Angina

Definition

Angina is pain , discomfort, or pressure in the chest that is caused by ischemia , an insufficient supply of oxygen-rich blood to the heart muscle. It is sometimes also characterized by a feeling of choking, suffocation, or crushing heaviness. This condition is also called angina pectoris.

Description

Often described as a muscle spasm and choking sensation, the term angina is used primarily to describe chest (thoracic) pain caused by insufficient oxygen to the heart muscle. An episode of angina is not an actual heart attack , but rather pain that results when the heart muscle temporarily receives too little blood. This temporary condition may be the result of demanding activities such as exercise and does not necessarily indicate that the heart muscle is experiencing permanent damage. In fact, episodes of angina seldom cause permanent damage to heart muscle.

Angina can be subdivided into two categories: angina of effort and variant angina.

Angina of effort

Angina of effort is a common disorder caused by the narrowing of the arteries (a condition called atherosclerosis ) that supply oxygen-rich blood to the heart muscle. In the case of angina of effort, the coronary arteries can provide the heart muscle (myocardium) adequate blood during rest but not during periods of exercise, stress , or excitement. The resulting pain is relieved by resting or by administering nitroglycerin, a medication that relaxes the heart muscle, opens up the coronary blood vessels, and lowers the blood pressure—all of which reduce the heart's need for oxygen. Patients with angina of effort have an increased risk of heart attack (myocardial infarction).

Variant angina

Variant angina is uncommon and occurs independently of atherosclerosis, which may incidentally be present. Variant angina occurs at rest and is not related to excessive work by the heart muscle. Research indicates that variant angina is caused by coronary artery muscle spasm that does not last long enough or is not intense enough to cause an actual heart attack.

Causes & symptoms

Angina is usually caused by an underlying obstruction to the coronary artery due to atherosclerosis. In some cases, it is caused by spasm that occurs naturally or as a result of ingesting cocaine. In rare cases, angina is caused by a coronary embolism or by a disease other than atherosclerosis that places demands on the heart.

Most episodes of angina are brought on by physical exertion, when the heart needs more oxygen than is available from the blood nourishing the heart. Emotional stress, extreme temperatures, heavy meals, cigarette smoking , and alcohol can also cause or contribute to an episode of angina.

Angina causes a pressing pain or sensation of heaviness, usually in the chest area under the breast bone (sternum). It is occasionally experienced in the shoulder, arm, neck, or jaw regions. In most cases, the symptoms are relieved within a few minutes by resting or by taking prescribed angina medications.

Diagnosis

Physicians can usually diagnose angina based on the patient's symptoms and the precipitating factors. However, other diagnostic testing is often required to confirm or rule out angina, or to determine the severity of the underlying heart disease .

Electrocardiogram (ECG)

An electrocardiogram is a test that records electrical impulses from the heart. The resulting graph of electrical activity can show if the heart muscle isn't functioning properly as a result of a lack of oxygen. Electrocardiograms are also useful in investigating other possible abnormal features of the heart, such as arrhythmia (irregular heartbeat).

Stress test

For many individuals with angina, the results of an electrocardiogram while at rest will not show any abnormalities. Because the symptoms of angina occur during stress, the heart's function may need to be evaluated under the physical stress of exercise. The stress test records information from the electrocardiogram before, during, and after exercise in search of stress-related abnormalities. Blood pressure is also measured during the stress test and symptoms are noted. In some cases a more involved and complex stress test (for example, thallium scanning) is used to picture the blood flow in the heart muscle during the most intense exercise and after rest.

Angiogram

The angiogram, which is a series of x rays of the coronary artery, has been noted as the most accurate diagnostic test to indicate the presence and extent of coronary disease. In this procedure, a long, thin, flexible tube (catheter) is inserted into an artery located in the forearm or groin. This catheter is passed further through the artery into one of the two major coronary arteries. A dye is injected through the catheter to make the heart, arteries, and blood flow clearer on the x ray. A fluoroscopic film, or series of "moving" x rays, shows the blood flowing through the coronary arteries. This will reveal any possible narrowing that can cause a decrease in blood flow to the heart muscle and associated symptoms of angina.

Treatment

Controlling existing factors that place the individual at risk is the first step in addressing artery disease that causes angina. These risk factors include cigarette smoking, high blood pressure, high cholesterol levels, and obesity .

