A2. Angina

A2. Angina


What is Angina?

Angina is a type of pain that occurs when not enough blood flows to the heart muscle. It may feel like pressure in the chest, jaw or arm.

Angina usually occurs because the blood vessels that supply blood to the heart become narrow due to atherosclerosis (plaque buildup in the arteries) or a spasm of the coronary arteries.

Types of Angina

Stable angina is a pain or tightness often triggered by a consistent high level of activity, such as walking upstairs after an emotional discussion or during stressful times. It is often predictable. Situations that make your heart work harder, such as cold weather or eating large meals, can result in chest pain if you have heart disease.

Resting, relaxing and potentially taking a nitroglycerin can relieve this pain.

Unstable angina is chest pain or tightness that occurs without an obvious trigger, or a sudden worsening of your stable angina. You may notice that you can’t exercise as well as you used to before getting chest pain, that the pain is more intense or lasts longer.

This is an emergency, and you should see your health care professional right away. If you are having active pain, you should go to the emergency room and call 911.

Variant angina is chest pain or pressure that occurs when the coronary artery suddenly spasms or contracts, cutting off blood flow to the heart muscle. This type of chest pain is also called Prinzmetal’s angina or vasospastic angina. Although the spasm is usually temporary, it can result in the same type of pain caused by a heart attack or coronary artery disease.

Although drugs such as cocaine are associated with coronary artery spasm, it can happen for unknown reasons in people who have never taken cocaine.

Variant angina typically occurs at rest. It is slightly more frequent at night but can happen in the morning or any time of day. It usually lasts a few minutes and then goes away. It can be relieved with nitroglycerin.

Signs and Symptoms

Typically, symptoms of angina are chest pain or pressure, which may extend to the neck, jaw or arm. However, some people experience angina as shortness of breath, upper belly pain, indigestion, lightheadedness, extreme weakness or tiredness, or general discomfort.

Women and diabetics frequently have symptoms that are different from chest pain or pressure symptoms.

When Should I Call My Doctor or Go to the Emergency Room?

Know what your angina feels like and what is typical for you so you know when to call for help. Do not wait to call 911 if your angina is worse than normal, for example more severe, more frequent or lasting longer. If any of these occur, call your health care professional right away.

Call 911 immediately if your symptoms:

  • are very severe
  • occur while at rest (not exerting yourself)
  • do not go away 10 minutes after taking nitroglycerin under your tongue

Getting help fast can save your life. Even if you are not sure your chest pain is a heart attack, have it checked out.

Exams and Tests

Chest pain can occur for a variety of reasons, some that are serious and some that are harmless. Separating angina from other causes of chest pain is not always easy.

Your health care professional should take a thorough history and physical exam. He or she should ask you about the quality of the pain in your chest. Where is it located? Are there any associated symptoms? When does it occur? How long does it last? What makes it better or worse?

An electrocardiogram (ECG), which shows how fast or evenly the heart is beating, may be done to look for signs of past heart attacks or decreased blood flow to the heart muscle, called ischemia. It also helps to determine what type of stress test you may need.

If your health care professional is concerned that your chest pain may be caused by coronary artery disease, he or she may order a stress test with or without pictures. During a stress test, a clinician tries to challenge your heart to see if the supply of blood to your heart muscle is enough to meet the demands of increased activity. A stress test can tell us if there are further signs of decreased blood flow to the heart muscle. The pictures can tell us if parts of your heart muscle do not get enough blood flow.

Other tests, such as coronary calcium score and coronary computed tomography, can look for atherosclerosis (plaque buildup) or narrowing of the coronary arteries. Sometime a stress cardiac MRI can be used to assess blood flow to the heart.


Staying active, not smoking, and adopting healthy eating habits are important ways to manage stable angina. Your health care professional may also prescribe medicine to help. Some of the medications help reduce the risk factors that lead to angina and coronary artery disease, while others help manage the symptoms.

Your health care professional will help you find the best combination of medications and treatments to manage your condition.

What medications are used to manage angina symptoms?

Beta blockers help ease the work the heart has to do by slowing down your heart rate and lowering your blood pressure. If you have had a heart attack, these medications will help prevent another one and help you live longer.

