Angina Pectoris
Angina pectoris is chest pain or discomfort that occurs when your heart muscle doesn’t receive enough oxygen-rich blood. This common symptom affects about 11 million people in the United States and serves as an important warning sign of underlying heart disease that requires proper diagnosis and treatment.
Table of contents
- What is Angina Pectoris?
- Types of Angina
- What Causes Angina?
- Risk Factors
- Symptoms and How Angina Feels
- Diagnosis and Testing
- Treatment Options
- Living with Angina
What is Angina Pectoris?
Angina pectoris, commonly called angina, is a type of chest pain or discomfort that happens when your heart muscle doesn’t get enough blood and oxygen[1]. The term comes from Latin words meaning “to choke or strangle,” which reflects how the condition can feel[9].
Angina is not itself a disease, but rather a symptom of an underlying heart condition. Most commonly, it signals coronary artery disease, which occurs when the blood vessels that supply your heart become narrowed or blocked[2]. When your heart doesn’t receive adequate blood flow, it cannot get the oxygen it needs to work properly, resulting in chest discomfort.
It’s important to understand that angina is not the same as a heart attack, but it does indicate an increased risk for having one[17]. About 9 million patients in the United States experience symptoms of angina[9]. The condition is relatively common and generally treatable when properly diagnosed and managed.
Types of Angina
There are several different types of angina, and understanding which type you have is important for proper treatment[1].
Stable angina is the most common form. It usually develops during physical activity or exertion and goes away with rest or angina medicine[1]. The pattern is predictable—it typically occurs in similar situations and lasts a short time, perhaps five minutes or less[2]. For example, chest pain that starts when you’re walking uphill or in cold weather may be stable angina.
Unstable angina is much more serious and is considered a medical emergency. This type is unpredictable and occurs at rest, without any clear triggers[2]. The pain is typically more severe than stable angina and lasts longer, maybe 20 minutes or more[1]. The discomfort doesn’t go away with rest or usual angina medicines. Unstable angina is dangerous because if blood flow doesn’t improve, the heart doesn’t get enough oxygen and a heart attack can occur[1].
Variant angina, also called Prinzmetal angina, is a rare type that differs from the others because it isn’t caused by coronary artery disease[1]. Instead, it results from a spasm in the coronary arteries[3]. This type usually occurs when you’re sleeping or resting, not during physical activity. An episode typically lasts five to 15 minutes[2].
Microvascular angina occurs when problems develop in the tiny blood vessels in your heart. The tightness or pressure can last 15 minutes or more, and treatment can help prevent damage to your heart from lack of oxygen[2].
What Causes Angina?
Angina occurs when there’s an imbalance between the blood supply to your heart muscle and the oxygen demand of that muscle[7].
The most common cause is coronary artery disease. This condition develops when plaque—deposits made up of cholesterol, fat, calcium, and other substances in the blood—builds up along the walls of the coronary arteries[3]. As the plaque becomes larger, it can narrow or block the arteries, reducing blood flow to the heart muscle. This process is called atherosclerosis, or hardening of the arteries[6].
Sometimes, plaque in an artery can rupture, leading to the formation of a blood clot that further blocks blood flow[3]. This can trigger angina or even cause a heart attack.
Other causes of reduced blood flow to the heart include poor blood flow through a narrowed heart valve, when the heart muscle pumps less effectively than normal, or coronary artery spasm[3]. Less common causes include aortic stenosis (narrowing of the aortic valve), pericarditis (swelling of the sac around the heart), and hypertrophic cardiomyopathy (a thickened or enlarged heart)[6].
Risk Factors
Several factors can increase your risk of developing angina and coronary artery disease[7].
Major risk factors include a family history of premature coronary artery disease, cigarette smoking, diabetes mellitus, high cholesterol levels, and high blood pressure[7]. Other contributing factors include being overweight or obese, lack of physical exercise, advanced age, and stress[4][6].
