Angina

Angina is chest pain or discomfort that comes on when the heart muscle is not getting as much blood and oxygen as it needs. People usually describe squeezing, pressure, heaviness or burning in the middle of the chest. It often turns up on a hill, on a staircase or after a heavy meal, and settles again within a few minutes of stopping to rest.

What angina is, and what it is not

Angina is a symptom, not a disease of its own. It is the signal that the arteries feeding the heart have been narrowed by a fatty build up called plaque, so the muscle runs short of oxygen when it has to work harder. That is why episodes tend to follow a pattern: a certain hill, a certain load, cold weather, or stress. Canadian cardiologists often grade angina by how much activity it takes to bring symptoms on.

It is also not the same thing as a heart attack, although the two can feel similar. Stable angina eases with rest or with a short acting nitrate. Pain that arrives at rest, lasts much longer than usual, or does not settle needs emergency assessment rather than watchful waiting. Angina can also come from the very small vessels of the heart, called microvascular angina, which is harder to see on standard tests and is described more often in women.

Signs and symptoms

• Tightness, pressure, squeezing or burning in the centre of the chest
• Discomfort that spreads to the jaw, neck, shoulders, arms, wrists or back
• Shortness of breath along with the chest discomfort
• Discomfort brought on by walking uphill, stairs, stress, a heavy meal, or cold weather
• Discomfort that eases within a few minutes once you stop and rest
• Unusual tiredness, sweating, nausea or dizziness during an episode
• In women, vaguer signs such as throat or neck tightness, breathlessness, or a feeling like anxiety

The pattern is personal. Some people get the same predictable ache for years, while others notice their triggers shifting over time, and any change in that pattern is worth reporting.

What raises the risk

Some risk factors cannot be changed:

• Getting older
• Being male
• A family history of early heart disease

Others can often be worked on, usually with support from a health care team:

• Smoking, and exposure to second-hand smoke
• High blood pressure
• High cholesterol
• Diabetes and high blood sugar
• Low physical activity, living with obesity, and heavy alcohol use

How angina is diagnosed in Canada

A family doctor or emergency physician starts with a careful description of what brings the pain on, how long it lasts and what settles it, then adds a physical exam, a blood pressure reading, an electrocardiogram, or ECG, and blood tests including cholesterol and troponin, a protein released when heart muscle is injured. Depending on the picture you may be referred for an exercise stress test, a stress echocardiogram or nuclear scan, a CT coronary angiogram, or a cardiac catheterization, where a thin tube is threaded up to the heart through an artery. Canadian cardiologists commonly record how much activity brings symptoms on using the Canadian Cardiovascular Society angina classification.

Treatment and day-to-day management

Clinical research for Angina is enrolling. See the current studies ↓

Care has two jobs: settling episodes when they happen, and treating the artery disease underneath. Depending on which arteries are involved and how you respond, a health care team may discuss:

• Short acting nitrates, such as nitroglycerin spray or tablets, used at the time of symptoms
• Medicines that reduce the workload of the heart, including beta blockers, calcium channel blockers and long acting nitrates
• Medicines aimed at the artery disease itself, including antiplatelet drugs and lipid lowering drugs such as statins and ezetimibe
• Procedures such as percutaneous coronary intervention, which is angioplasty with a stent, and coronary artery bypass surgery
• Cardiac rehabilitation, which combines supervised exercise, education and stop-smoking support

Two people with the same test results can end up on different plans, and that is normal. What happens next is a decision for you and your own clinician, not something this page can settle.

When to talk to a doctor

• Call 911 if chest discomfort lasts more than a few minutes, comes on at rest, wakes you from sleep, or does not settle after rest or your usual nitroglycerin. Do not drive yourself to hospital.
• Call 911 if chest discomfort comes with sweating, nausea, vomiting, fainting or severe shortness of breath.
• Contact your doctor promptly if your usual angina starts happening more often, with less activity, or lasting longer than it used to.

Why clinical research matters for angina

A sizeable group of people keep having angina despite medicines and procedures, and angina caused by the small vessels of the heart is still difficult to diagnose and manage, particularly in women. Studies now recruiting are evaluating anti-anginal drug classes that act on heart metabolism and heart rate, treatments aimed at coronary microvascular function, devices such as the coronary sinus reducer for angina that persists, and imaging or pressure-wire methods for deciding which narrowings need treating. Others compare structured exercise and rehabilitation programs with usual care.

Those questions are answered in clinical studies, one at a time. Taking part is voluntary, informed consent comes before anything begins, and you can withdraw at any point without affecting the care you get from your own doctor. No one can tell you in advance whether a study will help you personally.

Learn more from Canadian sources

• Heart & Stroke: angina
• Public Health Agency of Canada: angina
• Canadian Cardiovascular Society
• Hypertension Canada