Angina treatment angina symptoms
This article is for people with angina , and for their family and friends.
It explains:
• what angina is
• what causes angina
• the tests used to diagnose angina
• treatments for angina including drugs, coronary angioplasty and coronary bypass surgery
• what acute coronary syndrome is, and
• what to do, and what not to do, to prevent your angina getting worse.
www.highbloodpressuresymptoms.co.uk does not replace the advice that your doctors or nurses may give you, but it should help you to understand what they tell you.
What is angina ?
Angina is an uncomfortable feeling or pain in the chest. It usually feels like a heaviness or tightness in the centre of the chest which may spread to the arms, neck, jaw, back or stomach. In some people, the pain or tightness may affect only the arm, neck, stomach or jaw. Some people describe angina as a dull, persistent ache. Symptoms usually fade within about 10 to 15 minutes. For some people the tightness is severe; for others it is not much more than mild discomfort.
What brings on an angina attack ?
Angina can be brought on by physical activity or emotional upset. It often comes on when you are walking. If it is a cold day or if you are walking after a meal, the angina may be triggered more easily. You may sometimes get an attack of angina while you are resting, or it may even wake you when you are asleep.
Stable angina and unstable angina
Many people have angina that comes on with a particular amount of exercise, and is well controlled with drugs. This is known as stable angina .
Unstable angina is angina which has just developed for the first time, or angina which was previously stable but has recently got worse or changed in pattern. For example, your angina pain may come on after doing much less exercise or after less stress than usual, or it may even come on while you are resting. If the pattern of your angina changes in this way, tell your doctor about it immediately, as you may need to go to hospital for some tests and treatment.
What to do if you get an angina attack
If you get an attack of angina, you should stop what you are doing and rest until the discomfort has passed. You may also need to take medication to relieve the discomfort. Most people are prescribed a nitrate tablet or a spray for under the tongue to relieve angina.
What causes angina ?
The muscle of the heart needs its own supply of oxygen and nutrients so that it can pump blood around your body. The coronary arteries deliver oxygen-rich blood to the heart’s muscle. Two main coronary arteries (the left and the right) divide many times so that the blood reaches all the parts of the heart’s muscular wall.
The coronary arteries can become narrowed by a gradual build-up of fatty material within their walls. (This process is called atherosclerosis and the fatty material is called atheroma.) In time, the artery may become so narrow that it cannot deliver enough oxygen-containing blood to the heart muscle when its demands are high – such as when you are doing exercise. The pain or discomfort that happens as a result is called angina .
You are particularly likely to develop atherosclerosis if :
• you smoke any form of tobacco
• you have high blood pressure
• you have a high blood cholesterol level
• you take little physical activity, or
• you have diabetes .
Other risk factors are being overweight or obese, and having a family history of relatives having a heart attack or angina before the age of 55 for a man or 65 for a woman. (A ‘risk factor’ is something that increases your risk of developing atherosclerosis).
How will I know if it’s angina ?
The most common cause of chest pain is narrowed coronary arteries, but many chest pains or discomfort have nothing to do with the heart. Short, sharp stabbing pains are often muscular pains. Some people get a dull, persistent ache under the left breast when they are tense or anxious. Indigestion can also cause pain in the centre of the chest, but this is usually related to food rather than exercise. Severe anaemia can also cause chest pain. If you have a chest pain that you are worried about, it is important to talk to your doctor about it.
What’s the difference between angina and a heart attack ?
A heart attack happens when a narrowed coronary artery becomes blocked by a blood clot. The chest pain that comes with a heart attack is sometimes more severe than angina. Also, it usually lasts longer and it doesn’t usually go away with rest. You may sweat and feel sick. A nitrate tablet or spray, which are usually very effective in relieving angina, may not help. Unusual indigestion symptoms which do not get better after taking medication may be a heart attack. If you are in any doubt, it is best to call 999.
What is acute coronary syndrome ?
