Angina

Angina is a squeezing, pressure, tightness or weight lying on the chest like feeling. One may experience Chest Pain due to different reasons but, chest pain caused by reduced blood flow to the heart may be a symptom of coronary artery disease.The most common cause of reduced blood flow to your heart muscle is coronary artery disease (CAD) which happens when your arteries become narrowed by fatty deposits called plaque. This is called atherosclerosis. The blood carries oxygen, which your heart muscle needs to survive. Thus, when the heart muscle isn’t getting enough oxygen, it can lead to a condition called ischemia.

Symptoms

Angina symptoms include pain, discomfort, pressure, squeezing, burning or a fullness in the chest. Some may also experience pain in the arms, neck, jaw, shoulder or back.

Some other common symptoms of angina include:

• Dizziness
• Fatigue
• Nausea
• Shortness of breath
• Sweating

If you experience any of the above symptoms then a quick evaluation by a doctor is immediately required to determine whether you have stable angina, or unstable angina, which could lead to a heart attack.

Stable angina It is the most common type of angina or chest pain. It happens when you exert yourself too much and goes away when you take rest. Physical activity usually triggers it. When you climb stairs, exercise or walk, your heart demands more blood, but narrowed arteries slow down blood flow. Other triggers of stable angina may be emotional stress, cold temperatures, heavy meals and smoking that can narrow arteries.

Characteristics of stable angina

• It generally develops when your heart works harder, when you exercise or climb stairs
• Lasts for a short period of time, for five minutes or less
• Disappears if you rest or on taking angina medication

Unstable angina When plaque deposits in arteries rupture or a blood clot forms, it can block or reduce blood flow through a narrowed artery. This suddenly decreases the blood flow to the heart muscle leading to Unstable Angina. This can also be caused by blood clots that block or partially block your heart’s blood vessels.

Such angina isn’t relieved by rest or medications. If your heart is starved of oxygen for a long time then as a result a heart attack occurs. Thus, Unstable angina is dangerous and requires emergency treatment.

Characteristics of unstable angina (a medical emergency)

• Occurs even at rest
• Is unexpected
• It is more severe and lasts longer than stable angina, maybe 30 minutes or longer
• Rest or use of angina medication does not work
• Might signal a heart attack

Prinzmetal’s angina A sudden spasm in a coronary artery, temporarily narrowing the artery leads to Prinzmetal’s Angina. This narrowing reduces blood flow to the heart, resulting in severe chest pain. It often occurs at rest, typically overnight and occur in clusters. Emotional stress, smoking, migraine drugs and use of the illegal drug cocaine can also trigger Prinzmetal’s angina.

Characteristics of variant angina (Prinzmetal’s angina)

• Usually happens when you’re resting
• Is often severe
• May be relieved by angina medication

Angina in women

Symptoms of angina in women can be different from the common angina symptoms. This leads to late diagnosis and delays in seeking treatment. Chest pain is a common symptom in women with angina, but it may not be the most common symptom for women. They may also have symptoms such as:

• Nausea
• Shortness of breath
• Abdominal pain
• Discomfort in the neck, jaw or back
• Stabbing pain instead of chest pressure

When to see a doctor

Chest pain lasting longer than a few minutes and doesn’t go away when you rest or take your angina medications, may be sign of a heart attack. Call for emergency medical help immediately.

If chest pain is a new symptom for you, it’s important to consult a doctor to find out what is causing it and to get proper treatment. If you’ve been diagnosed with stable angina and it gets worse or changes, seek medical attention immediately.

