Angina
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Angina is chest pain or discomfort that occurs when your heart muscle
does not get enough blood. Angina may feel like pressure or a squeezing pain
in your chest. The pain may also occur in your shoulders, arms, neck, jaw,
or back. It may also feel like indigestion.
Angina is a symptom of coronary artery disease (CAD), the most common
type of heart disease. CAD occurs when plaque builds up in the coronary arteries.
This buildup of plaque is called atherosclerosis. As plaque builds up, the
coronary arteries become narrow and stiff. Blood flow to the heart is reduced.
This decreases the oxygen supply to the heart muscle.
There are 3 types of angina-stable, unstable, and variant (Prinzmetal's).
It is very important to know the differences among the types.
Stable angina is the most common type. It occurs when the
heart is working harder than usual.
There is a regular pattern to stable angina.
After several episodes, you learn to recognize the pattern and can predict
when it will occur.
The pain usually goes away in a few minutes when you rest or take your angina
medicine.
Stable angina is not a heart attack but makes it more likely that you will
have a heart attack in the future.
Unstable angina. Unstable angina is a very dangerous condition that requires
emergency treatment. It is a sign that a heart attack could occur soon. Unlike
stable angina, it does not follow a pattern. It can occur without physical
exertion and is not relieved by rest or medicine.
Variant angina. Variant angina is rare. It usually occurs at rest. The
pain can be severe and usually occurs between midnight and early morning. It
is relieved by medication.
Not all chest pain or discomfort is angina. Chest pain or discomfort can
be caused by a heart attack, lung problems (such as an infection or a blood
clot), heartburn, or a panic attack. However, all chest pain should be checked
by a doctor.
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Angina is caused by reduced blood flow to an area of the heart. This is
most often due to coronary artery disease (CAD). Sometimes, other types of
heart disease or uncontrolled high blood pressure can cause angina.
In CAD, the arteries that carry oxygen-rich blood to the heart muscle
are narrowed due to the buildup of fatty deposits called plaque. This is called
atherosclerosis. 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 inner walls of the arteries can cause angina
in two ways:
By narrowing the artery to the point where the flow of blood is greatly reduced
By forming blood clots that partially or totally block the artery.
Physical exertion is the most common cause of pain and discomfort from
stable angina. Severely narrowed arteries may allow enough blood to reach the
heart when the demand for oxygen is low (such as when you are sitting). But
with exertion like walking up a hill or climbing stairs, the heart works harder
and needs more oxygen. Other causes include:
Emotional stress
Exposure to very hot or cold temperature
Heavy meals
Smoking.
Unstable angina is caused by blood clots that partially or totally block
an artery. If plaque in an artery ruptures or breaks open, blood clots may
form. This creates a larger blockage. The clot may grow large enough to completely
block the artery and cause a heart attack. Blood clots may form, partly dissolve,
and later form again. Chest pain can occur each time a clot blocks an artery.
Variant angina is caused by a spasm in a coronary artery. The spasm causes
the walls of the artery to tighten. This narrows the artery, causing the blood
flow to the heart to slow or stop. Variant angina may occur in persons with
and without CAD. Other causes of spasms in the arteries that supply the heart
with blood are:
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Over 6 million people in the U. S. have angina.
People with coronary artery disease (CAD) or who have had a heart
attack are more likely to have angina.
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 with variant angina are often younger than those with other
forms of angina.
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The pain or discomfort of angina:
Is often described as pressure, squeezing, burning, or tightness in the chest
Usually starts in the chest behind the breastbone
May also occur in the arms, shoulders, neck, jaw, throat, or back
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, fatigue,
shortness of breath, sweating, light-headedness, or weakness may also occur.
Stable Angina
The pain or discomfort:
Occurs when the heart must work harder, usually during physical exertion
Is expected, and episodes of pain tend to be alike
Usually lasts a short time (5 minutes or less)
Is relieved by rest or angina 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
Is unexpected
Is more severe and lasts longer (as long as 30 minutes) than stable angina
episodes
Is usually not relieved with rest or angina medicine
May get continuously worse
May signal 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 angina medicine.
Chest pain that lasts longer than a few minutes and is not relieved by rest
or angina medicine may mean you are having-or are about to have-a heart attack.
Get emergency help right away.
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To find out if you have angina, your doctor will:
Do a physical exam
Ask about your symptoms
Ask about your risk factors and your family history of coronary artery disease
(CAD) or other heart disease.
Sometimes, your doctor can diagnose angina by noting your symptoms and how
they occur. Your doctor may order one or more tests to help make a diagnosis
of angina. The tests your doctor may order include:
EKG or ECG (electrocardiogram). This test measures the rate and regularity
of your heartbeat. Some people with angina have a normal EKG.
