Angina: your questions answered

The heart and coronary arteries

Heart nurse June Davison puts questions about angina, a common symptom of coronary heart disease, to Dr Sarah Clarke, an interventional cardiologist at Papworth Hospital in Cambridge.

What is angina and what causes it?

Angina is a symptom caused by coronary heart disease (CHD). It’s a pain, heaviness or discomfort felt in your chest, which may also be felt in your arms, neck, jaw, back or stomach.

So what’s coronary heart disease?

CHD is the most common type of heart disease and as well as causing angina can also cause heart attacks. The disease affects the coronary arteries (pictured), which sit on the surface of the heart and supply the heart muscle with the blood and oxygen it needs. This enables the heart to pump blood around the body to supply oxygen and nutrients to vital organs.

CHD is caused by the build-up of fatty material inside the walls of the coronary arteries; this process is called atherosclerosis and can cause the artery to narrow, restricting blood flow to the heart. If the artery becomes too narrowed, insufficient blood gets through, and this can cause the symptoms of angina.

How would I know I had angina?

The symptoms can be variable but patients generally describe a dull ache or heaviness, or tightness, in the chest which can also be felt in the neck, jaw or arms and sometimes the back and stomach area. It’s usually triggered by exercise, emotional upset, or you might experience an attack after eating or in cold weather. The symptoms can sometimes be mistaken for indigestion.

What should you do if you think you’re having angina for the first time?

Stop and rest until the angina discomfort has passed. Make an appointment to see your GP straight away. If the pain doesn’t ease, call 999 immediately, because it’s possible you could be having a heart attack.

How can I differentiate the pain of angina from a heart attack?

It can be difficult because symptoms are similar. Any angina-like symptoms which do not resolve with rest (or glyceryl trinitrate medicine – GTN – if you’ve been prescribed it) could be the onset of a heart attack. Heart attacks can be fatal, so when chest pain or discomfort persists you should call 999 immediately.

How would someone be diagnosed with angina?

Your doctor may be able to tell if you have angina from the symptoms you describe. Many people with angina symptoms are likely to be referred to a heart specialist. The tests you have will depend on the level of suspicion of underlying heart disease. Where suspicions are high it’s likely you’ll be referred for an angiogram. This test can determine if there are any narrowings in the coronary arteries.

It also helps to decide the best treatment for you. A small tube is placed in an artery in your arm or at the top of your leg, and through that tube is passed another thin hollow tube, called a catheter, which is fed up to the heart and placed in the coronary arteries. Contrast (dye) is injected down the coronary arteries which can be seen on an X-ray screen; we take several images at different angles and can see any narrowings in the arteries.

If someone has been diagnosed with angina, does this increase their risk of a heart attack?

"Just because you have angina symptoms it doesn’t necessarily mean that you’re going to have a heart attack"

Most people who are diagnosed with angina have underlying CHD, which puts you at a higher risk of a heart attack. But just because you have angina symptoms it doesn’t necessarily mean that you’re going to have a heart attack.

However, if your symptoms become more frequent or severe, come on after doing less activity, resolve more slowly on resting or come on at rest, you could be at risk of having an imminent heart attack, so it’s vital you see or contact your doctor as soon as possible. If you experience symptoms while you are resting and they persist, you must call 999.

What medications and treatment are available if someone has angina?

The aim of treatment is to relieve and prevent symptoms, slow down the progression of your CHD and reduce your risk of having a heart attack. Lifestyle changes are vital in helping here – stopping smoking, keeping active and ensuring control of weight, cholesterol, blood pressure and diabetes.

A common treatment for angina is GTN, which can be given as a spray or as a tablet under the tongue. This can be taken when you get an episode of angina. GTN helps the arteries relax and allows more blood to get through to the heart muscle, relieving the symptoms. A longer acting form of GTN (nitrates) can also be taken daily to prevent angina episodes.

It’s also likely that you’ll need to take a combination of other medicines regularly every day; beta-blockers and calcium channel blockers reduce the work of the heart, helping to relieve angina symptoms. Aspirin and statins help reduce the risk of a heart attack and ACE-inhibitors are also prescribed as they can have a protective effect.

What other treatments are available?

Other treatments include coronary angioplasty and stenting or coronary artery bypass graft (CABG).

Coronary angioplasty and stenting is a procedure that opens up a narrowed artery. The start of the procedure is similar to an angiogram: through the catheter that’s sitting in the artery a fine wire is fed through the narrowing. A balloon slides over the wire and is inflated, pushing the fatty material against the wall of the artery. A second balloon with a stent (usually metal) crimped on it is then inflated to position the stent, which covers the narrowed segment. The stent acts like a scaffold to keep the artery open and improve the blood flow to the heart.

"Lifestyle changes are vital in helping"

Over the years, there have been great advances in stent technology. Sometimes the artery re-narrows but various drug coatings on the metal stents have reduced the risk of this and hence reduced the risk of recurrent symptoms.

Bioabsorbable stents are the new generation of stents, which don’t leave any metal scaffold behind. The stent reabsorbs over time, allowing the artery to remodel and function as normal. Currently, they’re not being implanted routinely, but eventually it’s thought that they may replace traditional stents. Anything that doesn’t leave any foreign material behind is a good thing.

Around 80,000 angioplasties are carried out each year in the UK – three times more than a decade ago.

And what about bypass surgery?

CABG is another treatment option and the decision as to whether a stent or surgery is required will be made by the heart team, involving discussions with the patient. CABG involves taking arteries from behind the breast bone or the forearm or veins from the legs. These grafts are then used to ‘bypass’ a narrowed section of a coronary artery, so the blood bypasses the narrowing. It’s a major operation but if you’re recommended to have it, results can be very good.

In the longer term, people tend to have fewer recurrent symptoms with surgery so are less likely to return for further treatment compared with people who have angioplasty and stenting.

However, the risk of stroke is higher with CABG. Each case is addressed individually as to what would be the recommended and preferred treatment for patients.

How effective are these treatments?

Following both angioplasty and CABG, many people can be symptom free for a long time. People who have stenting are more likely to have a recurrence of symptoms compared with patients who have bypass surgery. But patients play a big part in determining what happens. If they don’t take their medication, or live an unhealthy lifestyle, their symptoms are more likely to return sooner.

Can someone live a normal life with angina?

Many people can lead a normal life if they take their medication and address their risk factors.

There are always exceptions, but if someone has had treatment to reduce their symptoms then they can have a very good quality of life and should be able to continue their normal day-to-day activities.

What can people do to decrease the risk of developing CHD and angina?

"Many people can lead a normal life if they take their medication and address their risk factors"

If you’re over the age of 40, you’re entitled to a health check at your GP practice, which will assess your risk. Then, along with your doctor or nurse, you can look at what you can do to reduce your risk.

If you’re a smoker, stopping is the most important thing you can do. Keeping to a healthy weight, having a healthy balanced diet, which is low in saturated fat, and keeping active can help you to protect yourself. If you’ve got a family history of heart disease it’s even more important to look at the risk factors you can do something about.

Although men are more likely to get CHD at an earlier age than women, women are less likely to report symptoms, and sometimes don’t think heart disease happens to them, so it’s really important that women pay attention to their risk factors too.

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