BRADIA

What Is Angina?
Angina is chest pain or discomfort that occurs when an area of your heart muscle does not get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. The pain may also occur in your shoulders, arms, neck, jaw or back. It could often be mistaken for indigestion.
Angina itself is not a disease. Rather, it is a symptom of an underlying heart problem. Angina is usually a symptom of the coronary artery disease (CAD), the most common type of heart disease.

CAD occurs when a fatty material called plaque builds up on the inner walls of the coronary arteries. These arteries carry oxygen-rich blood to your heart. When plaque builds up in the arteries, the condition is called atherosclerosis.

Types of Angina
The three types of angina are stable, unstable, and variant (Prinzmetal's). It is important to be aware that there are different types of angina. This is because their symptoms are different and require to be treated differently.

Stable Angina
Stable angina is the most common type. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. If you know that you have stable angina, you would learn to recognize the pattern and predict when the pain is likely to occur.
The pain usually passes in a few minutes after you rest or take your angina medicine.
Stable angina is not a heart attack, but it makes a heart attack more probable in the future.

Unstable Angina
Unstable angina does not follow a pattern. It could occur with or without physical exertion and is not relieved by rest or medicine.
Unstable angina is very dangerous and requires emergency treatment. It is a sign that a heart attack may occur soon.

Variant (Prinzmetal's) Angina. This is a rare form of angina which generally occurs while resting, typically between midnight and early morning.  The pain could be severe but the condition could be brought under control with medication.

Overview
It is thought that nearly 7 million people in the United States suffer from angina. About 400,000 patients go to their doctors with new cases of angina every year.
Angina occurs equally in men and women. It could be a sign of heart disease, even when initial tests do not show evidence of CAD.
Not all chest pain or discomfort is angina. A heart attack, lung problems (such as an infection or a blood clot), heartburn or a panic attack could also cause chest pain or discomfort. All chest pain should be referred to and checked by a doctor.
What Causes Angina?

Underlying Causes
Angina is a symptom of an underlying heart condition. The pain caused by angina is the result of reduced blood flow to an area of the heart muscle. Coronary artery disease (CAD) usually causes the reduced blood flow.

This means that the underlying causes of angina are generally the same as the underlying causes of CAD.

Research suggests that damage to the inner layers of the coronary arteries causes CAD. Smoking, high levels of fat and cholesterol in the blood, high blood pressure, and a high level of sugar in the blood (due to insulin resistance or diabetes) could damage the coronary arteries.

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. Plaque narrows or blocks the arteries, reducing blood flow to the heart muscle.

Some plaque is hard and stable and leads to narrowed and hardened arteries. Other plaque is soft and is more likely to break open and cause blood clots.

The buildup of plaque on the arteries' inner walls could cause angina in two ways. It could:

• Narrow the arteries and significantly reduce the flow of blood to the heart
• Form blood clots that partially or totally block the arteries

Immediate Causes
There are different triggers for angina pain, depending on the type of angina you have.

Stable Angina
Physical exertion is the most common trigger of stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low (such as when you are sitting). But with exertion, like walking up a hill or climbing stairs, the heart works harder and needs more oxygen.
Other triggers of stable angina include:

• Emotional stress
• Exposure to very hot or cold temperatures
• Heavy meals
• Smoking

Unstable Angina
Blood clots that partially or totally block an artery cause unstable angina. If the plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. A clot may grow large enough to completely block the artery and cause a heart attack. Blood clots may form, partly dissolve, and later, form again. Angina could occur each time a clot blocks an artery.

Variant Angina
A spasm in a coronary artery causes variant angina. The spasm causes the walls of the artery to tighten and narrow. Blood flow to the heart slows or stops. Variant angina may occur in people with or without CAD.

Other causes of spasms in the coronary arteries are:

• Exposure to cold
• Emotional stress
• Medicines that tighten or narrow blood vessels
• Smoking
• use of cocaine

Who Is At Risk for Angina?
Angina is a symptom of an underlying heart condition, usually, a coronary artery disease (CAD). So if you are at risk of getting CAD, you are also at risk of suffering from angina.
The risk factors for CAD include:

Unhealthy cholesterol levels.