Exercise stress test. This test shows how well your heart pumps at higher
workloads when it needs more oxygen. EKG and blood pressure readings are
taken before, during, and after exercise to see how your heart responds
to exercise. The first EKG and blood pressure reading are done to get a
baseline. Readings are then taken while you walk on an exercise treadmill,
pedal a stationary bicycle, or receive medicine to make your heart beat
faster. The test continues until you reach a heart rate set by your doctor.
The exercise part is stopped if chest pain or a very sharp rise in blood
pressure occurs. Monitoring continues for 10 to 15 minutes after exercise
or until your heart rate returns to baseline.
Chest x-ray. A chest x-ray takes a picture of the organs and structures inside
your chest. These include your heart, lungs, and blood vessels.
Nuclear heart scan. This test shows blood flow to the heart and any damage
to the heart muscle. A radioactive dye (technetium or thallium) is injected
into your bloodstream. A special camera can then see the dye and find areas
where there is less blood flow. Nuclear heart scans are often taken while
you are at rest and again after exercise. If you cannot exercise, a medication
is given to increase the workload of the heart. The before-and-after exercise
scans are compared.
Echocardiogram. This test uses sound waves to create a picture of the heart.
The picture is more detailed than an x-ray image. The test shows how well
your heart chambers fill with blood and pump it to the rest of the body.
An echocardiogram also can help identify areas of poor blood flow to the
heart, areas of heart muscle that are not contracting normally, and previous
injury to the heart muscle caused by poor blood flow. An echocardiogram
can also be used with a stress test.
Cardiac catheterization. A thin flexible tube (catheter) is passed through
an artery in the groin or arm to reach the coronary arteries. Your doctor
can determine pressure and blood flow in the heart's chambers, collect
blood samples from the heart, and examine the arteries of the heart by
x-ray.
Coronary angiography. This test is done during cardiac catheterization. A
dye that can be seen by x-ray is injected through the catheter into the
coronary arteries. Your doctor can see the flow of blood through the heart
and see where there are blockages.
Your doctor may also order blood tests, such as:
A fasting lipoprotein profile to check your cholesterol levels.
Fasting glucose test to check your blood sugar level.
C-reactive protein (CRP) test. This blood test measures CRP, a protein in
the blood that shows the presence of inflammation. Inflammation is the
body's response to injury. High levels of CRP may be a risk factor for
CAD.
A test to check for low hemoglobin in your blood. Hemoglobin is the part
of red blood cells that carries oxygen to all parts of your body.
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Treatment for angina includes lifestyle changes, medication, surgery, and
rehabilitation. The main goals of treatment are to:
Reduce the frequency and severity of symptoms
Prevent or lower the risk of heart attack and death.
Lifestyle changes and medication may be the only treatments needed if your
symptoms are mild and are not getting worse. Unstable angina is an emergency
condition that requires treatment in the hospital.
The first thing that you need to do is change your living habits to
avoid bringing on an episode of angina. If angina comes on
With exertion, slow down or take rest breaks.
Avoid large meals and rich foods that leave you feeling
stuffed.
Try to avoid situations that make you upset or stressed. Learn
techniques to handle stress that can't be avoided.
Other changes that you need to make include:
Eat a healthy diet to prevent or reduce high blood pressure and high blood
cholesterol, and obesity
If you smoke, quit.
Exercise as directed by your doctor. Scientists have discovered that you can add three and a half years to your life with regular exercise and your heart can benefit from simple exercises such as brisk walking for half-hour a day. A study found several walking routines can improve heart health: walking for 30 minutes three or four days a week, moderately or briskly, improved cardio-respiratory fitness. Fast-paced walking five days or more per week can lower cholesterol levels in the short-term.
Lose weight if you are overweight.
If you have diabetes, follow your doctor's orders and take all medications
as directed.
Medications
Nitrates are the most commonly used medicines to treat angina. Fast-acting
preparations are taken when angina occurs or is expected to occur. Nitrates
relax and widen blood vessels, allowing more blood to flow to the heart while
reducing its workload.
You can use nitrates in different forms to:
Relieve an episode that is occurring by using the medicine when the pain
begins
Prevent episodes from occurring by using the medicine just before pain or
discomfort is expected to occur
Reduce the number of episodes that occur by using the medicine regularly
on a long-term basis.
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. (Nitroglycerin in these forms acts
too slowly to relieve pain during an angina attack.)
Other medicines used to treat angina include:
Beta blockers, which slow heart rate and lower blood pressure. They
can delay or prevent the onset of angina.
