What Is Angina?
Angina (an-JI-nuh or AN-juh-nuh) is chest pain or
discomfort that occurs when an area of your heart muscle doesn't get enough
oxygen-rich blood. Angina may feel like pressure or squeezing in your chest.
The pain also may occur in your shoulders, arms, neck, jaw, or back. It can
feel like indigestion.
Angina itself isn't a disease. Rather, it's a
symptom of an underlying heart problem. Angina is usually a symptom of
coronary
artery disease (CAD), the most common type of heart disease.
CAD occurs when a fatty material called plaque
(plak) builds up on the inner walls of the coronary arteries. These arteries
carry oxygen-rich blood to your heart. When plaque builds up in the arteries,
the condition is called
atherosclerosis
(ATH-er-o-skler-O-sis).
Atherosclerosis
Figure A shows a normal artery with
normal blood flow. Figure B shows an artery containing plaque buildup.
Plaque causes the coronary arteries to become narrow
and stiff. The flow of oxygen-rich blood to the heart muscle is reduced. This
causes pain and can lead to a
heart
attack.
Types of Angina
The three types of angina are stable, unstable, and
variant (Prinzmetal's). Knowing how the types are different is important. This
is because they have different symptoms and require different treatment.
Stable Angina
Stable angina is the most common type. It occurs
when the heart is working harder than usual. Stable angina has a regular
pattern. If you know you have stable angina, you can learn to recognize the
pattern and predict when the pain will occur.
The pain usually goes away in a few minutes after
you rest or take your angina medicine.
Stable angina isn't a heart attack, but it makes a
heart attack more likely in the future.
Unstable Angina
Unstable angina doesn't follow a pattern. It can
occur with or without physical exertion and isn't relieved by rest or medicine.
Unstable angina is very dangerous and needs
emergency treatment. It's a sign that a heart attack may happen soon.
Variant (Prinzmetal's) Angina
Variant angina is rare. It usually occurs while
you're at rest. The pain can be severe. It usually happens between midnight and
early morning. This type of angina is relieved by medicine.
Overview
It's thought that nearly 7 million people in the
United States suffer from angina. About 400,000 patients go to their doctors
with new cases of angina every year.
Angina occurs equally in men and women. It can be a
sign of heart disease, even when initial tests don't show evidence of CAD.
Not all chest pain or discomfort is angina. A heart
attack, lung problems (such as an infection or a blood clot), heartburn, or a
panic attack also can cause chest pain or discomfort. All chest pain should be
checked by a doctor.
Other Names for Angina
- Angina pectoris
- Acute coronary syndrome
- Chest pain
- Coronary artery spasms
- Prinzmetal's angina
- Stable or common angina
- Unstable angina
- Variant angina
What Causes Angina?
Underlying Causes
Angina is a symptom of an underlying heart
condition. Angina pain is the result of reduced blood flow to an area of heart
muscle.
Coronary
artery disease (CAD) usually causes the reduced blood flow.
This means that the underlying causes of angina are
generally the same as the underlying causes of CAD.
Research suggests that damage to the inner layers of
the coronary arteries causes CAD. Smoking, high levels of fat and
cholesterol
in the blood,
high
blood pressure, and a high level of sugar in the blood (due to insulin
resistance or
diabetes) can damage the coronary arteries.
When damage occurs, your body starts a healing
process. Excess fatty tissues release compounds that promote this process. This
healing causes plaque to build up where the arteries are damaged. Plaque
narrows or blocks the arteries, reducing blood flow to the heart muscle.
Some plaque is hard and stable and leads to narrowed
and hardened arteries. Other plaque is soft and is more likely to break open
and cause blood clots.
The buildup of plaque on the arteries' inner walls
can cause angina in two ways. It can:
- Narrow the arteries and greatly reduce blood flow
to the heart
- Form blood clots that partially or totally block
the arteries
Immediate Causes
There are different triggers for angina pain,
depending on the type of angina you have.
