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What is Angina?

Angina is a common condition which, according to the British Heart Foundation affects about two percent of the UK population. It is important to note that angina is not a heart attack. Angina, or Angina Pectoris to give it it’s proper title is a specific type of chest pain, discomfort or tightness in the chest that is caused by a lack of oxygen being supplied to the heart, due to a reduction in the flow of blood to the heart. It may also be accompanied by shortage of breath or even a feeling of choking. It is usually a symptom of coronary heart disease or coronary artery disease, and may indicate an increased risk of heart attack Difference between Angina and Heart Attack. A Heart Attack or Myocardial Infarction (MI) occurs when a coronary artery becomes completely blocked, and the heart muscle supplied by that artery will die unless the blockage is quickly removed. The pain of a heart attack is more severe and prolonged than angina and cannot be relieved by the usual angina treatments. If you are having a heart attack, you may also feel sick, breathless and sweaty, and may vomit. Sometimes, however, there are no symptoms at all.

Causes of Angina

Angina is caused by a shortfall in the demand by the heart for blood supplied from the coronary arteries. These are the two main arteries by which oxygen and nutrient rich blood enters the heart to supply the requirements of the beating heart muscle. When a person suffers from coronary artery disease Atherosclerosis the arteries become narrowed over time by fatty deposits known as plaques or Atheroma. This narrowing of the arteries restricts the flow of incoming blood, and the reaction of the heart is to cause a pain in the chest. Angina pain tends to manifest itself when an extra load is placed on the heart, for example by climbing stairs, running, or other strenuous exercise. It is also sometimes experienced after eating a heavy meal. There are also pyschological causes, or aggravating factors which may trigger or worsen an attack of angina including anger, stress or other psychological or emotional trauma.

Different types of Angina

There are three main types of angina:

1. Stable Angina

This type of angina is usually triggered by physical activity, and occurs as a result of the coronary arteries being unable to supply sufficient blood to meet the demands of the additional activity, due to their narrowing, which restricts the flow of blood at times of peak demand. This type of angina pain usually lasts for only a few minutes and then goes away when the physical activity is reduced to ‘normal’ levels. However, if the activity is resumed, then the pain usually returns. This type of angina usually builds up gradually, and does not normally lead to instant life threatening situations, unless early symptoms are ignored.

2. Unstable angina

Unstable angina is a type of angina pain that is triggered by only a small amount of physical activity, or by no physical activity whatsoever. The cause is still related to a narrowing of the coronary arteries, but this may be due to a transient event such as a blood clot or a piece of dislodged plaque causing a sudden extrem narrowing of an artery.This type of angina leads to a greater risk of an imminent heart attack than stable angina. Unstable Angina is a medical emergency, and the only safe course of action is to seek emergency medical treatment.

3. Variant angina

This is a less common type of angina than the stable and unstable types. It usually occurs without warning, and for a different reason, being caused by a ‘spasm’ of a coronary artery, similar to a muscle spasm. It is a difficult condition to diagnose, often requiring more complex investigation, and possibly involving other symptoms such as erratic heart beart or Arrythmia.

Symptoms and Diagnosis of Angina

The symptoms of Angina are primarily pain in the chest, which may spread to the neck throat and arms. These may also be accompanied by additional symptoms such as nausea, loss of breath, sweating and a feeling or dread or fear. When a patient complains of chest pain, their physician will inevitably attempt to rule out trivial causes such as muscle strain, excessive coughing, or physical injury. Combined with an examination of the patients medical history, age, lifestyle and risk factors. Angina may then be suspected as a possible cause. However, the physician will usually also examine the patient’s medical history, ask for a detailed description of the pain and carry out a comprehensive physical examination involving some simple tests:-

• Tests for blood pressure and heart rate
• Tests for pulse rate in the legs
• Examination of the ankles for swelling
• Listening to the heart rhythm using the stethoscope
• Examination of any physical symptoms of high blood pressure
• Testing of cholesterol levels
• Testing for or anaemia.

More complex diagnostic tests may then need to be performed to confirm the diagnosis of angina, including:-

• Exercise-ECG (electrocardiograph)
• Blood tests for diabetes or anaemia
• Chest X-ray
• Echocardiogram
• Coronary angiogram

Who is likely to suffer from Angina?

