Angina Pectoris: Symptoms, Causes & Treatment

Angina pectoris is a common medical condition that occurs when the heart muscle does not receive enough oxygen and blood supply. It results from narrowing of the coronary arteries (arteries that supply the heart) due to accumulation of fatty deposits and atherosclerosis. Unlike a heart attack, angina does not cause permanent damage to heart cells and is usually a temporary condition that resolves with rest within minutes or with prescribed medications.

Angina affects millions of people worldwide and serves as an important warning sign of coronary heart disease. In the Middle East and Jordan specifically, heart diseases have become leading causes of mortality and disability. The severity of symptoms varies from person to person: it may be mild and resemble indigestion, or very severe. Doctors classify angina pectoris into two main types: stable angina (which occurs regularly during exertion) and unstable angina (which may occur without apparent cause or even during rest).

Early diagnosis and appropriate treatment are essential to prevent progression to a heart attack. The good news is that angina is manageable and controllable through medications and lifestyle changes, allowing most patients to live normal lives.

Symptoms of angina pectoris are multiple and vary depending on disease severity and patient condition. Symptoms typically appear during physical exertion or psychological stress in stable angina, while they may occur without apparent cause in unstable angina. Symptoms may differ between men and women; women sometimes report atypical symptoms such as severe fatigue or shortness of breath without clear chest pain. Gender and age differences are important: women may experience more subtle symptoms, and elderly patients may present with fatigue rather than classic chest pain.

• Chest pain or pressure: Main symptoms, may be sharp or mild, lasting 2 to 15 minutes.
• Pain radiating to the left arm: May also spread to the neck, jaw, and shoulder.
• Shortness of breath: Sensation of difficulty breathing or breathlessness accompanying chest pain.
• Nausea and vomiting: May accompany the episode, especially in elderly men.
• Dizziness and vertigo: Feeling of imbalance or impending fainting.
• Cold sweating: Abnormal sweating despite no exertion.
• Severe fatigue: Unusual tiredness that may precede an episode by hours.
• Indigestion or upper abdominal pain: Symptoms may resemble gastrointestinal problems.
• Anxiety or depression: Severe fear may accompany pain.

• Coronary artery atherosclerosis: Accumulation of fatty deposits (plaque) on the walls of arteries supplying the heart, narrowing them and reducing blood flow.
• Coronary artery vasospasm: Sudden involuntary contraction of heart arteries that reduces blood flow, even if the arteries are not permanently narrowed.
• Small blood clots: Formation of clots in coronary arteries that may partially block blood flow to the heart.
• Inflammation of blood vessels: Inflammation of coronary artery walls may narrow them or reduce their elasticity.
• Severe anemia: Reduction in red blood cells decreases the amount of oxygen delivered to the heart.
• Chronic high blood pressure: Increases pressure on coronary arteries and accelerates atherosclerosis.
• Thyroid disorders: Hyperthyroidism increases the heart's oxygen demand.
• Severe fatigue and psychological stress: Increases heart rate and puts pressure on the heart, which may cause angina.

• Advanced age: Risk increases after age 40 for men and 50 for women.
• Male gender: Men are more susceptible to angina than women at younger ages.
• Family history: Family history of heart disease increases risk.
• Smoking: Accelerates atherosclerosis and increases narrowing likelihood.
• High cholesterol: High levels of harmful LDL cholesterol contribute to plaque buildup.
• High blood pressure: Damages artery walls and accelerates disease progression.
• Diabetes: Increases risk of atherosclerosis and angina.
• Obesity and sedentary lifestyle: Increase strain on the heart and worsen other risk factors.
• Chronic psychological stress: Persistently raises blood pressure and heart rate.
• Excessive alcohol consumption: May increase blood pressure and affect heart health.

Angina diagnosis is made through a combination of medical examinations and tests that confirm the disease and assess its severity. The doctor begins by taking a complete medical history and performing a clinical examination, then proceeds to specialized tests. Early and accurate diagnosis is crucial to prevent progression to a heart attack.