Nitroglycerin increases the blood flow to the heart by opening up, or dilating, the blood vessels in the body. This allows blood to flow to the heart muscle more easily when coronary arteries are narrowed. It also decreases the workload on the heart to supply blood to the body.

Calcium channel blockers, like beta blockers, help ease the work the heart has to do by slowing down your heart rate and lowering your blood pressure. Not all medications of this type will slow down heart rate as well as others, but they are all useful for reducing high blood pressure.

Ranolazine works directly at the heart to help it relax better. It helps to slow down the heart muscle so that it does not have to work as hard. Unlike other medications used in angina, it is able to do this without changing your blood pressure or your heart rate.

What other interventions can help?

Angioplasty and Bypass Surgery

Opening up narrowed coronary arteries to restore blood flow to the area of the heart muscles that is not getting enough can relieve the symptoms of angina. There are two main ways to restore blood flow to the heart:

  • Angioplasty, also called percutaneous coronary intervention (PCI), with a stent or a balloon procedure
  • Coronary artery bypass graft (CABG) surgery, or open heart surgery

These treatments can significantly improve quality of life for patients with advanced coronary artery disease. The treatment recommended by your health care professional will depend on your symptoms and preferences, the number and locations of narrowed arteries, your age, overall health, and other risk factors. You should discuss these options with your cardiologist.

Cardiac Rehab

Cardiac rehabilitation is typically a 12-week, medically supervised program. It includes counseling on exercise, nutrition, stress management and smoking cessation. It also educates individuals about how to take better control of your health. Cardiac rehab can decrease angina, reduce heart risk factors and improve quality of life.

Enhanced External Counterpulsation Therapy 

Enhanced external counterpulsation (EECP) therapy may be recommended in some patients if you have angina that limits you from your daily activities and that has not improved with standard treatments.

During EECP, inflatable cuffs (similar to blood pressure cuffs) are placed on the calves, thighs and buttocks. The cuffs inflate and deflate in rhythm with your heart, improving blood flow to the heart. EECP may generate the formation of new small blood vessels in the heart to create a natural bypass around blocked or narrowed arteries. EECP may increase exercise duration and decrease angina.


In order to prevent angina caused by atherosclerosis, it is important to try to decrease the risk factors that lead to coronary artery disease.

What Medications Help Lower Heart Risk Factors?

Your health professional may recommend a “baby” aspirin daily because it helps blood flow through blood vessels. In addition, if you have had a heart attack or stroke, aspirin will help prevent another one and potentially help you live longer.

Statins help reduce levels of low density lipoprotein (LDL), also called the “bad” cholesterol, in your blood. Too much LDL cholesterol in your blood means that there is a greater chance of it being inside the blood vessels in the heart or in the brain. This can lead to a heart attack or stroke. If you have had a heart attack or stroke, statins will help prevent another one and help you live longer. Even if you have not had a heart attack or stroke, statins may decrease the chances of a cardiac event in certain people, including those with angina.

What Else Can I Do to Prevent Angina?

Lifestyle modifications are also extremely important in preventing heart disease and angina. These include:

  • Control blood pressure:Keep your blood pressure readings within a healthy range using medications and lifestyle changes.
  • Smoking cessation:Smoking is the No. 1 cause of preventable death in the U.S. Quitting smoking also is one of the most effective changes anyone can make to prevent a second heart attack.
  • Exercise:Staying active is important for your heart. You should try to get 10,000 steps in a day or try to exercise (brisk walking, running, or biking) for 30 minutes at least five times a week. This can reduce blood pressure, increase HDL (healthy) cholesterol, and improve glucose control.
  • Healthy diet:Anyone who has heart disease or who is at increased risk of developing heart disease should eat a well-balanced diet high in fruits, vegetables, whole grains, fish and lean meats. You should avoid sugary beverages, refined grains, and processed or red meats.
  • Stress reduction:Stress is physical, mental, or emotional strain or tension. Low to moderate levels of stress can be healthy by increasing motivation and productivity. However, chronic high levels of stress can be dangerous and increase the rate of cholesterol plaque buildup and narrowing in the coronary arteries, leading to heart disease and angina. Leading a well-balanced life is vital to heart health. If you experience stress that causes or worsens your symptoms of angina, discuss these symptoms with your health care professional.