When someone has a persistent chest pain or chest discomfort which seems to be coming from the heart, it is sometimes difficult for the doctors and nurses to tell whether the person is having an episode of unstable angina or a heart attack. The term used when this happens is ‘acute coronary syndrome’. ‘Syndrome’ means a set of symptoms that happen at the same time, and ‘coronary’ means to do with the coronary arteries. So, acute coronary syndrome is a general term that describes a heart attack or unstable angina.
How can doctors diagnose angina ?
Your GP may be able to tell if you have angina from the symptoms you describe. However, it is harder to diagnose angina in women than in men. The GP will listen to your heart to check its rate and rhythm, and will assess your general condition. He or she will also carry out tests to assess your risk factors, such as a test for diabetes and a blood cholesterol test. (A blood cholesterol test measures the level of cholesterol and other fats in your blood.)
Your doctor may also send you for one or more specific tests on the heart.
These include:
• an electrocardiogram ( ECG ) or an exercise ECG
• a stress echocardiogram
• a radioisotope scan
• a coronary angiogram ( cardiac catheterisation ).
Some people may have an MRI scan or a CT scan . All these tests are usually carried out in hospital as a day case (which means that you don’t have to stay overnight).
Electrocardiogram ( ECG ) or exercise ECG
Your doctor is likely to send you for an electrocardiogram ( ECG ), which records the rhythm and electrical activity of your heart. The test is painless and usually takes about five minutes.
Small patches, set in sticky plaster, are put on your arms, legs and chest and are connected to a recording machine. The machine then takes a reading. If you have narrowing of the coronary arteries, the ECG may show an abnormal reading. The ECG can provide evidence to diagnose angina and help to establish how severe it is. However, you could have a normal ECG reading and still have narrowed coronary arteries and get angina .
Angina often occurs with physical activity. This means that, if the ECG is done while you are resting, it may show a normal reading. For this reason you may be asked to do an exercise ECG . This is an ECG carried out while you are pedalling an exercise bike or walking on a treadmill.
Stress echocardiogram
Bats fly in the dark by sending out pulses of sound and listening for echoes reflected from objects around them. A similar idea is used to record an echocardiogram.
A recorder (probe) is placed on your chest and a pulse of high-frequency sound is passed through the skin of your chest. Lubricating jelly is rubbed on your chest first, to help make a good contact with the probe. The probe then picks up the echoes reflected from various parts of your heart and shows the echoes as an echocardiogram – a picture on a screen. You can see different parts of the heart as the probe is moved around on your chest. Recording these images is a skilful job and can take up to an hour. The test doesn’t hurt at all.
A ‘ stress echocardiogram ’ is when the echocardiogram is recorded after the heart has been put under stress – either with exercise or with a drug.
Radioisotope scan
This test is also known as a radionuclide scan or a myocardial perfusion scan. It is useful for people who cannot exercise ( and who, as a result, cannot do an exercise ECG ). For women, a radioisotope scan can be more useful than the exercise ECG for diagnosing angina.
Some radioactive material ( isotope ) – technetium , tetrofosmin , technetium MIBI or thallium – is injected into the blood. This is sometimes done while you are on an exercise bike. If you are unable to exercise, you will be given a drug called adenosine or dobutamine instead. This mimics the effect of exercise on the body, while you are still resting. Or you may be asked to do a little bit of gentle exercise and have a small amount of adenosine or dobutamine as well.
A large camera, positioned close to the chest, picks up the gamma rays the isotope produces. This shows which parts of the heart muscle are short of blood and measures how severe the condition is.
The amount of radiation you are exposed to during a radionuclide scan is the equivalent of having about 900 chest X-rays.
Is there any radiation in these tests ?
Some of the tests described on www.highbloodpressuresymptoms.co.uk – radioisotope scans, coronary angiograms and CT scans – involve radiation. Every day you are exposed to small amounts of naturally occurring radiation in the environment. Having an X-ray of any type increases your exposure to radiation. A chest X-ray, for example, can be compared to one and a half days of natural background radiation. Your doctor will think carefully before arranging for you to have any test which involves radiation. ECGs , stress ECGs and MRI scans do not involve any radiation.
