Angina pectoris

Angina pectoris is a symptom that indicates coronary heart disease (CHD). However, since it is a very characteristic and important symptom which should always be followed by medical clarification, angina pectoris is often evaluated and considered as a disease in its own right.

Heart disease with characteristic symptoms

In German, angina pectoris (AP) is also described as a narrowing of the heart. And this also refers to the complaints that are summarized as AP. These include, above all, a sudden severe pain in the chest and the feeling as if it were being compressed. Some patients describe it as if an elephant is sitting on the chest, causing pain and interfering with breathing.

Circulatory disturbance leads to symptoms

The symptoms of AP are caused by reduced blood flow to the heart muscle. This is because the heart muscle is surrounded by an entire network of so-called coronary vessels that supply the muscle with blood from the outside. If one of these vessels is blocked, severe symptoms immediately occur, which should never be negated.

Symptoms especially during exertion

In most cases, the reduced supply of blood to the heart only occurs during exertion. The vessels are thus permanently reduced in size, but this only comes into play when the heart has an increased demand for nutrients and oxygen. If the symptoms also occur at rest, it must be assumed that the vessels are almost no longer permeable. Then a heart attack threatens, which must be prevented by all means.

Widespread occurrence of angina pectoris

In our latitudes, angina pectoris is a very widespread disease. In the course of a lifetime, about one in three men and one in six women experience the symptom of chest tightness. Age plays a major role: the older we get, the higher the probability of developing angina pectoris.

In women, the risk of coronary heart disease increases sharply after menopause. Estrogens during the fertile years are thought to protect not only the brain, but also the blood vessels and the heart. When these are then reduced due to menopause, heart problems are more likely to occur.

The causes for the development of angina pectoris are very diverse and complex. There is not only one cause, but it is a complex interaction of several risk factors that ultimately lead to the development of the symptom.

Risk factors for angina pectoris

The risks for developing AP can be grouped into several categories.

• Lifestyle: Lifestyle greatly determines the extent to which our heart can remain healthy. A bad lifestyle puts a lot of strain on the heart, which is why it often leads to damage and heart disease. Poor eating habits, lack of exercise, nicotine and alcohol consumption and obesity play a particularly important role here.
• Pre-existing conditions: Some pre-existing conditions can further promote the development of angina pectoris. Therefore, these should be treated adequately. These include arteriosclerosis, high blood pressure, derailed cholesterol levels and diabetes mellitus.
• Triggers for AP seizures: An AP attack rarely just happens, most often it is provoked by certain circumstances. These include increased strain on the heart due to physical exertion or psychological stress. Special attention must also be paid to stress of any kind. A change in the weather, sudden cold and sumptuous meals also play a certain role.
• Uncontrollable risk factors: All the above risk factors can be influenced. Only advancing age and a positive family history, meaning heart disease in the family tree, cannot be influenced.

Resting AP versus stress AP

Generally, a distinction is made between stress AP and rest AP, depending on the cause. In stress AP, the vessel is still permeable enough to allow normal blood supply to the heart. However, if physical or mental stress or other circumstances increase the performance of the heart and thus also the oxygen consumption, the remaining lumen is no longer sufficient to guarantee an adequate supply.

In resting AP, there is an undersupply of oxygen and other nutrients to the heart muscle even at rest. This is especially the case when the vessel lumen is more than 90% constricted. With a resting AP, one must also always assume that a heart attack is close at hand.

Special form: Prinzmetal angina

A special form of angina pectoris is Prinzmetal's angina. Here, the vessels around the heart contract for a period of time, preventing blood from reaching the heart. This can last either just a few seconds or even several minutes.

This rare form of angina causes severe problems, especially in diagnosis, because people often forget about this mechanism and then it is difficult to make a diagnosis.

Angina pectoris is a symptom of coronary heart disease. In the true sense, it is not a disease in its own right. However, since only an undersupply of the heart muscle leads to this symptom, great importance is attributed to angina pectoris.

Characteristics of angina pectoris

Characteristic of angina pectoris is that the symptomatology begins suddenly and lasts only a relatively short time, a few seconds to a few minutes. The pain is often described as burning, heartburn, tearing, or a pressure on the chest. The pain often radiates to the shoulders and arms, the upper abdomen and back, or down the neck into the lower jaw.

Often also atypical symptoms

Especially in women, atypical symptoms are not uncommon. For example, the pain does not always have to be felt behind the breastbone, but can also occur in the upper abdomen, between the shoulder blades or in the right half of the chest. In addition to the pain, many patients experience shortness of breath, (death) anxiety, and sweating. Some patients also describe nausea and vomiting or an oppressive feeling in the throat.

In women, the simultaneous presence of fatigue, a drop in performance, pain in the upper abdomen and shortness of breath in particular indicate that there is an insufficient supply of blood to the heart. Due to these uncharacteristic symptoms, however, coronary heart disease remains undetected for a long time in many women.

CHD in diabetes mellitus

Coronary heart disease is particularly insidious in people who suffer from diabetes mellitus. One consequence of the disease is that nerves are increasingly destroyed. This includes the nerve plexus that surrounds the heart. Thus, both angina pectoris and myocardial infarction proceed silently, i.e. no discomfort is felt. Thus, the warning signals indicating that a heart attack may be imminent in the near future are also absent.

