Angina

What angina is and what happens in the heart

Angina is a centralised chest pain that occurs due to a reduction of blood flow to the heart muscle, in arteries that have become narrowed by fatty substances. That narrowing process is known as atherosclerosis. The most useful thing to understand up front is that angina is a symptom rather than a disease in its own right. It is the pain or pressure your heart produces when its muscle is not getting enough oxygen rich blood.

Your heart is a muscle, and like any muscle it needs a constant supply of oxygen rich blood to do its work. The coronary arteries are the small blood vessels that deliver that supply, and they are only 3 to 4 millimetres wide. Over years they can narrow gradually as fatty plaque builds up on the artery walls. When that narrowing becomes significant, the heart muscle can struggle to get the blood it needs, particularly when demand goes up.

Angina is the symptom of that mismatch. At rest, the narrowed arteries can usually deliver enough blood to keep things ticking along. The moment the heart has to work harder, however, the supply falls short and the muscle complains. That complaint is angina. The relief you feel when you slow down is the heart finding its balance again as demand drops back to what the arteries can manage.

Angina is not usually life threatening in itself, but it can pose a warning that you may be at risk of a heart attack or a stroke. Symptoms can be controlled with treatment and lifestyle changes, and managing them well can ultimately reduce the risk of further issues.

The different types of angina

Patients sometimes assume angina is a single thing, but it is better understood as a spectrum. There are two main types, stable and unstable, and two less familiar forms that affect the smaller vessels or cause the arteries to go into spasm.

Distinguishing between these types changes what happens next. The treatment for stable angina with significant artery narrowing looks very different from the treatment for microvascular angina, and getting the diagnosis right is what makes the treatment work.

• Stable angina is the most common form. The pattern is predictable, so the same kind of effort brings on the same kind of discomfort, and rest or a glyceryl trinitrate (GTN) spray usually settles it within a few minutes. Stable angina suggests the underlying coronary disease is established but not actively unstable.
• Unstable angina is less common but more serious. Attacks do not normally have a trigger and are unpredictable. It may come on with less effort than before, at rest, or wake you from sleep, and it is often more severe and lasts longer. Symptoms might continue despite rest. Unstable angina is a warning that a plaque inside an artery may have become inflamed or partially ruptured, and it sits on the spectrum towards a heart attack. Some people develop it after having stable angina. If your symptoms have changed in this way, that warrants urgent assessment rather than waiting.
• Microvascular angina affects the very small blood vessels of the heart rather than the main coronary arteries. The arteries may look normal on standard tests, but the smaller vessels are not dilating properly. This form is more common in women and is sometimes missed because the larger investigations come back clean.
• Vasospastic angina, also called Prinzmetal's angina, is caused by temporary spasm of a coronary artery rather than a fixed narrowing. It often happens at rest, sometimes during the night, and it can affect people whose arteries look reasonably healthy on imaging.

What angina actually feels like

Anginal chest pain can feel like a tight squeeze on the chest or a dull ache that does not go away. The classic textbook description is a heavy, tight, crushing sensation in the centre of the chest, but in real life patients describe it in a much wider range of ways. The feeling may also spread beyond the chest, and it can sometimes resemble the symptoms of a heart attack.

The most reliable feature of angina is not where it hurts or how it feels, but the pattern. Anginal pain is usually triggered by physical activity, emotional stress or cold weather, and it normally stops after a few minutes of rest. Discomfort that comes on with exertion, builds gradually, eases with rest within a few minutes and is reproducible by the same level of effort is the classic clinical signature.

Heart symptoms are rarely the dramatic, crushing chest pain you see on television. In Dr Jogiya's practice, around two out of three patients referred with chest pain turn out not to have classical angina once the full picture has been put together, which is why a proper assessment matters before anyone is labelled.

• A pressure, or a band tightening across the chest
• Heaviness, or a dull ache in the centre of the chest that does not shift
• Burning, or a sensation that feels like indigestion
• Discomfort spreading to the left arm, both arms, the jaw, neck, upper back or stomach
• Breathlessness, sweating, nausea or unusual fatigue alongside the chest discomfort

What raises your risk

Angina shares the same risk factors as the rest of cardiovascular disease, and the more of them you have, the higher your risk. The main ones are set out below.