Stable Angina
Physical exertion is the most common trigger of
stable angina. Severely narrowed arteries may allow enough blood to reach the
heart when the demand for oxygen is low (such as when you're sitting). But with
exertion, like walking up a hill or climbing stairs, the heart works harder and
needs more oxygen.
Other triggers of stable angina include:
- Emotional stress
- Exposure to very hot or cold temperatures
- Heavy meals
- Smoking
Unstable Angina
Blood clots that partially or totally block an
artery cause unstable angina. If plaque in an artery ruptures or breaks open,
blood clots may form. This creates a larger blockage. A clot may grow large
enough to completely block the artery and cause a heart attack. For more
information, see the animation in
"What
Causes a Heart Attack?"
Blood clots may form, partly dissolve, and later
form again. Angina can occur each time a clot blocks an artery.
Variant Angina
A spasm in a coronary artery causes variant angina.
The spasm causes the walls of the artery to tighten and narrow. Blood flow to
the heart slows or stops. Variant angina may occur in people with or without
CAD.
Other causes of spasms in the coronary arteries are:
- Exposure to cold
- Emotional stress
- Medicines that tighten or narrow blood vessels
- Smoking
- Cocaine use
Who Is At Risk for Angina?
Angina is a symptom of an underlying heart
condition, usually
coronary
artery disease (CAD). So if you're at risk for CAD, you're also at risk for
angina.
Risk factors for CAD include:
You can read more about CAD risk factors in "Who
Is At Risk for Coronary Artery Disease?"
Populations Affected
People sometimes think that because men have more
heart
attacks than women, men also suffer from angina more often. In fact, angina
occurs equally among women and men. It can be a sign of heart disease, even
when initial tests don't show evidence of CAD.
Unstable angina occurs more often in older
adults.
Variant angina is rare. It accounts for only about 2
out of 100 cases of angina. People who have variant angina are often younger
than those who have other forms of angina.
What Are the Signs and Symptoms of Angina?
Pain and discomfort are the main symptoms of angina.
Angina is often described as pressure, squeezing, burning, or tightness in the
chest. It usually starts in the chest behind the breastbone.
Pain from angina also can occur in the arms,
shoulders, neck, jaw, throat, or back. It may feel like indigestion.
Some people say that angina discomfort is hard to
describe or that they can't tell exactly where the pain is coming from.
Symptoms such as nausea (feeling sick to your
stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness,
or weakness also may occur. Women are more likely to feel discomfort in their
back, shoulders, and abdomen.
Symptoms vary based on the type of angina.
Stable Angina
The pain or discomfort:
- Occurs when the heart must work harder, usually
during physical exertion
- Doesn't come as a surprise, and episodes of pain
tend to be alike
- Usually lasts a short time (5 minutes or less)
- Is relieved by rest or medicine
- May feel like gas or indigestion
- May feel like chest pain that spreads to the
arms, back, or other areas
Unstable Angina
The pain or discomfort:
- Often occurs at rest, while sleeping at night, or
with little physical exertion
- Comes as a surprise
- Is more severe and lasts longer (as long as 30
minutes) than episodes of stable angina
- Is usually not relieved with rest or medicine
- May get continually worse
- May mean that a
heart
attack will happen soon
Variant Angina
The pain or discomfort:
- Usually occurs at rest and during the night or
early morning hours
- Tends to be severe
- Is relieved by medicine
Lasting Chest Pain
Chest pain that lasts longer than a few minutes and
isn't relieved by rest or angina medicine may mean you're having (or are about
to have) a heart attack. Call 911 right away.
How Is Angina Diagnosed?
The most important issues to address when you go to
the doctor with chest pain are:
- What's causing the chest pain
- Whether you're having or are about to have a
heart
attack
Angina is a symptom of an underlying heart problem,
usually
coronary
artery disease (CAD). The type of angina pain you have can be a sign of how
severe the CAD is and whether it's likely to cause a heart attack.
If you have chest pain, your doctor will want to
find out whether it's angina. He or she also will want to know whether the
angina is stable or unstable. If it's unstable, you may need emergency medical
attention to try to prevent a heart attack.
