Angina is a common problem usually starting after the age of 50 but sometimes occurring earlier. The underlying cause is usually due to a build up of atheroma in one or more of the blood vessels of the heart (the coronary arteries). Atheroma is a fatty deposit that is found on the inside wall of some arteries. It tends to form little plaques (lumps) at first. Gradually these can become bigger causing narrowing of the inside of the arteries (hardening of the arteries ). Just like any other muscle, the heart needs a good blood supply. If the heart muscle has a reduced blood supply because of narrowed arteries, then angina may develop.
A diagnosis of angina can be frightening, as it may produce ideas of disability or, worse, of death. With modern management most sufferers of angina are able to live full lives for many years.

What are the symptoms?

The classical symptom is an uncomfortable feeling in the chest that is usually brought on by exertion or emotional upset. It is often described as a pain or ache felt across the front of the chest or sometimes as a heaviness, pressing, tightness or gripping sensation. This sensation is often also felt in the left or both arms, the jaw and neck.

So why don't I just feel pain in my heart?

While some people do just feel pain in the chest area near the heart, others feel pain in one or other of the arms, the throat, or between the shoulder blades. Pain messages have to travel to the brain before you can "feel" them. This usually happens very fast and the brain is able to pinpoint exactly where the pain is happening. The heart only has a few connections to the brain, and the pain message from the heart has to travel along a nerve that joins other nerves from the arm or neck. So when the pain messages arrive in the brain (like telephone lines to a switchboard), the brain doesn't know exactly where the pain is coming from, and so " feels" it in the other areas.
These symptoms (Angina) quickly ease on resting. They are intermittent and do not usually last longer than a few minutes. Sometimes emotion can bring on an angina attack, e.g. vivid dreams. Some people have non-typical pains, e.g. coming on when bending or eating. If the symptoms are not typical then it is sometimes difficult to tell the difference between angina and other causes of chest pain (e.g. muscular pains, indigestion).
The anginal symptoms are caused by the heart needing more blood to cope with the extra exertion. As the coronary arteries are narrowed, they cannot deliver the extra amount of blood needed by the heart muscle. The symptoms, in a sense, are the heart saying to the body 'slow down I cannot cope'. Symptoms vary from person to person in how often they come on and how much exertion or emotion is needed to bring on an attack. In the same person angina attacks may vary from day to day. They tend to come on more easily after meals or in cold winds. With treatment, most people with angina lead normal lives. If the coronary artery narrowing is more advanced then some restriction in lifestyle may have to be accepted.

People with angina have a higher risk of developing a heart attack in the future but this risk is reduced with treatment.

The differences between Angina and a Heart Attack are that the pain or symptoms are often more severe than normal and they may last longer, GTN is often unhelpful and the symptoms can be unprovoked.

What can you do to help yourself ?

An important aspect of managing angina is the control or correction of a number of risk factors that could be the cause of the atheroma. It is your job to help adapt your lifestyle in order to minimise the risk of further trouble from your angina.

There are several known 'risk factors'. These encourage atheroma deposits to form and can make angina worse. The following risk factors should be considered:-

• Smoking. This should stop. Smoking is a high risk factor for atheroma. The risk of a heart attack is reduced by 50% within 5 years of stopping smoking.
• High blood pressure. Make sure this is checked at least once a year and is treated if high. In addition it would be prudent to pay attention to the risk factors that make blood pressure worse i.e. smoking, overweight, lack of exercise, alcohol abuse and overuse of salt with your food, no salt should be added to your food except during the cooking
• Weight. Being overweight can put an extra burden on the heart. Losing some weight will help to reduce your heart's workload and keep your blood pressure under control.
• Cholesterol. A high cholesterol level encourages atheroma to develop. Doctors may advise to have this checked.
• Exercise. Regular exercise keeps the heart muscle in good shape. A regular exercise regime should be aimed for. This applies to most people with angina. Occasionally angina is due to a heart valve problem where exercise may not be so good. Ask your doctor to confirm about regular exercise being OK.

Treatments

There are a variety of treatments available for angina. Broadly speaking they fall into the two categories of preventative and symptomatic.

• Aspirin. (preventative) A low dose of Aspirin is usually prescribed. It has an effect of reducing the 'stickiness' of platelets thus reducing the chance of clots (thrombosis ) forming. Platelets are tiny particles in the blood stream which help the blood to clot after cuts. However, if platelets become stuck in to atheroma plaques in large numbers inside an artery they can form a clot (thrombus). Taking low dose Aspirin therefore reduces the chance of having a heart attack due to a thrombosis.
• GTN. (symptomatic) Glycerol TriNitrate comes as tablets or sprays. At the beginning of an angina attack, GTN taken under the tongue is absorbed quickly into the body. It has the effect of 'opening up' the blood vessels and usually helps to take away the angina pain. Sometimes people take a GTN tablet or a spray prior to any anticipated exercise e.g. at the bottom of a hill that has to be climbed etc. Sometimes GTN causes a headache and remember the tablet form has a short shelf life of 8 weeks, and so the prescription needs regularly renewing. (see the accompanying leaflet GTN Treatment for Angina).

