Guide by Condition: Angina
Posted by Mike Phipps on July 14, 2021
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Angina is where you suffer pain in your chest which is caused by a lack of blood flow to your heart. It is not a heart attack, but could be a warning sign that you are at higher risk of having one.
Your heart has a special blood flow of its own. Much like every other part of your body, it needs a healthy supply to work properly. If the blood vessels ‘feeding’ the heart become narrowed by cholesterol, or clots, then this can restrict the amount of blood getting to your heart. This might occasionally cause chest pain, or discomfort, for short periods.
Your heart needs more blood when you are doing things like exercising than when you are relaxing and sitting down. For this reason, angina generally happens when you exercise. It can also occur when you get emotional, or stressed.
Angina is caused by narrowings in your blood vessels where a clot has built up. This clot is called an atheroma. These narrowings are generally contributed to by several different things, rather than having one singular cause.
Firstly, high blood pressure will put a strain on your arteries. This causes the walls of your arteries to shear (break off), in small amounts. A clot then builds up on the broken surface. This clot can be made up of platelets, cholesterol, and other fibres. If you have high cholesterol, you are more likely to build up these clots. The clot will just continue to build until it could eventually block the artery altogether. This is what causes a heart attack, and also what can cause certain types of strokes.
Is Angina A Heart Attack?
No, because your heart is only getting a reduced blood flow for short periods, it is not getting any structural damage. A heart attack is where the blood flow becomes so reduced, your heart muscle becomes damaged. In angina, your heart muscle does not become damaged, and the pain should go away when you rest.
Are There Any Risk Factors For Angina?
There are numerous risk factors that will make you more likely to develop angina. Some of the causes of angina are:
High cholesterol levels
- Being overweight
- High blood pressure
- Getting older
- Family history of heart disease
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Broadly speaking, there are two types of angina – stable and unstable. Stable angina is where you only get short periods of chest pain when exercising. Unstable is where the pain is more prolonged, or happens at rest. Your angina could also be classed as unstable if it is happening more frequently. For example, if you normally only get angina once a week, or when walking up a steep hill, but then you start to get it every day, and when only walking short distances, this would be unstable angina.
If you are suffering with symptoms of unstable angina, you must see a doctor. If you cannot get an urgent appointment with your GP call NHS 111 or attend A&E.
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Your doctor might split your symptoms of angina into two groups, typical and atypical.
Typical symptoms of angina can feel a lot like a heart attack. You might experience:
- Chest pain – this may be a feeling of tightness across your chest, or it could be a dull ache. Some people describe a burning sensation.
- A pain that spreads to the following – shoulders, arms, neck, jaw. You might also get a tingling sensation in these areas.
- It when exercising, or when you feel stressed, and the pain goes away when resting for a few minutes.
Atypical symptoms include:
- A feeling of indigestion, or pain in the top part of your abdomen
- Extreme tiredness
- Feeling short of breath
Whether you get typical, or atypical symptoms doesn't really matter with regards to your angina. It does not mean that you are getting it more severely, or less severely. For your doctor, it is important because it helps with diagnosing the actual problem. If you are suffering with only atypical symptoms, diagnosis may be more difficult, and you may require more tests before a confirmed diagnosis can be made.
I Think I Am Getting Angina, When Should I Seek Help?
If you haven’t been diagnosed with angina, and your pain has come on when you were exercising, or when feeling stressed, and it subsides within a few minutes of rest, call NHS 111 for an urgent appointment.
If your symptoms don’t go away with rest, call 999. You will need to go into a hospital to be assessed by a doctor to make sure that you are not having a heart attack.
If you are known to suffer with angina, you will likely have GTN prescribed by your doctor. GTN, or Glyceryl Trinitrate, is a drug which dilates the blood vessels around your heart. This improves your heart's blood supply and should ease your pain. Stop what you are doing and rest. Take your GTN whichever way you have been told to by your doctor. This might be in the form of a spray, or a tablet, which you put under your tongue and it then dissolves.
If your pain comes on whilst you are resting, or it is worse than usual, you should call 999. You should also do this if the pain does not go away within a few minutes.
Why Is Angina An Important Warning Signal?
Angina is an important warning signal that the blood supply to your heart might not be as good as it should be. This means that you could be at greater risk of having a heart attack and that you need further investigation. If it is the first time you have had it, then you will need some tests to make sure that the blood vessels around your heart are working well enough.
The first time you are diagnosed, you will undergo an assessment by your doctor to give an estimate of how likely you are to suffer a heart attack over the next few years. They will take a careful history, asking questions about how your symptoms initially started, what you were doing at the time, whether you have a family history of heart disease and more. The way you are investigated will depend on how high risk you are based on this history.
What Kind Of Investigations Will I Get?
There are lots of different investigations you might end up getting. Which ones your doctor orders will probably depend on how high risk you are, and how you presented with your initial symptoms.
If your symptoms were severe, or happened more recently, you might receive blood tests. These will probably include a special test called a troponin, which gives an indication about whether your heart has suffered any damage. If it is raised, this means that your heart muscle has been damaged, and this is how a heart attack is diagnosed. In angina, we would expect this test to be normal.
Other tests include:
- An Electrocardiogram (ECG) – this is a tracing of the electrical activity in your heart. If your heart has been damaged, or you are currently having a heart attack, it might be possible to see this on an ECG. You might, however, have a completely normal ECG and still be suffering with angina.
- An Echocardiogram – this is a scan which visualises your heart structure, and how well it is pumping. You may, or may not need this, and the decision will be left up to whoever is treating you. It is a painless scan which uses ultrasound, or a “jelly-scan,” i.e. the same type of scan pregnant women get to look at their babies, only of your heart this time.
