Angina (also called angina pectoris) is chest pain associated with decreased blood flow to the heart. Although the “classic” pain is described as chest discomfort that radiates down the arm or up the jaw, it can occur in many different ways. For example, women have a different type of pain than men; in addition, people who have diabetes, particularly those who take insulin or have poorly controlled blood sugars and nerve damage elsewhere in the body (such as in the feet) may have minimal symptoms. Angina can be confused with gallbladder disease, stomach ulcers and acid reflux. It usually goes away within a few minutes with rest or with the use of nitroglycerin.

Angina is not the same as a heart attack although the symptoms may be similar. Chest pain that causes a heart attack does not typically stop. The chest pain from angina often occurs with physical activity. Other things that can trigger it are stress, smoking, extreme heat and cold, heavy meals and excessive alcohol consumption. Usually with angina, if you stop and rest for a few minutes or take a prescribed cardiac medication such as nitroglycerin, the pain stops.

Causes

Angina can be a symptom of coronary artery disease. This condition can be caused by high LDL (low-density lipoprotein) cholesterol, high triglyceride levels and reduced HDL (high-density lipoprotein) cholesterol; high blood pressure; physical inactivity; smoking; obesity; a diet high in saturated fat; and diabetes. These are risk factors that you can control. Risk factors you cannot control include family history, age and sex. Males are believed to be at higher risk of coronary artery disease than females, but this may be misleading. Women often have different symptoms and, therefore wait to seek medical care until they have much more advanced forms of disease. As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

Symptoms

Symptoms of angina vary but typically include:

• A pressing, squeezing or crushing pain, usually in the chest underneath the breastbone or in the upper back, the arms or neck
• Pain radiating in the arms, shoulders, jaw, neck or back from the chest
• Shortness of breath
• Weakness or fatigue

Angina can be a symptom of coronary artery disease, also called coronary heart disease. In coronary artery disease, arteries that carry blood to the heart are narrowed or blocked, often due to atherosclerosis.

If you have angina, it does not necessarily mean you are going to have a heart attack. Angina does indicate that you have coronary artery disease and that your heart is not receiving an adequate blood supply. If you have angina, you have an increased risk of a heart attack.

Angina that occurs with exertion is called stable angina. Angina that changes in pattern from previously stable angina, is sudden or occurs at rest is called unstable angina and may indicate a heart attack is coming.

There are two other forms of angina:

• Variant angina pectoris (Prinzmetal’s angina): A rare form that occurs almost exclusively when a person is at rest not typically during exertion or stress. The pain from this form of angina can be very painful, and usually occurs between midnight and 8 a.m. This form of angina is caused by a spasm in the artery or arteries supplying the heart and can be treated with medications that can help relax the arteries.
• Microvascular angina: A recently discovered type of angina. People who have this condition experience chest pain but have no apparent coronary artery blockages. The pain is caused by poor function of the very tiny blood vessels that nourish the heart and that cannot be seen by imaging techniques such as coronary angiogram. This form of angina can be treated with some of the same medications used for angina pectoris.

Diagnosis

Tests we use to diagnose the cause of angina and the extent of coronary artery disease include:

• Electrocardiogra (EKG/ECG) – A test that records the electrical activity of the heart.
• Exercise stress test – A test performed on a treadmill or stationary bicycle to measure heart, lung and muscle function during physical activity. You are attached to an electrocardiogram (EKG/ECG) to record electrical activity of the heart.
• Cardiac catheterization – A procedure to check for problems in coronary arteries. A long, thin tube (catheter) is inserted into an artery or vein in the groin, arm or neck, then threaded to the heart. The physician injects a contrast solution into the artery and takes X-rays to check for blockage and other abnormalities.

Treatments

Medications

Medications prescribed for angina aim to increase blood flow to the heart muscle and decrease the workload of the heart. This increase of blood flow widens the blood vessels and relieves the pain you may experience with angina.

Nitroglycerin is the most commonly prescribed medication for people who have angina. Sometimes the arteries become tolerant of this medication and greater amounts may be required to have the same benefits.

Medications also may be prescribed to treat coronary artery disease, the underlying cause of angina. These medications include: Antiplatelet agents, anticoagulants, antihyperlipidemics (cholesterol-lowering drugs), beta-blockers and antihypertensives (blood pressure-lowering drugs).

Procedures

If your symptoms are severe enough, your physician may recommend a nonsurgical minimally invasive procedure to treat the cause of angina, which is coronary artery disease. These cardiac catheterization procedures increase blood flow to the heart muscle and decrease the risk of a heart attack. If a blockage is found, then an angioplasty (also called percutaneous coronary intervention or PCI) can be performed. This procedure can include removing a clot by suctioning it out, opening the blocked artery with balloon angioplasty or placing a stent to restore blood flow to the heart muscle. These are common treatments. Ohio State’s Ross Heart Hospital performs more than 5,000 procedures a year, making it one of the highest volume centers in the area. Because we’ve done so many procedures, our staff is better equipped and more experienced in handling even the most difficult cases.

Surgery

Coronary artery bypass graft (CABG) may be necessary to restore your coronary blood flow if you have had a heart attack.

Some patients have severe coronary artery disease and angina that cannot be treated with medication, stents or the CABG surgery mentioned above. In those cases, Ohio State heart surgeons can sometimes use a special laser to drill small holes in the heart to improve blood flow. In extreme cases, heart transplantation may be considered.

With surgical approaches to treating CABG and angina, cardiac rehabilitation may be recommended as you recover.