Coronary angiogram
A coronary angiogram is an X-ray picture of the blood vessels. A fine, flexible, hollow tube called a catheter is passed into an artery either in your groin or arm. It is gently passed through until it reaches the coronary arteries. A dye is then injected into the coronary arteries and X-rays are taken from several angles.
The X-rays are like a ‘road map’ of all your arteries, showing where the arteries are narrowed and how narrow they have become.
The test is not usually painful as you will have a local anaesthetic first. Some people feel a ‘hot flush’ or warm feeling when the dye is being injected. The amount of radiation you are exposed to during a coronary angiogram is the equivalent of having about 500 chest X-rays.
While a coronary angiogram is being done, it is sometimes possible to treat narrowed coronary arteries, using a technique called coronary angioplasty .
CT scan of the coronary arteries
More and more patients who are having tests for coronary heart disease – especially those who have private health care – are now being offered a CT scan. This test is also known as a computed tomography scan or a CAT scan.
What is it ?
A CT scan is a sophisticated type of X-ray. It is useful for looking at the organs in your body, such as your heart or lungs.
What happens during the test?
The radiographer or nurse will ask you to lie down on a narrow bed. He or she may inject a substance known as a contrast agent into a vein in your arm. The contrast agent will make it easier to see the arteries around your heart during the scan. Your kidneys will get rid of the contrast agent from your body within a few hours. When the test starts, the bed will move slowly along the scanner. You will hear a mechanical noise as the scanner is switched on. You will be alone in the room while the scan is taking place, but you will be able to speak to the radiographer using a microphone. The test does not cause any pain and takes about 15 minutes to half an hour. The level of radiation you are exposed to during a CT scan of the coronary arteries is the equivalent to having about 650 chest X-rays.
What can the test show ?
A CT scan of your heart can show two things. The most common thing it can show is the amount of calcified or hardened fatty areas in the arteries around your heart. This is given to you as a calcification score.
If you get a low calcification score, it is unlikely that you have coronary heart disease, so you won’t need any more tests.
A high calcification score means that you have a considerable amount of hardened fatty deposits lining the arteries around your heart. However, a high calcification score on its own does not give your cardiologist enough information to help him or her decide what treatment you need. So, if you get a high calcification score, you will probably have to have other tests such as a stress ECG and possibly an angiogram.
Multi-slice CT scan
Another sophisticated type of CT scan – called a multi-slice CT scan – can also show very good pictures of the arteries around your heart. Some people may be offered this type of CT scan instead of a conventional coronary angiogram . There is still some debate about whether the pictures produced by a multi-slice CT scan are as good as those produced by a conventional angiogram . The technology is improving all the time, so in the future multi-slice CT scans may replace angiograms as a diagnostic test. However, at the moment coronary angiograms are still more widely used than multi-slice CT scans to investigate coronary heart disease.
MRI scan
Magnetic Resonance Imaging ( MRI ) is a technique which produces detailed pictures of your internal organs – such as your heart – by putting you inside a strong magnetic field. MRI scans are not routinely used to diagnose angina. However, you may have an MRI scan if your cardiologist thinks that you were born with an abnormality of one of the arteries around your heart.
The test takes about an hour and is not uncomfortable. You can have the test done as a day case. To have the scan done, you lie in a short tunnel, which holds a large magnet. The MRI scanner sends out short bursts of magnetic fields and radio waves and creates images of
the heart which can be processed and analysed. You will have to take off all jewellery before you have the scan. You need to lie still while you are having the test done. You will hear knocking noises while the scan is being carried out, but you don’t need to worry about them. Because of the high cost of the MRI scanner , there are only a few centres in the UK where you can have this test done. If you need to have an MRI scan , your cardiologist may refer you to one of these centres, but there may be a waiting list.
If you have a pacemaker, you cannot have an MRI scan because it can affect how the pacemaker works.
How is angina treated ?
