Angina pectoris: what it is and how to treat it

By Cristiano Antonino On Feb 1, 2022

Angina pectoris is a disease that is largely identified with its main symptom; the term comes from the Latin and means pain in the chest

It is caused by a temporary lack of blood flow to the heart resulting in a lack of oxygen to the heart tissue.

The phenomenon is also called ischaemia; in angina pectoris the ischaemia is reversible and does not go so far as to cause permanent cardiac damage.

The disease usually manifests itself as sudden, acute and transient chest pain; heaviness in the chest and upper limbs, tingling or soreness at the same site, fatigue, sweating, nausea have also been described.

Symptoms can vary greatly in intensity and duration from individual to individual.

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What is angina pectoris?

Angina can be divided into different forms:

Stable or exertional angina: it is triggered by physical effort, cold or emotion. In this case the symptom of the disease manifests itself when one is performing physical activity, especially if exposed to low temperatures, or at the height of emotional stress. It is the most common form and also the most controllable.
Unstable angina: in this case the pain occurs unexpectedly, even at rest, or during moderate physical exertion. The cause may be temporary obstruction of a coronary artery by a clot, also known as a thrombus, which forms on an atherosclerotic disease of the vessel walls. It is therefore the most dangerous form of angina, which must be treated promptly, as it is strongly associated with the risk of progression to an acute myocardial infarction. Variant angina or Prinzmetal’s angina can also be considered a form of unstable angina. Variant angina is caused by a spasm in one of the coronary arteries, with significant, albeit temporary, narrowing of the vessel to the point where blood flow is significantly impaired and ischaemia associated with chest pain occurs. Prinzmetal angina is a fairly rare disease that is generally not associated with atherosclerosis of the coronary vessel affected by the spasm.
Secondary angina: this includes all forms of cardiac “ischaemia” that are not caused by coronary narrowing or obstruction, but by other pathologies such as aortic insufficiency, mitral stenosis, severe anaemia, hyperthyroidism and arrhythmias.

What are the causes of angina pectoris?

Angina is caused by a temporary reduction in the blood supply to the heart.

Blood carries the oxygen needed by the tissues of the heart muscle to live.

If the blood flow is inadequate, the conditions for ischaemia are created.

Reduced flow can be produced by a critical narrowing of the coronary arteries (stenosis), so that when there are increased demands for oxygen from the heart tissue (during physical activity, cold or emotional stress), there is in fact not enough supply.

This occurs most often in the presence of coronary atherosclerosis, a disease that involves the walls of blood vessels through the formation of plaques with a lipid or fibrous content, which evolve towards the progressive reduction of the lumen or towards ulceration and the abrupt formation of a clot above the point of injury.

Coronary artery obstruction/shrinkage may also occur more rarely by spasm of the coronary artery, usually without atherosclerotic changes in the vessel walls.

Conditions that favour the development of atherosclerosis are smoking, diabetes, hypertension and obesity.

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What are the symptoms of angina pectoris?

Symptoms of angina include:

Acute pain, heaviness, tingling or soreness in the chest, which can sometimes radiate to the shoulders, arms, elbows, wrists, back, neck, throat and jaw
Prolonged pain in the upper abdomen
Shortness of breath (dyspnoea)
Sweating
Fainting
Nausea and vomiting

How to prevent angina pectoris?

Angina pectoris is prevented primarily by preventing coronary atherosclerosis, by implementing all measures aimed at controlling the main cardiovascular risk factors.

It is necessary to avoid sedentariness, carry out moderate and regular physical activity; avoid, if you have had episodes of angina pain, excessive strain and sources of psychophysical stress; avoid overweight and obesity, follow a healthy diet, low in fat and rich in fruit and vegetables; avoid large meals and alcohol intake; do not smoke or stop smoking.

People with diabetes should implement all measures for adequate blood glucose control.

In addition, blood pressure should be checked periodically.