Once the angina has subsided, the cause should be determined and treated. Atherosclerosis, a major associated cause, requires diet and lifestyle adjustments, primarily including regular exercise, reduction of dietary sugar and saturated fats, and increase of dietary fiber.

In recent years, several specific cholesterol-lowering treatments have gained the attention and interest of the public. One of the most recent popular treatments is garlic (Allium sativum ). Some studies have shown that garlic can reduce total cholesterol by about 10% and LDL (bad) cholesterol by 15%, and can raise HDL (good) cholesterol by 10%. Other studies have not shown significant benefit. Although its effect on cholesterol is not as great as the effect achieved by medications, garlic may help in relatively mild cases of high cholesterol, without causing the side effects associated with cholesterol-reducing drugs.

A 1999 study published in the American Journal of Clinical Nutrition found that red yeast extract can significantly reduce cholesterol when it's taken in conjunction with a low-fat diet. Red yeast extract, available in the United States under the trade name Cholestin, has been used in Chinese medicine to treat heart maladies for hundreds of years. The effectiveness of the extract depends on the patient's cholesterol level and medical history, so individuals should consult with their healthcare professionals before taking the supplement. Additional herbal remedies that may help lower cholesterol include oats (Avena sativa ), alfalfa (Medicago sativa ), fenugreek (Trigonella foenumgraecum ), Korean ginseng (Panax ginseng ), myrrh (Commiphora molmol ), and turmeric (Curcuma longa ).

Yarrow (Achillea millefolium ), linden (Tilia europaea ), and hawthorn (Crataegus spp. ) are sometimes recommended for controlling high blood pressure, a risk factor for heart disease. In particular, hawthorn extract appears to benefit the aging heart. A 2001 report of a European study reported that patients using hawthorn extract showed improvements in exercise tolerance, fatigue , and shortness of breath.

Tea (Camellia sinensis )—especially green tea—is high in antioxidants , and studies have shown that it may help prevent atherosclerosis. Other antioxidants, including vitamin A (beta carotene ), vitamin C, vitamin E , and selenium , can also limit the damage to the walls of blood vessels by oxidation, which may be lead to the formation of atherosclerotic plaque.

Vitamin and mineral supplements that reduce, reverse, or protect against coronary artery disease include chromium, calcium and magnesium , B-complex vitamins, L-carnitine, and zinc . Yoga and other bodywork, massage, aromatherapy , and music therapy may also help reduce angina symptoms by promoting relaxation and stress reduction.

Traditional Chinese medicine may recommend herbal remedies (such as a ginseng and aconite combination), massage, acupuncture , and dietary modification. Exercise and a healthy diet, including cold-water fish as a source of essential fatty acids , are important components of a regimen to prevent angina and heart disease.

Allopathic treatment

Angina is often controlled by medication, most commonly with nitroglycerin. This drug relieves symptoms of angina by increasing the diameter of the blood vessels that carry blood to the heart muscle. Nitroglycerin is taken whenever discomfort occurs or is expected. It may be taken sublingually, by placing the tablet under the tongue. Or it may be administered transdermally, by placing a medicated patch directly on the skin.

In addition, beta-blockers or calcium channel blockers may be prescribed to decrease the heart's rate and workload. In late 2001, a study reported that the drug Nicorandil had become the first to demonstrate a reduction in risk of angina and to improve symptoms in patients with chronic stable angina. Guidelines released late in 2000 promoted use of lopidogrel to help prevent recurring events. A study group that used clopidogrel and aspirin showed a significant decrease in cardiovascular death, nonfatal heart attack, and stroke compared to patients in a control group that received a placebo and aspirin.

When conservative treatments are not effective in reducing angina pain and the risk of heart attack remains high, physicians may recommend angioplasty or surgery. In coronary artery bypass surgery, a blood vessel (often a long vein surgically removed from the leg) is grafted onto the blocked artery to bypass the blocked portion. This newly formed pathway allows blood to flow adequately to the heart muscle.

Another procedure used to improve blood flow to the heart is percutaneous tranluminal coronary angioplasty, usually called coronary or balloon angioplasty. In this procedure, the physician inserts a catheter with a tiny balloon at the end into a forearm or groin artery. The catheter is then threaded up into the coronary arteries, and the balloon is inflated to open the vessel in narrowed sections. Other techniques to open clogged arteries are under development and in limited use, including the use of lasers, stents, and other surgical devices.

