Stable angina

Causes

Your heart muscle is working all the time, so it needs a constant supply of oxygen. This oxygen is provided by the coronary arteries, which carry blood.

When the heart muscle has to work harder, it needs more oxygen. Symptoms of angina occur when the coronary arteries are narrowed or blocked by hardening of the arteries (atherosclerosis), or by a blood clot.

The most common cause of angina is coronary heart disease (CHD). Angina pectoris is the medical term for this type of chest pain.

Stable angina is less serious than unstable angina, but it can be very painful or uncomfortable.

The risk factors for coronary heart disease include:

• Diabetes
• Family history of coronary heart disease before age 50
• High blood pressure
• High LDL cholesterol and low HDL cholesterol
• Male gender
• Not getting enough exercise
• Obesity
• Smoking

Anything that makes the heart muscle need more oxygen can cause an angina attack in someone with heart disease, including:

• Cold weather
• Exercise
• Emotional stress
• Large meals

Other causes of angina include:

• Abnormal heart rhythms (usually ones that cause your heart to beat quickly)
• Anemia
• Coronary artery spasm (also called Prinzmetal's angina)
• Heart failure
• Heart valve disease
• Hyperthyroidism

Symptoms

Symptoms of stable angina are often predictable. This means that the same amount of exercise or activity may cause your angina to occur. Your angina should improve or go away when you stop or slow down the exercise.

The most common symptom is chest pain that occurs behind the breastbone or slightly to the left of it. The pain of stable angina usually begins slowly and gets worse over the next few minutes before going away.

The pain may feel like tightness, heavy pressure, squeezing, or crushing pain. It may spread to the:

• Arm (usually the left)
• Back
• Jaw
• Neck
• Shoulder

Some people say the pain feels like gas or indigestion.

Some patients (women, older adults, and people with diabetes) may have different symptoms, such as:

• Back, arm, or neck pain
• Fatigue
• Shortness of breath
• Weakness

The pain of stable angina usually:

• Occurs after activity or stress
• Lasts an average of 1 - 15 minutes
• Is relieved with rest or a medicine called nitroglycerin

Angina attacks can occur at any time during the day, but a higher number occur between 6 a.m. and noon.

Other symptoms of angina include:

• A feeling of indigestion or heartburn
• Dizziness or light-headedness
• Nausea, vomiting, and sweating
• Palpitations
• Shortness of breath
• Unexplained tiredness after activity (more common in women)

Exams and Tests

Your health care provider will do a physical exam and measure your blood pressure. Tests that may be done to diagnose or rule out angina include:

• Coronary angiography
• Coronary risk profile (special blood tests)
• ECG
• Exercise tolerance test (stress test or treadmill test)
• Nuclear medicine (thallium) stress test
• Stress echocardiogram

Treatment

The options for treating angina include lifestyle changes, medications, and procedures such as coronary angioplasty or stent placement and coronary artery bypass surgery.

You and your doctor should agree on a plan for treating your angina on a daily basis. This should include:

• What medicines you should be taking to prevent angina
• What activities are okay for you to do, and which ones are not
• What medicines you should take when you have angina
• What are the signs that your angina is getting worse
• When you should call the doctor or 911

MEDICATIONS

You may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your doctor's directions closely to help prevent your angina from getting worse.

Nitroglycerin pills or spray may be used to stop chest pain.

Taking aspirin and clopidogrel (Plavix) or prasugrel (Effient) helps prevent blood clots from forming in your arteries, and reduces your risk of having a heart attack. Ask your doctor whether you should be taking these medications.

Your doctor may give you one or more medicines to help prevent you from having angina.

• ACE inhibitors to lower blood pressure and protect your heart
• Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart
• Nitrates to help prevent angina
• Ranolazine (Ranexa) to treat chronic angina

NEVER STOP TAKING ANY OF THESE DRUGS ON YOUR OWN. Always talk to your doctor first. Stopping these drugs suddenly can make your angina worse or cause a heart attack. This is especially true of anti-clotting drugs (aspirin, clopidogrel, and prasugrel).

Your doctor may recommend a cardiac rehabilitation program to help improve your heart's fitness.

SURGICAL TREATMENT

Some people will be treated with medicines and will not need surgery to treat a blockage or narrowing. Others will need a procedure to open narrowed or blocked blood vessels that supply blood to the heart.

• Angioplasty and stent placement (also called percutaneous coronary intervention)
• Blockages that cannot be treated with angioplasty may need a heart bypass

Outlook (Prognosis)

Stable angina usually improves with medication.

Possible Complications

• Heart attack
• Sudden death caused by abnormal heart rhythms (arrhythmias)
• Unstable angina

When to Contact a Medical Professional

Seek medical attention if you have new, unexplained chest pain or pressure. If you have had angina before, call your doctor.

Call 911 if your angina pain:

• Is not better 5 minutes after you take nitroglycerin
• Does not go away after three doses of nitroglycerin
• Is getting worse
• Returns after the nitroglycerin helped at first

Call your doctor if:

• You are having angina symptoms more often
• You are having angina when you are sitting (rest angina)
• You are feeling tired more often
• You are feeling faint or light-headed
• Your heart is beating very slowly (less than 60 beats a minute) or very fast (more than 120 beats a minute), or it is not steady
• You are having trouble taking your heart medicines
• You have any other unusual symptoms

Seek medical help right away if a person with angina loses consciousness.

Prevention

Your doctor may tell you to take nitroglycerin a few minutes in advance if you plan to perform an activity that may trigger the pain of angina.

The best way to prevent angina is to lower your risk for coronary heart disease:

• Avoid or reduce stress as much as you can.
• Control your blood pressure, diabetes, and cholesterol.
• Eat well-balanced meals that are low in fat and cholesterol and include several daily servings of fruits and vegetables.
• Get regular exercise. If your weight is normal, get at least 30 minutes of exercise every day. However, talk to your doctor before starting exercise or increasing your activity level.
• Lose weight if you are overweight.
• Stop smoking

Moderate amounts of alcohol (one glass a day for women, two for men) may reduce your risk of heart problems. However, drinking larger amounts does more harm than good.

Reducing your heart disease risk factors may prevent the blockages from getting worse and can make them less severe, which reduces angina pain.

New guidelines no longer recommend hormone replacement therapy, vitamins E or C, antioxidants, or folic acid to prevent heart disease. The use of hormone replacement therapy in women who are close to menopause or who have finished menopause is controversial at this time.

Alternative Names

Angina - stable; Angina - chronic; Angina pectoris

References

Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007;116:2762-2772.

Morrow DA, Boden WE. Stable ischemic heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 57.

Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):776S-814S.

Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961-972. Epub 2009 Feb 18.

Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women -- 2011 update: A guideline from the American Heart Association. J Am Coll Cardiol. 2011; 57:1404-1423.

Update Date: 5/23/2011

Updated by: Michael A. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.