Most people who are diagnosed with angina will have drug treatment at first, but some people will need coronary angioplasty or coronary bypass surgery. The treatment you are offered will depend on how severe your angina is, whether the angina is stable or unstable, and your overall condition.
Drug treatment
You can think of drugs for angina as those which prevent your condition from getting worse and reduce the risk of a heart attack, and those that relieve your symptoms.
Drugs for people with angina can:
• reduce the chance of blood clots developing ( anti-platelet drugs such as aspirin )
• increase the blood supply to your heart ( nitrates and potassium channel activators )
• reduce the work your heart has to do ( beta-blockers and some calcium channel blockers ), and
• help keep your blood cholesterol levels down ( statins and fibrates ).
Remember, never run out of your tablets !
Once you have been diagnosed with angina, it is likely that you will have to keep taking some drugs for the rest of your life. Most people with coronary heart disease are prescribed aspirin and a cholesterol-lowering drug and, depending on how severe your angina is, you may also be given some of the other drugs listed above – to protect your heart from further damage. Even if you have a coronary angioplasty or a coronary bypass operation, you will most probably still need to continue taking a
combination of drugs afterwards.
Anti-platelet drugs ( such as aspirin )
Anti-platelet drugs help to prevent the blood from clotting. They do this by reducing the ‘stickiness’ of platelets – the small blood cells that can clump together to form a clot. So anti-platelet drugs can help to prevent heart attacks and strokes.
Aspirin
The most commonly used anti-platelet drug is aspirin. Aspirin has been used for relieving pain for more than 100 years. The dose of aspirin you need for the anti-platelet effect is smaller than the dose you would need to relieve a headache.
Aspirin is used for most people with known coronary heart disease, unless there are strong reasons for not giving it – for example, if you are allergic to it or if you have had a serious unwanted effect from aspirin before, such as serious bleeding.
Clopidogrel
Clopidogrel is another anti-platelet drug. It is sometimes given along with aspirin to certain people for a set period of time. It is useful for people with unstable angina or for those who have recently had a coronary angioplasty with stenting . Sometimes, clopidogrel is used for people who can’t take aspirin because they have a condition such as asthma.
Unwanted effects of anti-platelet drugs
Anti-platelet drugs can cause indigestion, nausea and vomiting. More seriously, they can occasionally provoke or worsen bleeding from the stomach. Occasionally aspirin can bring on an asthma attack. These harmful effects are not common, but because of them, anti-platelet drugs are not recommended as a way to prevent heart attacks or strokes in healthy people.
Nitrates
Nitrates open up the blood vessels. They reduce the work of the heart and also help to widen the coronary arteries. Nitrates come in tablet or spray form, or as skin patches.
GTN tablets
As soon as you get an attack of angina, place a glyceryl trinitrate ( GTN ) tablet under your tongue and let it dissolve. GTN tablets are not effective if you swallow them. Or, you can take a tablet just before doing something that is likely to bring on your angina. However, you should only do this if you have previous experience of getting chest pain while doing that activity. It is not advisable to take your nitrates ‘just in case’ – unless you have specific instructions from your doctor to do so.
Keep your tablets in the container that they come in. The tablets lose their strength quite quickly and you should replace them with a fresh supply after eight weeks.
GTN spray
Glyceryl trinitrate can be given in an aerosol spray (a GTN spray). You need to take one or two doses under your tongue and close your mouth after each dose. You don’t need to shake the canister before spraying. The spray has the advantage of having a longer lifespan than GTN tablets. You can keep it for up to two years.
Oral nitrates
Some nitrates are used to prevent angina. These are sometimes given as tablets – for example, isosorbide mononitrate and isosorbide dinitrate.
GTN skin patch
Self-adhesive skin patches containing glyceryl trinitrate are effective in relieving or preventing angina, but they may become less effective if they are used continuously for a 24-hour period. So, it may be helpful to leave the patches off for several hours in each 24-hour period. You can still use your spray or tablets under your tongue if you have an angina attack.