Diagnosis

If you have an episode of angina, even a suspected one, you should report it promptly to your doctor for examination:

Electrocardiogram (ECG): records the electrical activity of the heart and allows the detection of abnormalities suggestive of myocardial ischaemia. The Holter is the prolonged 24-hour monitoring of the ECG: in the case of suspected angina it allows the ECG to be recorded in everyday life and especially in those contexts where the patient reports symptoms.
Stress test: the examination consists of recording an electrocardiogram while the patient performs physical exercise, usually walking on a treadmill or pedalling on an exercise bike. The test is carried out according to predefined protocols aimed at assessing the functional reserve of the coronary circulation. It is interrupted when symptoms, ECG changes or high blood pressure occur or when the maximum activity for that patient is reached in the absence of signs and symptoms indicative of ischaemia.
Myocardial scintigraphy: is a method used to assess exercise ischaemia in patients whose electrocardiogram alone would not be adequately interpretable. Also in this case, the patient can perform the examination on an exercise bike or treadmill. In addition to electrocardiographic monitoring, a radioactive tracer is administered intravenously, which is localised in the heart tissue if the blood supply to the heart is regular. The radioactive tracer emits a signal that can be detected by a special device, the gamma camera. By administering the radiotracer at rest and at the peak of activity, it is possible to assess whether there is a lack of signal in the latter condition, which is a sign that the patient is suffering from exercise ischaemia. The examination allows not only to diagnose the presence of ischaemia but also to provide more accurate information on its location and extent. The same examination can be carried out by producing the hypothetical ischaemia with an ad hoc drug and not with actual exercise.
Echocardiogram: this is an imaging test that visualises the structures of the heart and the functioning of its moving parts. The device dispenses a beam of ultrasound to the chest, through a probe resting on its surface, and processes the reflected ultrasound which returns to the same probe after interacting in different ways with the various components of the cardiac structure (myocardium, valves, cavities). Real-time images can also be collected during an exercise test, providing valuable information on the heart’s ability to contract correctly during physical activity. Similarly to scintigraphy, the echocardiogram can also be recorded after the patient has been given a drug that may trigger ischaemia (ECO-stress), allowing the diagnosis and assessment of its extent and location.
Coronography or coronary angiography: this is the examination that allows the coronary arteries to be visualised by injecting a radiopaque contrast agent into them. The examination is carried out in a special radiology room, where all the necessary sterility measures are observed. The injection of contrast into the coronary arteries requires the selective catheterization of an artery and the advancement of a catheter to the origin of the explored vessels.
CT heart or computed tomography (CT): this is a diagnostic imaging test to assess the presence of calcifications due to atherosclerotic plaques in the coronary vessels, an indirect indicator of a high risk of major coronary artery disease. With today’s devices, by also administering intravenous contrast medium, it is possible to reconstruct the coronary lumen and obtain information on any critical narrowings.
Nuclear Magnetic Resonance Imaging (NMR): produces detailed images of the structure of the heart and blood vessels by recording a signal emitted by cells subjected to an intense magnetic field. It allows assessment of the morphology of heart structures, cardiac function and any changes in wall motion secondary to pharmacologically induced ischaemia (cardiac stress MRI).

Treatments of angina

The treatment of angina is aimed at improving coronary perfusion and avoiding the risk of infarction and thrombosis.

The therapy includes several options, pharmacological or interventional, which are evaluated by the cardiologist in relation to the clinical picture:

Nitrates (nitroglycerin): this is a category of drugs used to promote vasodilation of the coronary arteries, thus allowing increased blood flow to the heart.
Aspirin: scientific studies have shown that aspirin reduces the likelihood of a heart attack. The antiplatelet action of this drug prevents the formation of blood clots. The same action is also carried out by other anti-platelet drugs (ticlopidine, clopidogrel, prasugrel and ticagrelor), which can be administered as an alternative or in combination with aspirin, depending on the clinical condition.
Beta-blockers: these slow down the heartbeat and lower the blood pressure, thus helping to reduce the work of the heart and thus its need for oxygen.
Statins: drugs to control cholesterol that limit its production and accumulation on artery walls, slowing the development or progression of atherosclerosis.
Calcium channel blockers: these have a vasodilating effect on the coronary arteries, increasing blood flow to the heart.

The interventional option includes:

Percutaneous coronary angioplasty, an operation in which a small balloon usually associated with a metal mesh structure (stent) is inserted into the lumen of the coronary artery during angiography, which is inflated and expanded at the narrowing of the artery.

This procedure improves blood flow downstream, reducing or eliminating angina.

Coronary artery bypass, a surgical procedure in which vascular conduits (of venous or arterial origin) are placed to “bypass” the point of narrowing of the coronary artery, thereby allowing the upstream portion of the narrowing to communicate directly with the downstream portion.

The operation is performed with the chest open, the patient under general anaesthesia and almost always with the support of extracorporeal circulation.

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