Angina (pronounced “AN-gin-a”; or “an-GY-nuh”) is chest pain that’s due to Coronary Artery Disease (CAD), when “plaque” (mixture of clots, fats, white blood cells, and more) builds up over the years in the coronary arteries, which supply blood to the heart muscle so it can pump (see Diagram — Heart Anatomy). When not enough blood circulates, it causes chest pain called Angina (not enough blood circulating in whatever part of the body is called “ischemia“). If part of the coronary artery blood circulation gets completely cut off, it causes Heart Attack.
Angina is just uncomfortable, but it’s a warning sign for a future full-blown heart attack. If we diagnose coronary artery disease in time, treatment can be life-saving.
We suspect Angina by a combination of symptoms and risks:
1. Symptoms of Angina
- Heavy chest pain (or pressure, ache, discomfort, etc.), not “sharp,” and not one that gets worse with each breath. It’s felt in mid- or left-chest, rarely on the right, maybe in left shoulder, upper arm, or jaw.
- Pain gets worse with exertion, eases with rest.
- May be accompanied by shortness of breath, nausea or vomiting, cold sweats on forehead, or lightheadedness
- Angina never lasts less than 45 seconds, and not longer than 5 minutes (pain from a full-blown heart attack can go on indefinitely)
2. Risk Factors for Coronary Artery Disease (major ones)
- Age: Men >35-40; Women after menopause
- High Blood Pressure (Hypertension)
- Smoking (or less than 3 years since quitting)
- High Cholesterol (Hyperlipidemia)
- Family History of Heart Attack (at near the same age as patient)
- Same-day Stimulant Use (cocaine, meth, etc.)
Diagnosis — An abnormal electrocardiogram (EKG) can sometimes identify Angina, but it’s usually normal, because we do it with a patient lying still on a table. [The “K” in the abbreviation is from the German word; sometimes it’s called “ECG” in English, but not often]. So then we order a “Stress Test,” which is an EKG done while a patient is exercising on a treadmill or maybe stationary bicycle.
If the original EKG is slightly abnormal, but not in a way that identifies Angina, then the stress test EKG may be impossible to interpret. So instead, we order a test with the patient exercising during an echocardiogram (“Stress Echo”) or while injecting dye (“Nuclear Medicine Perfusion Stress Test”). If during exercise all heart muscle moves normally, or takes up dye normally, there’s no significant coronary artery disease.
If the above tests are abnormal during exercise, we can’t tell if there’s not enough circulation (“Ischemia“), or maybe no circulation at all from a previous heart attack (“Infarction“). So we repeat the test with patient resting: normal test means there was ischemia with exercise; same abnormality at rest means dead muscle from an old heart attack (often without symptoms at the time), but the rest of the heart is doing OK.
If a patient can’t exercise (arthritis, etc.), we order a “Pharmacologic Stress Test.” The technician injects medicine to make the heart race, and does the Stress Echo or Perfusion Test.
If any of these tests are positive, suggesting coronary artery disease that could cause a future heart attack, we refer the patient to a cardiologist for Coronary Catheterization (or “Cath” for short). They thread a thin tube into the coronary arteries, inject dye, and see for sure if any arteries are clogged (angioplasty). Sometimes they can unclog them on the spot, and insert a “stent” to hold them open. Sometimes that’s impossible, and the patient needs a By-Pass (open heart surgery).
There are no good ways to accurately detect coronary artery disease in people without any symptoms. Tests exist, like EKG and stress tests discussed above, and a low-radiation CT scan looking for calcium buildup in coronary arteries. But there are lots of false-positive results, and no good evidence that they help improve outcomes or save lives. Some professional organizations recommend testing for some people about to begin a vigorous exercise program, & they’re often done on pilots, bus drivers, etc., in the interest of public safety.
No matter what, we provide preventive advice & treatment to avoid future heart attacks. This means not smoking, regular exercise, and a combination of medicine and diet to control blood pressure, high cholesterol, and diabetes if those conditions exist.