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Definition

Angina is pain, "discomfort," or pressure localized in the chest that is caused by an insufficient supply of blood (ischemia) to the heart muscle. It is also sometimes characterized by a feeling of choking, suffocation, or crushing heaviness. This condition is also called angina pectoris.

Description

Often described as a muscle spasm and choking sensation, the term "angina" is used primarily to describe chest (thoracic) pain originating from insufficient oxygen to the heart muscle. An episode of angina is not an actual heart attack, but rather pain that results from the heart muscle temporarily receiving too little blood. This temporary condition may be the result of demanding activities such as exercise and does not necessarily indicate that the heart muscle is experiencing permanent damage. In fact, episodes of angina seldom cause permanent damage to heart muscle.

Angina can be subdivided further into two categories: angina of effort and variant angina.

Angina of effort

Angina of effort is a common disorder caused by the narrowing of the arteries (atherosclerosis) that supply oxygen-rich blood to the heart muscle. In the case of angina of effort, the heart (coronary) arteries can provide the heart muscle (myocardium) adequate blood during rest but not during periods of exercise, stress, or excitement--any of which may precipitate pain. The pain is relieved by resting or by administering nitroglycerin, a medication that reduces ischemia of the heart. Patients with angina of effort have an increased risk of heart attack (myocardial infarction).

Variant angina

Variant angina is uncommon and occurs independently of atherosclerosis which may, however, be present as an incidental finding. Variant angina occurs at rest and is not related to excessive work by the heart muscle. Research indicates that variant angina is caused by coronary artery muscle spasm of insufficient duration or intensity to cause an actual heart attack.

Causes and symptoms

Angina causes a pressing pain or sensation of heaviness, usually in the chest area under the breast bone (sternum). It occasionally is experienced in the shoulder, arm, neck, or jaw regions. Because episodes of angina occur when the heart's need for oxygen increases beyond the oxygen available from the blood nourishing the heart, the condition is often precipitated by physical exertion. In most cases, the symptoms are relieved within a few minutes by resting or by taking prescribed angina medications. Emotional stress, extreme temperatures, heavy meals, cigarette smoking, and alcohol can also cause or contribute to an episode of angina.

Diagnosis

Physicians can usually diagnose angina based on the patient's symptoms and the precipitating factors. However, other diagnostic testing is often required to confirm or rule out angina, or to determine the severity of the underlying heart disease.

Electrocardiogram (ECG)

An electrocardiogram is a test that records electrical impulses from the heart. The resulting graph of electrical activity can show if the heart muscle isn't functioning properly as a result of a lack of oxygen. Electrocardiograms are also useful in investigating other possible abnormal features of the heart.

Stress test

For many individuals with angina, the results of an electrocardiogram while at rest will not show any abnormalities. Because the symptoms of angina occur during stress, the functioning of the heart may need to be evaluated under the physical stress of exercise. The stress test records information from the electrocardiogram before, during, and after exercise in search of stress-related abnormalities. Blood pressure is also measured during the stress test and symptoms are noted. A more involved and complex stress test (for example, thallium scanning) may be used in some cases to picture the blood flow in the heart muscle during the most intense time of exercise and after rest.

Angiogram

The angiogram, which is basically an x ray of the coronary artery, has been noted to be the most accurate diagnostic test to indicate the presence and extent of coronary disease. In this procedure, a long, thin, flexible tube (catheter) is maneuvered into an artery located in the forearm or groin. This catheter is passed further through the artery into one of the two major coronary arteries. A dye is injected at that time to help the x rays "see" the heart and arteries more clearly. Many brief x rays are made to create a "movie" of blood flowing through the coronary arteries, which will reveal any possible narrowing that causes a decrease in blood flow to the heart muscle and associated symptoms of angina.

