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Angina


Signs and Symptoms
Causes
Risk Factors
Diagnosis
 
Preventive Care
Treatment Approach
Supporting Research

Angina is chest pain caused by restricted blood flow to the heart (called ischemia). It often occurs when you are under emotional or physical stress, such as exercise. When the heart doesn't get enough oxygen from the coronary arteries, you feel a squeezing chest pain or pressure across your chest that usually goes away after you stop the activity. The most common cause of angina is hardening of the arteries (atherosclerosis).

Chest pain that is fairly predictable and usually occurs when you exercise is called stable angina. It is relieved with rest or nitroglycerin. Chest pain that occurs when you are resting, or at unpredictable times, is known as unstable angina. Because it can lead to a heart attack, you should immediately call 911 if you experience unstable angina.

It can be difficult to determine whether your chest pain is something serious or a milder condition. For that reason, you should always see your doctor for a diagnosis and treatment. Angina can lead to a heart attack, so you should never try to diagnose or treat it on your own.

Signs and Symptoms

Chest pain from angina can feel like pain due to other causes, such as heartburn, a muscle strain, or asthma. When in doubt, assume that the pain is related to your heart until proven otherwise, especially if you are experiencing pain that you have never felt before.

The classic chest pain from angina feels like significant pressure, squeezing, or tightness in the center of your chest. It has been described as feeling like a band across the chest or a weight pressing down on the chest. You may also feel pain in your left arm and shoulder, neck, and jaw. Other possible sensations include indigestion, rapid or skipping heartbeat, or mild discomfort.

Causes

Coronary heart disease, which occurs when the arteries leading to the heart become narrowed or blocked by plaque, is almost always the cause of angina.

Risk Factors

The risk factors for angina are the same as the risk factors for developing heart disease, including:

  • Age
  • Male gender
  • Menopause
  • Family history of heart disease
  • Diabetes
  • Smoking or exposure to second hand smoke
  • High cholesterol
  • High blood pressure
  • Obesity
  • Sedentary lifestyle
  • Stress
  • Thyroid disease

See Atherosclerosis and Heart attack for more information about risk factors.

Diagnosis

Your doctor may run several tests to determine the cause of your chest pain.

  • Electrocardiogram (ECG) -- Records heart activity through electrodes fastened to your chest.
  • Stress test -- Measures how your heart performs when you exert yourself. You will be hooked up to an ECG machine and asked to exercise (usually on a treadmill or stationary bike) or receive a drug that causes your heart to act as it does when you exercise. The stress test also may be done with imaging (like thallium, sestimibi, or an echocardiogram) to look at the blood flow and muscle function of your heart.
  • Coronary catheterization -- Examines arteries to see if they are narrowed or blocked and involves injecting a dye into your arteries through a thin catheter.
  • Other tests may include an electron beam computed tomography (EBCT) scan or cardiovascular magnetic resonance imaging (MRI).

Preventive Care

If you will be doing an activity that usually triggers your angina, your doctor may tell you to take nitroglycerin a few minutes in advance to prevent the pain.

The best prevention for angina is to modify as many risk factors for heart disease as possible:

  • Stop smoking
  • Maintain a proper weight
  • Control blood pressure, diabetes, and cholesterol
  • Eat a diet low in saturated fats, and high in whole grains, fiber, fruits, and vegetables
  • Exercise at least 30 minutes per day, 5 days per week
  • Reduce stress

Treatment Approach

In treating angina, your doctor will treat the underlying heart disease to prevent it from getting worse. By doing this, blood flow to the heart improves and angina gets better. Lifestyle changes and certain medications can improve blood flow and make you feel better fairly quickly. Keep track of what causes your angina pain, what it feels like, how often you get it, and how long it lasts. If there's a change in your pattern for the worse (for example, if it happens more frequently or with less exertion), let your doctor know right away.

Lifestyle

Changing your diet, exercising regularly, and practicing relaxation techniques to reduce your response to stress can help improve blood flow to your heart and reduce angina. These steps can also help treat your risk factors for heart disease.

Diet

A diet low in saturated fat and high in whole grains, fruits, and vegetables will help your heart and also keep your weight under control. The American Heart Association recommends that you do the following to prevent or treat heart disease:

  • Eat a variety of nutritious foods from all the food groups, especially whole grains, fruits and vegetables, and low fat dairy products.
  • Eat at least 2 servings of fish per week, particularly fish high in Omega-3 fats, such as salmon, trout, and herring.
  • Limit sodium intake to 1,500 mg per day.
  • Limit alcohol intake to 2 drinks per day for men and 1 drink per day for women.
  • Reduce your consumption of beverages and foods with added sugars. 
  • Burn as many calories as you take in. Get at least 30 minutes of exercise most days (or, better still, every day). If you can't find a 30-minute block of time for exercise, aim for three 10-minute sessions suring the course of the day.

