Chest Pain (Angina)

What is Angina?

Angina, or angina pector is, is the medical term for chest pain, pressure, or tightness. Angina is caused by reduced blood flow to the heart, indicating underlying coronary artery disease, or heart disease, which puts you at greater risk for a heart attack. Heart disease is caused by atherosclerosis, where fatty plaque builds up in your arteries and they get stiffer and narrower, making it more difficult for blood to flow through. Blood carries oxygen, so when blood flow to your heart is restricted, the heart muscle doesn’t get enough oxygen and this can cause chest pain (similar to a cramp).

Not all chest discomfort is angina. For example, acid reflux (heartburn) and lung infection or inflammation can also cause chest pain.

What are stable and unstable Angina?

The two main types of angina are stable and unstable. Stable angina, sometimes called chronic stable angina, is recurrent pain or discomfort in your chest, and possibly your jaw, shoulder, back, or arm.1 It differs from unstable angina because stable angina is predictable; it is usually triggered by specific things that cause your heart muscle to need more oxygen than usual, such as physical exertion or emotional stress. Unstable angina has no recognizable pattern and can occur when a person is at rest. Stable angina generally goes away when you rest or when you take nitroglycerin, a medication that dilates (widens) your blood vessels allowing more blood and oxygen to reach your heart.

How common is stable angina?

Each year, about 400,000 new cases of stable angina are diagnosed in the US. More American women than men suffer from stable angina: about 3.3 million compared with 3.2 million men. Women who have stable angina are usually older than men with stable angina.4 Among women aged 20 or older, 3.5% of white women have stable angina, 4.7% of African-American women, and 2.2% of Mexican-American women. Diabetes is also more prevalent in women with stable angina compared with women with Syndrome X.

What are Prinzmetal’s angina and Syndrome X?

Prinzmetal’s or variant angina is a form of unstable angina in which chest pain occurs at rest. The chest pain of Prinzmetal’s angina is caused by coronary artery spasm, which is an abnormal or involuntary constriction of the muscle (the spasm) in an artery of the heart. Syndrome X is a type of stable angina, which is more common in women than men. It occurs in people who have chest pain but do not show evidence of underlying heart disease, meaning that no obvious blockages in the arteries of the heart are found.

Does angina mean I’m having a heart attack?

An episode of stable angina is not a heart attack, but it does mean that you have a greater chance of having a heart attack. Angina pain means that some of the heart muscle is not getting enough blood and oxygen temporarily. A heart attack, on the other hand, occurs when the blood flow to a part of the heart is suddenly and completely cut off, usually by a blood clot. This can lead to serious heart damage.

Still, chest pain is the most common symptom of a heart attack. Here are some signs that your chest pain may not be an episode of angina and that you may be having a heart attack. If you have any of these signs, call 9-1-1 immediately:

  1. Pain or discomfort that is very bad, gets worse, and lasts longer than 20 minutes
  2. Pain or discomfort along with weakness, feeling sick to your stomach, sweating, or fainting
  3. Pain or discomfort that does not go away when you take nitroglycerin
  4. Pain or discomfort that is worse than you have ever had before

Chest Pain (Angina) – Symptoms & Diagnosis

What are the symptoms of stable angina?

People with stable angina usually feel discomfort (often a pressure-like pain) in or around the chest, shoulders, jaw, neck, back, or arms. It may feel like a squeezing or pressing sensation in the chest. The pain usually lasts 2 to 5 minutes.

One study found that women felt more pain in the back of their shoulder and middle back area than men,6 and another found that women feel pain more often in their throat, neck, and jaw areas.

If you have chest pain that is more of a fleeting discomfort or a dull ache lasting for hours, it is probably NOT stable angina. If you have chest pain that does not go away within 15 minutes, episodes of chest pain that are getting progressively worse, or if you begin to experience chest pain when at rest, you may have unstable angina; this is a more serious condition and you should go to the emergency room.

How is stable angina diagnosed?

Stable angina can usually be diagnosed by the symptoms that you describe to your healthcare provider. That’s why it is very important that you accurately describe your symptoms to your healthcare provider, especially what brings on the chest pain, what relieves it, and how long episodes tend to last. Stable angina is marked by chest pain that occurs during exercise and is relieved with rest; it follows a predictable pattern and you can usually anticipate when it will occur. On the other hand, unstable angina is marked by chest pain that occurs while at rest or that increases in frequency or intensity compared to your usual pattern.

