Angina

What causes angina?

Angina is caused by a reduction in blood flow to your heart muscle. It is almost always an underlying symptom of coronary artery disease (a form of heart disease).

This chest pain occurs when one or more of the coronary arteries become narrowed. This narrowing is usually the result of a build-up of fatty acids, also known as plaques, inside the artery. This narrowing of the arteries, known as atherosclerosis, means that the heart muscle does not always receive the oxygen it needs, leading to angina. Angina symptoms can be brought on by different triggers, including physical activity and stress.

Although angina is commonly a symptom of coronary artery disease, this is not always the case. For example, Prinzmetal's angina (also known as vasospastic angina) is caused by sudden spasms in a coronary artery, and not by atherosclerosis associated with coronary artery disease.

Microvascular angina is another rare type of angina. It affects the tiny arteries in the heart known as micro vessels, causing them to become blocked or go into spasms, even in people without coronary artery disease.

However, in the majority of cases, angina is the result of atherosclerosis caused by coronary artery disease. Causes of atherosclerosis include:

• Diabetes
• High blood pressure
• Smoking
• Being overweight
• Not getting enough exercise
• Age (older people are at greater risk)
• Eating an unhealthy diet
• A family history of coronary artery disease
• Stress

It may be possible to reduce your risk of angina and coronary artery disease by giving up smoking, maintaining a healthy weight, leading an active lifestyle and eating a healthy, balanced diet.

What does angina feel like?

Not everyone experiences angina in the same way and different types of angina can cause different symptoms. Many people describe angina as a pain which can feel like tightness, heaviness, dullness or pressure, or which feels like a heavy weight pressing on their chest.

Although the symptoms of angina vary, most people describe it as:

• Pain, discomfort, a burning sensation or pressure in the chest
• A feeling of fullness in the chest
• Sharp, stabbing pains in the chest (this is more common in women than men)
• Chest pain which spreads to your arms, neck, jaw or back
• Chest pain which is triggered by exercise or exertion

Types of angina

There are several types of angina, each with its own symptoms and differing levels of severity.

Stable angina

This is the most common type of angina. It is characterised by chest pain which is brought about by physical exertion, such as stress or exercise, and usually lasts around five minutes. Most people with stable angina find that it disappears after resting for a few minutes, or after taking angina treatment medication.

Unstable angina

This is more serious than stable angina. Attacks can be unpredictable with no obvious trigger. Attacks of unstable angina are usually longer, often lasting up to 30 minutes, may not respond to angina medication and may continue even after you have rested.

People who have previously been diagnosed with stable angina can sometimes develop unstable angina. An attack of unstable angina can sometimes signal a heart attack, so you should call an ambulance immediately if this occurs.

Microvascular angina

This is a rare type of angina which affects the tiny arteries in the heart, causing them to become blocked or go into spasms. Symptoms of microvascular angina can be different to the usual pain associated with stable angina and may include:

• Chest pain which can last up to 30 minutes and may be more severe than for other types of angina
• Pain which may be accompanied by shortness of breath, sleep problems, fatigue or lack of energy
• Chest pain at times of stress, such as during exercise
• Symptoms similar to anxiety or panic attacks

Microvascular angina can be difficult to diagnose, as common tests for angina look for signs of coronary artery disease. In the case of microvascular angina, only the small arteries of the heart are affected, and these don’t show up on traditional scans or angiograms.

Variant (Prinzmetal) angina

Variant angina, also known as vasospastic or Prinzmetal angina, is caused by sudden spasms in a coronary artery, and not by atherosclerosis. In most cases, variant angina flares up at times of rest, rather than during periods of stress or exercise. Typically, attacks occur between midnight and 8am. Attacks of variant angina can be brought on by:

• Cold weather
• Stress
• Medicines which constrict blood vessels, for example, certain migraine medicines
• Smoking
• Cocaine use

Variant angina is quite rare and can usually be treated with medication and lifestyle changes.

How is angina diagnosed?

If you have had symptoms of angina or experienced an angina attack, then it’s important to arrange to see your doctor as soon as possible. To diagnose angina, your doctor will first ask you a range of questions, including:

• Medical history: Any existing medical problems you may have, including your family history (angina and heart problems can run in families).
• Symptoms: You will need to describe your symptoms, how severe they were and how long they lasted.
• Activity: What you were doing when the symptoms began (whether you were under stress, or engaged in a strenuous activity).
• Lifestyle factors: These will include whether you smoke, follow a healthy diet, lead an active lifestyle or have any other risk factors for angina.

Your doctor will also carry out a physical examination, which will include:

• Blood pressure check: High blood pressure is often related to angina.
• Listening to your heart: A simple test of the sound of your heart, using a stethoscope.
• Checking your BMI: This stands for body mass index, which measures whether you are a healthy weight for your height. High BMI (being overweight or obese) is related to angina and coronary artery disease.
• Measurement of your waist: Men with a waist size over 37in and women with a waist size over 31.5in are at high risk of coronary artery disease.

