ANGINA (CHEST PAIN)

Angina is a type of chest pain or discomfort that occurs when not enough blood flows to the heart muscle. Angina may feel like pressure in the chest, jaw or arm. It often occurs with exercise or stress. As the heart pumps harder to keep up with what you are doing, it needs more oxygen-rich blood. If this demand is not met, you may feel pain or discomfort in your chest. Some people with angina also report feeling lightheaded, overly tired, short of breath or nauseated.

If you have what is called stable angina, this pain or tightness is often triggered by a high level of activity, such as during stressful times or walking upstairs after an emotional discussion. In fact, you usually know when it might happen, perhaps during a specific exercise. Cold weather or eating large meals – both of which can make the heart work harder – can result in chest pain if you have heart disease.

The good news is that the symptoms of stable angina are usually short-lived and generally stop with rest or medicine.

If you have unstable angina, your chest pain might be very sudden or might happen with you are not exerting yourself. It can be a symptom of a heart attack.

Because chest pain can be a symptom of a heart attack, it is always best to tell your health care team about it and any other concerning symptoms. Keep in mind that there are other reasons why you might have chest pain, like eating too quickly, acid reflux, muscle spasms or breathing issues.

The best way to prevent angina is to adopt heart-healthy habits. You should also keep track of when your chest pain occurs, where you feel it, for how long and what seems to make it better or worse. Use this condition center to learn more about angina.

Angina is a type of chest pain or discomfort that occurs when not enough blood flows to the heart muscle. The discomfort may not always be in the chest. It may feel like pressure in the chest, jaw or arm.

Angina usually occurs because the blood vessels that supply blood to the heart (coronary arteries) become narrow due to atherosclerosis (plaque buildup in the arteries) or a spasm of the coronary arteries.

Types of Angina

Stable angina is a pain or tightness often triggered by a consistent high level of activity, such as walking upstairs after an emotional discussion or during stressful times. It is often predictable. Situations that make your heart work harder, such as cold weather or eating large meals, can result in chest pain if you have heart disease.

Resting, relaxing and potentially taking a nitroglycerin can relieve this pain.

Unstable angina is chest pain or tightness that occurs without a clear trigger, or a sudden worsening of your stable angina. You may notice that you can’t exercise as well as you used to before getting chest pain, or that the pain is more intense or lasts longer.

This is an emergency, and you should see your health care professional right away. If you are having active pain, you should go to the emergency room and call 911.

Variant angina is chest pain or pressure that occurs when the coronary artery suddenly spasms or contracts, cutting off blood flow to the heart muscle. This type of chest pain is also called Prinzmetal’s angina or vasospastic angina. Although the spasm is usually temporary, it can result in the same type of pain caused by a heart attack or coronary artery disease.

Although drugs such as cocaine are associated with coronary artery spasm, it also can happen in people who have never taken cocaine.

Variant angina typically occurs at rest. It is slightly more frequent at night but can happen in the morning or any time of day. It usually lasts a few minutes and then goes away. It can be relieved with nitroglycerin.

Typically, symptoms of angina are chest pain or pressure, which may extend to the neck, jaw or arm. However, some people experience angina as shortness of breath, upper belly pain, indigestion, lightheadedness, extreme weakness or tiredness, or general discomfort.

Women often have other symptoms in addition to chest pain or pressure symptoms.

When Should I Call My Doctor or Go to the Emergency Room?

Know what your angina feels like and what is typical for you so you know when to call for help. Do not wait to call 911 if your angina is worse than normal, for example more severe, more frequent or lasting longer.

If any of these occur, call your health care professional right away. Also call for emergency help if your chest pain occurs while you are at rest (not exerting yourself).

If you think you might be having a heart attack, don’t delay. Call 911 right away. Getting help fast can save your life. An ambulance is the safest way to get to the hospital.

Chest pain can occur for a number of reasons, some that are serious and some that are harmless. Separating angina from other causes of chest pain is not always easy.

Your health care professional will take a thorough history and physical exam. They will ask you about the pain in your chest. Where do you feel it? Do you have other symptoms as well? When do you feel it? How long does it last? What makes it better or worse?

An electrocardiogram (ECG), which shows how fast or evenly the heart is beating, may be done to look for signs of past heart attacks or decreased blood flow to the heart muscle, called ischemia. It also can help show what type of stress test you may need.