To diagnose chest pain as stable or unstable angina,
your doctor will do a physical exam, ask about your symptoms, and ask about
your risk factors and your family history of CAD or other heart disease.
He or she may also ask questions about your
symptoms, such as:
- What brings on the pain or discomfort and what
relieves it?
- What does the pain or discomfort feel like (for
example, heaviness or tightness)?
- How often does the pain occur?
- Where do you feel the pain or discomfort?
- How severe is the pain or discomfort?
- How long does the pain or discomfort last?
Diagnostic Tests and Procedures
If your doctor suspects that you have unstable
angina or that your angina is related to a serious heart condition, he or she
may order one or more tests.
EKG (Electrocardiogram)
An
EKG
is a simple test that detects and records the electrical activity of your
heart. An EKG shows how fast your heart is beating and whether it has a regular
rhythm. It also shows the strength and timing of electrical signals as they
pass through each part of your heart.
Certain electrical patterns that the EKG detects can
suggest whether CAD is likely. An EKG also can show signs of a previous or
current heart attack.
However, some people with angina have a normal EKG.
Stress Testing
During
stress
testing, you exercise to make your heart work hard and beat fast while
heart tests are performed. If you can't exercise, you're given medicine to
speed up your heart rate.
During exercise stress testing, your blood pressure
and EKG readings are checked while you walk or run on a treadmill or pedal a
bicycle. Other heart tests, such as
nuclear
heart scanning or
echocardiography,
also can be done at the same time.
If you're unable to exercise, a medicine can be
injected into your bloodstream to make your heart work hard and beat fast.
Nuclear heart scanning or echocardiography is then usually done.
When your heart is beating fast and working hard, it
needs more blood and oxygen. Arteries narrowed by plaque can't supply enough
oxygen-rich blood to meet your heart's needs.
A stress test can show possible signs of CAD, such
as:
- Abnormal changes in your heart rate or blood
pressure
- Symptoms such as shortness of breath or chest
pain
- Abnormal changes in your heart rhythm or your
heart's electrical activity
Chest X Ray
A
chest x ray takes a picture of the organs and structures
inside the chest, including your heart, lungs, and blood vessels. A chest x ray
can reveal signs of
heart
failure, as well as lung disorders and other causes of symptoms that aren't
due to CAD.
Coronary Angiography and Cardiac
Catheterization
Your doctor may ask you to have
coronary
angiography (an-jee-OG-ra-fee) if other tests or factors show that you're
likely to have CAD. This test uses dye and special x rays to show the insides
of your coronary arteries.
To get the dye into your coronary arteries, your
doctor will use a procedure called
cardiac
catheterization (KATH-e-ter-i-ZA-shun). A long, thin, flexible tube called
a catheter is put into a blood vessel in your arm, groin (upper thigh), or
neck. The tube is then threaded into your coronary arteries, and the dye is
released into your bloodstream. Special x rays are taken while the dye is
flowing through the coronary arteries.
Cardiac catheterization is usually done in a
hospital. You're awake during the procedure. It usually causes little to no
pain, although you may feel some soreness in the blood vessel where your doctor
put the catheter.
Blood Tests
Blood tests check the levels of certain fats,
cholesterol, sugar, and proteins in your blood. Abnormal levels may show that
you have risk factors for CAD.
Your doctor may order a blood test to check the
level of C-reactive protein (CRP) in your blood. Some studies suggest that high
levels of CRP in the blood may increase the risk for CAD and heart attack.
Your doctor also may order a blood test to check for
low hemoglobin (HEE-muh-glow-bin) in your blood. Hemoglobin is an iron-rich
protein in the red blood cells that carries oxygen from the lungs to all parts
of your body. If you have low hemoglobin, you may have a condition called
anemia
(uh-NEE-me-eh).
How Is Angina Treated?