Certain situations can trigger angina episodes in people who already have narrowed arteries. These triggers include physical activity, emotional stress, extreme cold or heat, heavy meals, drinking too much alcohol, and smoking or long-term exposure to secondhand smoke[3].
Metabolic syndrome—a cluster of conditions including high blood sugar, abdominal obesity, low HDL cholesterol, high triglycerides, and high blood pressure—significantly increases the risk of developing coronary artery disease and angina[7].
Symptoms and How Angina Feels
Angina is often described as squeezing, pressure, heaviness, tightness, or pain in the chest[1]. It may feel like a heavy weight lying on the chest. Most people describe having chest pressure or discomfort rather than actual pain[2].
Common descriptions of how angina feels include squeezing, tightness, heaviness, crushing, or a burning sensation similar to heartburn or indigestion[2]. The most common symptom is a pressing, squeezing, or crushing pain, usually in the chest under your breastbone[3].
The discomfort may spread beyond your chest to other parts of your upper body. Pain can radiate to your jaw, teeth, shoulders, arms, neck, or back[2][3].
Angina can occur alongside other symptoms, including shortness of breath, extreme tiredness, dizziness, sweating, nausea, weakness, gas or bloating, upset stomach, feeling clammy, skin that’s paler than usual, and a feeling of impending doom[2][3].
Healthcare providers sometimes use a scale of 1 to 4 to describe the severity of angina based on what triggers it. The higher the number, the more severe the condition. Level 1 means angina occurs only during strenuous physical activity, while level 4 means any physical activity or even resting can trigger angina[2].
Diagnosis and Testing
To diagnose angina, a healthcare professional will examine you and ask questions about your symptoms, risk factors, and family history of heart disease[10]. A thorough medical history and physical examination are critical first steps[3].
Several tests may be performed to confirm the diagnosis and evaluate the severity of your condition:
Electrocardiogram (ECG or EKG) is a quick and painless test that measures the electrical activity of your heart. Sticky patches called electrodes are placed on your chest and sometimes on your arms and legs[10]. The test can show if your heart is beating too fast or too slow and can reveal if you’re having or have had a heart attack[3].
Blood tests can identify certain heart proteins called cardiac enzymes that leak into the blood after heart damage. These tests can also check for elevated cholesterol, LDL, and triglycerides that increase your risk for coronary artery disease[4][3].
Chest X-ray helps determine the condition of your heart and lungs and can rule out other sources of chest pain[4][10].
Stress test evaluates how well your heart performs during physical activity. You’ll usually be asked to walk on a treadmill or ride a stationary bike while your heart is monitored with an ECG[3][10]. If you cannot exercise, medications that mimic the heart’s response to exercise may be used instead.
Echocardiogram uses sound waves to create images of the heart in motion. These images show how blood flows through the heart and can be performed during a stress test[10].
Coronary CT angiography evaluates the coronary arteries to determine the extent of narrowing due to plaque buildup without needing an invasive catheter[4].
Cardiac catheterization involves passing a thin, long tube into an artery in your leg and guiding it up to your heart. A contrast material is injected into your coronary arteries, and X-ray images are taken to see narrowing, blockages, and blood flow[3][10].
Treatment Options
The main goals of angina treatment are to relieve symptoms, slow disease progression, and reduce the risk of future events like heart attack and premature death[13]. Treatment approaches depend on the type and severity of your angina.
Medications
Several types of medicines can help manage angina and reduce your risk:
Beta-blockers help your heart beat slower and with less force, which lowers your blood pressure and reduces the heart’s workload[12][16]. If you’ve had a heart attack, these medications help prevent another one and can help you live longer.
Nitrates, such as nitroglycerin, widen and relax blood vessels. This lowers the heart’s workload and increases blood flow to the heart muscle[12]. Fast-acting nitrate pills or sprays can quickly relieve pain during an angina episode[12]. Long-acting versions are also available for prevention.
