symptoms, the physician will determine further steps. The choices include evaluating the patient on an out-patient basis, referring the patient to a specialist in heart disorders (cardiologist), or admitting the patient to the hospital for further diagnosis.

What medications treat angina?

Nitroglycerin is a sublingual (under the tongue) medication that 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 person has symptoms or expects to have them. Slow (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 person 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 person is still having angina with beta blockers. Calcium channel blockers also lower blood pressure and certain ones slow heart rate. Calcium channel blockers are to be taken every day.

Aspirin: Daily aspirin therapy is mandatory to decrease the possibility of having sticky platelets in the blood start 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 the level of his blood lipids/fats.

Miscellaneous anti-angina drugs: New drugs are being studied to treat angina.


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Adapted from eMedicineHealth