Chest pain, when is it angina pectoris?

By Cristiano Antonino On Feb 21, 2023

Angina pectoris is a chronic condition characterized by chest pain in the retrosternal region, sometimes radiating to the arms, shoulders, back, or neck

The onset of this condition is caused by a degeneration of the internal walls of the arteries, which can lead to a reduction in the supply of blood, oxygen and nutrients to the heart muscle.

The disorder can be of a different nature and some of the risk factors can be: an unhealthy lifestyle and an unbalanced diet, a genetic predisposition or the presence of other related pathologies.

There are some specific tests to find the causes of angina pectoris and its treatment can vary according to the type of cause.

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What is angina pectoris

The term angina pectoris, whose meaning derives from the Latin terms angina or pain and pectoris or chest, defines a cardiac syndrome that involves severe pain in the chest and surrounding areas, caused by a lack of oxygen, often due to damage to the arteries or coronary blockages.

The causes of the damages can be of various nature.

Some of the main risk factors are:

genetic predisposition;
sedentary lifestyle;
hypertension;
smoking;
unbalanced diet with excesses of sugar, fat and cholesterol or lack of fiber and vitamins;
alcohol abuse;
dyslipidemia;
diabetes mellitus;
previous chest radiotherapy.

In patients affected by this condition, the arterial walls are damaged, favoring the formation of plaques and deposits of cholesterol or other cellular material; the presence of these accumulations causes a temporary decrease in the blood flow to the heart muscle which, therefore, is insufficient to guarantee the correct functioning of the heart and can lead to transient myocardial ischemia.

Anginal attacks are typically classified based on a number of criteria:

Location: typically upper-middle retrosternal region; in other cases it can affect the entire chest and surrounding areas;
Quality: the pain can be oppressive, squeezing, burning or suffocating and have a variable intensity from mild to severe; generally it is not possible to relieve the pain with breathing or by changing the position.
Duration: the episodes can have variable duration, starting from a few moments up to 20-30 minutes; if the attack lasts longer it is possible that it is a myocardial infarction;
Frequency: patients subject to angina pectoris may experience discomfort regularly or be limited to sporadic episodes.

Types of angina pectoris

Angina pectoris is characterized by a slow process and a gradual degeneration, which however can affect patients from a young age.

Nonetheless, it is a reversible condition if treated promptly and correctly.

From a clinical point of view, two types of angina pectoris are distinguished: stable angina and unstable angina.

Stable angina or exertional angina

Stress angina is the chronic and most widespread form of the syndrome which, in most cases, occurs when the body is subjected to physical effort or, in general, when a greater blood flow to the heart is required.

Stable angina is the least serious, as acute episodes can be prevented and treated with specific medicines.

Unstable angina or pre-infarction syndrome

Unstable angina includes different forms of angina pectoris, all united by the instability of the clinical picture.

The most worrying feature of this type of angina is the acute ingravescence, i.e. the rapid worsening of the duration and intensity of the anginal attacks, up to the onset of episodes even in conditions of absolute rest.

Unstable angina in turn is divided into:

Silent ischemia: a transient condition in which there is a discrepancy between consumption and blood supply to the heart muscle; unlike other forms of angina, silent ischemia has no obvious symptoms or pain.
Prinzmetal’s variant angina: this is a rather rare form of angina, characterized by the chronic onset of pain even at rest, usually always at the same time and in particular at night. It is caused by excessive spasm of the coronary arteries, although in many cases these do not have atherosclerotic plaques.

Other types of angina

Angina can be primary or secondary depending on the pathophysiological mechanisms that determine it.

In the first case there is a reduction in coronary flow caused by a temporary obstruction of a vessel; in the second case instead the anginal pain arises due to an increase in the oxygen demand of the myocardium.

Finally, functional angina includes all forms of angina due to other diseases that compromise the blood supply to the heart: for example, aortic stenosis and insufficiency, severe anemia, hyperthyroidism and arrhythmias.

What are the main causes of angina pectoris

As seen previously, when the heart does not receive an adequate blood supply, the body is put under strain, as the blood not only carries the oxygen and nutrients necessary for the cells to function, but at the same time also removes the waste products rejection; when blood is scarce, therefore, the tissues suffer and accumulate toxic metabolites.

Some of the main causes attributable to the onset of angina pectoris are:

Transient stenosis due to the presence of atherosclerotic plaques, a degenerative disease that affects the arteries and which causes a thickening of the artery walls with a consequent decrease in elasticity.
Coronary spasm, a condition that affects healthy arteries by narrowing their vessel lumen, due to an abnormality of the normal mechanisms of vasoconstriction and vasodilatation.

There are also some diseases that can cause angina pectoris:

Anemia;
Tachycardia;
Hypertensive crisis;
Cardiac pathologies, myocarditis and endocarditis;

Mitral stenosis and other pathologies of the heart valves.

Finally, the anginal attack can be caused by some secondary factors, in situations in which the demand for oxygen by the myocardium increases; some examples are: physical exertion, psycho-somatic stress or intense emotions, cold snaps, severe frights or fits of anger, large meals or sexual intercourse.

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Symptoms and complications

The most common symptom in patients with angina pectoris is a feeling of tightness in the chest, with severe chest pain; often the pain can also extend to the left arm, fingers and sometimes even to the neck and throat, jaw, stomach or back.

The attacks usually occur gradually, with a progressive intensification of the pain: in less severe cases, the malaise subsides and disappears simply by remaining at rest; alternatively, the administration of trinitrin can be useful for relieving pain.

Other typical symptoms of angina pectoris are dyspnoea with a feeling of suffocation, profuse sweating, nausea and in some cases vomiting.

Precisely for this reason, angina can often be confused with other pathologies, such as, for example, gastroesophageal reflux which causes similar retrosternal pain, or cervical inflammation which affects the shoulders and arms as in subjects suffering from angina.

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Diagnosis

Angina pectoris can often be confused with other pathologies that present similar symptoms, for this reason the diagnosis of this disorder requires some specific tests:

Stress test: This is the most common test to diagnose angina. During this assessment, the patient is monitored while he is subjected to physical effort, usually on a stationary bike, to evaluate parameters such as the presence of ischemia and any ECG arrhythmias and effort tolerance.
Coronary angiography: this is an examination carried out in the most serious cases of arterial degeneration, which involves the insertion of a contrast medium via a catheter to evaluate the state of health of the coronary arteries.
Scintigraphy: during this test, the patient is administered a particular type of radioactive contrast medium, harmless to the body, capable of attaching itself to the cells of the heart in order to evaluate the distribution of the tracer and the state of the coronary arteries.
Electrocardiogram: allows you to record the rhythm and electrical activity of the heart in the form of a trace, through a series of electrodes connected to the patient’s chest and arms; to obtain more precise information, a Holter electrocardiogram is sometimes used, which records the tracing for a period of at least 24 hours.
Echocardiography: it is a simple routine examination thanks to which it is possible to obtain a three-dimensional ultrasound of the heart muscle to evaluate its state of health.

Therapy and treatment

As mentioned above, angina pectoris is a condition characterized by a slow degenerative process, which can be kept under control if treated appropriately.

First of all, it is necessary to intervene to eliminate the main risk factors connected to an unregulated lifestyle, eliminating habits harmful to health.

To treat any predisposing pathologies, the most common drugs are aspirin and other antiplatelet agents, beta-blockers, calcium channel blockers or nitrate-based drugs.

In the most serious cases, an intervention may be necessary, which can be percutaneous (angioplasty) or surgical (aortocoronary bypass).

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