Diagnosis

The Doctor will start by doing a physical exam, ask about your symptoms and enquire about other conditions including whether you have a family history of heart disease. He may then ask one to do the following tests after that:

• Electrocardiogram (ECG or EKG). An electrocardiogram records the beats or electrical signals that are generated by the cells of the heart. The doctor can see if the blood flow through your heart has been slowed or interrupted or if you’re having a heart attack.
• Stress test. The harder the heart works, the easier it is to test Angina. So, during a stress test, walking on a treadmill or pedaling a stationary bicycle helps to monitor the blood pressure and ECG readings.
• Echocardiogram. Sound waves are used to show images of the heart in an Echocardiogram. These images help doctors to identify angina-related problems, heart muscle damage due to poor blood flow and areas of the heart that are not getting enough blood.
• Nuclear stress test. In this stress test a radioactive substance is injected into your bloodstream that mixes with your blood and travels to your heart. It helps to measure blood flow to the heart muscle at rest and during stress.
  It shows how the substance moves with the blood in your heart muscle and poor blood supply to any part of your heart can be seen on the images easily
• Chest X-ray. This is done to find an explanation for the symptoms and to see if you have an enlarged heart.
• Blood tests. Presence of certain heart enzymes slowly leaking out into your blood can sometimes point towards heart damaged by a heart attack.
• Coronary angiography. Coronary angiography a part of cardiac catheterization procedure whichuses X-ray imaging to examine the inner portion of the heart’s blood vessels. A dye visible by X-ray machine is injected into the blood vessels of your heart. The X-ray machine then takes a series of images known as angiograms, that offer a closer and clearer look at the inside of your blood vessels.
• Cardiac computerized tomography (CT) scan. During a cardiac CT scan, one is required to lie on a table inside a doughnut-shaped machine. The X-ray tube present inside the machine then rotates around your body and clicks images of your heart and chest, which helps to show if ones heart’s arteries are narrowed or if the heart is enlarged.
• Cardiac MRI. It is a tubelike machine that produces images of your heart’s structure and its blood vessels.

Treatment

There are several treatment options like lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery to treat Angina. These help to reduce the frequency and severity of symptoms and lower the risk of a heart attack and death.

Medications

If lifestyle changes alone don’t help then, you may need to take medications like:

• Nitrates. They help to relax and widen your blood vessels, allowing more blood to flow to your heart muscle. The most common form of nitrate prescribed by doctors to treat angina is nitroglycerin tablets, which you put under your tongue.
• Aspirin. Aspirin helps to prevent blood clots thus reducingthe risk of a heart attack buttake them only on doctor’sadvise.
• Clot-preventing drugs. Other clot preventing drugs such as clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta) may be recommended if you can’t take aspirin.
• Beta blockers. Beta blockers block the effects of the hormone epinephrine, better known as adrenaline. They help blood vessels to relax and open up to improve blood flow, slower heartbeat, reduces blood pressure thus preventing angina.
• Statins. They are used to lower blood cholesterol by helpingthe body to reabsorb cholesterol that has accumulated as plaques in your artery walls, thus helping prevent further blockage in your blood vessels.
• Calcium channel blockers. These also help to relax and widen blood vessels by affecting the muscle cells in the arterial walls. They help to increase the blood flow in the heart, reducing or preventing chances of angina.
• Blood pressure-lowering medications. Medications to lower blood pressure may also help to prevent angina
• Ranolazine (Ranexa). Ranexa can be used alone or with other angina medications mentioned earlier to prevent angina

Medical procedures and surgery

Lifestyle modification and medications can help to treat stable angina but medical procedures like angioplasty, stenting and coronary artery bypass surgery may also be useful to treat angina.

• Angioplasty and stenting. Angioplasty, also known as a percutaneous coronary intervention (PCI) is a procedure where a tiny balloon is inserted into your narrowed artery. The balloon is then inflated to widen the artery, while a small wire mesh coil (stent) is inserted to keep the artery open, thus improving blood flow in your heart, reducing or eliminating angina. Angioplasty and stenting are good treatment option if you have unstable angina or if lifestyle changes and medications is not able to treat stable angina.
• Coronary artery bypass surgery. During this surgery, a vein or artery from somewhere else in the body is used to create a bypass fora blocked or narrowed heart artery to increase the blood flow to your heart and reduce/eliminate angina. It is a good treatment option for unstable angina as well as stable angina that has not responded to other treatments.
• External Counterpulsation (ECP). In this procedure, blood pressuretype of cuffs are placed around the calves, thighs and pelvis to increase blood flow to the heart. There are multiple sessions required for this treatment. It may help people with symptoms in people with refractory angina.