Angina

What is angina?

Angina is the tight, heavy or squeezing pain you feel when your heart muscle isn't getting the blood and oxygen it needs. It usually happens in your chest, though you might also feel it in your arms, neck, jaw, back or stomach.

What causes angina?

Angina usually happens because your coronary arteries, the blood vessels that feed your heart muscle, have narrowed. This narrowing is known as coronary heart disease, and it develops when a fatty substance called plaque builds up on the artery walls over time. With less room for blood to get through, your heart can struggle to get enough oxygen whenever it has to work harder, such as during exercise, in cold weather, during a stressful moment, or after a heavy meal.

A less common cause is when the arteries around your heart tighten up temporarily on their own, even without plaque narrowing them. This is known as vasospastic or microvascular angina.

Some things make angina more likely. You could be at higher risk if you:

• are a man aged 45 or over, or a woman aged 55 or over
• smoke, or spend a lot of time around secondhand smoke
• have high blood pressure or high cholesterol
• are overweight or living with obesity
• have diabetes, or another condition such as anaemia, kidney disease or arthritis
• have had heart problems before, or have close relatives who have
• don't get much exercise, or are under a lot of stress
• drink more than 14 units of alcohol a week.

Angina itself isn't something you inherit. But a strong family history of heart disease raises your own chances of developing the artery narrowing that leads to it.

Are there different types of angina?

Doctors usually group angina by how predictable it is and what sets it off.

• Stable angina is the most common type. It tends to follow a pattern you'll come to recognise, brought on by things like walking uphill, and settles again within about 5 minutes of resting or taking your angina medicine.
• Unstable angina is more serious. It can start with no warning, even while you're at rest, and tends to feel worse and last longer, sometimes 15 minutes or beyond, without settling when you rest or take your usual medicine. Because it can be an early sign of a heart attack, unstable angina always needs emergency treatment.
• Vasospastic angina (sometimes called Prinzmetal's angina) happens when a coronary artery goes into spasm and briefly narrows. It's rare, often strikes at night or while resting, and an episode commonly runs anywhere from around 5 up to 15 minutes.
• Microvascular angina affects your heart's smallest blood vessels rather than the main arteries. It's often set off by physical effort or emotional strain, and can run on longer than stable angina, sometimes past 15 minutes.

How is angina diagnosed?

Your GP will usually begin by asking about your symptoms, including where you feel the pain, what brings it on, how long it lasts and what eases it. They'll also ask about your own and your family's medical history, and check things like your blood pressure and weight.

If they suspect angina, you'll usually be referred to a cardiologist (a heart specialist) for further tests, which might include:

• an electrocardiogram (ECG), a test that records your heart's electrical activity and rhythm
• blood tests, to check things like your cholesterol and blood sugar
• a chest X-ray or exercise stress test, to see how your heart copes with exertion
• an echocardiogram, an ultrasound scan showing how well your heart is pumping
• a coronary angiogram or CT scan, which lets your specialist see whether your arteries have narrowed.

These tests help your care team work out whether you have stable or unstable angina, since that changes how quickly you need treatment.

How is angina treated?

Non-surgical treatment

Most people manage angina with a mix of medicine and lifestyle changes. If you have an angina attack, follow these steps:

1. Stop what you're doing and sit down to rest.
2. Use your prescribed spray or tablets, often glyceryl trinitrate (GTN), which you use under your tongue.
3. If the pain hasn't eased after about 5 minutes, take a second dose.

Longer term, your doctor may prescribe:

• medicine to relax your blood vessels and ease symptoms, such as nitrates or calcium channel blockers
• beta blockers, to reduce how hard your heart has to work
• aspirin or statins, to lower your risk of a heart attack or stroke.

Small changes to your daily routine can also cut down how often symptoms strike:

• stopping smoking
• eating a balanced diet that's lower in saturated fat and salt
• staying as active as your symptoms allow
• keeping your weight, blood pressure and cholesterol within a healthy range
• cutting back on alcohol and finding ways to manage stress.

Surgical and procedural treatment

If medicine on its own doesn't control your symptoms well enough, your cardiologist may suggest a procedure to improve blood flow to your heart, such as:

• coronary angioplasty, where a small balloon widens the narrowed section of the artery, often followed by a stent (a small mesh tube) that holds it open
• coronary artery bypass surgery, which builds a new route for blood to reach your heart muscle, going around the blocked section.

When should I see a doctor?

Call 999 straight away if you get chest pain or pressure that doesn't ease off, particularly alongside:

• pain spreading to your arm, neck, jaw, back or stomach
• sweating, nausea, dizziness or breathlessness.

This combination can be a sign of a heart attack, so don't drive yourself to hospital. Ask someone else to drive you, or wait for the ambulance.

If you've already been diagnosed with angina, follow your usual attack plan (rest, then GTN, repeating after 5 minutes if you still need it). Call 999 if your pain hasn't eased 5 minutes after that second dose, or if it feels different, more severe, or starts happening at rest, since these can point to unstable angina.

For chest pain that comes and goes but doesn't match the pattern above, contact your GP or call NHS 111, particularly if it's happening for the first time.