If your health care professional is concerned that your chest pain may be caused by coronary artery disease, they may order a stress test with or without pictures. During a stress test, a clinician tries to challenge your heart to see if the supply of blood to your heart muscle is enough to meet the demands of increased activity.

A stress test can tell us if there are further signs of decreased blood flow to the heart muscle. The pictures can tell us if parts of your heart muscle do not get enough blood flow. Other types of imaging stress tests use ultrasound to take pictures of the heart muscle before and after exercise. In these tests reduced heart muscle movement suggests that the blood flow to that heart muscle has a tightness or blockage.

Other tests, such as coronary calcium score and coronary computed tomography, can look for atherosclerosis (plaque buildup) or narrowing of the coronary arteries. Sometimes a stress cardiac MRI can be used to assess blood flow to the heart muscle.

If there is a concern about a heart attack, blood work may be done. You may be advised to go directly to the emergency department.

Staying active, not smoking, and adopting healthy eating habits are important ways to manage stable angina. Your health care professional may also prescribe medicine to help. Some of the medications help control the risk factors that lead to angina and coronary artery disease, while others help manage the symptoms.

Your health care professional will help you find the best combination of medications and treatments to manage your condition.

Medications

Several medications are used to manage the symptoms of angina.

Beta blockers help ease the work the heart has to do by slowing down your heart rate and lowering your blood pressure. If you have had a heart attack, these medications will help prevent another one and help you live longer.

Nitroglycerin and nitrates increase the blood flow to the heart by opening up, or dilating, the blood vessels in the body. This allows blood to flow to the heart muscle more easily when coronary arteries are narrowed. It also decreases the workload on the heart to supply blood to the body. Long-acting versions of these medications are also commonly used.

Calcium channel blockers, like beta blockers, help ease the work the heart has to do by slowing down your heart rate and lowering your blood pressure. Not all medications of this type will slow down heart rate as well as others, but they are all useful to lower high blood pressure. They are not used if your heart is weak.

Ranolazine works directly at the heart to help it relax better. It helps the heart muscle not have to work as hard. Unlike other medications used in angina, it is able to do this without changing your blood pressure or your heart rate.

Procedures/Surgery

Opening up narrowed coronary arteries to restore blood flow to the area of the heart muscle that is not getting enough can relieve the symptoms of angina. There are two main ways to restore blood flow to the heart:

  • Angioplasty, also called percutaneous coronary intervention (PCI), with a stent or a balloon procedure
  • Coronary artery bypass graft (CABG) surgery, or open heart surgery

These treatments can improve quality of life for patients with advanced coronary artery disease.

Your treatment will depend on your symptoms and preferences, how many narrowed or blocked arteries you have and where they are, your age, overall health, and other risk factors. You will need to take antiplatelet medications after PCI. Talk about these options with your heart doctor.

Cardiac Rehabilitation
Cardiac rehabilitation (rehab) is typically a 12-week, medically supervised program. It includes counseling on how to exercise, eat heart healthy, manage stress and quit smoking. It also teaches you how to take better control of your health.

Intensive cardiac rehab might be available in your area and consists of nine weeks of four-hour sessions, two times per week. In these sessions you will have supervised exercise, as well as an hour of nutrition counseling and a meal, an hour of stress relief, and an hour of group support. The outcomes from this intensive program are usually even better than traditional cardiac rehab.

Cardiac rehab can decrease angina, reduce heart risk factors and improve quality of life.

Enhanced External Counterpulsation Therapy 
Enhanced external counterpulsation (EECP) therapy may be recommended in some patients if you have angina that limits you from your daily activities and that has not improved with standard treatments.

During EECP, inflatable cuffs (similar to blood pressure cuffs) are placed on the calves, thighs and buttocks.  The cuffs inflate and deflate in rhythm with your heart, improving blood flow to the heart.  EECP may generate the formation of small blood vessels in the heart to create a natural bypass around blocked or narrowed arteries. EECP may increase exercise duration and decrease angina.

To prevent angina caused by atherosclerosis, it is important to try to decrease the risk factors that lead to coronary artery disease.

What Medications Help Lower Heart Risk Factors?

Aspirin
If you have atherosclerosis, your health care team may recommend a “baby” aspirin daily because it helps blood flow through blood vessels. If you have had a heart attack or stroke, aspirin will help prevent another one and potentially help you live longer.

