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FREQUENTLY ASKED QUESTONS
Frequently Asked Questions
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Presented in part with the support of Novartis Pharmaceuticals and Boston Scientific / Guidant
Angina Pectoris
1. Facts About Angina2. Angina Pectoris, Expanded
Facts About Angina
What is angina?ANGINA PECTORIS ("ANGINA") is a recurring pain or discomfort in the chest that happens when some part of the heart does not receive enough blood. It is a common symptom of coronary heart disease (CHD), which occurs when vessels that carry blood to the heart (the coronary arteries) become narrowed and blocked due to atherosclerosis.
Angina feels like a pressing or squeezing pain, usually in the chest under the breast bone, but sometimes in the shoulders, arms, neck, jaws, or back. Angina is usually precipitated by exertion. It is usually relieved within a few minutes by resting or by taking prescribed angina medicine.
What brings on angina?
Episodes of angina occur when the heart's need for oxygen increases beyond the oxygen available from the blood nourishing the heart. Physical exertion is the most common trigger for angina. Other triggers can be emotional stress, extreme cold or heat, heavy meals, alcohol, and cigarette smoking.
Does angina mean a heart attack is about to happen?
An episode of angina is not a heart attack. Angina pain means that some of the heart muscle in not getting enough blood temporarily--for example, during exercise, when the heart has to work harder. The pain does NOT mean that the heart muscle is suffering irreversible, permanent damage. Episodes of angina seldom cause permanent damage to heart muscle.
In contrast, a heart attack occurs when the blood flow to a part of the heart is suddenly and permanently cut off. This causes permanent damage to the heart muscle. Typically, the chest pain is more severe, lasts longer, and does not go away with rest or with medicine that was previously effective. It may be accompanied by indigestion, nausea, weakness, and sweating. However, the symptoms of a heart attack are varied and may be considerably milder.
When someone has a repeating but stable pattern of angina, an episode of angina does not mean that a heart attack is about to happen. Angina means that there is underlying coronary heart disease. Patients with angina are at an increased risk of heart attack compared with those who have no symptoms of cardiovascular disease, but the episode of angina is not a signal that a heart attack is about to happen. In contrast, when the pattern of angina changes--if episodes become more frequent, last longer, or occur without exercise--the risk of heart attack in subsequent days or weeks is much higher.
A person who has angina should learn the pattern of his or her angina--what cause an angina attack, what it feels like, how long episodes usually last, and whether medication relieves the attack. If the pattern changes sharply or if the symptoms are those of a heart attack, one should get medical help immediately, perhaps best done by seeking an evaluation at a nearby hospital emergency room.
Is all chest pain "angina?"
No, not at all. Not all chest pain is from the heart, and not all pain from the heart is angina. For example, if the pain lasts for less that 30 seconds or if it goes away during a deep breath, after drinking a glass of water, or by changing position, it almost certainly is NOT angina and should not cause concern. But prolonged pain, unrelieved by rest and accompanied by other symptoms may signal a heart attack.
How is angina diagnosed?
Usually the doctor can diagnose angina by noting the symptoms and how they arise. However one or more diagnostic tests may be needed to exclude angina or to establish the severity of the underlying coronary disease. These include the electrocardiogram (ECG) at rest, the stress test, and x- rays of the coronary arteries (coronary "arteriogram" or "angiogram").
The ECG records electrical impulses of the heart. These may indicate that the heart muscle is not getting as much oxygen as it needs ("ischemia"); they may also indicate abnormalities in heart rhythm or some of the other possible abnormal features of the heart. To record the ECG, a technician positions a number of small contacts on the patient's arms, legs, and across the chest to connect them to an ECG machine.
For many patients with angina, the ECG at rest is normal. This is not surprising because the symptoms of angina occur during stress. Therefore, the functioning of the heart may be tested under stress, typically exercise. In the simplest stress test, the ECG is taken before, during, and after exercise to look for stress related abnormalities. Blood pressure is also measured during the stress test and symptoms are noted.
