Angina: Symptoms, Causes, Image, Medication, Treatment

Angina is a condition where an individual feels recurrent chest pain or discomfort. It occurs when the heart muscles don't receive enough blood and oxygen. It often manifests as a squeezing or pressure-like sensation in the chest. This pain can often spread to the neck, jaw, arms, or back. 

Angina pain is a symptom of an underlying heart problem called Ischemic Heart Disease(IHD). As per the 2019 Global Burden of Disease(GBD) report, India has witnessed an average of 109 deaths per 100,000 individuals in the last 30 years due to IHD. This overwhelming number suggests the need for early treatment and detection of risk factors like angina.

Angina does not affect everyone in the same way. There are different types of angina, each with its unique characteristics:

1. Stable Angina: It is the most prevalent form. It can be observed when physical activity or emotional stress triggers temporary chest discomfort. The pain can often be relieved by rest or medication.

2. Unstable Angina: This condition is more severe and less predictable. It can occur under minimal exertion with no relief from medication or rest. It is considered a medical emergency and may indicate a heart attack.

3. Variant (Prinzmetal's) Angina: Caused by spasms in the coronary arteries it results in reduced blood flow to the heart. It often occurs at rest and can be intense. It is less common than stable or unstable angina.

4. Refractory Angina: This is characterised by recurrent episodes of angina even after taking preventive measures or angina medications.

5. Microvascular Angina: It is characterised by pain resulting from issues in the small blood vessels of the heart. It frequently affects women and may not be diagnosed through standard tests.

6. Silent Ischemia: Some individuals, especially those with diabetes, may experience reduced blood flow to the heart without typical angina symptoms. This condition is often identified through specialised testing.

Grades of Angina

Angina is typically classified into various grades or categories that describe the seriousness and frequency of its symptoms. The most commonly employed grading system for angina is the Canadian Cardiovascular Society (CCS) grading system, which consists of four grades:

1. Grade I: It is the mildest form of angina. Individuals experience it during vigorous physical activity or due to intense emotional stress. The discomfort is generally minor and brief. It resolves when physical activity is stopped.

2. Grade II: Light activities like brisk walking or climbing stairs may induce chest pain. Angina in this grade is typically manageable with rest or medication.

3. Grade III: This is more severe. Individuals may face limitations in their daily activities. Due to the frequency and intensity of the angina attacks. 

4. Grade IV: Chest pain occurs at rest or with minimal activity. The symptoms can be chronic with no response to medication or rest. It is deemed a medical emergency.

Angina is associated with a variety of symptoms, which typically encompass:

1. Chest Discomfort: It is often described as a pressing, tightness, weight, or burning sensation in the chest region. It is commonly centred behind the breastbone (sternum) but can radiate to the arms, neck, jaw, shoulders, or back.

2. Breathlessness: Angina may lead to shortness of breath, especially during physical activity or when the heart is under stress.

3. Tiredness: Individuals with angina may experience unusual fatigue or weakness, which may be exacerbated during angina pain.

4. Nausea: Some people with angina may feel uneasy or may experience vomiting.

5. Dizziness: Angina can result in a feeling of light-headedness, particularly if it is causing a drop in blood pressure.

6. Perspiration: Excessive sweating, often described as cold, clammy sweat, can be indicative of angina.

7. Apprehension: Feelings of anxiety or a sense of impending trouble are not uncommon during episodes of angina attack.

Angina is attributed to various biological factors, primarily related to the cardiovascular system. These underlying causes encompass:

1. Atherosclerosis: This condition involves the accumulation of fat within the inner walls of the coronary arteries. The heart muscle receives blood through these arteries. Over time, these deposits can narrow the arteries, diminishing blood flow and oxygen delivery to the heart, thus giving rise to angina symptoms.

2. Coronary Artery Spasms: Some individuals encounter angina due to spasms in the coronary arteries (Prinzmetal's angina). These can transiently constrict the blood vessels, impeding blood flow to the heart muscle and causing angina symptoms.

3. Coronary Microvascular Disease: In certain instances, angina arises from issues affecting the tiny blood vessels, or microvasculature, within the heart. This impairs the dilating ability of the vessels. Thus reducing the blood flow to the heart muscle, resulting in chest pain.

4. Reduced Oxygen Delivery: Any factor that diminishes the cardiac oxygen supply can result in angina. This includes conditions like anaemia, which reduces the oxygen transmission through blood, and ailments affecting the heart's pumping efficiency, such as heart failure.

5. Emotional Stress: This can trigger the release of stress hormones, which have the potential to constrict blood vessels. This may potentially induce angina in individuals with underlying coronary artery disease.

6. Physical Exertion: Vigorous exercise can elevate the heart's demand for oxygen. In cases where coronary arteries are narrowed, this heightened demand may exceed the reduced supply, provoking angina.