Treatments for angina include lifestyle changes,
medicines, medical procedures, and cardiac rehabilitation (rehab). The main
goals of treatment are to:
- Reduce pain and discomfort and how often it
occurs
- Prevent or lower the risk of
heart
attack and death by treating the underlying heart condition
Lifestyle changes and medicines may be the only
treatments needed if your symptoms are mild and aren't getting worse. When
lifestyle changes and medicines don't control angina, you may need medical
procedures or cardiac rehab.
Unstable angina is an emergency condition that
requires treatment in the hospital.
Lifestyle Changes
Making lifestyle changes can help prevent episodes
of angina. You can:
- Slow down or take rest breaks if angina comes on
with exertion.
- Avoid large meals and rich foods that leave you
feeling stuffed if angina comes on after a heavy meal.
- Try to avoid situations that make you upset or
stressed if angina comes on with stress. Learn ways to
handle stress that can't be avoided.
You also can make lifestyle changes that help lower
your risk of heart disease. An important lifestyle change is adopting a healthy
diet. This will help prevent or reduce
high
blood pressure,
high
blood cholesterol, and
obesity.
Follow a heart healthy eating plan that focuses on
fruits, vegetables, whole grains, low-fat or no-fat diary products, and lean
meat and fish. The plan also should be low in salt, fat, saturated fat,
trans fat, and cholesterol.
Examples of healthy eating plans are the National
Heart, Lung, and Blood Institute's
Therapeutic
Lifestyle Changes (TLC) diet and the
Dietary
Approaches to Stop Hypertension (DASH) eating plan.
Your doctor may recommend TLC if you have high
cholesterol or the DASH eating plan if you have high blood pressure. Even if
you don't have these conditions, you can still benefit from these heart healthy
plans.
Other important lifestyle changes include:
- Quitting smoking, if you smoke. Avoid secondhand
smoke.
- Being physically active. Check with your doctor
to find out how much and what kinds of activity are safe for you.
- Losing weight, if you're overweight or obese.
- Taking all medicines as your doctor prescribes,
especially if you have
diabetes.
Medicines
Nitrates are the most commonly used medicines to
treat angina. They relax and widen blood vessels. This allows more blood to
flow to the heart while reducing its workload.
Nitroglycerin is the most commonly used nitrate for
angina. Nitroglycerin that dissolves under your tongue or between your cheeks
and gum is used to relieve an angina episode. Nitroglycerin in the form of
pills and skin patches is used to prevent attacks of angina. These forms of
nitroglycerin act too slowly to relieve pain during an angina attack.
You also may need other medicines to treat angina.
These medicines may include beta blockers, calcium channel blockers, ACE
inhibitors, oral antiplatelet (an-ty-PLAYT-lit) medicines, and anticoagulants
(AN-te-ko-AG-u-lants). These medicines can help:
- Lower blood pressure and cholesterol levels
- Slow the heart rate
- Relax blood vessels
- Reduce strain on the heart
- Prevent blood clots from forming
Medical Procedures
When medicines and other treatments don't control
angina, you may need a medical procedure to treat the underlying heart disease.
Angioplasty
(AN-jee-oh-plas-tee) and
coronary
artery bypass grafting (CABG) are both commonly used to treat angina.
Angioplasty opens blocked or narrowed coronary
arteries. During angioplasty, a thin tube with a balloon or other device on the
end is threaded through a blood vessel to the narrowed or blocked coronary
artery. Once in place, the balloon is inflated to push the plaque outward
against the wall of the artery. This widens the artery and restores blood flow.
Angioplasty can improve blood flow to your heart,
relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh
tube called a
stent
is placed in the artery to keep it open after the procedure.
During CABG, healthy arteries or veins taken from
other areas in your body are used to bypass (that is, go around) your narrowed
coronary arteries. Bypass surgery can improve blood flow to your heart, relieve
chest pain, and possibly prevent a heart attack.
Your doctor will help decide which treatment is
right for you.
Cardiac Rehabilitation
Your doctor may prescribe cardiac rehab for angina
or after angioplasty, CABG, or a heart attack.