Relaxation

Relaxation techniques may help you reduce stress -- which can be a contributing factor to heart disease -- and relieve chest pain. Such practices might include the use of meditation, progressive muscle relaxation, breathing exercises, yoga, self-hypnosis, or biofeedback.

Medications

For the treatment of stable angina, your doctor will likely recommend daily aspirin as well as a combination of the following prescription medications:

  • Nitroglycerin and oral nitrates -- Temporarily dilate coronary arteries, allowing the heart to get more blood and oxygen.
  • Beta-blockers -- Slow heart rate and blood pressure, reducing the heart's need for oxygen. You should never abruptly stop taking a beta-blocker, because serious side effects can occur. Talk to your doctor about how to slowly wean off of this drug. Beta-blockers include:
    • Atenolol (Tenormin)
    • Metoprolol (Lopressor, Toprol-XL)
    • Propranolol (Inderal, Inderal LA)
  • Calcium-channel blockers -- Slow heart rate and cause arteries to dilate. Calcium-channel blockers include:
    • Nifedipine (Procardia)
    • Amlodipine (Norvasc)
    • Diltiazem (Cardizem)
  • Statins -- Lower cholesterol, which is associated with a higher risk of heart attacks due to cardiovascular disease. 
  • Ranolazine (Ranexa) -- Used only when other anti angina drugs don't work, due to potential side effects. It is used with other anti-angina medications, such as beta-blockers or nitroglycerin.

Surgery and Other Procedures

If lifestyle changes and medications are not effective or if unstable angina develops, you may need coronary artery bypass graft surgery, angioplasty with stent placement, or another type of procedure to improve blood flow to your heart.

See also: Atherosclerosis

Other procedures include transmyocardial laser revascularization (TMR), which is usually done along with coronary artery bypass; and, for those who are not candidates for standard treatments, a procedure called enhanced external counter pulsation (EECP).

Nutrition and Dietary Supplements

Eat a well balanced diet with plenty of whole grains, fruits, vegetables, and low fat dairy products. If approved by your physician, make sure you exercise at least 30 minutes a day most days of the week.

There are many supplements that can help reduce your chances of developing heart disease and its consequences, including angina.

See also: Atherosclerosis

A few supplements are being studied specifically to reduce the pain from angina. However, you should never try to treat angina on your own, and should only take supplements or herbs under your doctor's supervision. The doses given below are ones that have been used in studies; it is important to talk to your doctor about what dose might be best for you.

  • L-carnitine (1 g 2 times per day), an amino acid, may help reduce symptoms of angina, according to several clinical trials. L-carnitine can potentially interact with blood-thining medications such as Coumadin (Warfarin) and thyroid hormone.
  • Coenzyme Q10 or CoQ10 (150 mg per day) is important for heart health and several studies suggest that taking it may allow people with angina to exercise more without pain. High doses of CoQ10 may interfere with some blood thinners. If you take blood thinners, talk to your doctor before taking CoQ10.
  • Arginine or l-arginine (2 g 3 times per day) is another amino acid that may improve blood flow and increase exercise tolerance in people with angina. L-argnine can increase bleeding and lower blood pressure. It can also interact with medications that treat erectile dysfunction and aggravate herpes symptoms.
  • Magnesium (365 mg 2 times per day) acts similar to a calcium-channel blocker in the body, although it is much weaker. One study suggested it may help reduce chest pain caused by exercise. Magnesium can lower blood pressure and cause diarrhea, so talk to your doctor before taking it.

Herbs

The use of herbs is a time honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider. If you have angina, do not take any herbs without your doctor's supervision.

There are several different herbs that may be helpful for the treatment and prevention of heart disease, including those that help you reduce your cholesterol, blood pressure, and other risk factors.

See also:

Herbs that may be helpful for angina include:

  • Hawthorn (Crataegus monogyna, 60 mg 3 times per day) has been used traditionally to treat heart disease. One small clinical trial suggested that people with angina who took hawthorn improved blood flow to the heart and were better able to exercise without pain. However, the trial was small and more studies are needed. Hawthorn can cause side effects and interact with other drugs, so do not take it without your doctor's supervision.
  • Kudzu (Pueria lobota, 30 mg - 120 mg per day) has been used in Chinese medicine for centuries to treat heart disease. A few clinical trials have indicated that kudzu may reduce the frequency of angina in people, but the trials were poorly designed. More research is needed. Kudzu can cause side effects and interact with other drugs, so do not take it without your doctor's supervision.
  • Terminalia arjuna, an herb used in Ayurvedic medicine, was shown in one study to be as effective as isosorbide mononitrate (Imdur) in reducing the number of angina attacks and increasing exercise capacity. However, more studies are needed.
  • Suxiao jiuxin wan is widely used in China for angina. One study found that suxiao jiuxin wan improved ECG measurements and reduced symptoms and frequency of acute angina attacks compared with nitroglycerin.