Important reminder: Don’t stop or start taking any medication without talking to your care team first. 

Statins
Statins help reduce levels of low density lipoprotein (LDL), also called the “bad” cholesterol, in your blood. Too much LDL cholesterol in your blood means that there is a greater chance of it being inside the blood vessels in the heart or in the brain. This can lead to a heart attack or stroke.

If you have had a heart attack or stroke, statins will help prevent another one and help you live longer. Even if you have not had a heart attack or stroke, statins may decrease the chances of a cardiac event in certain people, including those with angina.

What Can I Do to Prevent Angina?

Lifestyle changes are also important in preventing heart disease and angina. These include:

  • Control blood pressure: Keep your blood pressure readings within a healthy range with lifestyle changes and medications, if needed.
  • Stop Smoking: Smoking is the No. 1 cause of preventable death in the U.S. Quitting smoking also is one of the best changes you can make to help prevent a heart attack.
  • Exercise: Staying active is important for your heart. You should try to exercise (brisk walking, running, or biking) for 30 minutes at least five times a week. This can reduce blood pressure, increase HDL (good) cholesterol, and improve control of sugar, called glucose, in your blood.
  • Healthy diet: Everyone – especially if you have heart disease or a higher chance of developing heart disease – should eat a well-balanced diet high in fruits, vegetables, whole grains, fish and lean meats. Stay away from sugary beverages, refined grains, and processed or red meats.
  • Stress reduction: Stress is physical, mental, or emotional strain or tension. Low to moderate levels of stress can be healthy by increasing motivation and productivity. However, chronic high levels of stress can lead to heart disease and angina. A well-balanced life is important for heart health. If you experience stress that causes or worsens your symptoms of angina, talk about these symptoms with your health care professional.

If you’ve been diagnosed with angina, there are several key questions that you should ask your heart doctor during your next visit. These questions will ensure that you and your doctor have discussed your major risk factors so that you can become or stay as healthy as possible.

  • What is the difference between chronic angina and a heart attack?
  • Does having angina mean that I have blockages in the arteries that supply my heart muscle with blood?
  • What medications are available to treat angina?
  • What changes in my symptoms should alert me to notify my health care team?
  • What are the side-effects of medications used to treat angina (particularly beta-blockers, nitrates, and calcium channel blockers)?
  • I have tried many medications for angina but I still have symptoms. Is there a role for ranolazine? Other therapies?
  • What risk factors are linked with angina?
  • Can I continue to exercise if I have angina? How active can I be?
  • What lifestyle changes can I make to reduce my symptoms?
  • Should I have a stress test for angina?
  • Should I have an elective cardiac catheterization to look for blockages in my arteries?
  • Can a cardiac computed tomography scan help identify blockages in my arteries?

VISUAL AIDS

How the normal heart works

What is Angina

In Dr Salahaddin Ubaid I had a medical genius who also contributed significantly to aiding me overcome all of the negative worries and emotions I was feeling. The care he provided to me, his attention to detail, his personal knowledge, expertise, experience and skills was outstanding.

Your kindness and good humour were very much appreciated and certainly put me at ease throughout the procedure, which on other ocassions has been quite daunting, your relaxed approach to my problem was very calm and professional.

What I valued as much as his erudition was his people skills, he related to everyone as an individual, his understanding, communications, interactions and personable nature were exceptional. Dr Ubaid was quite simply staggering, he is somebody that has had a significant impact on me, not just for giving me my life back and for his medical genius but for being the person that he is.

His presence radiates a warmth, he instils confidence in all those around him, he sets an example for others to follow and is a role model for others to aspire to be like. He was kind, courteous, professional, understanding, caring and highly approachable and relatable as well as the medical guru we all benefit from and rely on to give us our lives back.

Dr Ubaid works well with all the staff. His approach to his fellow workers is both patient and respectful. His easy going manner makes him very approachable to ask advice and he accommodates any delays graciously. I personally look forward to working with him.

In life we all need role models, if I was in training to be a doctor you would certainly fit that role for me. I thank you so much for what you have done to allow me to continue with my fitness regime and wish you well in the life ahead of you.

A great team player, all of the nursing staff are very happy to work with Salahaddin as he is polite, efficient, and has a great aura of calmness and competence and appreciates the time to be light-hearted.

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