• Unhealthy cholesterol levels
• High blood pressure
• Smoking
• Insulin resistance or diabetes
• Overweight or obesity
• Metabolic syndrome
• Lack of physical activity
• Age (The risk increases for men and women who are over 45 and 55 years old respectively)
• Family history of early heart disease

Populations Affected

It is often assumed that because men are more prone to heart attacks than women, they are also more prone to angina attacks. In actual fact, angina occurs equally among women and men. It could be a sign of heart disease, even when initial tests do not show evidence of CAD.

Unstable angina occurs more often in older adults.
Variant angina is rare. It accounts for only about 2 out of 100 cases of angina. People who have variant angina are often younger than those who have other forms of angina.


What Are the Signs and Symptoms of Angina?
Pain and discomfort are the main symptoms of angina. Angina is often described as pressure, squeezing, burning, or tightness in the chest. It usually starts in the chest behind the breastbone.
Pain from angina could also occur in the arms, shoulders, neck, jaw, throat or back.  It may also reflect the typical symptoms of an indigestion.

It is said that the discomfort that angina causes is hard to describe or that it is hard to pinpoint exactly where the pain is coming from.

Symptoms such as nausea, fatigue, shortness of breath, sweating, light-headedness, or weakness also may occur. Women are more likely to feel discomfort in their backs, shoulders, and abdomen.

Symptoms vary based on the type of angina.


Stable Angina
The pain or discomfort:

• Occurs when the heart must work harder, usually during physical exertion.
• Does not come as a surprise, and episodes of pain tend to be alike.
• Usually lasts a short time (5 minutes or less).
• Is relieved by rest or medication.
• May appear to have typical symptoms of indigestion, like bloating, belching, heartburn.
• In the chest area spreads to the arms, back, or other areas.

Unstable Angina
The pain or discomfort:

• Often occurs at rest, while sleeping at night, or with little physical exertion.
• Comes as a surprise.
• Is  more severe and lasts. longer (as long as 30 minutes) than episodes of stable angina.
• Is usually not relieved with rest or medication.
• May get continually worse.
• May mean that a heart attack would occur soon.

Variant Angina
The pain or discomfort:

• Usually occurs at rest, generally, during the night or early hours of the morning.
• Tends to be severe.
• Is relieved by medication.

Lasting Chest Pain

Chest pain that lasts longer than a few minutes and is not relieved by rest or medication for angina may mean that you are having (or are about to have) a heart attack. Call 9–1–1 right away.


How Is Angina Diagnosed?
The most important issues to address when you visit the doctor with chest pain are:

• What is causing the chest pain, and,
• Whether you are having or are about to have a heart attack

Angina is a symptom of an underlying heart problem, usually coronary artery disease (CAD). The type of angina pain you have could be a sign of how severe the CAD is and whether it is likely to cause a heart attack.

If you have chest pain, your doctor would want to find out whether it is angina. He or she would also want to know whether the angina is stable or unstable. If it is unstable, you may need emergency medical attention to try to prevent a heart attack.

To diagnose chest pain as stable or unstable angina, your doctor would do a physical examination, question you about your symptoms, your risk factors and your family history of CAD or other heart diseases.

He or she may also probe more about your symptoms, such as:

• What brings on the pain or discomfort and what relieves it?
• What does the pain or discomfort feel like (for example, heaviness or tightness)?
• How often does the pain occur?
• Where do you feel the pain or discomfort?
• How severe is the pain or discomfort?
• How long does the pain or discomfort last?

Diagnostic Tests and Procedures

If your doctor suspects that you have unstable angina or that your angina is related to a serious heart condition, he or she may order one or more tests.


EKG (Electrocardiogram)
An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart.

Certain electrical patterns that the EKG detects would suggest whether CAD is likely. An EKG could also show signs of a previous or current heart attack.
However, some people with angina have a normal EKG.

Stress Testing
During stress testing, you exercise to make your heart work harder and beat faster while heart tests are performed. If you cannot exercise, you are given medicine to speed up your heart rate.

During exercise stress testing, your blood pressure and EKG readings are checked while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, could also be done at the same time.
If you are unable to exercise, a medicine could be injected into your bloodstream to make your heart work harder and beat faster. Nuclear heart scanning or echocardiography is then usually done.