Homeopathy

Homeopathy should never be used instead of immediate medical attention for unstable angina, new onset chest pain, or chest pain that has changed in intensity, frequency, or other characteristics. Homeopathy may, however, be used to help reduce your risk of heart disease, along with other medications. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for you as an individual.

Acupuncture

Studies using acupuncture to treat angina have found mixed results. While some show no benefit, others have found that acupuncture may help reduce the frequency of angina attacks and the need to use nitroglycerin. One Chinese study found that pressing fingertips to an acupuncture point located at the sternum at nipple height during a stable angina incidents was as effective as taking nitroglycerin. It also worked faster than taking pills.

Prognosis and Complications

With the right treatment -- including eating proper diet, getting enough exercise, and taking medication -- blood flow to the heart can dramatically improve, lessening the likelihood of angina attacks.

Supporting Research

Almeda FQ, Parrillo JE, Klein LW. Alternative therapeutic strategies for patients with severe end-stage coronary artery disease not amenable to conventional revascularization. Catheter Cardiovasc Interv. 2003;60(1):57-66.

Bakloanov D, Simons M. Arteriogenesis: lessons learned from clinical trials. Endothelium. 2003;10(4-5):217-223.

Bharani A, Ganguli A, Mathur LK, et al. Efficacy of Terminalia arjuna in chronic stable angina: a double-blind, placebo-controlled, crossover study comparing Terminalia arjuna with isosorbide mononitrate. Indian Heart J. 2002;54:170-175.

Budoff MJ, Achenbach S, Duerinckx A. Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography. J Am Coll Cardiol. 2003;42(11):1867-1878.

Budzynshi J, Pulkowski G, Suppan K, et al. Improvement in health-related quality of life after therapy with omneprazole in patients with coronary artery disease and recurrent angina-like chest pain. A double-blind, placebo-controlled trial of the SF-36 survey. Health Qual Life Outcomes. 2011;9:77.

Bueno EA, Mamtani R, Frishman Wh. Alternative approaches to the medical management of angina pectoris: acupuncture, electrical nerve stimulation, and spinal cord stimulation. Heart Dis. 2001;3(4):236-241.

Chaitman BR, Laddu AA. Stable angina pectoris: anti-anginal therapies and future directions. Nat Reve Cardiol. 2011 Aug 30. Doi:10.1038/nrcardio.2011.129. [Epub ahead of print.]

Cunningham C, Brown S, Kaski JC. Effects of transcendental meditation on symptoms and electrocardiographic changes in patients with cardiac syndrome X. Am J Cardiol. 2000;85(5):653-655, A10.

Day W. Relaxation: a nursing therapy to help relieve cardiac chest pain. Aust J Adv Nurs. 2000;18(1):40-44.

Duan X, Zhou L, Wu T, Liu G, Qiao J, Wei J, Ni J, Zheng J, Chen X, Wang Q. Chinese herbal medicine suxiao jiuxin wan for angina pectoris. Cochrane Database Syst Rev. 2008;(1):1469-493X.

Eid F, Boden WE. The evolving role of medical therapy for chronic stable angina. Curr Cardiol Rep. 2008;10(4):263-71.

Ferri: Ferri's Clinical Advisor 2010, 1st ed. Philadelphia, PA: Mosby Elsevier Inc. 2009.

Fihn SD, Bucher JB, McDonell M, et al. Collaborative care intervention for stable ischemic heart disease. Arch Intern Med. 2011;171(16):1471-9.

Fugh-Berman A. Herbs and dietary supplements in the prevention and treatment of cardiovascular disease. Prev Cardiol. 2000;3(1):24-32.

Fujita M, Tambara K. Recent insights into human coronary collateral development. Heart. 2004;90(3):246-250.

Furnagalli S, Fattirolli F, Guarducci L, et al. Coenzyme Q10 terclatrate and creatine in chronic heart failure: a randomized, placebo-controlled, double-blind study. Clin Cardiol. 2011;34(4):211-7.

Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina – summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). J Am Coll Cardiol. 2003;41(1):159-168.

Gilbert C. Clinical applications of breathing regulation. Beyond anxiety management. Behav Modif. 2003;27(5):692-709.

