Angina Pectoris

Definition

Angina pectoris is chest pain caused by myocardial ischemia, a condition in which the amount of oxygen getting to the heart muscle is insufficient. It usually occurs on exertion and is relieved by rest. Angina generally is a symptom of coronary artery disease. In most severe cases, it may occur with minimal effort or at rest.

Description

Angina pectoris is a common manifestation of coronary artery disease. The pain is caused by reduced blood flow to a segment of heart muscle (myocardial ischemia). It usually lasts for only a few minutes, and an attack is usually quickly relieved by rest or drugs (such as nitroglycerin). Also, it is possible to have myocardial ischemia without experiencing angina.

Typically, angina is described as a "pressure" or "squeezing" pain that starts in the center of the chest and may spread to the shoulders or arms (most often on the left side, although either or both sides may be involved), the neck, jaw or back. It is usually triggered by extra demand on the heart: exercise, an emotional upset, exposure to cold, digesting a heavy meal are common examples.

Some people experience angina while sleeping or at rest. This type of angina may be caused by a spasm in a coronary artery, which most commonly occurs at the site of atherosclerotic plaque in a diseased vessel.

Most people with angina learn to adjust their lives to minimize attacks. There are cases, however, when the attacks come frequently and without provocation - a condition known as unstable angina. This is often a prelude to a heart attack and requires special treatment, primarily with drugs. Angina affects both men and women, usually in middle age. Men are much more likely than women to experience it before age 60. It may develop weeks, months or even years before a heart attack, or may be experienced only after a heart attack has occurred.

Causes and Risk Factors

The primary cause of angina is coronary artery disease due to atherosclerotic change. This is due to the classic risk factors of smoking, sedentary lifestyle, hypertension, hypercholesterolemia, diabetes and family history.

Symptoms

Classic or typical angina occurs predictably with physical exertion or strong emotional reactions, and goes away just as predictably with rest. Starting immediately behind the sternum (breast bone), the pain may radiate to the left arm and shoulder or up to the jaw.

Most people describe the pain as a kind of squeezing pressure, tightness or heaviness. In some instances, chest pain results from other types of heart problems, including diseases that affect the heart muscle itself or the valves that control blood flow through the heart. Occasionally, ulcers, gallstones, abnormal contractions of the esophagus or severe anxiety and panic attacks can cause chest pain.

Diagnosis

Diagnosis of angina is based upon the classic history of chest pain on exertion and by means of tests, demonstrating the presence of coronary artery disease.

Treatment

In most instances, drugs are recommended for the treatment of angina before surgery is considered. The major classes of drugs used to treat angina include the following:

Nitrates. These come in several forms: nitroglycerine tablets to be slipped under the tongue during or in anticipation of an attack; ointment to be absorbed through the skin; long-acting medicated skin discs; or long-acting tablets. The latter three forms are used mostly to prevent rather than relieve attacks. The nitrates work by reducing the oxygen requirements of the heart muscle.

Beta-blocking Drugs. These agents act by blocking the effect of the sympathetic nervous system on the heart, slowing heart rate, decreasing blood pressure, and thereby, reducing the oxygen demand of the heart. Recent studies have found that these drugs also can reduce the chances of dying or suffering a recurrent heart attack if they are started shortly after suffering a heart attack and continued for two years.

Calcium-channel Blocking Drugs. These drugs are prescribed to treat angina that is thought to be caused by coronary artery spasm. They can also be effective for stable angina associated with exercise. All muscles need varying amounts of calcium in order to contract. By reducing the amount of calcium that enters the muscle cells in the coronary artery walls, the spasms can be prevented. Some calcium-channel blocking drugs also decrease the workload of the heart and some lower the heart rate as well.

Use of Nitroglycerin

Nitroglycerin is usually effective in relieving anginal chest discomfort. It also can be used to prevent anginal pain. It is usually taken in tiny tablets which are placed under the tongue to dissolve, but may also be prescribed as an oral spray. The nitroglycerin tablets are inexpensive and quick-acting. Keep a fresh, sealed supply of the tablets on hand at all times. As a general rule, avoid transferring your nitroglycerin tablets out of the original, dark glass bottle, since the tablets are sensitive to heat, light and air. Do not keep cotton in the bottle because it will absorb the nitroglycerin.

Always use the medicine as directed by your doctor. Be sure to carry the nitroglycerin with you at all times. Take a tablet just before starting an activity you know is likely to cause anginal discomfort. Also, take a tablet when the discomfort does not subside within a minute or two after you have stopped the activity, or if it occurs when you are not physically active. Let your doctor know what usually causes your angina so that he can advise you about preventing attacks. It may take several tablets a day to control your symptoms.

Nitroglycerin is safe and not habit forming, so don't be afraid to take it. Ask your doctor what to do if nitroglycerin is not effective in relieving your angina completely or if the pain begins to increase in frequency or severity.

In some people, nitroglycerin causes a short headache or a feeling of fullness in the head. Often these symptoms will disappear after you have taken nitroglycerin several times. If not, your doctor may want to reduce the dosage in each tablet.

If your angina is not relieved after taking three (3) tablets within a 10-minute period, seek medical attention promptly. If your doctor is not immediately available, go to your local hospital Emergency Room.

Ask your doctor about refilling your nitroglycerin prescription at six-month intervals, since old tablets can lose their strength; tables that are effective should cause stinging or burning under the tongue.

Your doctor may also prescribe longer-acting nitroglycerin compounds which are taken by mouth or applied to the skin as an ointment or skin patch.

Questions to Ask Your Doctor

Could the chest pain be the result of any other disorder other than heart disease?

What is the cause of the angina?

Are there any tests recommended to determine the degree of heart disease?

What is the procedure for this test?

What medications will be prescribed? What are the side effects?

Do the medications just relieve the symptoms or do they help relieve the cause?

What are the chances that surgery will be needed?

What other procedures are used to alleviate the coronary problem?

What preventive measures can be taken to decrease the risk of angina and the chance of a heart attack?

If angina is brought on by exercise, then what form of physical activity can be done to decrease heart disease and keep me healthy?