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Stable Angina

Definition :
Angina is a type of chest pain or discomfort caused by reduced blood flow to the heart muscle. Angina (an-JI-nuh or AN-juh-nuh) is a symptom of coronary artery disease. When your heart muscle (myocardium) doesn't get enough oxygen-rich blood, you may have chest pain. Angina is typically described as squeezing, pressure, heaviness, tightness or pain in your chest. Many people with angina say it feels like someone is standing on their chest.

Angina, also called angina pectoris (pectoris means chest), may be stable or unstable :

  • Stable angina (also called chronic stable angina)
  • Unstable angina (signals an impending heart attack)

A third, a rare type of angina called variant angina (also called Prinzmetal's angina) is caused by a coronary artery spasm.

Angina is relatively common. More than 6 million people in the United States have angina. Angina can be hard to distinguish from other types of chest pain, such as the pain or discomfort of indigestion. If you have unexplained chest pain, seek medical attention right away.

Causes :
Angina is caused by reduced blood flow to your heart muscle. Your blood carries oxygen, which your heart muscle needs to survive. When your heart muscle isn't getting enough oxygen, it causes a condition called ischemia.

The most common cause of reduced blood flow to your heart muscle is coronary artery disease (CAD). Your heart (coronary) arteries can become narrowed by fatty deposits called plaques. This is called atherosclerosis.

This reduced blood flow is a supply problem — your heart is not getting enough oxygen-rich blood. You may wonder why you don't always have angina if your heart arteries are narrowed due to fatty buildup. This is because during times of low demand — when you're resting, for example — your heart muscle may be able to get by on the reduced amount of blood flow without triggering angina symptoms. But when you increase the demand for oxygen, such as when you exert yourself, this can cause angina.

  • Stable angina. Stable angina is triggered by physical exertion. When you climb stairs, exercise or walk, your heart demands more blood, but it's harder for the muscle to get enough blood when your arteries are narrowed. Besides physical activity, factors such as emotional stress, cold temperatures, heavy meals and smoking also can narrow arteries and trigger angina.
  • Unstable angina. If fatty deposits (plaques) in your blood vessel rupture or a blood clot forms, it can quickly block or further reduce flow through the already narrowed artery, suddenly and severely decreasing blood flow to the heart muscle. Unstable angina can also be caused by conditions such as severe anemia, especially if an individual already has narrowed coronary arteries. Unstable angina worsens and is not relieved by rest or your usual medications. If the blood flow doesn't improve, heart muscle deprived of oxygen dies — a heart attack. Unstable angina is dangerous and requires emergency treatment.
  • Variant angina. Variant angina, also called Prinzmetal's angina, is caused by a spasm in a coronary artery in which the artery briefly narrows. This narrowing reduces blood flow to your heart. Variant angina is relatively rare and accounts for about 2 percent of angina cases.

Risk Factor :
Having coronary artery disease increases your risk of angina. If you've had a heart attack, this also increases your risk. Unstable angina is more common in older adults. The following risk factors increase your risk of coronary artery disease and angina :

  • Tobacco smoke. Smoking and long-term exposure to secondhand smoke damage the interior walls of arteries — including arteries to your heart — allowing deposits of cholesterol to collect and hamper blood flow.
  • High blood pressure. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. Over time, high blood pressure damages arteries that feed your heart by accelerating atherosclerosis. High blood pressure can be an inherited problem. The risk of high blood pressure increases as you age, but the main culprits for most Americans are eating a diet too high in salt, stress, inadequate exercise and being overweight.
  • High blood cholesterol or triglyceride levels. Cholesterol is a major part of the deposits that can narrow arteries throughout your body, including those that supply your heart. A high level of the wrong kind of cholesterol in your blood increases your risk of angina and heart attacks. Low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries. A high LDL level is undesirable and is often a byproduct of a diet high in saturated fats and cholesterol. A high level of triglycerides, a type of blood fat related to your diet, also is undesirable. However, a high level of high-density lipoprotein (HDL) cholesterol (the "good" cholesterol) is desirable and lowers your risk of angina and heart attacks.
  • Lack of physical activity. An inactive lifestyle contributes to high blood cholesterol levels and obesity. Conversely, people who get regular aerobic exercise have a lower overall risk of coronary artery disease, angina and heart attacks. Exercise is beneficial in lowering high blood pressure, which may account for much of the benefit. However, it is important to consult with your doctor before starting an exercise program.
  • Obesity. Obesity involves having a high proportion of body fat. Obesity raises the risk of angina and heart disease because it's associated with high blood cholesterol levels, high blood pressure and diabetes. Also, your heart has to work harder to supply blood to the excess tissue.
  • Diabetes. Diabetes is the inability of your body to produce or respond to insulin properly. Insulin, a hormone secreted by your pancreas, allows your body to use glucose, which is a form of sugar from foods. Diabetes can occur in childhood, but it appears more often in middle age and among overweight people. Diabetes greatly increases the risk of coronary artery disease, which leads to angina and heart attacks by speeding up atherosclerosis and negatively affecting blood cholesterol levels.
  • Stress. You may respond to stress in ways that can increase your risk of angina and heart attacks. If you're under stress, you may overeat or smoke from nervous tension. Too much stress, as well as anger, can also raise your blood pressure. Adrenaline surges produced during stress can constrict arteries and worsen angina.
  • Alcohol. Consumed in moderation, alcohol may help raise HDL levels — the "good" cholesterol — and can have a protective effect against heart attack. On the other hand, excessive drinking can damage your heart muscle and raise your blood pressure and triglyceride levels, increasing your risk of angina and heart attacks.