Goldman JP. New techniques and applications for magnetic resonance angiography. Mt Sinai J Med. 2003;70(6):375-385.

Heatlie GJ, Pointon K. Cardiac magnetic resonance imaging. Postgrad Med J. 2004;80(939):19-22.

Henderson RA, timmis AD. Almanac 2011: stable coronary artery disease. An editorial overview of seleccted research that has driven recent advances in clinical cardiology. Heart. 2011;97(19):1552-9.

Ignarro LJ, Balestrieri ML, Napoli C. Nutrition, physical activity, and cardiovascular disease: an update. Cardiovasc Res. 2007 Jan 15;73(2):326-40. Review.

Jacobson TA. Beyond lipids: the role of omega-3 fatty acids from fish oil in the prevention of coronary heart disease. Curr Atheroscler Rep. 2007 Aug;9(2):145-53. Review.

Kastrup J. Therapeutic angiogenesis in ischemic heart disease: gene or recombinant vascular growth factor protein therapy? Curr Gene Ther. 2003;3(3):197-206.

Kendler BS. Supplemental conditionally essential nutrients in cardiovascular disease therapy. J Cardiovasc Nurs. 2006 Jan-Feb;21(1):9-16. Review.

King MS, Carr T, D'Cruz C. Transcendental meditation, hypertension and heart disease. Aust Fam Physician. 2002;31(2):164-168.

Kleiman NS, Patel NC, Allen KB, et al. Evolving revascularizaton approaches for myocardial ischemia. Am J Cardiol. 2003;92(9B):9N-17N.

Koch e, Malek FA. Standarized extracts from hawthorn leaves and flowers in treatment of cardiovascular disorders -- preclinical and clinical studies. Planta Med. 2011;77(11):1123-8.

Kones R. Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization. Vasc Health Risk Manag. 2010;6:749-74.

Manchanda A, Agarwal A, Agarwal N, et al. Management of refractory angina pectoris. Cardiol J. 2011;18(4):343-51.

Muhling O, Jerosch-Herold M, Nabauer M, Wilke N. Assessment of ischemic heart disease using magnetic resonance first-pass perfusion imaging. Herz. 2003;28(2):82-89.

Nevado JB, Imasa MS. Homocysteine predicts adverse clinical outcomes in unstable angina and non-ST elevation myocardial infarction: implications from the folate intervention in non-ST elevation myocardial infarction and unstable angina study. Coron Artery Dis. 2008;19(3):153-61.

Nikolaou K, PoonM, Sirol M, Becker CR, Fayad ZA. Complementary results of computed tomography and magnetic resonance imaging of the heart and coronary arteries: a review and future outlook. Cardiol Clin. 2003;21(4):639-655.

O'Rourke RA. Optimal medical therapy is a proven option for chronic stable angina. J Am Coll Cardiol. 2008;52(11):905-7.

Rakel & Bope: Conn's Current Therapy 2009, 1st ed. Philadelphia, PA: Saunders Elsevier, Inc. 2008.

Rigelsky JM, Sweet BV. Hawthorn: pharmacology and therapeutic uses. Am J Health Syst Pharm. 2002;59(5):417-422.

Ruel M, Sellke FW. Angiogenic protein therapy. Semin Thorac Cardiovasc Surg. 2003;15(3):222-235.

Staniute M, Brozaitiene J, Vunevicius R. Effects of social support and stressful life events on health-related quality of life in coronary artery disease patients. J Cardiovasc Nurs. 2011 Nov 2. [Epub ahead of print.]

Tackling tough-to-treat chest pain. Harv Health Lett. 2002;13(3):5-6.

Teragawa H, Kato M, Yamagata T, et al. The preventive effect of magnesium on coronary spasm in patients with vasospastic angina. Chest. 2000;118:1690-5.

Tripathi P, Chandra M. Misra MK. Protective role of l-arginine against free-radical mediated oxidative damage in patients with unstable angina. Indian J Clin Biochem. 2010;25(3):302-6.

Wang Q, Wu T, Chen X, Ni J, Duan X, Zheng J, et al. Puerarin injection for unstable angina pectoris. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004196. Review.

Wang YM, Wang QY, Zhang J, et al. Comparative study on acupoint pressing and medication for angina pectoris due to coronary heart disease. Zhongguo Zhen Jiu. 2010;31(7)595-8.

Webster KA. Therapeutic angiogenesis: a complex problem requiring a sophisticated approach. Cardiovasc Toxicol. 2003;3(3):283-298.

Yeh JL, Giordano FJ. Gene-based therapeutic angiogenesis. Semin Thorac Cardiovasc Surg. 2003;15(3):236-249.


Review Date: 12/15/2011
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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