Angina pectoris, commonly known as angina, is a type of chest pain that happens when the heart muscle does not get enough oxygen-rich blood. It is usually a symptom of coronary artery disease (CAD). Angina itself is not a disease but an indicator of an underlying heart problem that needs careful attention and management.
Causes
- Coronary artery disease due to atherosclerosis (narrowing of heart arteries from fatty deposits)
- Coronary artery spasm (temporary tightening of the muscles within the artery walls)
- Severe anaemia reducing oxygen supply to the heart
- Hypertrophic cardiomyopathy (thickening of the heart muscle)
- Aortic stenosis (narrowing of the aortic valve)
- Uncontrolled high blood pressure (hypertension) increasing heart demand
Pathophysiology
Angina occurs when the oxygen demand of the heart muscle exceeds its supply. In most cases, it is caused by atherosclerotic plaque build-up inside coronary arteries, narrowing the lumen and reducing blood flow. During times of increased demand, like exercise or emotional stress, the limited blood supply cannot meet the heart’s needs, leading to ischemia. This ischemia causes chest pain, which typically resolves with rest or medication that improves blood flow.
Signs and Symptoms
- Chest pain or discomfort described as pressure, squeezing, or fullness
- Pain may spread to the shoulders, arms, neck, jaw, or back
- Shortness of breath
- Nausea, sweating, and dizziness
- Symptoms typically triggered by physical exertion or emotional stress and relieved by rest or nitroglycerin
- In atypical presentations, especially in women and older adults, symptoms may be less specific, like fatigue or indigestion
Risk Factors
- Smoking
- Diabetes mellitus
- High blood pressure (hypertension)
- High cholesterol levels (dyslipidaemia)
- Obesity
- Sedentary lifestyle
- Family history of heart disease
- Older age
- Chronic kidney disease
Investigation (Imaging or Labs)
- Resting ECG (Electrocardiogram): May show signs of ischemia but often normal in stable angina
- Exercise ECG (Stress Test): Looks for ECG changes during exertion
- Cardiac biomarkers (Troponins): To exclude myocardial infarction if chest pain is suspected to be unstable
- Coronary CT Angiography (CCTA): First-line imaging to detect coronary artery disease according to NICE guidelines
- Invasive coronary angiography: For patients at high risk or with positive non-invasive tests
- Blood tests: To check cholesterol levels, blood sugar, kidney function
- Echocardiography: To assess heart structure and function if needed
Management
1. Non-Pharmacological Management
- Lifestyle changes: smoking cessation, healthy diet (low saturated fat, high fibre), regular exercise tailored to the patient’s capacity
- Weight management
- Stress reduction techniques
- Patient education about recognising angina and when to seek emergency help
2. Pharmacological Management
Anti-anginal medications:
- Short-acting nitrates (e.g., glyceryl trinitrate spray/tablet) for immediate relief
- Beta-blockers to reduce heart workload
- Calcium channel blockers if beta-blockers are not tolerated
- Long-acting nitrates, ivabradine, nicorandil, or ranolazine in certain cases
Secondary prevention:
- Antiplatelet therapy (aspirin) to prevent clots
- Statins to lower cholesterol
- ACE inhibitors or ARBs for blood pressure control and heart protection
- Management should be individualised based on patient tolerance and comorbidities
Surgical Management
- Percutaneous Coronary Intervention (PCI): Angioplasty with or without stent placement to open blocked arteries
- Coronary Artery Bypass Grafting (CABG): Recommended for severe, complex coronary disease or left main stem disease
Complications
- Myocardial infarction (heart attack)
- Heart failure
- Life-threatening arrhythmias
- Sudden cardiac death
- Decreased quality of life due to chronic chest pain and limited physical activity
References
- National Institute for Health and Care Excellence (NICE) Guidelines: Chest Pain of Recent Onset: Assessment and Diagnosis (NG12)
- Royal College of Physicians: Stable Angina Management Pathway
- British Cardiovascular Society (BCS) Clinical Guidelines
- General Medical Council (GMC) Good Medical Practice Standards
- European Society of Cardiology (ESC) Guidelines referenced in UK cardiology practice