Angina pectoris

Angina pectoris is a sign of coronary artery disease in which the heart is insufficiently supplied with oxygen and can be a precursor to a heart attack. Angina pectoris must be carefully investigated in order to establish the exact underlying diagnosis and initiate optimal treatment.

Overview: What is angina pectoris?

Angina pectoris literally means a feeling of tightness in the chest. The term angina comes from the Latin word angor (oppression, tightness, fear) and also includes the well-known disease angina, in which the tonsils in the throat are inflamed and cause a feeling of tightness in the throat. Angina pectoris is not a disease, but a symptom that indicates insufficient blood flow to the heart muscle.

Narrowing of the coronary arteries leads to a lack of blood flow to the heart muscle and therefore too little oxygen. Angina pectoris is the symptom of a condition known in medicine as “coronary heart disease”.

Coronary heart disease is one of the most common diseases in adults and is high on the list of causes of death. Men over the age of 45 and women over the age of 55 are particularly at risk. The risk of being affected by coronary heart disease in Switzerland is around 20 percent – slightly higher for men and slightly lower for women. The risk is lower at a young age, but increases significantly with age.

Symptoms: How does angina pectoris manifest itself?

The typical sign of an angina attack is a sudden feeling of pressure, tightness, pulling or burning, the center of which is behind the breastbone. From here, the pain can radiate to the surrounding areas of the body – to the shoulders, arms, back or jaw.

However, there are exceptions to this common pattern:

• Women may experience other symptoms instead of chest pain: They may experience angina pectoris in the form of shortness of breath, nausea, stomach problems or fatigue.
• Older people may experience similar angina pectoris symptoms. Like many women, they may also not feel any pain in the breast area. Instead, they often experience breathing difficulties during an angina attack or suffer from a lack of performance or general fatigue.
• Diabetes patients can suffer nerve damage that prevents the complete transmission of pain stimuli. Those affected then experience an attack of angina pectoris painlessly as so-called silent angina pectoris.

Causes and risk factors: How does coronary heart disease develop?

The cause of an angina attack is insufficient blood flow to the heart muscle. Too little blood means too little oxygen. This undersupply is usually the result of narrowed coronary vessels due to deposits (plaques) in the form of cholesterol or calcification (known as arteriosclerosis). Sometimes a spasm of the coronary arteries can also lead to angina pectoris.

Various risk factors favor the formation of deposits in the blood vessels:

• Tobacco smoke contains substances that damage blood vessel walls.
• High blood pressure puts a strain on the arteries.
• High blood sugar levels (diabetes) can inflame blood vessel walls.
• Cholesterol is deposited in the vessel walls
• Genetic predisposition favors the development of plaques
• Obesity and an unhealthy diet lead to deposits
• Lack of exercise has negative consequences for blood pressure and blood vessels
• Age leads to decreasing elasticity of the blood vessels
• Stress causes the release of harmful hormones and constricts the blood vessels

Manifestations of coronary heart disease

The manifestation of angina pectoris can vary. Doctors distinguish between two main forms: stable angina pectoris or angina pectoris in the context of a heart attack.

Stable angina pectoris

Patients with narrowing of the coronary arteries may experience symptoms that are known in medicine as “stable angina pectoris”. This form is temporary, and the pain usually subsides after a few minutes. The symptoms often occur during physical exertion, but also during psychological stress, in cold weather or after a substantial meal.

If a fast-acting medication (nitroglycerin) is administered during an attack of stable angina pectoris, there is usually an immediate improvement. Without such acute therapy, the symptoms usually subside when the strain eases or ceases, otherwise within about 15 minutes.

Angina pectoris during a heart attack

Angina pectoris symptoms can also occur in the context of a heart attack. This is usually a sudden complete or partial occlusion of a coronary vessel. The symptoms usually last longer and are often accompanied by cold sweats, anxiety, nausea or shortness of breath. Since such symptoms indicate a life-threatening heart attack, the emergency services should be called immediately (144) so that professional help can arrive quickly.

