Angina (Unstable Angina, Stable Angina, Angina Pectoris, Cardiac Angina, Variant Angina)

Coronary Artery Disease 2008 Nucleus Medical Art, Inc. Stable or Unstable AnginaAngina occurs when your heart's need for blood and oxygen is increased by: Exercise, exertionCold weatherA large mealEmotional stress Stable angina becomes unstable when symptoms occur more often, last longer, or is triggered more easily. Variant or Prinzmetal's Angina Variant or prinzmetal's angina is usually caused by a spasm of a coronary vessel. It may indicate that you have one of the following conditions: Coronary artery disease Extremely high blood pressureHypertrophic cardiomyopathyDiseases of the heart valves Risk FactorsA risk factor is something that increases your chance of getting a disease or condition. Major risk factors for coronary artery disease (CAD) include the following: Gender: maleAdvancing ageStrong family history of heart diseaseObesity and overweight SmokingHigh blood pressureSedentary lifestyleHigh blood cholesterol (specifically, high LDL cholesterol and low HDL cholesterol) Diabetes Other risk factors for CAD: StressExcessive alcohol intake Symptoms Pressure or squeezing chest pain Some people do not experience the pain as severeElderly people, women, and people with diabetes more likely to have atypical or subtle symptoms Some people have "silent ischemia" and experience no symptoms of chest pain Chest pain of any kind deserves a medical evaluation to determine its cause Chest pain or discomfort is the hallmark symptom of anginaWhen chest discomfort is severe, lasts more than 15 minutes, and is accompanied by other symptoms listed below, then the likelihood of a heart attack is increasedPain in the shoulder(s) or arm(s), or into the jawWeaknessSweatingNauseaShortness of breath DiagnosisTests will be done right away to see if you are having an episode of angina or a heart attack. If you have a stable pattern of angina, other tests may be done to determine the extent of your disease. The test results will help to create a treatment plan.

The doctor will ask about your symptoms and medical history, and perform a physical exam. Tests may include: Blood teststo look for certain blood markers to determine if you are having a heart attackElectrocardiogram (ECG, EKG)a record of the heart's electrical activity, to look for evidence of past heart attacks, acute heart attacks, or heart rhythm problemsEchocardiogramhigh-frequency sound waves (ultrasound) to examine the structure and function of the heartExercise stress testrecords the heart's electrical activity during increased demandA medication is used to simulate the effects of physical exertion for those that can not exercise Nuclear scanningradioactive material is injected into a vein to highlight areas with low blood flow Electron-beam CT scan (coronary calcium scan, heart scan, CT angiography)a type of x-ray that uses a computer to make detailed pictures of the heart, coronary arteries, and surrounding structuresType of CT scan measures the amount of calcium deposits in the coronary arteries to determine the risk of heart disease or heart attacksThe American Heart Association (AHA) published guidelines in 2006 indicating that heart scans are not for everyone and are most likely to benefit patients at intermediate risk of coronary artery diseaseCoronary angiographydye is injected into the arteries to highlight abnormalities (narrowing or blockage) in the arteries TreatmentTreatments for angina include:

MedicationsNitroglycerinusually given during an attack of angina. It can be given as a tablet that dissolves under the tongue or as a spray. Longer-lasting types may be used to prevent angina before an activity. The medication may be given as pills, or applied as patches or ointments.Blood thinnersa small, daily dose of aspirin has been shown to decrease the risk of heart attack. Patients who have had unstable angina or a heart attack may benefit from the addition of warfarin (eg coumadin). There is an increased risk of bleeding with this medication. *Talk to your doctor before taking aspirin daily or warfarin. Beta-blockers and calcium-channel blockersused regularly, these medications may reduce the occurrence of angina.Cholesterol-lowering medicationsmay prevent the progression of coronary artery disease. They may even improve existing coronary artery disease.Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) lower blood pressure. They are especially beneficial for patients who have had a heart attack in the past. They also decrease the workload on your heart. Surgery Patients with severe angina or unstable, progressing angina may benefit from: Coronary artery bypass graftCoronary angioplasty PreventionIf you already have angina, you can prevent an onset by being aware of what starts it.

If you don't have angina, preventing the development of coronary artery disease may reduce your chance of getting the condition. Steps to prevent coronary artery disease include managing risk factors: Maintain a healthy weight.Begin a safe exercise program with the advice of your doctor.Stop smoking.Eat a healthful diet, one that is low in saturated fat and rich in whole grains, fruits, and vegetables.Appropriately treat high blood pressure and/or diabetes. Appropriately treat abnormal cholesterol levels or high triglycerides. RESOURCES: American Academy of Family Physicianshttp://familydoctor.org/ American Heart Associationhttp://www.americanheart.org/ National Heart, Lung, and Blood Institutehttp://www.nhlbi.nih.gov/ CANADIAN RESOURCES: Canadian Cardiovascular Societyhttp://www.ccs.ca/ Canadian Family Physicianhttp://www.cfpc.ca/ REFERENCES: Dambro MR. Griffith's 5-Minute Clinical Consult. 2001 ed. Philadelphia, PA: Lippincott Williams & Wilkins;2001. Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet. 2002;360:752.

Lopez-Sendon J, Swedberg K, McMurray J, et al. Expert consensus document on angiotensin converting enzyme inhibitors in cardiovascular disease. The Task Force on ACE-inhibitors of the European Society of Cardiology. Eur Heart J. 2004;25:1454. Reenan J. Clinical Pearl: Indications for bypass surgery. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/category/11853.html. Accessed November 16, 2006. What is angina? American Heart Association website. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3007460. Accessed June 16, 2008. What is angina? National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Angina/Angina_WhatIs.html. Accessed June 16, 2008. *Updated section on Blood Thinners on 7/14/06 according to the following study, as cited by DynaMed's Systematic Literature Surveillance: Andreotti F, Testa L, Biondi-Zoccai GG, et al. Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients. Eur Heart J. 2006;27:519-26.

Last reviewed December 2007 by J. Peter Oettgen, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.