Treatment

Conservative treatment

Artery disease causing angina is addressed initially by controlling existing factors placing the individual at risk. These risk factors include cigarette smoking, high blood pressure, high cholesterol levels, and obesity. Angina is often controlled by medication, most commonly with nitroglycerin. This drug relieves symptoms of angina by increasing the diameter of the blood vessels carrying blood to the heart muscle. Nitroglycerin is taken whenever discomfort occurs or is expected. It may be taken by mouth by placing the tablet under the tongue or transdermally by placing a medicated patch directly on the skin. In addition, beta blockers or calcium channel blockers may be prescribed to also decrease the demand on the heart by decreasing the rate and workload of the heart.

Surgical treatment

When conservative treatments are not effective in the reduction of angina pain and the risk of heart attack remains high, physicians may recommend angioplasty or surgery. Coronary artery bypass surgery is an operation in which a blood vessel (often a long vein surgically removed from the leg) is grafted onto the blocked artery to bypass the blocked portion. This newly formed pathway allows blood to flow adequately to the heart muscle.

Another procedure used to improve blood flow to the heart is balloon angioplasty. In this procedure, the physician inserts a catheter with a tiny balloon at the end into a forearm or groin artery. The catheter is then threaded up into the coronary arteries and the balloon is inflated to open the vessel in narrowed sections. Other techniques using laser and mechanical devices are being developed and applied, also by means of catheters.

Alternative treatment

During an angina episode, relief has been noted by applying massage or kinesiological methods, but these techniques are not standard recommendations by physicians. For example, one technique places the palm and fingers of either hand on the forehead while simultaneously firmly massaging the sternum (breast bone) up and down its entire length using the other hand. This is followed by additional massaging by the fingertip and thumb next to the sternum, on each side.

Once the angina has subsided, the cause should be determined and treated. Atherosclerosis, a major associated cause, requires diet and lifestyle adjustments, primarily including regular exercise, reduction of dietary sugar and saturated fats, and increase of dietary fiber. Both conventional and alternative medicine agree that increasing exercise and improving diet are important steps to reduce high cholesterol levels. Alternative medicine has proposed specific cholesterol-lowering treatments, with several gaining the attention and interest of the public. One of the most recent popular treatments is garlic (Allium sativum). Some studies have shown that adequate dosages of garlic can reduce total cholesterol by about 10%, LDL (bad) cholesterol by 15%, and raise HDL (good) cholesterol by 10%. Other studies have not shown significant benefit. Although its effect on cholesterol is not as great as that achieved by medications, garlic may possibly be of benefit in relatively mild cases of high cholesterol, without causing the side effects associated with cholesterol-reducing drugs. Other herbal remedies that may help lower cholesterol include alfalfa (Medicago sativa), fenugreek (Trigonella foenum-graecum), Asian ginseng (Panax ginseng), and tumeric (Curcuma longa).

Antioxidants, including vitamin A (beta carotene), vitamin C, vitamin E, and selenium, can limit the oxidative damage to the walls of blood vessels that may be a precursor of atherosclerotic plaque formation.

Prognosis

The prognosis for a patient with angina depends on its origin, type, severity, and the general health of the individual. A person who has angina has the best prognosis if he or she seeks prompt medical attention and learns the pattern of his or her angina, such as what causes the attacks, what they feel like, how long episodes usually last, and whether medication relieves the attacks. If patterns of the symptoms change significantly, or if symptoms resemble those of a heart attack, medical help should be sought immediately.

Prevention

In most cases, the best prevention involves changing one's habits to avoid bringing on attacks of angina. If blood pressure medication has been prescribed, compliance is a necessity and should be a priority as well. Many healthcare professionals--including physicians, dietitians, and nurses--can provide valuable advice on proper diet, weight control, blood cholesterol levels, and blood pressure. These professionals also offer suggestions about current treatments and information to help stop smoking. In general, the majority of those with angina adjust their lives to minimize episodes of angina, by taking necessary precautions and using medications if recommended and necessary. Coronary artery disease is the underlying problem that should be addressed.

Key Terms

Ischemia

Decreased blood supply to an organ or body part, often resulting in pain.

 

Myocardial infarction

A blockage of a coronary artery that cuts off the blood supply to part of the heart. In most cases, the blockage is caused by fatty deposits.

 

Myocardium

The thick middle layer of the heart that forms the bulk of the heart wall and contracts as the organ beats.

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