The following facts may help to understand who is likely to develop angina:- Angina is more common in men than women Older people are more likely to develop the condition than younger people Smoking may lead to Angina High Cholesterol may lead to angina High blood Pressure may cause the condition Sedentary lifestyle with little or no exercise is a risk factor Diabetes Mellitus sufferers are vulnerable to the condition People who are overweight are also at risk Family history increases the risk of developing angina

Treatments for Angina

There are three different types of treatment for Angina – Lifestyle Changes, Medication and Surgical Intervention. Note – Unstable angina is a medical emergency which requires immediate medical treatment in a hospital, due to the risk of an immediate heart attack. A single 300mg dose of aspirin is usually administered to the patient as a precautionary measure against the enlargement of any blood clot in the coronary arteries. Other Anticoagulants (medicines that prevent the clotting of the blood) such as heparin, as well intravenous (by injection into a vein) nitrates and beta-blockers may also be necessary.

Lifestyle Changes to treat Angina

These are generally within the control of the patient and may prevent future angina problems or a worsening of the condition, or even a heart attack. The top ten lifestyle changes are :-

• Stopping Smoking
• Losing weight, if overweight or obese
• Reducing blood cholesterol
• Changing diet to a low-fat, high-fibre diet, rich in fruit and vegetables and oily fish
• Stress reduction
• Drinking alcohol in moderation
• Taking regular exercise under the advice of your physician
• Attending regular health check-ups with your physician
• Lowering your blood pressure
• If you have diabetes, you should aim to closely control your blood sugar levels, as advised by your nurse or doctor.

Medication for Angina

Angina medication falls into two categories – immediate relief from symptoms, and treatment for the the longer term.

Immediate Treatments for Angina

The purpose of immediate treatment is to provide rapid pain relief and to prevent the recurrence of angina pains, as much as can be achieved. The following treatments may be administered to provide rapid relief of the symptoms of angina:-

• Glyceryl trinitrate (GTN) is a quick acting nitrate that is prescribed to provide pain relief before, or during angina attacks. It comes as a oral spray or in tablet form, and is usually taken at the start of an angina attack. GTN is effective in relaxing the coronary arteries so that more blood can flow through them and reach the heart muscle, but the benefit only lasts for a short period of time.
• Aspirin. If you have unstable angina, you will probably be given aspirin as soon as you are admitted to hospital, to help stop your blood from clotting and prevent a heart attack.
• Heparin. This is another medicine that prevents the blood from clotting. You will probably be given a heparin if you have unstable angina, while you are in hospital.

Long-term treatment for the prevention of Angina attacks

Under the care of a physician or heart surgeon, one or more of the following long term treatments for angina may be prescribed:-

• Low Dose Aspirin. You will probably be prescribed a small daily dose of aspirin if you have stable angina, as it lowers the risk of having a heart attack. However, aspirin increases your risk of stomach problems such as ulcers or indigestion, so it is not suitable for some patients. Ask your GP for advice about whether you should take aspirin.
• Beta-blockers (eg atenolol, bisoprolol, carvedilol, metoprolol, sotalol). These slow your heart rate and the pumping power of the heart. This reduces your heart’s demand foroxygen. Beta-blockers aren’t suitable for people with asthma.
• Long-acting nitrates (eg isosorbide mononitrate, isosorbide dinitrate). These widen the coronary arteries to improve blood flow to the heart. They are available as tablets or patches. Although they do not provide relief as quickly as GTN, there effects are much longer lasting.
• Calcium-channel blockers (eg amlodipine, felodipine, diltiazem, nicardipine, nifedipine, verapamil). These relax the coronary arteries and other blood vessels, and reduce the force of the contraction of the heart.
• Statins (for example, atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin) lower the blood cholesterol level by preventing cholesterol from being made in the liver. Generally, the higher the blood cholesterol level, the greater the risk of developing atheroma or plaques (fatty deposits) in the arteries. The aim is to reduce the total blood cholesterol level to below 4 mmol/l or by 25% of the original blood level – whichever gives the greatest reduction.
• Potassium-channel activators (eg nicorandil). These relax coronary arteries to increase blood flow. Statins (eg simvastatin). These help reduce your cholesterol level, preventing fatty deposits in your coronary arteries from building up further.

Surgical Intervention for Angina

For people with severe angina, the best treatment may be surgery or angioplasty.

Angioplasty

Angioplasty (also known as percutaneous coronary intervention or PCI) uses a miniature collapsed balloon, which is threaded through the blood vessels until it reaches the arteries of the heart. The balloon is inflated to widen the blocked coronary artery. A stent (flexible mesh tube) is sometimes inserted to help keep the artery open after the operation.

Coronary artery bypass graft (CABG)

This is a surgical procedure where healthy blood Vessels from the legs or chest are used to bypass the artery blockage. This creates a new channel through which the blood can be directed past the blocked part of the artery. As a result, more blood can reach the heart muscle. It is classed as a type of open-heart surgery and therefore is more complex, and requires a longer stay in hospital. Due to the dependency of the location of the narrowed artery, not all angina patients are suitable for CABG.