Because stable angina is associated with underlying heart disease, it is likely that you will undergo some diagnostic procedures to determine whether or not you have heart disease. These tests may include an exercise electrocardiogram (ECG), a stress echocardiogram or ultrasound of the heart, or a nuclear stress test, in which a radioactive dye is injected to produce computer pictures of your heart muscle and arteries. These tests can determine the extent of the blockages in your arteries. You may also undergo cardiac catheterization, which involves an angiogram or X-ray of the coronary arteries. For women with stable angina, the signs of heart disease are often less obvious than in men with stable angina.8 Women are less likely than men to have significant amounts of fatty plaque buildup in the arteries of their heart. If there are no signs of underlying heart disease during these diagnostic procedures, you may be diagnosed with Syndrome X.

Treatment of Stable Angina

How is stable angina treated?

Lifestyle changes and medicine are the most common ways to control stable angina. Angina is often one of the first signs of heart disease. Treating the underlying heart disease will not only reduce the number and severity of chest pain episodes, but it is also a step towards preventing a future heart attack. In addition to medications to treat your pain, your doctor may also prescribe medication to help you get your blood pressure and cholesterol down to healthy levels. Other treatments include balloon angioplasty and bypass surgery.

What lifestyle changes are used to treat angina?

Your major goals should be to quit smoking (if you smoke), to control high blood pressure, and to lower your cholesterol, exercise 3 to 4 times a week for 30 minutes, and maintain a healthy weight and heart healthy diet. Although angina may be brought on by exercise, regular exercise helps relieve chest pain in the long run. Your doctor can help you tailor an exercise program to meet your needs. It is important to continue making lifestyle changes even if you are taking medications or undergo more serious treatments such as angioplasty or bypass surgery.

What medications are used to treat angina?

There are several different types of medication you may be prescribed if you are diagnosed with stable angina. Most likely you will be prescribed nitroglycerin, which widens your blood vessels to allow more blood and oxygen to reach your heart. Nitroglycerin is taken when chest pain occurs or when it is expected, to head off the pain. If you have persistent angina, you may also be prescribed, such as a beta blocker or calcium channel blocker. Beta blockers slow down your heart rate and reduce the force of the heartbeat, lessening the heart’s workload. Calcium channel blockers cause muscle cells to relax and improve blood flow to the heart. Both types of medicine are also used to treat high blood pressure. Unfortunately, beta blockers are often under prescribed to women who need them.

If you are a high-risk patient, you may also be told to take daily aspirin because it helps prevent blood clots from forming. If you can’t take aspirin, you may be prescribed clopidogrel (Plavix), which is a similar blood thinning medication.

Do I need balloon angioplasty or bypass surgery if I have stable angina?

If medication alone is not successful in relieving your angina pain or if you have significant heart disease, you may have to undergo revascularization. Revascularization means restoring blood flow to a body part — in this case, your heart. This is usually done by one of two methods: balloon angioplasty with or without stent placement, or bypass surgery. In balloon angioplasty, a very small inflated balloon is used to widen narrowed arteries by pushing away fatty plaque. A stent – a tiny, wire-mesh tube – is then usually placed in the artery to prop it open. Bypass surgery is a form of open heart surgery that involves taking an artery from another part of your body (usually your thigh or chest) to create a detour around your blocked artery so that blood can again flow freely.

What other treatments are available if I can’t have angioplasty or bypass surgery?

There are two other therapies—transmyocardial revascularization (TMR) and enhanced external counterpulsation (EECP)—that are last resort options for people who do not get relief from medications and who cannot undergo balloon angioplasty or bypass surgery. TMR is a surgical procedure in which lasers are used to make small channels in the heart muscle. EECP is a noninvasive technique in which 3 air cuffs are placed on each of your legs and when the heart is at rest, the cuffs rapidly inflate in succession from the calf to the upper thigh, propelling blood back to the heart. These treatments are no substitute for angioplasty or bypass surgery, and still need further investigation. TMR and EECP may not be widely available.

What is the prognosis for stable angina patients?

The good news is that very few people die from stable angina — only about 2% to 3% of patients each year. But angina is an indicator of heart disease; if you do not receive treatment for stable angina your heart disease will worsen, increasing your risk of dying. About 1 out of every 5 deaths in the US is caused by heart disease.

For those who are treated with lifestyle changes, medication, or revascularization, the results are often good. A Swedish study of more than 800 chest pain patients who had undergone bypass surgery or balloon angioplasty found that 4 years later, men and women reported similar levels of pain relief, emotional well being, and general health perception as people who had not had angina. Overall, this study found that 60% of patients were free from angina, 28% experienced fewer than 3 episodes of angina per week, and only 12% had frequent angina.

Unfortunately in this study and in others, women were less likely than men to be free from angina pain after treatment. To address the lack of success for chest pain treatment in women the Nation Heart, Lung, and Blood Institute set up the Women’s Ischemic Syndrome Evaluation (WISE) study involving nearly 1,000 women with chest pain. Findings so far suggest that heart disease and chest pain develop differently in men and women. This ongoing study should help ensure that women with chest pain receive appropriate diagnostic tests and adequate symptom relief in the future.

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