Unwanted effects of nitrates
You can get a headache, flushing, dizziness and faintness with nitrates, but these side effects are most common with GTN tablets. These symptoms tend to reduce with continued use. I you are taking a long-acting nitrate (such as isosorbide mononitrate or isosorbide dinitrate), you should not take Viagra. Speak to your doctor if you are not sure about this.
Beta-blockers
Beta-blockers act by slowing the heart rate. This reduces the amount of work the heart has to do, so that it needs less oxygen, blood and nutrients. Beta-blockers are very effective in preventing attacks of angina, but work too slowly to be useful in relieving an attack of angina .
Beta-blockers come in tablet form and you need to swallow them whole.
These drugs are not usually suitable for people with asthma or bronchitis. If you have diabetes, your doctor may prefer not to give you beta-blockers, as they may
mask (hide) the symptoms of low blood sugar. However, so-called ‘selective’ beta-blockers have fewer effects on the lungs and are also less likely to mask the symptoms caused by low blood sugar.
Unwanted effects
Serious side effects are rare if beta-blockers are used carefully. Minor side effects are common but they tend to lessen as time goes by. The minor side effects include tiredness, fatigue, and cold hands and feet. Other less frequent effects include feeling sick, diarrhoea, skin rashes, impotence, nightmares, and dizziness. You should not stop taking beta-blockers suddenly without medical advice, because coming off them too quickly can make angina worse.
Calcium channel blockers
Calcium channel blockers are used to reduce the frequency of angina attacks. If you have asthma or bronchitis, your doctor may prescribe calcium channel blockers rather than beta-blockers. Some doctors prefer calcium channel blockers for people who also have diabetes.
Unwanted effects
Serious side effects are not common. Minor effects include flushing, headache, dizziness, faintness, swollen ankles, indigestion, feeling sick and vomiting.
Potassium channel activators
Potassium channel activators have a similar effect to nitrates as they relax the walls of the coronary arteries and so improve the flow of blood to the heart. Unlike nitrates, they do not appear to become less effective if you keep using them.
Unwanted effects
Unwanted effects of potassium channel activators may include a headache when you first take them, and also flushing, indigestion or dizziness. If you are taking a potassium channel activator, you should not take Viagra.
Cholesterol-lowering drugs ( lipid-lowering drugs )
You may be given cholesterol-lowering drugs (or lipid-lowering drugs) to reduce your risk of having a heart attack. ‘ Blood lipids ’ is the name for all the fatty substances in the blood, including LDL cholesterol (the harmful cholesterol), HDL cholesterol (the ‘good’ type of
cholesterol), and triglycerides. The overall aim of using drugs to treat high blood cholesterol is to lower the total amount of cholesterol in the blood, and particularly to lower the amount of LDL cholesterol.
The main type of drugs now used to reduce cholesterol levels is statins. Examples of statins are simvastatin, pravastatin, rosuvastatin and atorvastatin. Statins are not suitable for people who have liver disease or for women who are pregnant or breastfeeding. There are other types of drugs which can be used when statins are not suitable. Fibrates are useful for people who have a high level of both blood cholesterol and triglycerides. Nicotinic acid can help to raise HDL – the good type of cholesterol .
Ezetimibe is another type of cholesterol-lowering drug. It can be used along with a statin, or people who cannot take statins can take ezetimibe on its own. Ezetimibe helps to lower blood cholesterol levels by preventing cholesterol from being absorbed in the small intestine.
Unwanted effects of cholesterol-lowering drugs
Unwanted effects of cholesterol-lowering drugs can include feeling sick, vomiting, diarrhoea and headache. A rare side effect of statins is inflammation of the muscles (myositis). If you have any unexpected muscle pain, tenderness or weakness, you should tell your doctor. He or she may change the type of statin drug you are taking, or the dose. Don’t stop taking the drug without speaking to your doctor about it first.
Unwanted effects of ezetimibe include headaches, pain in the abdomen and diarrhoea.
Combinations of drugs
Nitrates and beta-blockers are often used together from the start of treatment. If they do not control the angina, a calcium channel blocker may be used as well.
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