When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque cannot supply enough oxygen-rich blood to meet your heart's needs.
A stress test could show possible signs of CAD, such as:

• Abnormal changes in your heart rate or blood pressure
• Symptoms such as shortness of breath or chest pain
• Abnormal changes in your heart rhythm or your heart's electrical activity.

Chest X-Ray
A chest X-ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. This could reveal signs of heart failure, as well as lung disorders and other causes of symptoms that are not due to CAD.

Coronary Angiography and Cardiac Catheterization
Your doctor may ask you to have coronary angiography if other tests or factors show that you are likely to have CAD. This test uses dye and special X-rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor would use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special X-rays are taken while the dye is flowing through the coronary arteries.

Cardiac catheterization is usually done in a hospital. You are awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor had inserted the catheter.

Blood Tests
Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you are at risk for CAD.

Your doctor may order a blood test to check the level of C-reactive protein (CRP) in your blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CAD and heart attack.

Your doctor may also order a blood test to check for low hemoglobin (HEE-muh-glow-bin) in your blood. Hemoglobin is an iron-rich protein in the red blood cells that carries oxygen from the lungs to all parts of your body. If you have a low hemoglobin count, you may be having a condition called anemia.


How Is Angina Treated?
Treatments for angina include lifestyle changes, medicines, medical procedures, and cardiac rehabilitation (rehab). The main goals of treatment are to:

• Reduce pain and discomfort and frequency of occurrences
• Prevent or lower the risk of heart attack and death by treating the underlying heart condition.

Lifestyle changes and medicines may be the only treatments needed if your symptoms are mild and are not getting worse. When lifestyle changes and medicines do not control angina, you may need medical procedures or cardiac rehab.
Unstable angina is an emergency condition that requires treatment in the hospital.


Lifestyle Changes
Making lifestyle changes could help prevent episodes of angina. You could:

• Slow down or take breaks if the angina comes on with exertion.
• Avoid large meals and rich foods that leave you feeling stuffed if the angina comes on after a heavy meal.
• Try to avoid situations that make you upset or stressed if the angina comes on with stress. Learn ways to handle stress that cannot be avoided.

You could make lifestyle changes that help lower your risk of heart disease. An important lifestyle change is adopting a healthy diet. This would help prevent or reduce high blood pressure, high blood cholesterol, and obesity.

Follow a heart-healthy eating plan that focuses on fruits, vegetables, whole grains, low-fat or no-fat diary products, and lean meat and fish. The plan also should be low in salt, fat, saturated fat, trans fats, and cholesterol.

• Quitting smoking, if you smoke. Avoid being a passive smoker.
• Being physically active. Check with your doctor to find out how much and what kinds of activity are safe for you.
• Losing weight, if you are overweight or obese.
• Taking all medication as your doctor prescribes, especially if you have diabetes.

Medicines
Nitrates are the most commonly used medicines to treat angina. They relax and widen blood vessels. This allows more blood to flow to the heart while reducing its workload.

Nitroglycerin is the most commonly used nitrate for angina. Nitroglycerin that dissolves under your tongue or between your cheeks and gum is used to relieve an angina episode.

Nitroglycerin in the form of pills and skin patches is used to prevent attacks of angina. These forms of nitroglycerin act too slowly to relieve pain during an angina attack.  Therefore, you may also need other medicines to treat angina such as, beta blockers, calcium channel blockers, ACE inhibitors, oral antiplatelet medicines, and anticoagulants. They do help:

• Lower blood pressure and cholesterol levels
• Slow the heart rate
• Relax blood vessels
• Reduce strain on the heart
• Prevent blood clots from forming.

Medical Procedures
When medicines and other treatments do not control angina, you may need a medical procedure to treat the underlying heart disease. Angioplasty and coronary artery bypass grafting (CABG) are both commonly used to treat angina.

Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores blood flow.

Angioplasty does improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure.

During CABG, healthy arteries or veins taken from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. Bypass surgery improves blood flow to your heart, relieves chest pain, and possibly, prevents a heart attack.
Your doctor would help decide which treatment is right for you.

Cardiac Rehabilitation
Your doctor may prescribe cardiac rehab for angina or after angioplasty, CABG, or a heart attack.

The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.
Rehab comprises of two parts:

• Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan would be based on your individual abilities, needs, and interests.
• Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk of future heart problems. The cardiac rehab team would help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.