Coronary artery disease due to atherosclerosis is by far the most common cause of unstable angina. Atherosclerosis is the buildup of fatty material called plaque along the walls of the arteries. This causes arteries to become narrowed and less flexible. The narrowing interrupts blood flow to the heart, causing chest pain.
People with unstable angina are at increased risk of having a heart attack.
Chest pain that you may also feel in the shoulder, arm, jaw, neck, back, or other area
Discomfort that feels like tightness, squeezing, crushing, burning, choking, or aching
Discomfort that occurs at rest and does not easily go away when you take medicine
Shortness of breath
With stable angina, the chest pain or other symptom only occurs with a certain amount of activity or stress. The pain does not occur more often or get worse over time.
Unstable angina is chest pain that is sudden and often gets worse over time. You may be developing unstable angina if the chest pain:
Starts to feel different, is more severe, comes more often, or occurs with less activity or while you are at rest
Lasts longer than 15 - 20 minutes
Occurs without cause (for example, while you are asleep or sitting quietly)
Does not respond well to a medicine called nitroglycerin
Occurs with a drop in blood pressure or shortness of breath
Unstable angina is a warning sign that a heart attack may happen soon. It needs to be treated right away. If you have any type of chest pain, see your doctor.
Signs and tests
The doctor will perform a physical examination and check your blood pressure. The doctor may hear abnormal sounds, such as a heart murmur or irregular heartbeat, when listening to your chest with a stethoscope.
Coronary angiography (taking pictures of the heart arteries using x-rays and dye) -- this is the most direct test to diagnose heart artery narrowing
Your doctor may want you to check into the hospital to get some rest, have more tests, and prevent complications.
Blood thinners (antiplatelet drugs) are used to treat and prevent unstable angina. You will receive these drugs as soon as possible, unless they would be unsafe for you to take. These medicines include aspirin and the prescription drug clopidogrel. Aspirin (and sometimes clopidogrel) may reduce the chance of a heart attack in certain patients.
During an unstable angina event:
You may get heparin (or another blood thinner) and nitroglycerin (under the tongue or through an IV)
Other treatments may include medicines to control blood pressure, anxiety, abnormal heart rhythms, and cholesterol (such as a statin drug)
Often if a blood vessel is found to be narrowed or blocked, a procedure called angioplasty and stenting can be done to open the artery.
Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart.
A coronary artery stent is a small, metal mesh tube that opens up (expands) inside a coronary artery. A stent is often placed after angioplasty. It helps prevent the artery from closing up again. A drug-eluting stent has medicine in it that helps prevent the artery from closing.
Heart bypass surgery may be done for some people. Whether this surgery is done depends on which arteries, how many arteries, and what parts of their coronary arteries are narrowed, and how severe the narrowings are.
Unstable angina is a sign of more severe heart disease.
How well you do depends on many different things, including:
How many and which arteries in your heart are blocked, and how severe the blockage is
Whether you have ever had a heart attack
How well your heart muscle is able to pump blood out to your body
Abnormal heart rhythms and heart attacks can cause sudden death.
Unstable angina may lead to:
Abnormal heart rhythms (arrhythmias)
A heart attack
Calling your health care provider
Seek medical attention if you have new, unexplained chest pain or pressure. If you have had angina before, call your doctor.
Call 911 if your angina pain:
Is not better 5 minutes after you take nitroglycerin (your health care provider may tell you to take three total doses)
Does not go away after three doses of nitroglycerin
Is getting worse
Returns after the nitroglycerin helped at first
Call your doctor if:
You are having angina symptoms more often
You are having angina when you are sitting (rest angina)
You are feeling tired more often
You are feeling faint or light-headed, or you pass out
Your heart is beating very slowly (less than 60 beats a minute) or very fast (more than 120 beats a minute), or it is not steady
You are having trouble taking your heart medicines
You have any other unusual symptoms
If you think you are having a heart attack, get medical treatment right away.
Lifestyle changes can help prevent some angina attacks. Your doctor may tell you to:
Lose weight if you are overweight
Drink alcohol in moderation only
Eat a healthy diet that is high in vegetables, fruits, whole grains, fish, and lean meats
Also keep strict control of your blood pressure, diabetes, and cholesterol levels. Some studies have shown that making a few lifestyle changes can prevent blockages from getting worse and may actually improve them.
If you have one or more risk factors for heart disease, talk to your doctor about taking aspirin or other medicines to help prevent a heart attack. Aspirin therapy (75 - 325 mg a day) or drugs such as clopidogrel or prasugrel may help prevent heart attacks in some people. Aspirin therapy is recommended if the benefit is likely to outweigh the risk of side effects.
Cannon CP, Braunwald E. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 56.
Montalescot G, Cayla G, Collet JP, Elhadad S, Beyqui F, Le Breton H, et al. Immediate vs. delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA. 2009;302:947-954.
Wright RS, Anderson JL, Adams CD, et al. ACCF/AHA Focused Update of the Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American College of Emergency Physicians Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;57:1920-1959
David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; and Michael A. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.