Calcium channel blockers, which relax blood vessels so that more blood flows
to the heart, reducing pain from angina. Calcium channel blockers also
lower blood pressure.
ACE inhibitors lower blood pressure and reduce the strain on the heart. They
also reduce the risk of a future heart attack and heart failure.
Medicines that may also be used by people with angina include:
Medicines to lower cholesterol levels
Medicines to lower high blood pressure
Oral antiplatelet (an-ty-PLAYT-lit) medicines (such as aspirin and clopidigrel)
taken daily to stop platelets from clumping together to form blood clots.
Platelets are small blood cell fragments that circulate through your blood
vessels and help stop bleeding by sticking together to seal small cuts
or breaks in tiny blood vessels. Antiplatelet medicines may not be appropriate
for some people because they increase the risk of bleeding. Discuss the
benefits and risks with your doctor before starting therapy with aspirin
or the other antiplatelet medicines.
Glycoprotein IIb-IIIa inhibitors are potent antiplatelet medicines that prevent
clots from forming in your arteries. They are given intravenously in hospitalized
patients in the treatment of angina or during and after angioplasty.
Anticoagulants (an-ty-ko-AG-u-lants) to prevent clots from forming in your
arteries and blocking blood flow.
Special (Invasive) Procedures
When medicines and other treatments do not control angina, special
procedures may be needed. Two commonly used procedures are:
Angioplasty to open blocked or narrowed coronary arteries. It can
improve blood flow to your heart, relieve chest pain, and possibly prevent
a heart attack. Sometimes a stent is placed in the artery to keep it propped
open after the procedure.
Coronary artery bypass surgery, which uses arteries or veins from other areas
in your body to bypass your blocked coronary arteries. Bypass surgery improves
blood flow to your heart, relieves chest pain, and can prevent a heart
attack.
Cardiac Rehabilitation (Rehab)
Your doctor may prescribe cardiac rehab for angina or after bypass
surgery, angioplasty, or a heart attack.
The cardiac rehab team may include:
Doctors
Your family doctor
A heart specialist
A surgeon
Nurses
Exercise specialists
Physical therapists and occupational therapists
Dietitians
Psychologists or other behavior therapists.
Rehab has two parts:
Exercise training to help you learn how to exercise safely, strengthen your
muscles, and improve your stamina. Your exercise plan will be based on
your individual ability, needs, and interests.
Education, counseling, and training to help 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.
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You can prevent or lower your risk for heart disease and angina by making
lifestyle changes and getting treatment for related conditions.
Make Lifestyle Changes
You can lower your risk of heart disease and angina by making healthy
lifestyle choices:
Eat a healthy diet to prevent or reduce high blood pressure and high
blood cholesterol, and maintain a healthy weight.
If you smoke, quit.
Exercise as directed by your doctor.
Lose weight if you are overweight or obese.
Treat Related Conditions
In addition to making lifestyle changes, you can help prevent heart
disease and angina by treating related conditions, such as:
High blood cholesterol. If you have high cholesterol, follow your
doctor's advice about lowering it. Take medications to lower your cholesterol
as directed.
High blood pressure. If you have high blood pressure, follow your doctor's
advice about keeping your blood pressure under control. Take blood pressure
medications as directed.
High blood sugar (diabetes). If you have diabetes, follow your doctor's advice
about keeping your blood sugar levels under control. Take medications as
directed.
Obesity. If you are overweight or obese, talk to your doctor about how to
lose weight safely.
How Can I Prevent Angina?
You can prevent or lower your risk for heart disease and angina by making lifestyle
changes and getting treatment for related conditions.
Make Lifestyle Changes
You can lower your risk of heart disease and angina by making healthy lifestyle
choices:
Eat a healthy diet to prevent or reduce high blood pressure and high
blood cholesterol, and maintain a healthy weight.
If you smoke, quit.
Exercise as directed by your doctor.
Lose weight if you are overweight or obese.
Treat Related Conditions
In addition to making lifestyle changes, you can help prevent heart
disease and angina by treating related conditions, such as:
High blood cholesterol. If you have high cholesterol, follow your
doctor's advice about lowering it. Take medications to lower your cholesterol
as directed.
High blood pressure. If you have high blood pressure, follow your doctor's
advice about keeping your blood pressure under control. Take blood pressure
medications as directed.
High blood sugar (diabetes). If you have diabetes, follow your doctor's advice
about keeping your blood sugar levels under control. Take medications as
directed.
Obesity. If you are overweight or obese, talk to your doctor about how to
lose weight safely.