If your doctor thinks that you may have angina, coronary artery disease or another heart problem, they will refer you for further investigations and tests. These may include:

• Blood tests: These provide information about your heart muscle by measuring the enzymes, cholesterol and proteins in your blood.
• Electrocardiogram (ECG): In this test, sensors are attached to your chest and the rate, rhythm and electrical activity of your heart are measured. It is a painless test which usually only takes a few minutes to complete.
• Exercise ECG (also known as a cardiac stress test): This is an ECG which is carried out while you are walking on a treadmill, to see how your heart responds to moderate exercise. This test usually takes around half an hour and you will be monitored by a consultant throughout. Your blood pressure will also be recorded.
• Cardiac CT scan: A high-definition CT scan looking at the arteries surrounding your heart.
• Coronary angiogram (also known as cardiac catheterisation): During this procedure a small, flexible tube is inserted into your artery, at the top of your leg or in your arm, and a fine wire is guided along the arteries of your heart. A dye is then injected and a series of X-rays are taken so that the consultant can see whether your coronary arteries are narrowed or blocked. An angiogram is a non-surgical procedure which is carried out under local anaesthetic, within a catheterisation lab or theatre. If blockages are detected in your coronary artery, your consultant may carry out a coronary angioplasty.
• Coronary angioplasty: This is when a balloon is used to inflate a narrowed artery, which is then held open by a stent (a small wire tube). This procedure can be used to treat the symptoms of angina and also as an emergency treatment following a heart attack.
• Other imaging tests: These include MRI for chest pain and PET scans, which provide high-definition images of your heart and surrounding arteries.

Your doctor will identify which tests are most appropriate for you. If you are worried about angina and would like to speak to a medical professional, HCA UK offers same-day and next-day private GP appointments.

Angina treatment

If you think you may have angina, then it’s extremely important to see your doctor and get a diagnosis as soon as possible. Getting the right treatment for angina symptoms can significantly relieve them, as well as help to decrease the risk of heart attack or stroke.

If you are diagnosed with angina, there are several different treatment options available, either through medication or procedures.

Medication

Your doctor may prescribe one or more of a variety of medications to help address the underlying issue. These could include:

• GTN: Most people with stable angina will be prescribed a medicine called glyceryl trinitrate (GTN), which comes either in spray form or as tablets which dissolve under your tongue. You should take GTN as soon as you feel an angina attack coming on. GTN works by dilating your arteries, which puts less pressure on the heart muscle.
• Beta blockers: These are sometimes prescribed to prevent angina attacks. Beta blockers slow down the heart by reducing the amount of adrenaline your body produces.
• ACE (Angiotensin-converting enzyme) inhibitors: These drugs reduce blood pressure by helping to relax your veins and arteries.
• Calcium channel blockers: These prevent calcium from entering your arteries and heart, helping the blood vessels to relax and reducing blood pressure.
• Aspirin: This helps to thin the blood and prevent heart attacks and strokes in people with angina.
• Statins: These are used to lower cholesterol, which helps prevent blockages in the blood vessels.

If you are diagnosed with unstable angina, then your doctor may also prescribe the medicine clopidogrel, ticagrelor or prasugrel, which prevent blood clots from forming.

If your angina is very serious, or if the medication you have been prescribed during treatment does not relieve symptoms, then your doctor may recommend surgery.

Procedures

There are two main types of procedures to treat coronary artery disease. These are:

Coronary Artery Bypass Graft (CABG): An artery from another part of your body, usually in the chest, leg or arm, is attached above and below the blocked section of the coronary artery to divert the blood flow (known as a graft). The operation is carried out under general anaesthetic and lasts for between three and six hours. You may need more than one graft, depending on how severe your coronary artery disease is.

Coronary Angiogram and stent insertion: This is a procedure performed in a cardiac catheterisation laboratory when a balloon is used to inflate a narrow artery, which is then held open by a stent (a small wire tube). This procedure can be used to treat the symptoms of angina, and also as an emergency treatment following a heart attack.

In addition to medication and surgical options, your doctor will probably recommend making some lifestyle changes to help with your symptoms of angina. These are likely to include:

• Eating a healthy diet and maintaining a healthy weight
• Cutting down on alcohol
• Giving up smoking
• Trying to avoid stress
• Taking regular exercise: You will need to start slowly and build up your activity level gradually. Ask your doctor for advice before starting a new exercise regime

Living with angina

If you are diagnosed with angina, then there is no reason you can’t go on to lead a long, healthy life, as long as you make the necessary changes to your lifestyle and follow the course of angina treatment recommended by your doctor.

Making lifestyle changes such as taking up regular exercise, improving your diet and giving up smoking can help to relieve your angina symptoms, prevent your coronary artery disease from getting any worse and reduce your risk of heart attack and stroke. In addition, such lifestyle changes can also help you avoid many other illnesses including cancer and type 2 diabetes.

With the right treatment, most people with angina can continue to work, drive and enjoy physical activity, including a normal sex life.

If you are finding it hard to come to terms with your angina diagnosis or would like to talk to someone in the same position as yourself, then the British Heart Foundation has a number of useful resources.

At HCA UK, we also offer a dedicated cardiac rehabilitation service which supports cardiac patients through their long-term recovery, promoting well-being through exercise, lifestyle management and education.