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What is angina?

Angina (chest pain) indicates an underlying heart problem such as coronary heart disease (CHD), which is a result of one or more blockages in the coronary arteries. It also may signal coronary microvascular disease (MVD), which affects the heart’s smallest coronary arteries (also called cardiac syndrome X or non-obstructive CHD). Coronary artery disease (CAD) is the gradual narrowing or blockage of the coronary arteries that supply blood to the heart. It is the most common cause of heart disease and is the major reason people have heart attacks.

There are several types of angina:

  • Stable angina (angina pectoris) — chest pain or discomfort caused by poor blood flow through the coronary arteries to the heart, when they become narrowed and blocked due to atherosclerosis or a blood clot. This symptom can last up to 15 minutes. Rest or nitroglycerin medicine can relieve the pain. An episode of angina does not indicate that a heart attack is occurring or is about to occur. It does indicate, however, that CAD is present and that some part of the heart is not receiving an adequate blood supply. Those with angina have an increased risk of heart attack. A person who has angina should note the patterns of his or her symptoms; what causes the chest pain, what it feels like, how long episodes usually last and whether medication relieves the pain. Stable angina is predictable, therefore less serious than unstable angina.
  • Unstable angina — a condition in which your heart doesn't get enough blood flow and oxygen. CAD due to atherosclerosis is the most common cause of unstable angina. You may be developing unstable angina if the chest pain feels different, is more severe, comes more often or occurs with less activity or even while you are at rest. It may last longer than 15 to 20 minutes, and is accompanied by shortness of breath or a drop in blood pressure. Unstable angina is a warning sign that a heart attack may happen soon, so it must be treated right away. However, nitroglycerin does not help this type of angina. Call for medical assistance immediately if the angina symptoms change sharply.
  • Variant (Prinzmetal’s) angina — a type of angina pectoris, it is a temporary increase in coronary vascular tone (vasospasm). It usually occurs at one site, either in a normal or diseased vessel, when a person is at rest rather than after physical exertion or emotional stress. Attacks can be very painful and usually occur between midnight and 8am. Most patients are younger women who may not have typical cardiovascular risk factors. This form of angina can be treated with medicine.
  • Microvascular angina — another form of angina pectoris (formerly called syndrome X), it affects the smallest coronary arteries in the heart and tiny vessels in the arms and legs. Spasms within their walls cause reduced blood flow to the heart. Patients with this condition experience chest pain but have no apparent coronary artery blockages, and can be treated with some of the same medications used for angina pectoris. Microvascular angina is more common in women.

Symptoms

You may feel pressure or squeezing, usually in the chest under the breastbone, and the discomfort may also be in your shoulders, arms, neck, jaw or back, especially during physical activity. Angina pain may even mimic indigestion. It usually occurs in the center or left side of the chest and lasts for more than a few minutes, or goes away and comes back. The chest pain associated with angina usually begins with physical exertion. Other triggers include emotional stress, extreme cold and heat, heavy meals, excessive alcohol consumption and cigarette smoking. Each individual may experience symptoms differently, but other common symptoms are:

  • Shortness of breath
  • Weakness or fatigue for no apparent reason
  • Dizziness/nausea
  • Irregular heartbeat

If you experience any of the symptoms listed above, your cardiologist may recommend a stress test to monitor and assess safe amounts of physical activity. Stress tests are also used for patients who have had a heart attack or angioplasty.

However, those symptoms are not always indicative of angina. They may signal other conditions such as:

  • Pulmonary embolism (blockage in a lung artery)
  • Aortic dissection (a tear in a major artery)
  • Lung infection
  • Aortic stenosis (narrowing of the heart’s aortic valve)
  • Hypertrophic cardiomyopathy (heart muscle disease)
  • Pericarditis (inflammation in the tissues around the heart)
  • A panic attack

Risk factors

Many people still think of heart disease as a man's problem, but more women are diagnosed with heart disease and CAD every year. It is now the No. 1 killer of women in the United States. The risk of heart disease rises as women age. Controllable risk factors include:

  • Smoking
  • High LDL, or "bad" cholesterol and low HDL, or "good" cholesterol levels
  • Hypertension (high blood pressure), stress and anger
  • Physical inactivity and obesity (more than 20 percent above one's ideal body weight)
  • Diabetes
  • Diet
  • High C-reactive protein (an indicator of inflammation elsewhere in the body)

Uncontrollable risk factors are:

  • Age
  • Family history of heart disease
  • Race (African-Americans, American Indians and Mexican-Americans are more likely to have heart disease than Caucasians are)

Diagnosis

If you have chest pain, see a doctor immediately to determine whether you have angina, and if you do, whether it is stable or unstable. Your doctor should determine whether the angina indicates a serious heart condition. Unstable angina may require emergency medical treatment to prevent a heart attack.
Your doctor should ask about your symptoms, family history and risk factors for heart disease and other cardiovascular conditions, as well as perform a physical exam.

If you have chest pain, or if your physician thinks your angina is related to a serious heart condition, you may be prescribed any of these tests and procedures:

  • Chest X-ray
  • EKG or ECG (electrocardiogram)
  • Stress test
  • Blood test
  • Coronary angiography and cardiac catheterization
  • Computed tomography angiography

The tests will reveal whether you have had a heart attack, and if so, how much your heart was damaged and what type of coronary artery disease you may have. Sometimes a heart attack is the first symptom of CAD, so these tests can tell your doctor what type(s) of treatment and lifestyle changes you need to prevent serious coronary events. Tests may involve noninvasive or invasive diagnostics.

Noninvasive tests include:

  • Chest X-ray
  • Electrocardiogram (EKG/ECG)
  • Holter monitoring (ambulatory ECG/EKG)
  • Computed tomography
  • This test may be a CT/CAT scan, EBCT, PET, DCA, DSA, multidetector CT or MDCT, MRI and SPECT.
  • Coronary angiogram
  • Echocardiogram
  • Stress tests
    • Exercise cardiac stress test (ECST)
    • Radionuclide stress imaging
    • Thallium stress test
    • MPI
    • MUGA scan
  • Blood testing
  • Cardiac catheterization

Prevention

Preventive cardiology provides advanced options for a wide range of heart diseases. Our staff of experienced cardiologists and cardiac healthcare professionals manages and implements a multifaceted approach that can include:

  • Cardiac rehabilitation
  • Cardiac procedures
  • Diagnostic testing
  • Diet and nutrition counseling
  • Management of blood pressure and cholesterol
  • Medications
  • Stress management
  • Smoking cessation

Coping & support

Rehabilitation can take anywhere from 12 to 36 weeks, depending on your age, physical condition and previous health issues. Cardiac rehabilitation programs are individually designed to help patients with heart disease or poor heart health to recover faster, and can start while you are still in the hospital. You must be referred to the program by your physician, and will be referred to cardiac rehabilitation by a cardiologist. Our cardiac rehabilitation team will review an initial assessment of medical history and risk factors. A stress test prior to starting will help define the goals and parameters of your exercise program. A rehab program can include:

  • Exercise
  • Health education
  • Nutrition counseling

For as long as your physician prescribes, the cardiac rehab process will continue when you leave the hospital. For best results, we recommend two to three cardiac rehabilitation visits per week.

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