Angina Risk Factors

Angina is influenced by various risk factors. They can be categorised into two groups: modifiable and non-modifiable.

Modifiable Risk Factors

These are the risk factors that can be controlled by an individual. These are listed below:

1. Obesity: Being overweight accompanies several risk factors(high cholesterol, diabetes and high blood pressure) that put a strain on the heart. It increases the chance of heart disease, which may lead to angina.

2. Medications: Some drugs that narrow blood vessels, like certain migraine medications, may trigger angina.

3. Lack of Exercise: A sedentary lifestyle can increase cholesterol levels, blood pressure and diabetes. This, in turn, can increase the chances of experiencing angina pain.

4. Tobacco Use: Smoking, chewing tobacco, and extended secondhand smoke exposure can injure arterial linings by increasing cholesterol deposits that reduce blood flow.

5. Drug Misuse: Stimulants like cocaine may cause blood vessel spasms, possibly causing angina.

Non-Modifiable Risk Factors

Non-modifiable angina risk factors include those which cannot be kept in check by an individual. These include:

1. Diabetes: High blood glucose levels can damage the blood vessels, which can give rise to angina attacks.

2. High Blood Pressure: High blood pressure can damage the arteries which carry blood from the body to the heart. This can lead to pain or discomfort in the chest.

3. Increasing Age: The incidence of angina is usually seen in older people but it can occur at any age. Men are typically at a higher risk of angina up to 45 years of age. However, the risk in women increases after menopause (after 55 years).

4. Family History: Genetic inheritance of heart disease or heart attacks increases the risk of angina.

Several strategies help in the prevention of angina and help maintain good heart health(28). Below are some important points to keep in mind:

1. Balanced Diet: Maintaining a heart-healthy eating plan rich in fruits, veggies, whole grains, lean proteins, and low-fat dairy can help prevent angina. This reduces bad cholesterol levels which is a risk factor for angina.

2. Regular Physical Activity: Consistent exercises like brisk walks, jogging, or swimming enhance cardiovascular health, trim weight, and avoid the risk of angina.

3. Avoid Smoking: Quitting smoking is paramount since it's a key heart disease risk, including angina. Smoking damages the blood vessels leading to increased angina risk.

4. Weight Control: Keep a healthy weight through a mix of balanced eating and routine exercise. It makes it easier for the heart to supply blood.

5. Blood Pressure Management: Tracking and managing blood pressure reduces the pressure on coronary arteries. This prevents an angina attack.

6. Reducing Cholesterol Levels: Keeping cholesterol levels in check with medicines and diet modifications is vital to thwart artery plaque buildup.

7. Diabetes: Managing high blood sugar via medicines, diet, and monitoring safeguards against heart issues, including angina. It causes inflammatory damage to blood vessels leading to angina.

8. Restrict Alcohol: Limiting its consumption can fend off heart-related problems. Excessive alcohol intake can cause irregular heartbeats, leading to a reduced blood supply, and eventually an angina attack.

9. Stress Control: Integrating mindfulness techniques like meditation, deep breathing, or yoga reduces emotional and physical stress and may prevent angina.

10. Adequate Rest: Establishing a steady sleep schedule with 7-9 hours of quality rest each night promotes overall heart health, reducing angina risk.

11. Regular Health Check-Ups: Scheduled healthcare follow-ups are vital for tracking overall heart health and incorporating preventive tactics.

Several diagnostic angina tests are utilised to evaluate and confirm the development of the condition in individuals. These procedures assist doctors in establishing precise diagnoses and formulating suitable treatment plans. Common diagnostic methods encompass:

1. Physical Examination: Before recommending any tests, doctors always check the physical fitness and medical history of the patients. They evaluate the severity of the condition and the various angina risk factors associated.

2. Blood Tests: It examines cardiac biomarkers, such as troponin and creatine kinase-MB (CK-MB). Elevated levels can signify heart muscle damage, which may occur during angina attacks.

3. Electrocardiogram (ECG or EKG): This records the cardiac electrical activity and detects irregular rhythms (arrhythmias). Identifying changes in the electrical patterns may detect underlying coronary artery disease (CAD) or myocardial ischemia, both potential causes of angina.

4. Exercise Stress Test: Also referred to as a treadmill test, this evaluates the heart's response to physical exertion. Patients engage in treadmill exercise while connected to an ECG machine. Alterations in the ECG pattern during exercise can signify reduced blood flow to the heart, aiding in angina diagnosis.

5. Nuclear Stress Test: This test involves injecting a trace amount of radioactive substance into the bloodstream. Special cameras capture images of the heart at rest and during stress (induced by exercise or medication). It offers insights into heart muscle perfusion and identifies areas with compromised blood flow.