The cardiac rehab team may include doctors, nurses,
exercise specialists, physical and occupational therapists, dietitians, and
psychologists or other behavioral therapists.
Rehab has two parts:
- Exercise training. This part helps you learn how
to exercise safely, strengthen your muscles, and improve your stamina. Your
exercise plan will be based on your individual abilities, needs, and interests.
- Education, counseling, and training. This part of
rehab helps you understand your heart condition and find ways to reduce your
risk of future heart problems. The cardiac rehab team will help you learn how
to cope with the stress of adjusting to a new lifestyle and to deal with your
fears about the future.
For more information on cardiac rehab, see the
Diseases and Conditions Index
Cardiac
Rehabilitation article.
How Can Angina Be Prevented?
You can prevent or lower your risk for angina and
coronary
artery disease (CAD) by making lifestyle changes and treating related
conditions.
Making Lifestyle Changes
Healthy lifestyle choices can help prevent or delay
angina and CAD. To make lifestyle changes, you can:
- Follow a healthy eating plan. (See "How Is Angina Treated" for more information.)
- Quit smoking, if you smoke. Avoid secondhand
smoke.
- Be physically active. Check with your doctor to
find out how much and what kinds of activity are safe for you.
- Learn ways to
handle stress and relax.
Treating Related Conditions
You also can help prevent or delay angina and CAD by
treating related conditions, such as:
- High
blood cholesterol. If you have high cholesterol, follow your doctor's
advice about lowering it. Take medicines as directed to lower your cholesterol.
-
High
blood pressure. If you have high blood pressure, follow your doctor's
advice about keeping your blood pressure under control. Take blood pressure
medicines as directed.
- Diabetes. If you have diabetes, follow your doctor's advice
about keeping your blood sugar level under control. Take medicines as directed.
-
Overweight or obesity. If you're overweight or obese, talk to your doctor
about how to lose weight safely.
Living With Angina
Angina isn't a
heart
attack, but it does mean that you're at greater risk of having a heart
attack than someone who doesn't have angina. The risk is even higher if you
have unstable angina. For these reasons, it's important that you know:
- The usual pattern of your angina, if you have it
regularly.
- What medicines you take (keep a list) and how to
take them. Make sure you're medicines are readily available.
- How to control your angina.
- The limits of your physical activity.
- How and when to seek medical attention.
Know the Pattern of Your Angina
Stable angina usually occurs in a pattern. You
should know:
- What causes the pain to occur
- What angina pain feels like
- How long the pain usually lasts
- Whether rest or medicine relieves the pain
After several episodes, you will learn to recognize
when you're having angina. It's important for you to notice if the pattern
starts to change. Pattern changes may include angina that occurs more often,
lasts longer, is more severe, occurs without exertion, or doesn't go away with
rest or medicines.
These changes may be a sign that your symptoms are
getting worse or becoming unstable. You should seek medical help. Unstable
angina suggests that you're at high risk for a heart attack very soon.
Know Your Medicines
You should know what medicines you're taking, the
purpose of each, how and when to take them, and possible side effects. It's
very important that you know exactly when and how to take fast-acting
nitroglycerin or other nitrates to relieve chest pain.
It's also important to know how to correctly store
your angina medicines and when to replace them. Your doctor can advise you on
this.
If you have side effects from your medicines, let
your doctor know. You should never stop taking your medicines without your
doctor's approval.
Talk to your doctor if you have any questions or
concerns about taking your angina medicines. Tell him or her about any other
medicines you might be taking. Some medicines can cause serious problems if
they're taken with nitrates or other angina medicines.
Know How To Control Your Angina
After several episodes, you will know the level of
activity, stress, and other factors that can bring on your angina. By knowing
this, you can take steps to prevent or lessen the severity of episodes.
Physical Activity
Know what level of activity brings on your angina
and try to stop and rest before chest pain starts. For example, if walking up a
flight of stairs leads to chest pain, then stop halfway and rest before
continuing.