A more complex stress test involves picturing the blood flow pattern in the heart muscle during peak exercise and after rest. A tiny amount of a radioisotope, usually thallium, is injected into a vein at peak exercise and is taken up by normal heart muscle. A radioactivity detector and computer record the pattern of radioactivity distribution to various parts of the heart muscle. Regional differences in radioisotope concentration and in the rates at which the radioisotopes disappear are measures of unequal blood flow due to coronary artery narrowing, or due to failure of uptake in scarred heart muscle.
The most accurate way to assess the presence and severity of coronary disease is a coronary angiogram, an x-ray of the coronary artery. A long thin flexible tube (a "catheter") is threaded into an artery in the groin or forearm and advanced through the arterial system into one of the two major coronary arteries. A fluid that blocks x-rays (a "contrast medium" or "dye") is injected. X-rays of its distribution show the coronary arteries and their narrowing.
How is angina treated?
The underlying coronary artery disease that causes angina should be attacked by controlling existing "risk factors." These include high blood pressure, cigarette smoking, high blood cholesterol levels, and excess weight. If the doctor has prescribed a drug to lower blood pressure, it should be taken as directed. Advice is available on how to eat to control weight, blood cholesterol levels, and blood pressure. A physician can also help patients to stop smoking. Taking these steps reduces the likelihood that coronary artery disease will lead to a heart attack.
Most people with angina learn to adjust their lives to minimize episodes of angina, by taking sensible precautions and using medications if necessary.
Usually the first line of defense involves changing one's living habits to avoid bringing on attacks of angina. Controlling physical activity, adopting good eating habits, moderating alcohol consumption, and not smoking are some of the precautions that can help patients live more comfortably and with less angina. For example, if angina comes on with strenuous exercise, exercise a little less strenuously, but do exercise. If angina occurs after heavy meals, avoid large meals and rich foods that leave one feeling stuffed. Controlling weight, reducing the amount of fat in the diet, and avoiding emotional upsets may also help.
Angina is often controlled by drugs. The most commonly prescribed drug for angina is nitroglycerin, which relieves pain by widening blood vessels. This allows more blood to flow to the heart muscle and also decreases the work load of the heart. Nitroglycerin is taken when discomfort occurs or is expected. Doctors frequently prescribe other drugs, to be taken regularly, that reduce the heart's workload. Beta blockers slow the heart rate and lessen the force of the heart muscle contraction. Calcium channel blockers are also effective in reducing the frequency and severity of angina attacks.
What if medication fails to control angina?
Doctors may recommend surgery or angioplasty if drugs fail to ease angina or if the risk of heart attack is high. Coronary artery bypass surgery is an operation in which a blood vessel is grafted onto the blocked artery to bypass the blocked or diseased section so that blood can get to the heart muscle. An artery from inside the chest (an "internal mammary" graft) or long vein from the leg (a "saphenous vein" graft) may be used.
Balloon angioplasty involves inserting a catheter with a tiny balloon at the end into a forearm or groin artery. The balloon is inflated briefly to open the vessel in places where the artery is narrowed. Other catheter techniques are also being developed for opening narrowed coronary arteries, including laser and mechanical devices applied by means of catheters.
Can a person with angina exercise?
Yes. It is important to work with the doctor to develop an exercise plan. Exercise may increase the level of pain-free activity, relieve stress, improve the heart's blood supply, and help control weight. A person with angina should start an exercise program only with the doctor's advice. Many doctors tell angina patients to gradually build up their fitness level--for example, start with a 5-minute walk and increase over weeks or months to 30 minutes or 1 hour. The idea is to gradually increase stamina by working at a steady pace, but avoiding sudden bursts of effort.
What is the difference between "stable" and "unstable" angina?
It is important to distinguish between the typical stable pattern of angina and "unstable" angina.