Calcium channel blockers, like beta-blockers, help ease the work your heart has to do by slowing down your heart rate and lowering your blood pressure[16].
Ranolazine may be prescribed in some cases. This medicine helps the heart relax and not work as hard, without changing your blood pressure or heart rate[16].
Aspirin helps blood flow through blood vessels. If you have atherosclerosis, your healthcare team may recommend a daily “baby” aspirin to help prevent heart attack or stroke[21].
Statins help reduce levels of LDL (“bad”) cholesterol in your blood, which decreases the chances of plaque buildup. If you’ve had a heart attack, statins help prevent another one and can help you live longer[13][21].
Medical Procedures
When lifestyle changes and medications cannot adequately control angina, medical procedures may be needed to restore blood flow:
Angioplasty and stenting is a minimally invasive procedure in which a small balloon is passed through an artery up to your heart. The balloon is inflated to open up the artery, and a stent—a small mesh tube—is permanently placed to keep the artery open[6][14].
Coronary artery bypass graft (CABG) surgery, also called open-heart surgery, creates new routes around narrowed or blocked arteries to restore blood flow to the heart[16].
Your treatment will depend on your symptoms and preferences, how many narrowed or blocked arteries you have and where they are located, your age, overall health, and other risk factors[16].
Cardiac Rehabilitation
Cardiac rehabilitation is typically a 12-week, medically supervised program that includes counseling on how to exercise safely, eat heart-healthy foods, manage stress, and quit smoking[16]. It teaches you how to take better care of your health and can significantly improve quality of life.
Living with Angina
Living well with angina requires ongoing care and lifestyle adjustments. Angina is a signal that you’re at greater risk of having a heart attack, so understanding your condition and following your treatment plan is essential[17].
Follow-up Care
You may need follow-up visits every 4 to 6 months for the first year after an angina diagnosis and every 6 to 12 months as long as your condition is stable[17]. Your care plan may need adjustment if your angina worsens or becomes unstable.
Lifestyle Changes
Heart-healthy lifestyle changes are crucial for managing angina and preventing complications:
Choose heart-healthy foods. Following a healthy eating plan helps prevent or control high blood pressure and high cholesterol. Eat plenty of fruits, vegetables, and whole grains. Choose lean proteins like skinless chicken, fish, and beans. Avoid foods high in sodium (salt), saturated fat, and partially hydrogenated fats[17][19]. If heavy meals trigger your angina, avoid large meals and rich foods[17].
Stay physically active. Regular aerobic exercise, such as walking, swimming, or bicycling, is beneficial. Aim for at least 40 minutes a day, at least 3 to 4 days a week, totaling at least 150 minutes per week[19]. Always talk to your provider about what activities are safe for you and when you can return to normal physical activity.
Stop smoking. If you smoke, quitting is one of the most important changes you can make. Smoking is a major risk factor for heart disease, and quitting can significantly reduce your risk[13][19].
Maintain a healthy weight. Strive for a body mass index (BMI) from 18.5 to 24.9 and a waist smaller than 35 inches for women[19].
Limit alcohol. If you drink, limit yourself to no more than 1 drink a day for women, or 2 a day for men[19].
Manage stress. Stress can trigger angina episodes. Practice stress management techniques such as meditation, yoga, and deep breathing[13][19].
Control other health conditions. Keep your blood pressure, blood sugar, and cholesterol at recommended levels through lifestyle changes and medications as prescribed[19].
Managing Angina Episodes
Create a plan with your provider for managing your angina. Your plan should include what activities are safe for you, which medicines to take when you have angina, what signs indicate your angina is getting worse, and when to call your provider or emergency services[19].
Know what can make your angina worse and try to avoid these triggers. For example, some people find that cold weather, exercising, eating large meals, or getting upset or stressed worsens their angina[19].
If you experience new or worsening chest pain that doesn’t respond to rest or your usual medicines, seek immediate medical attention. Unstable angina is a medical emergency that requires prompt treatment[1][2].