Angina refers to chest pain or discomfort when there is an inadequate supply of oxygenated blood to the heart muscle. This inadequacy is frequently experienced during times of increased demand for oxygen, such as exercise or stress.

Types:

• Stable angina – is predictable chest pain or discomfort during exercise or periods of stress and is minimal or non – existent at rest.
• Unstable angina – Chest pain occurs unpredictably at rest or with minimal exertion and worsens or becomes more frequent with time.
• Variant angina (Prinzmetal’s angina) – Rare painful attacks are experienced while resting, usually between midnight and early morning.
• Microvascular angina (Cardiac syndrome X) – Chest pain occurs for more than 10 minutes and is observed during routine daily activity or stress.

Causes:

• It occurs when the heart does not get an adequate supply of oxygenated blood. 
• This is usually associated with narrowing of the coronary arteries due to plaque buildup. These plaques clog the arteries and reduce the blood flow to the heart. 
• Damage to the tiny arteries, as seen in coronary artery disease and coronary microvascular disease, also contributes to angina.
• Spasms of the coronary arteries are another causative factor of angina.

Angina: Risk factors

• Age – Men above 45 years of age and women over 55 years of age are at a higher risk.
• Obesity – Unhealthy eating habits and people with a BMI greater than 30 kg/m2 are at a higher risk. 
• Occupational reasons – Working in construction sites, mines, working in a highly stressful environment, or being continuously exposed to radiation increases the risk of developing angina.
• Genetics – Family history of early heart disease or premature cardiovascular disease increases the likelihood of getting angina.
• Unhealthy lifestyle habits – Smoking, lack of sleep, drinking alcohol, physical inactivity, drug abuse, excessive stress, and chronic exposure to secondhand smoke are other risk factors.
• Other medical conditions – Cardiomyopathy, high blood pressure, metabolic syndrome, and heart valve disease-raise the risk in patients.
• Medical procedures – Coronary artery bypass grafting or stent placement may trigger angina in some cases.
• Ethnicity – African Americans are more prone to getting angina as compared to Whites. 

Signs and symptoms:

• Pressure, burning, or tightness in the chest
• Chest pain or discomfort
• Epigastric pain
• Pain radiating to the left shoulder, arm, back, or jaw
• Shortness of breath
• Sweating
• Fainting
• Pain during regular daily activity

Complications:

Other life-threatening complications that are more likely to occur due to angina include:

• Heart attack
• Arrhythmia
• Cardiomyopathy
• Sudden cardiac arrest

Diagnosis of Angina

• Medical history – The physician assesses signs and symptoms, family history, and other risk factors.
• Physical examination – Blood pressure, heart rate, and other vitals are examined.
• Diagnostic tests – The tests performed to diagnose angina are:
  • Blood tests – Blood levels of myoglobin, BNP (Brain natriuretic peptide), fats, glucose, cholesterol, sugar, and proteins are checked.
  • High–sensitivity cardiac troponin test – Blood levels of the cardiac biomarker troponin T are detected to diagnose heart damage and heart attacks more quickly.
  • Coronary angiography with cardiac catheterization – Blood flow and pressure in the heart are evaluated and examined for the presence of plaque buildup.
  • Hyperventilation testing – Rapid breathing under controlled conditions with medical monitoring done to assess changes in the ECG. This is used for the diagnosis of variant angina.
  • Provocation tests – Coronary arteries are checked to see if they spasm on the administration of acetylcholine. Coronary angiography is done for this purpose.
  • Exercise stress test – Functioning of the heart during exercise is tested. It helps to diagnose variant angina when done in the early morning.
  • Coronary calcium scan – The presence of calcium in the coronary vessels is detected as it is an indicator of plaque development.
  • Radionuclide imaging – Blood flow and narrowing of the blood vessels are visualized using a radioactive compound. 
  • Chest x-ray
  • Echocardiogram
  • Electrocardiogram (ECG)
  • Computed tomography angiography 
  • Magnetic resonance imaging (MRI)

Treatment of Angina

 The primary rationale behind treatment involves preventing or controlling angina episodes and providing relief of symptoms. It is also done to slow down the progression of the underlying heart diseases and reduce the risk factors in patients.

• Cardiac procedures – 
  • Angioplasty or Percutaneous coronary interventions – Cardiac catheterization is done to open narrowed or blocked blood vessels to increase blood flow and decrease chest pain.
  • Coronary artery bypass grafting – Rerouting of blood around the clogged region is done to restore blood supply to the heart muscle.
  • Stent placement – Stents are kept to prevent coronary narrowing, thus helping relieve chest pain and improve blood flow.
  • Transmyocardial revascularization – Small holes are made directly into the heart muscle to relieve severe angina in very ill patients who cannot undergo angioplasty.
• Medicines – Drugs that are frequently prescribed belong to the following classes:
  • Anticoagulants – Heparin, warfarin, etc., to prevent the formation of harmful clots in the blood vessels.
  • Antiplatelet drugs – Aspirin, clopidogrel, etc. to prevent clot formation in unstable angina.
  • Beta-blockers – Metoprolol, nadolol, etc., to relieve angina.
  • Calcium channel blockers – Verapamil, amlodipine, etc., to treat angina caused by the reduced blood supply to the heart muscle.
  • Statins – Atorvastatin, lovastatin, etc., to relieve blood vessel spams and lower the risk of a heart attack.
  • Vasodilators – Nitrates, including nitroglycerin, are used to relax and widen blood vessels and reduce cardiac workload.

Prevention:

• Living with angina –
  • Eating a heart-healthy diet
  • Managing stress
  • Quitting smoking
  • Increasing physical activity
  • Managing a healthy weight
  • Regular health checkup and follow – up care
• Preventing angina –
  • Keeping an account of the triggers of angina 
  • Reducing and managing stress
  • Avoiding exposure to extremes of temperature
  • Avoiding alcohol

When to see a doctor? :

Consult with a cardiologist immediately if a crushing sensation or stabbing chest pain is experienced for more than a few minutes and if it doesn’t disappear with rest or medications. The cost of angioplasty ranges from Rs. 1 to 3 lakhs. 

References:

• [1] – https://labtestsonline.org
• [2] – wikipedia
• [3] – https://www.nhlbi.nih.gov
• [4] – https://www.heart.org
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