Expected results

The prognosis for a patient with angina depends on the general health of the individual as well as on the origin, type, and severity of the condition. A person can improve his or her prognosis by seeking prompt medical attention and learning the pattern of his or her angina, such as what causes the attacks, what they feel like, how long episodes usually last, and whether medication relieves the attacks. Medical help should be sought immediately if patterns of the symptoms change significantly or if symptoms resemble those of a heart attack.

Prevention

In most cases, the best prevention involves changing habits to avoid bringing on attacks of angina. A hearthealthy lifestyle includes eating right, exercising regularly, maintaining an appropriate weight, not smoking, drinking in moderation, controlling hypertension , and managing stress. Most healthcare professionals can provide valuable advice on proper diet, weight control, smoking cessation, blood cholesterol levels, and blood pressure.

Resources

BOOKS

American Heart Association. 2000 Heart and Stroke Statistical Update. Dallas: American Heart Association, 1999.

Hoffmann, David. The Complete Illustrated Herbal. New York: Barnes & Noble, 1999.

PERIODICALS

Jancin, Bruce. "Nicorandil Relieves Stable Angina, Cuts Events." Internal Medicine News 34, no. 24 (December 15, 2001): 11.

Pinkowish, Mary Desmond. "Acute Coronary Syndromes: Recent Treatment Advances." Patient Care 35, no. 22 (November 30, 2001): 12.

Walsh, Nancy. "Hawthorn Extract Limits CHF, Mild Heart Ailments." Internal Medicine News 34, no. 19 (October 1, 2001): 9.

ORGANIZATIONS

American Heart Association. National Center. 7272 Greenville Avenue, Dallas, Texas 75231. (800) AHA-USA1. <http://www.americanheart.org>.

National Heart, Lung, and Blood Institute Information Center. P.O. Box 30105, Bethesda, MD 20824. (301) 251-1222. <http://www.nhlbi.nih.gov/health/infoctr/index.htm>.

Paula Ford-Martin

Teresa G. Odle

Angina

Definition

Angina is pain, "discomfort," or pressure localized in the chest that is caused by an insufficient supply of blood (ischemia ) to the heart muscle. It is also sometimes characterized by a feeling of choking, suffocation, or crushing heaviness. This condition is also called angina pectoris.

Description

Often described as a muscle spasm and choking sensation, the term "angina" is used primarily to describe chest (thoracic) pain originating from insufficient oxygen to the heart muscle. An episode of angina is not an actual heart attack, but rather pain that results from the heart muscle temporarily receiving too little blood. This temporary condition may be the result of demanding activities such as exercise and does not necessarily indicate that the heart muscle is experiencing permanent damage. In fact, episodes of angina seldom cause permanent damage to heart muscle.

Angina can be subdivided further into two categories: angina of effort and variant angina.

Angina of effort

Angina of effort is a common disorder caused by the narrowing of the arteries (atherosclerosis ) that supply oxygen-rich blood to the heart muscle. In the case of angina of effort, the heart (coronary) arteries can provide the heart muscle (myocardium) adequate blood during rest but not during periods of exercise, stress, or excitement—any of which may precipitate pain. The pain is relieved by resting or by administering nitroglycerin, a medication that reduces ischemia of the heart. Patients with angina of effort have an increased risk of heart attack (myocardial infarction).

Variant angina

Variant angina is uncommon and occurs independently of atherosclerosis which may, however, be present as an incidental finding. Variant angina occurs at rest and is not related to excessive work by the heart muscle. Research indicates that variant angina is caused by coronary artery muscle spasm of insufficient duration or intensity to cause an actual heart attack.

Causes and symptoms

Angina causes a pressing pain or sensation of heaviness, usually in the chest area under the breast bone (sternum). It occasionally is experienced in the shoulder, arm, neck, or jaw regions. Because episodes of angina occur when the heart's need for oxygen increases beyond the oxygen available from the blood nourishing the heart, the condition is often precipitated by physical exertion. In most cases, the symptoms are relieved within a few minutes by resting or by taking prescribed angina medications. Emotional stress, extreme temperatures, heavy meals, cigarette smoking, and alcohol can also cause or contribute to an episode of angina.

Diagnosis

Physicians can usually diagnose angina based on the patient's symptoms and the precipitating factors. However, other diagnostic testing is often required to confirm or rule out angina, or to determine the severity of the underlying heart disease.

Electrocardiogram (ECG)

An electrocardiogram is a test that records electrical impulses from the heart. The resulting graph of electrical activity can show if the heart muscle isn't functioning properly as a result of a lack of oxygen. Electrocardiograms are also useful in investigating other possible abnormal features of the heart.