Other forms of angina pectoris

Calcium or cholesterol deposits in the coronary arteries, which lead to the narrowing of the vessels, are not always responsible for angina pectoris. In rare cases, there may also be other causes for such a narrowing. For example, a spasm of the blood vessels. This special form of angina pectoris is called vasospastic angina (spasms are cramps) or Prinzmetal’s angina. In this case, the seizures often occur at rest or even during sleep.

Another form of angina pectoris is microvascular angina. In this case, the seizure-like symptoms do not originate from the large coronary vessels, but from the finely branched, smallest (microvascular) blood vessels.

Diagnosis: How can angina pectoris be diagnosed?

The diagnosis of angina pectoris is not always easy to make. For example, if the typical chest pain does not occur, but less common angina pectoris symptoms such as shortness of breath or tiredness. In this case – but also in the case of typical symptoms such as a feeling of tightness – a precise diagnosis can be made with thorough examinations.

Various diagnostic options are available for this purpose:

• The electrocardiogram (ECG ) records the electrical activity of the heart muscle in the form of a jagged curve and is altered in a specific way in the event of a heart attack.
• The ultrasound examination of the heart (also known as echocardiography ) shows the structure and function of the heart muscle and valves on a screen.
• Coronary angiography is an X-ray examination that can be used to visualize the coronary arteries and possible constrictions. If coronary arteries are found to be narrowed, they can usually be treated during the same procedure.
• Computed tomography (CT ) makes calcifications and narrowing of the coronary arteries visible.
• Magnetic resonance imaging of the heart (cardio-MRI) produces images of the blood flow in the heart muscle at rest and under stress.
• Myocardial perfusion scintigraphy (SPECT) and positron emission tomography (PET) are nuclear medicine procedures. They visualize the blood flow in the heart muscle using a weak radioactive substance. This can happen both at rest and under stress.

Therapy: How is coronary heart disease treated?

There are a number of therapeutic options for both the short-term treatment of an acute angina attack and for longer-term therapy.

Medication

In the event of an angina attack, the constricted coronary arteries must be widened as quickly as possible. Only then will the heart be supplied with the necessary amount of blood and therefore oxygen. Various angina drugs are available to achieve this goal:

• The active ingredient nitroglycerin is usually administered in the form of nitro spray or nitro capsules. Nitro usually relieves angina pectoris symptoms quickly because nitroglycerin has an immediate dilating effect on the coronary vessels.
• Morphine can reduce severe pain and helps the patient to relax and reduce anxiety.
• Beta-blockers prevent angina attacks by lowering the heart rate and blood pressure.
• Calcium antagonists dilate the blood vessels.

Invasive interventions

If the coronary arteries are significantly narrowed, this can be treated by surgery.

• Balloon dilatation and stent placement: The constricted blood vessels are dilated with a balloon catheter. This is done with a tiny balloon that is pushed through a thin tube (catheter) to the constriction and inflated there. This procedure is called balloon dilatation. In most cases, a stentis insertedat the dilated site after the balloon dilatation; this tubular metal mesh remains in the blood vessel and prevents a renewed narrowing at this point.
• Bypass surgery: In this procedure, the constricted area of the blood vessel is bridged with the body’s own artery, which allows the heart muscle to be supplied with blood again.

Prophylaxis: How prevention helps prevent further angina attacks

Angina pectoris and the underlying coronary heart disease cannot be cured in the causal sense. A high life expectancy with angina pectoris is nevertheless possible. To achieve this, you as a patient should try to prevent a second (secondary) disease after coronary heart disease. Secondary prophylaxis is all about maintaining a healthy lifestyle and avoiding all risk factors as far as possible. Above all, this includes a healthy diet, plenty of exercise and quitting smoking. Various medications are available to support this, for example aspirin and cholesterol-lowering drugs (statins).