6. Echocardiogram: Employing sound waves (ultrasound), this imaging procedure generates heart structure and function images. It can detect structural heart issues and assess cardiac pumping capabilities.

7. Coronary Angiography: An invasive method entails injecting contrast dye into coronary arteries while taking X-ray images. It delivers a comprehensive view of coronary artery blockages or narrowings, facilitating angina diagnosis and guiding potential interventions like angioplasty or stent placement.

8. Computed Tomography Angiography (CTA): It blends X-ray technology with computer processing to create detailed coronary artery images. It serves as a non-invasive alternative for evaluating the type of angina.

9. Magnetic Resonance Imaging (MRI): Offers comprehensive data about heart structure and function. Helping in the assessment of cardiac anatomy and identification of regions with restricted blood flow.

10. Holter Monitor: This portable device records heart electrical activity over an extended period, typically 24 to 48 hours. It captures irregular heart rhythms contributing to angina symptoms.

How to Prepare for the Doctor's Consultation?

In preparation for a doctor's consultation when faced with angina, patients should take the following steps:

1. Compile their medical history, medications, allergies, and lifestyle changes.

2. Keep a diary of angina symptoms, potential triggers, duration, and patterns.

3. Understand their risk factors, including smoking, family history, and underlying conditions.

4. Bring relevant medical records and test results.

5. Write down questions about their condition, treatment, and lifestyle changes. Here are some questions patients can ask :  

   1. What is the meaning of angina, and what causes it?

   2. What are the types of angina?

   3. What are the typical angina pain symptoms?

   4. How can I differentiate angina pain from a heart attack?

   5. What are the options for angina treatment? 

   6. Can I manage angina through lifestyle and dietary changes?

   7. Are there specific dietary restrictions I should follow?

Doctors have a range of treatment options to help control angina attacks and improve heart health. The main goal is to reduce the intensity of the pain and lower the risk of a heart attack. Listed below are some of the common procedures used.

Non Surgical Treatments

Angina can often be managed by employing various techniques without the need for medication or surgical treatment. These include:

1. Lifestyle Changes: Adopting a heart-healthy lifestyle is crucial. This includes a balanced diet, regular exercise, staying away from smoking and alcohol consumption, and stress management to reduce risk factors and improve overall heart health.

2. Home Remedies: Lie down in a comfortable position and stop any physical activity. This can help reduce the cardiac workload and relieve angina pain. Take slow and deep breaths.

3. Cardiac Rehabilitation: A structured program involving light exercise, education, and support helps individuals manage different types of angina.

4. Enhanced External Counterpulsation (EECP): EECP is a non-invasive procedure that involves wearing cuffs on the legs. It inflates and deflates, improving blood flow to the heart.

5. Ayurvedic Treatment: Traditional medicine has been used for a long time to address angina. These include the following:

1. Arjuna: This herb is widely used in Ayurveda to support heart health by strengthening the heart muscle and enhancing overall cardiovascular function.

2. Garlic: It is known for its potential to lower blood pressure and reduce cholesterol levels, potentially aiding in angina management.

3. Hawthorn: In Ayurveda, it is employed to enhance blood flow to the heart and reduce angina symptoms.

4. Yoga and Pranayama: Asanas(Yoga postures) and pranayama (breathing exercises) reduce stress, enhance circulation, and promote cardiovascular health. Regular practice may aid in angina management by fostering relaxation and symptom reduction.

5. Ayurvedic massage (Abhyanga): It is a therapeutic massage form in Ayurveda and is believed to enhance circulation and relaxation. It may promote overall cardiovascular health and relaxation.

6. Medication: Angina medications are commonly prescribed when lifestyle changes cannot provide the relief needed(37)(38). However, remember that these should only be taken after consulting a doctor. They include:

1. Nitrates: These relax and widen blood vessels, allowing more blood to reach the heart. Some people take it before activities that usually trigger angina, like exercise.

2. Aspirin: Aspirin lowers the risk of angina by facilitating blood flow through constrictive heart arteries and preventing blood clots.

3. Clot-preventing drugs: These medications prevent blood platelets from sticking together and causing clots. They might be used if aspirin isn't suitable.

4. Beta-blockers: These slow down the heart rate and reduce its force, lowering blood pressure and relaxing blood vessels for better blood flow.

5. Statins: Statins reduce blood cholesterol levels, which aids in the prevention of blood vessel blockages. Angina is made worse by high cholesterol.

Surgical Procedures

When lifestyle changes, medicines and other conservative treatments aren't enough, a person might need surgery or procedures for angina treatment. Here are the main options:

1. PCI (Percutaneous Coronary Intervention): Also known as coronary angioplasty, it is a procedure that opens narrowed or clogged blood arteries supplying blood to the heart. A catheter is used to reach the afflicted area, and a stent may be implanted to keep the artery open.