Stress test

For many individuals with angina, the results of an electrocardiogram while at rest will not show any abnormalities. Because the symptoms of angina occur during stress, the functioning of the heart may need to be evaluated under the physical stress of exercise. The stress test records information from the electrocardiogram before, during, and after exercise in search of stress-related abnormalities. Blood pressure is also measured during the stress test and symptoms are noted. A more involved and complex stress test (for example, thallium scanning) may be used in some cases to picture the blood flow in the heart muscle during the most intense time of exercise and after rest.

Angiogram

The angiogram, which is basically an x ray of the coronary artery, has been noted to be the most accurate diagnostic test to indicate the presence and extent of coronary disease. In this procedure, a long, thin, flexible tube (catheter) is maneuvered into an artery located in the forearm or groin. This catheter is passed further through the artery into one of the two major coronary arteries. A dye is injected at that time to help the x rays "see" the heart and arteries more clearly. Many brief x rays are made to create a "movie" of blood flowing through the coronary arteries, which will reveal any possible narrowing that causes a decrease in blood flow to the heart muscle and associated symptoms of angina.

Treatment

Conservative treatment

Artery disease causing angina is addressed initially by controlling existing factors placing the individual at risk. These risk factors include cigarette smoking, high blood pressure, high cholesterol levels, and obesity. Angina is often controlled by medication, most commonly with nitroglycerin. This drug relieves symptoms of angina by increasing the diameter of the blood vessels carrying blood to the heart muscle. Nitroglycerin is taken whenever discomfort occurs or is expected. It may be taken by mouth by placing the tablet under the tongue or transdermally by placing a medicated patch directly on the skin. In addition, beta blockers or calcium channel blockers may be prescribed to also decrease the demand on the heart by decreasing the rate and workload of the heart.

Surgical treatment

When conservative treatments are not effective in the reduction of angina pain and the risk of heart attack remains high, physicians may recommend angioplasty or surgery. Coronary artery bypass surgery is an operation in which a blood vessel (often a long vein surgically removed from the leg) is grafted onto the blocked artery to bypass the blocked portion. This newly formed pathway allows blood to flow adequately to the heart muscle.

KEY TERMS

Ischemia— Decreased blood supply to an organ or body part, often resulting in pain.

Myocardial infarction— A blockage of a coronary artery that cuts off the blood supply to part of the heart. In most cases, the blockage is caused by fatty deposits.

Myocardium— The thick middle layer of the heart that forms the bulk of the heart wall and contracts as the organ beats.

Another procedure used to improve blood flow to the heart is balloon angioplasty. In this procedure, the physician inserts a catheter with a tiny balloon at the end into a forearm or groin artery. The catheter is then threaded up into the coronary arteries and the balloon is inflated to open the vessel in narrowed sections. Other techniques using laser and mechanical devices are being developed and applied, also by means of catheters.

Alternative treatment

During an angina episode, relief has been noted by applying massage or kinesiological methods, but these techniques are not standard recommendations by physicians. For example, one technique places the palm and fingers of either hand on the forehead while simultaneously firmly massaging the sternum (breast bone) up and down its entire length using the other hand. This is followed by additional massaging by the fingertip and thumb next to the sternum, on each side.

Once the angina has subsided, the cause should be determined and treated. Atherosclerosis, a major associated cause, requires diet and lifestyle adjustments, primarily including regular exercise, reduction of dietary sugar and saturated fats, and increase of dietary fiber. Both conventional and alternative medicine agree that increasing exercise and improving diet are important steps to reduce high cholesterol levels. Alternative medicine has proposed specific cholesterol-lowering treatments, with several gaining the attention and interest of the public. One of the most recent popular treatments is garlic (Allium sativum ). Some studies have shown that adequate dosages of garlic can reduce total cholesterol by about 10%, LDL (bad) cholesterol by 15%, and raise HDL (good) cholesterol by 10%. Other studies have not shown significant benefit. Although its effect on cholesterol is not as great as that achieved by medications, garlic may possibly be of benefit in relatively mild cases of high cholesterol, without causing the side effects associated with cholesterol-reducing drugs. Other herbal remedies that may help lower cholesterol include alfalfa (Medicago sativa ), fenugreek (Trigonella foenum-graecum ), Asian ginseng (Panax ginseng ), and tumeric (Curcuma longa ).