Forms of angina pectoris

In general, AP can be divided into three different manifestations. It is important to separate these because they are also associated with a different risk of heart attack.

Stableangina pectoris: In stable AP, AP attacks occur repeatedly, but they always look the same and can be quickly brought under control by rest or medication.

Unstable angina: The first attack and any attack that is different from the previous attacks are called unstable AP. Usually, there is an ever-increasing severity of AP attacks. Unstable AP carries a high risk of myocardial infarction.

Angina decubitus and nocturna: The pain occurs mainly when lying down and at night, when more blood is transported through the venous system to the heart, overloading it.

Classification according to degrees (CSS classification)

In practice, the classification according to the recommendations of the Canadian Cardiovascular Society (CSS) is of particular importance.

Grade 0	Grade I	Grade II	Grade III	Grade IV
Although there is an undersupply of the heart, this does not cause any symptoms. The undersupply is then usually detected as an incidental finding.	AP symptoms occur exclusively during heavy physical exertion that does not correspond to normal everyday life.	In this case, mild AP complaints occur even with normal everyday exertion.	At this level, considerable AP complaints occur with normal everyday exertion, which can have a negative influence on everyday life.	A high degree of AP causes severe AP symptoms even at rest.

Angina is a clear symptom that can be easily diagnosed. Nevertheless, this cannot be treated lightly. On the contrary, accurate diagnosis must be done to accurately determine the severity and cause of the condition.

Importance of the anamnesis

Of extremely great importance is the accurate taking of the medical history. Not only must all the symptoms be recorded in their exact nature and severity, but above all it must be asked when exactly the complaints occurred and how long they lasted.

Further examination

To clarify angina pectoris, an ECG is taken both at rest and under stress. This means that the electrical currents in the heart are measured in order to detect changes in the heart muscle or conduction structures.

An ultrasound examination of the heart can provide further indications. In addition, the vessels of the heart can be precisely imaged in order to detect any constrictions. Today, certain MRI techniques can be used to do this without puncturing a vein. A myocardial scintigraphy can show the metabolism of the heart, which can provide further important information.

Exclusion of a heart attack

In the first few minutes of the AP attack, the focus is on ruling out a heart attack. Not only the ECG can be helpful in this, but above all the measurement of the so-called cardiac enzymes in the blood. These would be elevated if a heart attack were to lead to the destruction of heart muscle.

Risk assessment

Once the acute AP attack has been averted, the main focus is on diagnosing the individual risk in order to assess how great the danger of a heart attack is. In this way, a treatment plan can be designed for each individual patient to prevent further heart damage.

In therapy, one must distinguish whether one wants to treat an acute seizure or further seizures and prevent a progression of the disease. This is because different therapeutic agents must be used for different situations.

Therapy of the acute seizure

• Oxygen: Increases the supply of oxygen to the heart
• Glycerol trinitrate: medication to dilate the heart vessels
• Rest: relaxed lying with slightly raised upper body

Therapy to prevent a seizure

• Beta-blocker: medicine to relieve pressure on the heart
• aspirin or clopidogrel: blood thinner to prevent blood clots
• nitrates: medicine used to dilate the blood vessels in the heart + statins: medicine used to reduce the risk of heart attack
• statins: medicine to regulate cholesterol levels

Therapy to correct causes

• PTCA: widening of the heart vessels with a balloon
• Bypass: replacement of an artery with organic or artificial material

Angina pectoris must always be regarded as a warning signal of progressive disease of the coronary vessels. If nothing is done, sooner or later a heart attack will occur, which often leads to death. Any kind of chest pain must therefore be clarified by a doctor.

Reduction of risk factors

When symptoms occur, it is important to reduce the risk factors for a heart attack and for the progression of angina pectoris. If you can do this, you can usually control AP well and live a symptom-free life. Only extreme sports that put extra strain on the heart should be avoided so as not to take unnecessary risks.

Even leading a healthy lifestyle can greatly improve the prognosis for angina pectoris. Even if it is exhausting and tedious to get used to a new lifestyle, it is certainly worth it. After all, progressive AP symptoms lead not only to premature death, but also, more importantly, reduce the quality of life.

Great success with drug therapy

Drug therapy can also be used as a supportive measure. However, one has to be aware that one also has to change one's life, even if this sounds easier than one thinks.

Nevertheless, the prognosis for angina pectoris could be greatly improved by the sensible use of medication. Thus, freedom from symptoms can usually be achieved if one adheres to the medication exactly.

The cause of angina is almost always coronary heart disease (CHD). And this can be prevented by reducing the respective risk factors. It is best to discuss which measures make sense with a doctor. Here are just a few general tips.

• Abstinence from nicotine: Smoking promotes angina pectoris. Therefore, it should be refrained from as far as possible.
• Weight reduction: If you are overweight, you should definitely reduce your weight. Even small reductions can have great effects.
• Healthy diet: Not only the reduction of fats plays a role, but also the sufficient intake of vitamins and minerals. Sufficient exercise: even moderate regular exercise can strengthen the heart and thus prevent CHD.
• Treatment of pre-existing conditions: Diabetes, high blood pressure and high cholesterol should definitely be adequately treated.
• Avoid stress: Rest is essential not only for the mind but also for the body. Therefore, one should not get stressed too much, neither from work nor from personal life.