- Coronary angiography – this is another type of scan. It uses an injection of a special dye into your vein which then spreads through all of your blood vessels. X-rays are then taken around your heart. The dye lights up these blood vessels, which makes it possible to see if there are any blockages, or narrowings in the arteries around your heart.
Are There Any Treatments For Angina?
If you have unstable angina, or a coronary angiogram showing that the blood vessels around your heart have become very narrow, you might need surgery to prevent you from having a heart attack. This is likely to be done through the blood vessels in your groin, which means that you won’t end up with any large wounds.
A small tube called a stent is threaded with a wire through the artery in your groin, or possibly the artery in your wrist, and into any blood vessels which have been shown to be really narrow. This procedure is known as percutaneous coronary intervention, or PCI. The stent opens up the artery and hopefully, this means that they will not become blocked in the future, so avoiding a heart attack.
If this type of surgery isn’t an option, or you have multiple areas that need treating, then the treatment of angina might include a different type of surgery. People have classically heard of this type of surgery described as a “heart bypass”. People might describe it as being a “double heart bypass”, or “triple heart bypass”. Essentially, a blood vessel is taken from another part of your body and surgically “grafted” onto your heart to “bypass” any blood vessels which aren’t working as well as they should be. The number of vessels which you need to “bypass” leads to the “double” or “triple” description that people sometimes use.
If your angina is very stable, or no narrowings like this can be identified, you will probably not get any definitive treatment. You will be prescribed medications to reduce your risk of getting a heart attack in the future, and some medications to help deal with the pain when you get an attack.
The primary medication used to relieve symptoms is GTN, which we discussed earlier. Medications which are used to reduce your risk of a further heart attack include:
- Aspirin – this drug is used to decrease the build-up of clots in your arteries.
- Beta-blockers – these drugs are frequently used for people with high blood pressure. A common example which is prescribed would be Bisoprolol. As well as reducing blood pressure, these beta-blockers also cause the heart to beat more slowly, and with less pressure. This means the heart isn’t working as hard, which can help with angina.
- Calcium Channel Blockers – if you can’t take beta-blockers, you may instead be given one of these drugs. They relax the arteries around your heart, increasing the blood supply to your heart muscle.
- Drugs to lower your cholesterol – having high cholesterol is a risk factor for heart attacks. The most common drugs prescribed for this are statins, such as simvastatin.
- If you are found to suffer with high blood pressure, you may also be started on blood pressure medications. Beta-blockers and Calcium Channel Blockers do this, but if your blood pressure remains high, other medications may need to be added, such as an ACE inhibitor. A common example of an ACE inhibitor would be Ramipril.
Another important way to reduce your risk of heart attack is to make some healthy lifestyle changes. These can reduce your need for some of the medications listed above. They are unlikely to be able to completely reverse your angina on their own, but are important in improving your overall health.
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The NHS Live Well website has some helpful advice, tips and tools on how to implement some healthy lifestyle changes. Having a healthy lifestyle is one of the most important things you can do to reduce your risk of having a heart attack and stroke. A quick summary of things to try are:
- Exercising at least three times a week, and for 30-minute intervals.
- Eating a healthy, well-balanced diet.
- Eat at least 5 portions of fruit and vegetables a day.
- Stop smoking.
- Drink within the recommended guidelines for alcohol consumption.
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The British Heart Foundation is a charity dedicated to supporting patients who suffer with heart conditions, angina included. They organise support groups and charity events. You can contact them via email, or for those who prefer to just talk to someone, they operate a helpline.
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Medical terms are often baffling and difficult to fully understand. To help, we have listed some frequently used terms below.
- Abdomen – the section of the body that contains all of the structures between the chest area and the pelvis
- Arteries – blood vessels that carry oxygen-rich blood from the heart to body tissues
- Atheroma – a build-up of a clot inside of an artery
- Blood vessels – the channels through which blood is distributed to body tissues
- Cholesterol – a type of lipid; a fat-like substance that's produced naturally by the liver
- Clots – a semi-solidified mass, for example, of blood, or lymph
- Coronary Angiography – a scan using dye injected into the arteries to look at the blood vessels around the heart
- Diabetes – a condition when the body cannot product insulin which is required to control blood glucose levels
- Dilate – to enlarge, stretch, or cause to expand
- Echocardiogram – a scan using ultrasound waves to create an image of the heart in real-time. It can be used to show the structure of the heart, and how well it is pumping
- Electrocardiogram (ECG) – a tracing of the electrical activity of your heart onto a piece of paper. This is made by a machine which is connected to stickers which are placed onto your chest, and pick up the electrical activity in your heart. It can be used to identify heart attacks
- High blood pressure (hypertension) – recorded with 2 numbers (1) systolic pressure (the higher number) is the force at which the heart pumps blood around the body and (2) diastolic pressure (the lower number). High blood pressure puts strain on your blood vessels, heart and other organs such as the brain, kidneys and eyes
- Indigestion – a term that describes discomfort in the upper abdomen
- Nausea – the sensation of an urge to vomit (be sick)
- Percutaneous Coronary Intervention (PCI) – the placement of stents (small tubes) inside of arteries around the heart which have become narrow
- Statins – a class of prescription drugs to help lower cholesterol levels in the blood
- Stroke – occurs when the blood supply to part of the brain is interrupted, or reduced
- Troponin – an enzyme inside the heart muscle. If this enzyme is detected in the blood in high levels, it can indicate that you have had a heart attack