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Angina is not a heart attack, but it does mean that you are at greater
risk of having a heart attack than someone who does not have angina. The
risk is even
higher if you have unstable angina. For these reasons, it is important that
you know:
The usual pattern of your angina if you have it on a regular basis
About your medication
How to control your angina
The limits on 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 it feels like
How long it usually lasts
Whether it is relieved by rest or medicine.
After several episodes, you will learn to recognize when you are having angina.
It is important for you to notice if the pattern starts to change. The changes
in the pattern to look for are if episodes:
Occur more often
Last longer
Are more severe
Occur without exertion
Do not go away with rest or medication.
These changes in the pattern may be a sign that your symptoms are getting
worse or becoming unstable. You should seek medical attention. Unstable angina
suggests that you are at high risk for a heart attack very soon.
Know Your Medications
You should know what medications you are taking, the purpose of each,
how and when to take them, and possible side effects. It is very important
that you know exactly when and how to take fast-acting nitroglycerin or other
nitrates to relieve chest pain. They should be taken:
Immediately when pain begins or before stressful activity
Three times spaced 5 minutes apart if pain does not go away.
Always sit down before taking nitroglycerin.
Long-acting nitrate preparations should be used regularly as prescribed by
your doctor.
Men with impotence (erectile dysfunction) who take sildenafil (ViagraŽ)
should talk with their doctor. Taking sildenafil and nitroglycerin or other
nitrates within 24 hours of each other can cause serious problems.
Ask your doctor about your other medicines. Also follow the links
in the Treatment section to read descriptions of the medications that you
are taking.
After several episodes, you will know the level of activity, stress,
and other things that can bring on your angina. By knowing what brings on
your angina, you can take steps to prevent or lessen the severity of episodes.
Physical exertion. Know what level of activity brings on your angina
and try to stop and rest before chest pains start. For example, if walking
up a flight of stairs leads to chest pains, 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
does not go away or lasts longer than usual, call 9-1-1 and get 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 exposure
to situations that cause these emotions. Exercise and relaxation can help
relieve stress. Alcohol and drug use play a part in causing stress and
do not relieve it. If stress is a problem for you, talk with your doctor
about getting counseling to help you deal with stress.
Eating large meals. If this leads to chest pain, eat smaller meals. Also,
avoid eating rich foods.
Know the Limits on Your Physical Activity
Most people with stable angina can continue their normal activities.
This includes work, hobbies, and sexual relations. However, if you engage
in very strenuous activity or have a stressful job, you may need to discuss
this with your doctor.
If you have angina, you are at high risk of having a heart attack.
Therefore, it is 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:
The signs and symptoms of a heart attack
Instructions for the prompt use of aspirin and nitroglycerin
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 is more severe, lasts longer, or is not relieved
by rest or medication.
Sometimes, it may be difficult to tell the difference between unstable
angina and a heart attack. Most heart attack victims wait 2 hours or more
after their symptoms begin before they seek medical help. This delay can
result in death or lasting heart damage
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- Angina is chest pain or discomfort that occurs when your heart muscle
does not get enough blood. Angina may feel like pressure or a squeezing
pain in your chest. The pain may also occur in your shoulders, arms, neck,
jaw, or back.
- Most people with angina have coronary artery disease, with narrowed arteries
due to atherosclerosis. When arteries are narrowed, blood flow to the heart
is reduced.
- More than 6 million people in the U.S. have angina.
- The most common types of angina are stable angina and unstable angina.
A less-common type of angina is called variant angina.
- Stable angina is chest pain or discomfort that occurs when the heart
is working harder than usual. Stable angina pain 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 that requires emergency
treatment.
- Unstable angina is a sign that a heart attack could occur soon. Unstable
angina can occur without physical exertion. It is not relieved by rest or
medicine.
- Variant angina is caused by a spasm in a coronary artery. The spasm causes
the walls of the artery to tighten. This narrowing of the artery slows or
stops blood flow to the heart.
- Doctors diagnose angina based on your health history, family history,
physical exam, and the results of various tests.
- Angina is usually treated with medicines such as nitrates (nitroglycerin).
People with angina may need to take other medications to lower their blood
pressure or cholesterol. They also may take medicine to prevent blood clots.
- To both prevent and treat angina, it is important to make changes to
improve your health: get regular exercise, maintain a healthy weight, don't
smoke, and eat a healthy diet low in saturated fat and cholesterol. A cardiac
rehab program can be helpful for many people with angina.
- When medicines and lifestyle changes do not control angina, special procedures
may be needed. Angioplasty and coronary artery bypass surgery are two common
procedures used to treat angina.
- If you have angina, it is important to know the pattern of your angina,
about your medication, how to control your angina, and the limits on your
physical activity. You should know how and when to seek medical help.
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