2. Transmyocardial Laser Revascularization (TMR): This surgical procedure uses lasers to create channels in the heart muscle. It improves blood flow in areas with severe angina.

3. Coronary Endarterectomy: It is a surgical procedure to remove plaque buildup from the inner lining of coronary arteries. It is used in cases of advanced coronary artery disease.

4. Coronary Artery Bypass Grafting: When other treatments fail, this surgery may be suggested. It bypasses blocked coronary arteries with grafts, typically from other blood vessels, to restore blood flow to the heart muscle.

Note that the treatment approach and selection of procedures are dependent upon the patient’s health condition and the opinion of the treating doctor.

Cost of Angina Treatment

The cost of angina treatment may vary depending on factors such as location, the extent of damage to the heart, and the treatment chosen.

If angina is not addressed, it can lead to a range of complications and significant health risks:

1. Irregular Heartbeats (Arrhythmias): Angina can provoke abnormal heart rhythms, ranging from mild palpitations to severe and life-threatening irregularities. These can cause dizziness, fainting, and, in severe instances, sudden cardiac arrest.

2. Diminished Quality of Life: Recurrent angina symptoms can profoundly affect an individual's daily life and general well-being. The discomfort and limitations can restrict physical activity, reduce endurance, and increase anxiety and depression.

3. Progression of Coronary Artery Disease (CAD): Persistent chest pain typically indicates underlying chronic and progressive cardiac condition. It can lead to more extensive arterial blockages. And higher risk of severe complications like heart attacks and strokes.

4. Stroke: Neglected angina can elevate the risk of blood clot formation in the coronary arteries. These clots might travel to the brain, resulting in a stroke. This can cause various neurological impairments and, in extreme cases, prove fatal.

5. Heart Attack (Myocardial Infarction): It is a severe risk associated with untreated angina for a prolonged period. It is a condition when a coronary artery is fully blocked, cutting off blood flow to the heart muscle. This can cause lasting damage to the heart and, in severe cases, may prove fatal.

6. Heart Failure: This condition occurs when the heart cannot efficiently pump blood, leading to fluid accumulation in the lungs and other body parts. Symptoms may include shortness of breath, fatigue, and swelling in the legs and ankles.

7. Sudden Cardiac Death: In certain instances, untreated angina can escalate to a sudden cardiac event, such as ventricular fibrillation. This can be a life-threatening condition.

When to Consult a Doctor for Angina?

People suffering from angina should reach out to a doctor promptly if they:

1. Experience intense chest pain (more than 5 minutes).

2. Feel the pain spread to the jaw, neck, arms, back, or abdomen.

3. Difficulty in breathing, feeling dizzy, or faint.

4. Chest pain while at rest or with minimal physical effort.

5. Have a history of heart disease, diabetes, or other risk factors.

A low-fat diet can play a crucial role in managing angina. Patients should focus on a diet that supports the prevention and recovery after treatment. Given below is a sample diet plan that focuses on heart-healthy foods and portion control:

Breakfast 

1. 1 serving of oatmeal made with skim milk or water, topped with fresh fruits of your choice and a sprinkle of chopped nuts (like almonds or walnuts).

2. 1 small cup of green tea (unsweetened).

Mid-Morning Snack

A small bowl of mixed fruits, such as papaya, watermelon, or apple slices.

Lunch

1. 1 serving of brown rice or whole wheat roti (Indian bread).

2. 1 serving of dal (lentil soup) made with minimal oil and spices.

3. A side of mixed vegetables (sabzi) lightly sautéed in olive oil.

4. A small serving of low-fat yoghurt or raita made with cucumber and mint.

Afternoon Snack

1. A handful of unsalted, mixed nuts.

2. A glass of buttermilk (chaas) made with low-fat yoghurt and a pinch of cumin.

Evening Snack

A small serving of vegetable soup or a vegetable salad.

Dinner

1. Grilled or baked fish or skinless chicken breast.

2. A small portion of whole wheat pasta. Steamed broccoli or spinach as a side dish.

General Instructions

1. Drink 2-3 litres of water regularly to stay hydrated.

2. Limit or avoid sugary beverages and excessive caffeine.

3. The patient should avoid overeating.

4. Use minimal oil, and prefer heart-healthy oils like mustard oil, olive oil or coconut oil.

5. Limit salt intake and use herbs and spices for flavour.

6. Avoid fried, processed, and high-sugar foods.

7. Consult a registered dietitian or nutritionist for personalised guidance. Adjust the diet plan as per recommendations for addressing your health requirements.

Angina is a severe cardiac condition requiring accurate diagnosis and expert medical care. It presents in various forms, causing chest discomfort and radiating sensations. Early detection, lifestyle adjustments, and appropriate medical intervention reduce the risk of severe outcomes.

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