Stable angina

• Alternative Names

  Angina - stable; Angina - chronic; Angina pectoris

• Causes, incidence, and risk factors

  Your heart muscle is working all the time, so it needs a continuous supply of oxygen. This oxygen is provided by the coronary arteries, which carry blood.

  When the heart muscle has to work harder, it needs more oxygen. Symptoms of angina occur when the coronary arteries are narrowed or blocked by hardening of the arteries (atherosclerosis), or by a blood clot.

  The most common cause of angina is coronary heart disease (CHD). Angina pectoris is the medical term for this type of chest pain.

  Stable angina is predictable chest pain. Although less serious than unstable angina, it can be very painful or uncomfortable.

  The risk factors for coronary heart disease include:

  • Being male
  • Diabetes
  • Family history of coronary heart disease before age 50
  • High blood pressure
  • High LDL cholesterol and low HDL cholesterol
  • Not getting enough exercise
  • Obesity
  • Smoking

  Anything that requires the heart muscle to need more oxygen can cause an angina attack, including:

  • Cold weather
  • Exercise
  • Emotional tension
  • Large meals

  Other causes of angina include:

  • Abnormal heart rhythms
  • Anemia
  • Coronary artery spasm (also called Prinzmetal's angina)
  • Heart failure
  • Heart valve disease
  • Hyperthyroidism
• Symptoms

  The most common symptom is chest pain that occurs behind the breastbone or slightly to the left of it. It may feel like tightness, heavy pressure, squeezing, or crushing pain. The pain may spread to the:

  • Arm (usually the left)
  • Back
  • Jaw
  • Neck
  • Shoulder

  Some people say the pain feels like gas or indigestion.

  The pain typically:

  • Occurs after activity, stress, or exertion
  • Lasts an average of 1 - 15 minutes
  • Is relieved with rest or a medicine called nitroglycerin

  Angina attacks can occur at any time during the day, but most occur between 6 a.m. and noon.

  Other symptoms of angina include:

  • A feeling of indigestion or heartburn
  • Dizziness or light-headedness
  • Nausea, vomiting, and cold sweats
  • Palpitations
  • Shortness of breath
  • Unexplained tiredness after activity (more common in women)
• Signs and tests

  Your health care provider will perform a physical exam and measure your blood pressure. The following tests may be done to diagnose or rule out angina:

  • Coronary angiography
  • Coronary risk profile
  • ECG
  • Exercise tolerance test (stress test or treadmill test)
  • Stress echocardiogram
• Treatment

  The options for treating angina include lifestyle changes, medications, and invasive procedures such as coronary angioplasty or stent placement and coronary artery bypass surgery.

  You and your doctor should agree on a plan for treating your angina on a daily basis. This should include:

  • What medicines you should be taking to prevent angina
  • What activities are okay for you to do, and which ones are not
  • What medicines you should take when you have angina
  • What are the signs that your angina is getting worse
  • When you should call the doctor or 911

  MEDICATIONS

  You may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your doctor's directions closely to help prevent your angina from getting worse.

  Nitroglycerin pills or spray may be used to stop chest pain.

  Taking aspirin and clopidogrel (Plavix) helps prevent blood clots from forming in your arteries, and reduces your risk of having a heart attack. Ask your doctor whether you should be taking these medications.

  Your doctor may give you one or more medicines to help prevent you from having angina.

  • ACE inhibitors to lower blood pressure and protect your heart
  • Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
  • Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart
  • Nitrates to help prevent angina
  • Ranolazine (Ranexa) to treat chronic angina

  NEVER ABRUPTLY STOP TAKING ANY OF THESE DRUGS. Always talk to your doctor first. Stopping these drugs suddenly can make your angina worse or cause a heart attack.

  Your doctor may recommend a cardiac rehabilitation program to help improve your heart's fitness.

  INVASIVE AND SURGICAL TREATMENT

  Some patients may need surgery to help improve the flow of blood through the coronary arteries.

  Angioplasty and stent placement (also called percutaneous coronary intervention) is a procedure in which a physician inserts a catheter through an artery in either the arm or leg and advances the catheter into the heart. It is done to both open up and keep open a coronary artery that has become too narrow.

  Angioplasty with stenting probably does not help you live longer than treatment with medicine alone. However, it can reduce angina or other symptoms of coronary artery disease. Angioplasty with stenting can be a life-saving procedure if you are having a heart attack or unstable angina.

  Heart bypass surgery may be done for some people, depending on which of the coronary arteries are narrowed and the severity of the narrowing.

• Expectations (prognosis)

  Stable angina usually improves with medication.

• Complications
  • Heart attack
  • Sudden death caused by abnormal heart rhythms (arrhythmias)
  • Unstable angina
• Calling your health care provider

  Seek medical attention if you have new, unexplained chest pain or pressure. If you have had angina before, call your doctor.

  Call 911 or your local emergency number if you experience chest pain or heaviness. The pain may be a sign of unstable angina or a heart attack.

  Call your health care provider if:

  • Angina episodes happen more often, last longer than usual, or feel different than before
  • You have shortness of breath
  • You need to take more and more nitroglycerin to make your angina go away

  Seek immediate medical help if a person with angina loses consciousness.

• Prevention

  Your doctor may tell you to take nitroglycerin a few minutes in advance if you plan to perform an activity that may trigger angina pain.

  The best way to prevent angina is to lower your risk for coronary heart disease:

  • Control your blood pressure, diabetes, and cholesterol.
  • Lose weight if you are overweight.
  • Stop smoking
  • Avoid or reduce stress as much as you can.
  • Eat well-balanced meals that are low in fat and cholesterol and include several daily servings of fruits and vegetables.
  • Get regular exercise. If your weight is considered normal, get at least 30 minutes of exercise every day. If you are overweight or obese, experts say you should get 60 - 90 minutes of exercise every day.

  Moderate amounts of alcohol (one glass a day for women, two for men) may reduce your risk of cardiovascular problems. However, drinking larger amounts does more harm than good.

  Reducing risk factors may prevent the blockages from getting worse, and can make them less severe, which reduces angina pain.

• References

  Boden WE, O'rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007 Mar 26; [Epub ahead of print].

  Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007;116:2762-2772.

  Bluemke DA, Achenbach S, Budoff M, Gerber TC, Gersh B, Hillis LD, et al. Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention, and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Circulation. 2008;118:586-606.

  U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.

  Weintraub WS, Spertus JA, Kolm P, Maron Dj, Zhang Z, Jurkovitz C, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359:677-687.

Review Date: 4/23/2009

Reviewed By: Alan Berger, MD, Assistant Professor, Divisions of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.