When chest pain occurs during exertion, stop and
rest or take your angina medicine. The pain should go away in a few minutes. If
the pain doesn't go away or lasts longer than usual, call 911 for
emergency care.
Emotional Stress
Anger, arguing, and worrying are examples of
emotional stress that can bring on an angina episode. Try to avoid or limit
situations that cause these emotions.
Exercise and relaxation can help relieve stress.
Alcohol and drug use play a part in causing stress and don't relieve it. If
stress is a problem for you, talk with your doctor about getting help for it.
Eating Large Meals
If this leads to chest pain, eat smaller meals.
Also, avoid eating rich foods.
Know the Limits of Your Physical Activity
Most people with stable angina can continue their
normal activities. This includes work, hobbies, and sexual relations. However,
if you do very strenuous activities or have a stressful job, talk to your
doctor.
Know How and When To Seek Medical Attention
If you have angina, you're at a higher risk for a
heart attack than someone who doesn't have angina. So it's very important that
you and your family know how and when to seek medical attention.
Talk to your doctor about making an emergency action
plan. The plan should include making sure you and your family members know:
- The
signs
and symptoms of a heart attack
- How to use aspirin and nitroglycerin when
needed
- How to access emergency medical services in your
community
- The location of the nearest hospital that offers
24-hour emergency heart care
Be sure to discuss your emergency plan with your
family members. Take action quickly if your chest pain becomes severe, lasts
longer than a few minutes, or isn't relieved by rest or medicine.
Sometimes, it may be difficult to tell the
difference between unstable angina and a heart attack. Either way, it's an
emergency situation, and you should call 911 right away.
Key Points
- Angina is chest pain or discomfort that occurs
when your heart muscle doesn't get enough oxygen-rich blood. Angina is the
symptom of an underlying heart condition, usually
coronary
artery disease (CAD).
- CAD occurs when a fatty material called plaque
builds up on the inner walls of the coronary arteries. Plaque causes the
coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to
the heart muscle is reduced.
- Angina may feel like pressure or a squeezing pain
in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or
back.
- The most common types of angina are stable angina
and unstable angina. A rare type of angina is called variant angina.
- Stable angina occurs when the heart is
working harder than usual. Pain from stable angina goes away when you rest or
take your angina medicine. Angina medicine, such as nitroglycerin, helps widen
and relax the arteries so that more blood can flow to the heart.
- Unstable angina is a very dangerous condition
and needs emergency treatment. Unstable angina is a sign that a
heart
attack may happen soon. Unstable angina can occur with or without physical
exertion. It isn't relieved by rest or medicine.
- Variant angina is caused by a spasm
(tightening) in a coronary artery. This narrowing of the artery slows or stops
blood flow to the heart muscle. The pain may be severe. This type of angina is
relieved by medicine.
- Nearly 7 million people in the United States have
angina. It occurs equally in men and women.
- Because angina is usually a symptom of CAD, its
risk factors are usually the same as
those for CAD.
- Pain and discomfort are the main symptoms of
angina. Nausea (feeling sick to your stomach), fatigue (tiredness), shortness
of breath, sweating, light-headedness, or weakness also may occur.
- If you have chest pain, your doctor will want to
find out whether it's angina. To diagnose angina, your doctor will do a
physical exam and ask about your symptoms, risk factors, and family history of
heart disease. He or she also may order tests to confirm the diagnosis.
- Treatments for angina include lifestyle changes,
medicines, medical procedures, and
cardiac
rehabilitation. Lifestyle changes include following a healthy eating plan,
quitting smoking, being physically active, losing weight, and learning how to
handle stress and relax.
- You can prevent or lower your risk for angina and
CAD by making lifestyle changes and treating related conditions.
- If you have angina, it's important to know the
pattern of your angina, what medicines you take (keep a list) and how often you
should take then, how to control your angina, and the limits on your physical
activity. You should know how and when to seek medical help.
Links to Other Information About Angina
NHLBI Resources
Non-NHLBI Resources
Clinical Trials
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