Angina pectoris often recurs in a regular or characteristic pattern. Commonly a person recognizes that he or she is having angina only after several episodes have occurred, and a pattern has evolved. The level of activity or stress that provokes the angina is somewhat predictable, and the pattern changes only slowly. This is "stable" angina, the most common variety.
Instead of appearing gradually, angina may first appear as a very severe episode or as frequently recurring bouts of angina. Or, an established stable pattern of angina may change sharply; it may by provoked by far less exercise than in the past, or it may appear at rest. Angina in these forms is referred to as "unstable angina" and needs prompt medical attention.
The term "unstable angina" is also used when symptoms suggest a heart attack but hospital tests do not support that diagnosis. For example, a patient may have typical but prolonged chest pain and poor response to rest and medication, but there is no evidence of heart muscle damage either on the electrocardiogram or in blood enzyme tests.
Are there other types of angina?
There are two other forms of angina pectoris. One, long recognized but quite rare, is called Prinzmetal's or variant angina. This type is caused by vasospasm, a spasm that narrows the coronary artery and lessens the flow of blood to the heart. The other is a recently discovered type of angina called microvascular angina. Patients with this condition experience chest pain but have no apparent coronary artery blockages. Doctors have found that the pain results from poor function of tiny blood vessels nourishing the heart as well as the arms and legs. Microvascular angina can be treated with some of the same medications used for angina pectoris.
Angina Pectoris, Expanded
Your doctor has diagnosed the pain or discomfort in your chest as angina. This information sheet will answer many of your questions about angina. Understanding your condition and working with your doctor can help you lead a full, active life.What is angina pectoris?
Angina, or angina pectoris, is a recurring discomfort. It's usually located near the center of the chest. The pain or discomfort occurs when the blood supply to part of the heart muscle doesn't meet the heart's needs. As a result, the heart doesn't get enough oxygen and nutrients. The discomfort occurs most often during exercise or emotional stress. That's when the heart rate and blood pressure increase, and the heart muscle needs more oxygen. Anginal pain or discomfort is usually brief, lasting just a few minutes. People describe it as a heaviness, tightness, oppressive pain, burning, pressure or squeezing. Usually it's located behind the breastbone. Sometimes it spreads to the arms, neck or jaws. It may also cause a numbness in the shoulders, arms or wrists.
What is the relationship between angina and a heart attack?
Angina is different from a heart attack. Both relate to the blood flow through the coronary arteries (which bring blood to the heart muscle), but there is a key difference. With angina, the blood flow is reduced, especially when the heart must do more work. This imbalance between oxygen supply and demand is temporary leading to discomfort in the chest.
With a heart attack, the blood flow to part of the heart muscle is suddenly cut off when a coronary artery is blocked. The chest pain that results is usually more severe and lasts longer. As a general rule, attacks of angina don't permanently damage the heart muscle; a heart attack does. Many people who have angina have never had a heart attack, although angina can develop after one.
What Causes Angina?
Angina and heart attack have the same root cause: atherosclerosis. This is the narrowing of the coronary arteries caused by deposits of fatty substances such as cholesterol. It usually starts early in life. Everyone has it to some degree by middle age.
How is angina diagnosed?
Usually your doctor can accurately diagnose angina from your description of symptoms. If you're suffering from it, it's possible for your physical examination and resting electrocardiogram to be entirely normal. That's why your doctor may recommend an exercise test to increase your heart's demand for blood and oxygen. An electrocardiogram recorded during an exercise test can show if your heart isn't getting enough oxygen. Sometimes it's hard to diagnose angina even after a medical history, a physical examination and an exercise test. If that's the case, your doctor may order a thallium stress test. This is a special exercise test in which a radioisotope (thallium) is injected into a vein during exercise. It uses radioactivity detectors and computers to measure the blood flow to the heart muscle during exercise.