When to seek medical advice :
If your chest pain lasts longer than a few minutes and doesn't go away when you rest or take your angina medications, it may be a sign you're having a heart attack. Call 911 or emergency medical help. Drive yourself to the hospital only as a last resort.

Symptoms :
Chest pain and chest discomfort are the main symptoms or characteristics of angina. Nausea, fatigue, shortness of breath, anxiety, sweating or dizziness are other symptoms that may accompany angina.

Characteristics of angina
The chest pain and discomfort common with angina may be described as pressure, squeezing, fullness or pain in the center of your chest. Some people with angina symptoms describe angina as feeling like a vise is squeezing their chest, or feeling like a heavy weight has been placed on their chest. This pressure can extend to the arm, especially the left arm, neck, jaw, shoulder or back.

The severity, duration and type of angina can vary. It's important to recognize if you have new or changing chest pain. New or different symptoms may signal a more dangerous form of angina (unstable angina) or a heart attack.

Stable angina:

  • Develops when your heart works harder, such as when you exercise or climb stairs
  • Can usually be predicted and the pain is usually similar to previous types of chest pain you've had
  • Lasts a short time, perhaps 5 minutes or less
  • Disappears if you rest or use your angina medication
  • Could feel like indigestion
  • Might spread to your arms, back or other areas
  • Can be triggered by mental or emotional stress

Unstable angina:

  • Occurs even at rest
  • Is a change in your usual pattern of angina
  • Is unexpected
  • Is usually more severe and lasts longer than stable angina; maybe as long as 30 minutes
  • May not disappear with rest or use of angina medication
  • Might signal a heart attack

Variant angina:

  • Usually happens when you're resting
  • Is often severe
  • May be relieved by angina medication

Angina in women
A woman's angina symptoms can be different from the classic angina symptoms. For example, a woman may have chest pain that feels like a stabbing, pulsating or sharp form of chest pain rather than the more typical vise-like pressure. Women are also more likely to experience symptoms such as nausea or abdominal pain. These differences may lead to delays in seeking treatment.

Stable angina is the most common form of angina. If this is a new symptom for you, it's important to see your health care provider to establish the diagnosis and proper treatment. If your stable angina gets worse or changes, becoming unstable, seek medical attention immediately. You might be having a heart attack. Call 911 or emergency medical help. Drive yourself to the hospital only as a last resort.

Diagnosis:
To diagnose angina, your doctor will start by doing a physical exam and asking about your symptoms. You'll also be asked about any risk factors, including whether you have a family history of heart disease.

The doctor will also ask you to describe your discomfort or pain :

  • Is it pain? Discomfort? Tightness? Pressure? Sharp? Stabbing?
  • Where is the pain located? Is it in a specific area or more generalized?
  • Does the pain spread to your neck and arms?
  • How and when did the pain start? Did something specific seem to trigger the pain? Does it start gradually and build up? Or start suddenly?
  • How long does it last?
  • What makes it worse? Activity? Breathing? Body movement?
  • What makes it feel better? Rest? Deep breath? Sitting up?
  • Do you have other symptoms with the pain, such as nausea or dizziness?
  • Do you have trouble swallowing?
  • Do you have a lot of reflux and heartburn? (Heartburn can mimic the feeling of angina.)