• Electrocardiogram (ECG): Records the heart's electrical activity and can detect changes indicating angina. Normal values are regular waves at a rate of 60 to 100 beats per minute.
• Stress Test: ECG is performed during gradual physical exertion to see how the heart responds. It is considered positive if ECG changes or symptoms occur.
• Echocardiography (Ultrasound of the heart): Uses sound waves to visualize heart muscle movement, valves, and assess function.
• Cardiac Catheterization: Procedure in which a thin tube is inserted into arteries to directly visualize blood flow and degree of narrowing. It is the gold standard for diagnosis.
• Blood tests: Measurement of cholesterol levels (should be less than 200 mg/dL), triglycerides, and cardiac enzymes (troponin and CPK) to differentiate angina from heart attack.
• MRI or CT imaging: Advanced imaging providing detailed pictures of the heart and coronary arteries.
• Blood pressure measurement: Normal blood pressure should be less than 120/80 mmHg.

Medications

• Nitrates: Medications that dilate blood vessels and improve blood flow to the heart. Used when episodes occur or for prevention. Example: Nitroglycerin under the tongue (provides immediate relief in minutes).
• Beta-blockers: Reduce heart rate and workload, decreasing oxygen demand. Taken regularly daily.
• Calcium channel blockers: Dilate blood vessels and reduce heart rate. Examples: Nifedipine and Verapamil.
• ACE Inhibitors: Lower blood pressure and reduce cardiac workload, especially beneficial for diabetic patients or heart failure.
• Aspirin: Blood thinner reducing clot formation risk. Taken daily in low doses.
• Statins: Lower cholesterol levels and reduce atherosclerosis progression. Examples: Simvastatin and Atorvastatin.
• Anti-inflammatory medications: In rare cases where inflammation is the primary cause.

Procedures and Surgery

• Angioplasty: Procedure where a balloon-tipped catheter is inserted to widen the narrowed artery. A metal stent is placed to keep the artery open. Used for moderate to severe cases.
• Coronary Artery Bypass Grafting (CABG): Surgical procedure using a blood vessel from another body part to bypass the blocked artery. Used when multiple arteries are severely blocked.
• Shock Wave Therapy: Relatively modern technique stimulating formation of new blood vessels around the blocked area.

Lifestyle Changes

• Quit smoking: One of the most important steps to improve cardiovascular health.
• Regular exercise: Light to moderate exercises (brisk walking, swimming) for 150 minutes weekly, under medical supervision.
• Healthy diet: Low in salt and saturated fats, rich in fruits, vegetables, and fiber. Reduce cholesterol intake.
• Weight management: Reducing excess weight decreases cardiac strain.
• Stress management: Relaxation techniques, mindfulness, and psychological therapy if needed.
• Limit alcohol consumption: Avoid excessive alcohol.
• Adequate sleep: 7-9 hours daily improves heart health.
• Monitor blood pressure and diabetes: Adhere to medications and regular checkups.

• Heart Attack: One of the most serious complications. Occurs when blood flow is completely cut off from part of the heart, causing cell death. Can be fatal without immediate intervention.
• Arrhythmias (Heart rhythm disorders): May result from continuous cardiac stress and cause fast, slow, or irregular heartbeats, potentially leading to fainting or shock.
• Heart Failure: If angina continues untreated for extended periods, heart muscle may gradually weaken and cannot pump blood efficiently.
• Blood clots (Thrombosis): Clots form in arteries and may completely block blood flow, potentially causing stroke or severe chest pain.
• Left ventricular dysfunction: The most important part of the heart may gradually weaken, affecting its pumping ability.
• Fainting and severe dizziness: Sudden loss of consciousness may occur during severe angina episodes.
• Depression and anxiety: Angina diagnosis may psychologically affect the patient and increase chronic fear and anxiety.

• Quit smoking: Smoking is one of the strongest risk factors. Quitting significantly improves artery health within weeks.
• Eat a healthy balanced diet: Choose foods rich in fiber, fruits, and vegetables. Reduce saturated fats, salt, and simple sugars.
• Exercise regularly: Do moderate exercises like brisk walking or swimming for 150 minutes weekly.
• Maintain a healthy weight: Keep your Body Mass Index (BMI) between 18.5 and 24.9.
• Control blood pressure: Monitor blood pressure regularly and take prescribed medications. Target is below 120/80 mmHg.
• Manage cholesterol levels: Check cholesterol regularly and follow your doctor's advice, especially with family history.
• Control diabetes: If diabetic, keep blood sugar levels within normal ranges.
• Reduce psychological stress: Practice relaxation techniques like yoga, meditation, or psychological therapy.
• Limit alcohol consumption: If drinking, reduce to safe levels (no more than one drink daily for women and two for men).
• Regular medical checkups: See your doctor regularly for routine exams, especially if you have risk factors.