Your doctor may decide that a coronary arteriogram is necessary. This is an x-ray movie of your coronary arteries. It shows blood flow patterns as a radiopaque substance (a liquid that blocks x-rays) is injected into your arteries. If you have angina, an arteriogram will show if your coronary arteries are blocked or constricted, where the blockage is and how severe it is.
How is angina treated?
Nitroglycerin usually works well to relieve chest discomfort from angina. It can be used to prevent discomfort, too. It's usually taken in tiny tablets, which are put under the tongue to dissolve. It may also be prescribed as an oral spray. Nitroglycerin tablets are inexpensive and act quickly. Keep a fresh, sealed supply of them on hand at all times. As a general rule, avoid moving your tablets from their original, dark glass bottle, because they're sensitive to heat, light and air. And always use the medicine as directed by your doctor. Be sure to carry your nitroglycerin with you at all times. Take a tablet just before starting an activity you know is likely to cause anginal discomfort. Also, take a tablet if your discomfort doesn't begin to go away within a minute or two after you've stopped the activity, or if discomfort occurs when you aren't active. Tell your doctor what usually causes your angina so he or she can advise you about preventing attacks.
It may take several tablets a day to control your symptoms. Nitroglycerin is safe and not habit forming, so don't be afraid to take it. Ask your doctor what to do if nitroglycerin doesn't completely relieve your angina or if the pain starts to come more often or gets worse. Some people who take nitroglycerin get a short headache or a feeling of fullness in the head. Often these symptoms disappear after they've taken nitroglycerin several times. If you have this problem and it doesn't get better, your doctor may want to reduce the dosage in each tablet. Long acting forms of nitroglycerine are also available. The come in the form of long acting tablets, patches, and nitroglycerin paste.
Some Tips on Nitroglycerin:
1. If you have angina that does not go away after 15 minutes of taking 1 nitroglycerin tablet every 5 minutes, you should call the emergency medical service or have someone drive you to the nearest hospital emergency room.
2. Ask your doctor about refilling your prescription at six-month intervals. Old nitroglycerin tablets can lose their strength. Effective tablets will cause the area under your tongue to sting or burn.
3. Your doctor may also prescribe longer acting nitroglycerin compounds. These are taken by mouth or applied to the skin as an ointment or skin patch.
Other antianginal medications:
Your doctor may prescribe other medications besides nitroglycerin to reduce your attacks even more or for other reasons. One such medication might be a beta blocking drug. This class of drugs reduces the ability of adrenalin to stimulate your heart. As a result, it will reduce your heart's work during exercise by slowing the heart rate and lowering blood pressure. The so-called calcium blocking drugs are also often used. They work by reducing the blood pressure, and sometimes the heart rate, during exercise. They also relax and widen the arteries to the heart muscle like nitroglycerin does.
How can coronary blood flow be improved?
If medication doesn't control your angina, your doctor may suggest percutaneous transluminal coronary angioplasty (PTCA) or one of it's variations. This procedure can increase blood flow in a narrowed blood vessel.
In this treatment the doctor inserts a balloon-tipped catheter into an artery. When the tip is guided to where the blood vessel is narrowed, the balloon is inflated, compressing the plaque. Then the balloon is deflated and the catheter withdrawn. Variations include the use of devices to remove plaque (grinding or shaving devices) and the use of stents (metallic sleeves which help open the artery).
What is the role of heart surgery?
If you keep having frequent or disabling angina despite using medications, or if your coronary arteries are badly blocked, you may need surgery. Your doctor may advise coronary artery bypass surgery on one or more of your arteries. In this operation, a vein taken from the leg or an artery taken from the chest wall is grafted onto the blocked artery, bypassing the blocked area. If more than one artery is blocked, each one may receive a bypass.
What can you do to treat this disease?
You can improve your condition by altering your way of life to reduce the chance of attacks of angina. The suggestions that follow can help you live more comfortably with angina.