Age and sex matter too. Men tend to develop angina earlier than women, though women catch up after the menopause and often present with less typical symptoms, which is one of the reasons their diagnosis is sometimes delayed. Dr Jogiya's advice, particularly for people in their forties and fifties, is to know your numbers. Your blood pressure, your cholesterol, your diabetes risk and your waist measurement are the four numbers that most strongly predict whether angina is going to show up in your life.

• High blood pressure, which damages artery walls over time
• Raised cholesterol, which drives plaque build up
• Diabetes, which accelerates artery disease
• Smoking, which damages the arteries directly and reduces oxygen delivery
• A family history of heart disease, particularly in close relatives under sixty
• Being overweight or sedentary
• Chronic stress, which is arguably as important as diet or exercise

How angina is diagnosed

Diagnosing angina properly is a matter of pattern recognition combined with the right tests. An assessment with Dr Jogiya usually starts with a careful history. What brings the discomfort on, how long it lasts, what relieves it and what other symptoms come with it will often tell him more than almost any single test.

An ECG is almost always the first investigation. It can be completely normal between attacks, which is why it is often supplemented with further imaging. An echocardiogram gives a picture of the heart's structure and function at rest. A stress test or a CT coronary angiogram shows what happens when the heart is asked to work harder. If those results raise enough concern, an invasive coronary angiogram gives the most accurate map of the arteries and, where appropriate, the option to treat any narrowing in the same sitting.

For many patients with stable chest pain, a CT coronary angiogram works better than a standard exercise stress test, because it gives direct anatomical information about the arteries rather than indirect functional clues. National guidance reflects this, and it is why CT is now often the first imaging test used. The right test still depends on the individual, and that decision sits at the heart of a good cardiology consultation.

How angina is treated

Angina is highly treatable, and most patients do well with the right combination of approaches. Treatment for angina is usually aimed at three things, managing the longer term risk of a heart attack or a stroke, treating attacks when they happen, and preventing further attacks.

Lifestyle changes can make a big difference to symptoms. A balanced diet, cutting down on alcohol, quitting smoking, losing weight and regular exercise can all help to improve cardiac health and the symptoms of angina.

Dr Jogiya finds that the patients who do best are those who treat angina as a long term condition that responds well to consistent, joined up care. It is not a condition that is fixed once and then forgotten. It is managed carefully over years, and the benefits of doing that well build up over time.

• Lifestyle change comes first, and it is not optional. Stopping smoking, getting blood pressure and cholesterol under control, moving regularly (a 20 minute walk in the fresh air every day is a good starting point), and looking after your weight, sleep and stress levels genuinely slow the disease down. The effects are consistent and they compound over years.
• Medication is the backbone of treatment for most patients. This usually includes a statin to lower cholesterol, aspirin or another antiplatelet to reduce clot risk, and one or more medicines to reduce the heart's workload, such as beta blockers, calcium channel blockers or long acting nitrates. A GTN spray is used to dilate the arteries when symptoms occur. The aim is to control symptoms, lower the risk of a heart attack, and let you live a normal active life. Which medicines suit you is a decision for the cardiologist who has assessed you.
• Procedures are reserved for patients whose symptoms are not controlled by medication, or whose anatomy makes a stronger case for intervention. A coronary angioplasty with a stent opens a narrowed artery and props it open with a small mesh tube. Coronary artery bypass surgery, in which a healthy blood vessel is used to bypass a blocked artery, is used in more complex cases or when several arteries are involved.

When to seek help

Some patterns always warrant urgent attention rather than waiting for a routine appointment.

If you are getting symptoms that you cannot quite explain, and you have been putting them down to stress, indigestion or being out of shape, that is worth a proper cardiac assessment rather than continuing to second guess. The earlier these symptoms are investigated, the more options there usually are. You can contact the practice to arrange a consultation with Dr Jogiya.

• Call 999 if your chest pain is severe, lasts more than 15 minutes, does not ease with rest or a GTN spray, or comes with sweating, sickness, breathlessness or a feeling of impending doom. This may be a heart attack and minutes matter.
• If your usual angina pattern has changed, coming on with less effort, at rest, or more frequently, treat that as unstable angina until proven otherwise and seek same day medical assessment.
• If you collapse or someone collapses near you, call 999 straight away. A collapse is one of the ways a heart attack announces itself.
• This page is general information about angina and is not a substitute for advice about your own heart. If you are unsure, get assessed.