DO NOT DELAY - NIGHT OR DAY - If the symptoms have not gone after three sprays or tablets, or they are worse than usual, or accompanied by nausea, sweating, faintness, shortness of breath, palpitations then phone your GP straight away, dial 999 for an ambulance or attend the nearest casualty department.

GTN must not be used at the same time as Viagra, this is a very dangerous combination.

Other preventative drugs.

If angina is becoming frequent, then drugs are usually prescribed to prevent attacks. These are taken regularly and are often very successful at limiting the number of angina attacks (GTN can still be taken for breakthrough angina pains). There are many drugs available but they fall into three groups. These are Beta-blockers, Calcium Antagonists and Nitrates. Usually one drug is prescribed initially from one of these groups. If the symptoms are not controlled then another drug can be added from another group. 'Triple Therapy' (a drug from each group) is not uncommon. All the drugs are effective at easing angina pains but the three different groups of drugs work by different actions. Therefore, combinations of these drugs complement each other. Sometimes, if a particular drug does not suit, another is tried to find the best combination to treat an individual.

Following recent research patients with angina may well be recommended to also take a tablet called an Ace Inhibitor e.g. Ramipril.

• Beta blockers. These tablets act by reducing the heart rate. Therefore the heart's work is reduced and it needs less oxygen. The aim is to abolish or reduce the number of angina attacks.
• Calcium antagonists. Their role is to abolish or reduce the frequency of anginal attacks.
• Nitrates. These are a tablet or patch form of the GTN but are much longer acting. They open up the body's blood vessels. Therefore with more blood flowing freely around the body, the heart's work is easier. In addition they also widen the coronary arteries supplying the heart.
• Potassium Channel Activators, e.g. nicorandil.

Surgery and angioplasty

If medication is failing to control symptoms very well or if the coronary arteries become very narrow, surgery or angioplasty may be considered after special investigation of the coronary arteries (Coronary Angiogram or Cardiac Catheter test).

• Surgery The narrowed arteries are 'bypassed' by grafts (pieces of vein or artery from elsewhere in the body) during an open heart operation.
• Angioplasty involves expanding the narrowed section by a tiny balloon being inflated inside the artery. This is only suitable when the atheroma deposits are very localised to small sections of the coronary arteries.

Some common worries

• Exertion. 'Straining of the heart' by exertion is a common misguided worry. On the contrary, more steady and sustained exercise is usually encouraged. A diagnosis of angina often makes people take stock of their sedentary lifestyle etc. There are cases reported of angina greatly reducing with a gradually increasing exercise programme combined with attention to lifestyle factors.
• Sex. Some people with angina have an unfounded worry that the physical effort of sexual relationships will damage the heart. Sex does not need to stop. An understanding partner may be able to help to reduce the amount of physical effort needed during love making. If sex does bring on an angina attack it may be helpful to take some GTN beforehand.
• Driving. There is no restriction to driving a private car for most people with angina. However, if driving provokes angina attacks, then you should inform the DVLA, and their medical advisory branch will probably ask your GP for a report. You should check with your insurance company and inform them that you have been diagnosed as suffering from angina. PSV and HGV licences carry much stricter rules. Those people with angina who drive for a living or who hold PSV/HGV licencesa must declare this to the DVLA, even if the symptoms are mild and not provoked by driving.
• Work. Once a diagnosis is made and treatment is established there is no reason why people with angina should not lead a normal or certainly near-normal life, and this includes the continuance of work. The reduction of unnecessary stressful situations is beneficial in helping to control any anginal symptoms and in maintaining a normal blood pressure.
• Holidays and travel. Holidays are important and recommended but common sense is needed so as to avoid any unnecessary stress, such as hurrying! Air travel is no problem in modern pressurised aircraft. If you are planning a holiday abroad you should consult your doctor first so that the suitability of your destination can be confirmed. A holiday trekking at high altitude and in the middle of nowhere would not generally be encouraged!

When you experience an anginal pain if it settles with rest then there is nothing else to do. If the symptoms do not settle with rest you should use the GTN as described above, if the symptoms have not gone after three sprays or tablets, or they are worse than usual, or accompanied by nausea, sweating, faintness, shortness of breath, palpitations then phone your GP straight away, dial 999 for an ambulance or attend the nearest casualty department.

If angina symptoms come on more frequently or whilst resting then you should discuss this with your GP as soon as is convenient, or if for any reason this is not possible, the local casualty department.

See Also

• Stalbridge Surgery | Medical Advice | Heart | GTN Treatment for Angina

Useful Websites

• Stalbridge Surgery has prepared a list of useful websites for patients
• Online Medical Dictionary compiled by The CancerWEB Project.

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