Angina

Overview

Angina is chest discomfort caused by reduced blood flow to the heart. The NHS says it is usually due to coronary heart disease, where fatty deposits narrow the arteries that supply the heart. It is often brought on by physical effort or stress and tends to ease within a few minutes of rest. The British Heart Foundation describes four main types: stable, unstable, vasospastic and microvascular angina. The NHS describes angina as a warning sign of a risk of serious problems such as heart attacks and strokes.

Symptoms

What a clinician may find

• A GP may check blood pressure, BMI and cholesterol when angina is suspected.
• An ECG records the heart's rhythm and electrical activity.

Complications

• Angina is a warning sign of a risk of serious problems such as heart attacks and strokes, according to the NHS.
• Unstable angina carries a higher risk of a heart attack, according to the BHF.

Diagnosis

A GP may check blood pressure, BMI and cholesterol and ask about symptoms and family history. If angina is suspected, NHS 111 Wales says the person is referred to a heart specialist (cardiologist). Hospital tests listed by the NHS include an ECG, an exercise ECG, coronary angiography and blood tests.

Treatment

The NHS describes three main approaches: medicines to relieve attacks, medicines to prevent attacks, and surgery. For stable angina, the usual approach is a medicine used during an attack, glyceryl trinitrate (GTN), with other medicines to prevent attacks and reduce heart risk. Some people need surgery, such as angioplasty with a stent or a coronary artery bypass graft.

Prevention

The BHF lists stopping smoking, staying active and keeping weight, cholesterol, blood pressure and diabetes under control as central to managing angina. The NHS says avoiding triggers such as stress, cold weather and large meals can help prevent attacks.

Key facts

What does angina feel like?

Chest pain could be angina if it feels tight, dull or heavy, spreads to the arms, neck, jaw or back, is triggered by physical effort or stress, and stops within a few minutes of rest, according to the NHS. Some people also have breathlessness, nausea or tiredness. Stable angina typically lasts five minutes or less.

Angina is often set off by physical effort or stress and tends to ease with rest or angina medicine. The NHS says avoiding triggers such as stress, cold temperatures and large meals can help prevent attacks. The BHF notes that angina is not a mini heart attack and generally does not leave lasting damage. A heart attack is different: its symptoms usually last longer and are not relieved by rest or by GTN spray.

Angina and heart attack symptoms can overlap. The BHF says angina-like symptoms that do not settle with rest or GTN could be the start of a heart attack, and the NHS advises calling 999 for an ambulance if symptoms do not stop within a few minutes.

What are the different types of angina?

The BHF describes four main types of angina. Stable angina is the most common. It is typically brought on by exertion and generally eases with rest or medicine. Unstable angina is less predictable. It can occur at rest, may not respond well to medicine, and carries a higher risk of a heart attack, according to the BHF.

Vasospastic angina, also called Prinzmetal's angina or variant angina, is caused by a coronary artery going into spasm. It usually comes on at rest, often in the early morning or at night, and people with it typically do not get angina during exercise.

Microvascular angina, also called cardiac syndrome X, affects the smallest coronary arteries and tends to appear under physical or emotional stress. The BHF notes that it can occur alongside vasospastic angina.

How is angina diagnosed?

According to the NHS, assessment starts with a GP, who asks about symptoms, lifestyle and family history. The GP measures blood pressure, calculates body mass index (BMI) from weight and height, measures waist size and takes blood to check cholesterol. NHS inform says the checks can include blood tests for diabetes or anaemia.

If a GP thinks someone may have angina, NHS 111 Wales says the person is referred to a heart specialist, called a cardiologist. Hospital tests listed by the NHS include an ECG, an exercise ECG, coronary angiography and blood tests. An ECG is a test that checks the heart's rhythm and electrical activity.

The US National Heart, Lung, and Blood Institute notes that an ECG can help recognise types of angina and other serious heart problems, but the result may be normal even in someone who has angina. It also says tests can help rule out other conditions and show whether urgent medical attention is needed.

How is angina treated?

The NHS describes three main approaches: medicines to relieve attacks, medicines to prevent attacks, and surgery. Glyceryl trinitrate, known as GTN, is the usual medicine for an attack and comes as a mouth spray or tablets that dissolve under the tongue. The NHS says GTN works by widening blood vessels.

To prevent attacks, the NHS lists beta blockers, which slow the heart and reduce the force of its contraction, and calcium channel blockers, which widen the arteries. Low-dose aspirin, statins and ACE inhibitors are used to lower the risk of heart attack and stroke. NICE guidance for stable angina recommends offering either a beta blocker or a calcium channel blocker first, and says statin treatment is offered in line with its lipid guidance.

Some people need surgery. Coronary angioplasty with stenting widens a narrowed artery using a small tube called a stent. A coronary artery bypass graft reroutes blood around a blocked section using a vessel taken from elsewhere in the body. Common GTN side effects are headache, dizziness and facial flushing, and the NHS notes that stopping regular GTN may make angina worse.

When is chest pain an emergency?

The NHS says to call 999 if chest pain does not stop after resting for a few minutes or after taking angina medicine. It also lists pain that spreads to the arm, neck, jaw or back, and chest pain with sweating, nausea, light-headedness or shortness of breath, as reasons to call 999. The NHS advises against driving oneself to A&E.

For chest pain that has not been diagnosed, the NHS advises stopping and resting, and calling 999 for an ambulance if symptoms do not stop within a few minutes. If the pain goes away within a few minutes, the NHS advises making an urgent GP appointment. Someone with chest pain on exertion that eases with rest and no diagnosis is advised to contact the GP practice.

Because angina and heart attack symptoms overlap, the NHS says that anyone who is unsure should call 999 for an ambulance.

Frequently asked questions