Antioxidants, including vitamin A (beta carotene), vitamin C, vitamin E, and selenium, can limit the oxidative damage to the walls of blood vessels that may be a precursor of atherosclerotic plaque formation.

Prognosis

The prognosis for a patient with angina depends on its origin, type, severity, and the general health of the individual. A person who has angina has the best prognosis if he or she seeks prompt medical attention and learns the pattern of his or her angina, such as what causes the attacks, what they feel like, how long episodes usually last, and whether medication relieves the attacks. If patterns of the symptoms change significantly, or if symptoms resemble those of a heart attack, medical help should be sought immediately.

Prevention

In most cases, the best prevention involves changing one's habits to avoid bringing on attacks of angina. If blood pressure medication has been prescribed, compliance is a necessity and should be a priority as well. Many healthcare professionals—including physicians, dietitians, and nurses—can provide valuable advice on proper diet, weight control, blood cholesterol levels, and blood pressure. These professionals also offer suggestions about current treatments and information to help stop smoking. In general, the majority of those with angina adjust their lives to minimize episodes of angina, by taking necessary precautions and using medications if recommended and necessary. Coronary artery disease is the underlying problem that should be addressed.

Resources

ORGANIZATIONS

National Heart, Lung and Blood Institute. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251-1222. 〈http://www.nhlbi.nih.gov〉.

OTHER

"Angina." Healthtouch Online Page. Sepember 1997. [cited May 21, 1998]. 〈http://www.healthtouch.com〉.

angina pectoris , condition characterized by chest pain that occurs when the muscles of the heart receive an insufficient supply of oxygen. This results when the arteries that supply the heart muscle with oxygenated blood are narrowed by arteriosclerosis . In rare cases angina results from spasms of the coronary arteries. Angina is a primary symptom of coronary artery disease .

The pain is usually experienced under or to the left of the sternum (breastbone) and radiates to the left shoulder and down the upper arm; less frequently, it spreads to the right shoulder. The attack usually subsides without residual discomfort and, when precipitated by physical exertion, is quickly halted when the subject rests. Often the attacks are separated by weeks, months, even years in which symptoms subside. Symptoms usually begin after the age of 50, more often in men than women, and frequently follow physical exertion, excitement, eating, smoking, or exposure to cold. Associated symptoms are faintness and difficulty in breathing.

Nitrates (e.g., amyl nitrite or nitroglycerin), drugs that dilate the blood vessels of the heart, are traditionally used in treatment. Newer drug treatments include beta-blockers and calcium-channel blockers . Significant narrowing of the coronary arteries may require surgical treatment, such as a coronary artery bypass, a procedure that splices healthy blood vessels taken from elsewhere in the body to the affected coronary arteries in such a way that the clogged areas are bypassed. In angioplasty , a balloon-tipped catheter is inserted through the skin into a blood vessel and maneuvered to the clogged artery. There it is threaded into the blockage and inflated, compressing the plaque against the arterial walls. New techniques use atherotomes to mechanically cut the plaque or cold lasers to remove plaque with bursts of ultraviolet light.

angina (an-jy-nă) n. a sense of suffocation or suffocating pain. a. pectoris pain in the centre of the chest, which is induced by exercise and relieved by rest and may spread to the jaws and arms. Angina pectoris occurs when the demand for blood by the heart exceeds the supply of the coronary arteries and it usually results from coronary artery atheroma. It may be prevented or relieved by such drugs as glyceryl trinitrate and propranolol or by surgery (see angioplasty, coronary artery bypass graft). See also Ludwig's angina.

an·gi·na / anˈjīnə/ • n. 1. (also an·gi·na pec·to·ris / ˈpektəris/ ) a condition marked by severe pain in the chest, caused by an inadequate blood supply to the heart. 2. any of a number of disorders in which there is an intense localized pain: Ludwig's angina.

angina Pain in the chest due to an insufficient blood supply to the heart, usually associated with diseased coronary arteries. Generally induced by exertion or stress, it is treated with drugs, such as glyceryl trinitrate, or surgery.

angina (angina pectoris) Paroxysmal thoracic pain and choking sensation, especially during exercise or stress, due to partial blockage of a coronary artery (blood vessel supplying the heart), as a result of atherosclerosis.

angina †quinsy XVI; short for angina pectoris XVIII. — L. angina quinsy — Gr. agkhónē strangling, with assim. to angere (see ANGUISH).

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