There are several other tests your doctor may order to help confirm whether you have angina :

  • Electrocardiogram (ECG). Each beat of your heart is triggered by an electrical impulse generated from special cells in your heart. An electrocardiogram — also called an ECG or EKG — records these electrical signals as they travel through your heart. Your doctor can look for patterns among these heartbeats and rhythms to see if these patterns indicate you have angina.
  • Stress test. Sometimes angina is easier to diagnose when your heart is working harder. During a stress test, you exercise by walking on a treadmill or pedaling a stationary bicycle. While exercising, your blood pressure is monitored and your EKG readings are watched. Other tests also may be conducted while you're undergoing stress testing. If you're unable to exercise, you may be given drugs that cause your heart to work harder to simulate exercising.
  • Chest X-ray. This commonly used test takes images of your heart and lungs. This is to look for other conditions that might explain your symptoms.
  • Echocardiogram. An echocardiogram uses sound waves to produce images of the heart. Your doctor can use these images to identify angina-related problems, including whether there are areas of your heart not getting enough blood or heart muscle that's been damaged by poor blood flow. An echocardiogram is often given during a stress test.
  • Nuclear stress test. A nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It is similar to a routine stress test but during a nuclear stress test, a radioactive substance is injected into your bloodstream. This substance mixes with your blood and travels to your heart. A special scanner — which detects the radioactive material in your heart — creates images of your heart muscle. Inadequate blood flow to any part of your heart will show up as a light spot on the images — because not as much of the radioactive substance is getting there.
  • Coronary angiography. Coronary angiography is a procedure that uses X-ray imaging to examine the inside of your heart's blood vessels. It's part of a general group of procedures known as cardiac catheterization. During coronary angiography, a type of dye that's visible by X-ray machine is injected into the blood vessels of your heart. The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at the inside of your blood vessels.
  • Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Samples of your blood can be tested for the presence of these enzymes.

Complications :
The chest pain that can occur with angina can make doing some normal, daily activities, such as walking, uncomfortable. However, the most dangerous complication to be concerned about with angina is a heart attack.

If the chest pain or discomfort you normally experience with angina changes, or if it lasts longer than a few minutes and doesn't go away when you rest or take your angina medications, it may be a sign you're having a heart attack. Call 911 or emergency medical help. Drive yourself to the hospital only as a last resort.

Treatment:
There are many options for angina treatment, including lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery. The goals of treatment are to reduce the frequency and severity of your symptoms, and lower your risk of heart attack and death.

If your angina is mild, lifestyle changes may be all you need to do. However, if you have unstable angina or angina pain that's different from what you usually have, such as occurring when you're at rest, you need immediate treatment in a hospital.

Lifestyle changes

  • Because angina is often brought on by exertion, it's helpful to pace yourself and take rest breaks.
  • Avoid large meals.
  • Avoiding stress is easier said than done, but try to find ways to relax. Talk with your doctor about stress-reduction techniques.
  • If you smoke, stop smoking. Avoid exposure to secondhand smoke.
  • Eat a healthy diet with limited amounts of saturated fat, lots of whole grains and many fruits and vegetables.
  • Talk to your doctor about starting a safe exercise plan.
  • If you're overweight, talk to your doctor about weight-loss options.

Medications

  • Aspirin. Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clots can also reduce your risk of a heart attack.
  • Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, which allows more blood to flow to your heart muscle. You might take a nitrate when you have angina-related chest discomfort, before doing something that normally triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is with nitroglycerin tablets put under your tongue.
  • Beta blockers. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, the heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina.
  • Statins. Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in plaques in your artery walls, helping prevent further blockage in your blood vessels.
  • Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina.
  • Angiotensin-converting enzyme (ACE) inhibitors. These drugs help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system in numerous ways, including narrowing your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder.
  • Ranolazine (Ranexa). This is a relatively new drug for treating stable angina. It's used only when other anti-anginal drugs haven't worked because it can cause a heart problem known as QT prolongation, which increases your risk of heart rhythm problems. It's used with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.

Lifestyle changes and medications are frequently used to treat stable angina. But invasive techniques such as angioplasty and stenting also have been used to reopen narrowed heart arteries. However, recent research suggests it may be appropriate to try lifestyle changes and medications before having angioplasty and stenting. A medical study called the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) evaluated treatments for chronic, stable angina. The study found angioplasty and stenting was no better than medication and lifestyle changes over the long term when treating stable angina.

Angioplasty and stenting is a good treatment option if you have unstable angina or if lifestyle changes and medications don't effectively treat your chronic, stable angina.

Invasive options

  • Angioplasty and stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — a tiny balloon is inserted into your narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open. This procedure improves blood flow in your heart, reducing or eliminating angina. Angioplasty and stenting, or heart bypass surgery, is often used to treat unstable angina.
  • Coronary artery bypass surgery. During coronary artery bypass surgery, a vein or artery from somewhere else in your body is used to bypass a blocked or narrowed heart artery. Bypass surgery increases blood flow to your heart and reduces or eliminates angina. It's a treatment option for unstable angina.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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