Angina

Angina is chest pain caused by reduced blood flow to the heart muscles. It usually is not life threatening, but it is a warning sign of increased risk of a heart attack or stroke.

With treatment and healthy lifestyle changes, it is possible to control angina and reduce the risk of these more serious problems.

There are 2 main types of angina:

• stable angina (more common) – attacks have a trigger (such as stress or exercise) and stop within a few minutes of resting
• unstable angina (more serious) – attacks are more unpredictable (they may not have a trigger) and can continue despite resting

Some people develop unstable angina after having stable angina.

The main symptom of angina is chest pain. Some people also have other symptoms. Call emergency services for an ambulance for chest pain that does not stop after a few minutes. This could be a heart attack.

Causes of angina

Angina is usually caused by the arteries supplying blood to the heart muscles becoming narrowed by a build-up of fatty substances called cholesterol. This is called atherosclerosis.

Things that can increase the risk of atherosclerosis include:

• an unhealthy diet
• a lack of exercise
• smoking
• increasing age
• a family history of atherosclerosis or heart problems

Angina can also be caused by other conditions affecting the heart and arteries.

Symptoms

• Chest pain

Chest pain could be angina if it:

• • feels tight, dull or heavy – although some people (especially women) may have sharp, stabbing pain
  • spreads to their arms, neck, jaw or back

• • is triggered by physical exertion or stress
  • stops within a few minutes of resting

• Other symptoms

Angina can also cause:

• • breathlessness
  • feeling sick (nausea)
  • pain in the lower chest or stomach – similar to indigestion
  • feeling very tired

Some people have these symptoms without obvious chest pain.

Reacting to symptoms

With no diagnosis of angina:

• Stopping the current activity and resting
• Make an urgent appointment to see a GP if the symptoms go away in few minutes.
• Call an ambulance if the symptoms do not stop in a few minutes – this could be a heart attack.
• If aspirin is easily available and there is no history of allergies to this medication, chew 1 tablet while waiting for an ambulance – this can help in case it is a heart attack.

With angina diagnosis:

• Stopping the current activity and resting
• Take the medicine prescribed for angina (glyceryl trinitrate, or GTN, spray or tablets)
• Take another dose after 5 minutes if the first one does not help
• Call an ambulance if symptoms are still present 5 minutes after taking the second dose.

Diagnosis

There may need to be several tests to diagnose angina.

• Seeing a GP

When seeing a GP after an attack of chest pain, they may ask about the persons:

• symptoms
• cause
• lifestyle – for example, what their diet is like and if they drink or are a smoker
• family's medical history – because heart problems can run in families

They may also do some checks to assess the likelihood of a heart problem, such as:

• measuring blood pressure
• calculating the body mass index (BMI) of the person – this involves measuring weight and height
• measuring waist size
• blood tests to check cholesterol (blood fats) level

If they think someone might have angina or another heart problem, they may refer that person to hospital for some tests.

Tests in hospital

There may be tests to do to see if someone has angina and assess the risk of more serious problems like heart attacks or stroke. There may be:

• an electrocardiogram (ECG) – a test to check heart's rhythm and electrical activity
• a coronary angiography – a scan taken after having an injection of a dye to help highlight the heart and blood vessels
• an exercise ECG – an ECG carried out while walking on a treadmill or using an exercise bike
• blood tests

Treatment (stable angina)

Treatment can help stop angina attacks and reduce the risk of further problems like heart attacks.

Most people with angina need to take several medicines. Surgery may be recommended if medicines do not help. It is also important to make healthy lifestyle changes.

Medicines to treat attacks

In stable angina (the most common type), the treatment of choice is usually medicine to take when during angina attacks. This is usually glyceryl trinitrate, or GTN. It comes as a mouth spray or tablets that dissolve under the tongue.

Medicine is not a replacement for the bullet points listed under symptoms for "reacting to an angina attack." If the medicine does not stop the attack after 5 minutes, another dose is taken. Though medicine should be taken, if after (the second dose) 5 minutes the attack is still ongoing, an ambulance should be called.

GTN can be taken to avoid an attack before doing something like exercise. It may cause headache, flushing or dizziness soon after using it.

GTN tablets usually expire about 8 weeks after the packet is opened, at which point it will need to be replaced. GTN spray lasts much longer, so may be more convenient.

Medicines to prevent attacks

To help avoid more attacks, at least 1 other medicine will also need to be taken every day for the rest of the patients life. Some need to take 2 or more medicines. The main medicines used to prevent angina attacks are:

• beta blockers – to make the heart beat slower and with less force
• calcium channel blockers – to relax the arteries, increasing blood supply to the heart muscle

If someone cannot have either of these medicines, they may be given another medicine such as ivabradine, nicorandil or ranolazine.

Medicines to prevent hearts attacks and strokes

Angina is a warning sign of a higher risk of serious problems like heart attacks or strokes. Other medicines may also have to be taken to reduce this risk. These include:

• a low dose of aspirin to prevent blood clots
• statins to reduce cholesterol (blood fats) level
• ACE inhibitors to reduce blood pressure

Surgery

Surgery may be recommended if medicines are not helping control the angina. The 2 main types of surgery for angina are:

• coronary artery bypass graft (CABG) – a section of blood vessel is taken from another part of the body and used to reroute blood around a blocked or narrow section of artery
• coronary angioplasty and stent insertion – a narrowed section of artery is widened using a tiny tube called a stent

Both of these operations are similarly effective. The best one for each person depends on their circumstances. If surgery is recommended, talk to a doctor or surgeon about the options. Some medicines will probably still have to be taken after surgery.

Treatment (unstable angina)

With unstable angina (where symptoms develop unpredictably), medicines that prevent blood clots and reduce the risk of having a heart attack or stroke are needed. These medicines may be given:

• low-dose aspirin
• clopidogrel
• an injection of a blood-thinning medicine soon after diagnosis
• Surgery (either CABG or PCI) may be recommended in people with a high risk of having another angina attack, or if they are at a high risk of having a heart attack or stroke.

Living with

It is usually possible to live a normal life with angina. Some things that can make it better are:

• have a balanced diet
  • cut down on alcohol
  • stop smoking in those who smoke
  • lose weight in those that are overweight
• Exercise and sport
  • It's also important to stay active with angina. Some may worry that exercising could trigger their symptoms or cause a heart attack, but the risk is low if they:
    • build up activity level gradually and take regular breaks
    • keep GTN spray or tablets nearby
    • if needed, use the spray or take a tablet before starting exercise

However a GP should offer exercise advice to the specific individual.

• Work
  • People who can, usually continue to do so
  • Just make sure to keep the GTN medicine nearby in case of having an attack at work
  • If the job involves heavy lifting or manual labour, speak to the employer about changes which can be made to reduce the risk of an attack. This may mean changing duties or cutting back on how much heavy work the person does
• Having sex
  • Some people worry that having sex will trigger an angina attack, but the risk of this happening is low.
• Driving
  • People who drive do not usually need to stop. They do not need to tell the issuers of drivers licenses in the UK, unless they hold a higher level/tier license (such as bus or lorry drivers)
  • Driving only needs to stop if attacks occur at rest, while driving, or are triggered by emotion. Driving can start again when the symptoms are well controlled.

Getting support

Living with angina can be difficult at times.

Speak to the GP if it has someone feeling down for a few weeks. They may recommend treatments that can help, such as medicines or talking therapy.