1. Control your physical activity.
Learn what kinds of physical activities bring on your angina, and avoid doing them. Remember, it's how strenuously you exert yourself, not how long you do so, that causes angina. Some people can walk a mile or more without discomfort if they pace themselves. These same people may have an anginal attack if they walk rapidly for half a block. Others can perform certain kinds of manual labor all day, but brief, intense physical effort will quickly bring chest discomfort. If causes angina, discuss this with your doctor. Sometimes taking nitroglycerin can prevent angina during sex. Many people find they're more prone to attacks of angina when they exert themselves in extremes of temperature (hot or cold) or after a heavy meal. You may find that what you can do easily in mild weather will cause chest discomfort if done in the cold and wind. If this happens, cut back on your activities in winter weather and dress warmly whenever you're outdoors. Consult your doctor before you try to shovel snow or do other hard work in cold weather.
2. Exercise regularly.
Moderate exercise may be good for you. Many times symptoms of angina decrease when a person starts a program of progressive exercise. Ask your doctor about the best types and amounts of exercise for you. If your discomfort occurs during daily exercise, reduce your exercise and consult your doctor.
3. Avoid emotional upsets.
Any kind of emotional upset, including outbursts of temper, can trigger angina. Excitement can also cause chest discomfort. Learning to control your emotions will help you control your angina. Many people are surprised at how well they can control their emotions when they try. Even so, it's impossible to avoid all emotional or anxiety producing situations. Try to anticipate these situations and use your nitroglycerin in advance to help prevent chest discomfort. Some kinds of recurring emotional problems can be very hard to handle. If you're having difficulty, seek professional help. If long-standing tensions seem to aggravate your angina, discuss them with your doctor, a clergyman or a family counselor. Identify everyday situations in which you feel pressured and try to control them. Avoid time pressures like deadlines and overcrowded schedules. Also, don't insist on doing everything yourself.
Meditation and relaxation exercises are good ways to calm your emotions. Some doctors suggest that you totally relax all your muscles twice a day for 20 minutes. Others advise doing deep breathing exercises or concentrating on a pleasant thought or experience whenever you feel under stress. If these practices don't seem to help, your doctor may recommend a mild tranquilizer. You may feel that taking tranquilizers is a sign of weakness or worry about becoming dependent upon them. If so, don't worry. Tranquilizers are safe and effective for controlling angina if you follow your doctor's advice.
4. Adopt good eating habits.
Like exercise, digestion causes the heart to work harder. That means it needs more blood. Heavy meals can put a strain on your heart. You may find that you're especially prone to anginal discomfort after eating. Try to avoid large meals and rich foods that leave you feeling stuffed. Relax for a while after eating. If you often get angina after meals, your doctor may advise you to use nitroglycerin before eating. Extra weight can also aggravate angina. Many times a person's angina decreases or disappears after weight loss. Even if you aren't overweight, your doctor may recommend that you control the amount of fat in your daily diet. He or she may prescribe a diet. Ask about what books are available that discuss heart healthy diets.
5. Moderate alcohol intake.
Drinking a moderate amount of alcohol helps some people relax and may not be harmful for you. The good form of cholesterol in your blood may be increased by alcohol. But drinking too much alcohol can be potentially harmful, because it affects the heart. Some people with angina have other medical conditions that keep them from drinking alcohol. Ask your doctor's advice about drinking alcohol. And remember, if you're trying to lose weight, you shouldn't drink too much. Alcoholic drinks are usually high in calories.
5. Don't use any tobacco products.
Cigarette smoking is bad for your general health. It's critical to avoid smoking if you have angina or any form of heart disease. Cigarette smoking often makes angina worse, and it increases the risk of heart attack and other circulatory disorders. If you smoke, QUIT!
6. Control high blood pressure.
High blood pressure increases the risk of developing heart disease and other circulatory disorders. It also increases the heart's work and can aggravate angina. Controlling high blood pressure is essential, so follow your doctor's advice about treatment.
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