Angina is a type of chest pain caused by restricted blood flow to the heart (ischaemia). It is also known as ischaemic chest pain or angina pectoris. It is not usually a life-threatening condition but might be an early warning sign of a heart attack or stroke.(1) The UK government has very clear advice on whether or not to drive when you have angina.
What is Angina?*Image credit by CC BY-SA 3.0, Link
Angina symptoms mainly consist of pain and discomfort in the chest, variously described by sufferers as pressure, burning, squeezing, or a feeling of fullness.
Other symptoms you may experience include:
- Shortness of breath
In women or people assigned female at birth (AFAB), symptoms are often different to those in men or people assigned male at birth (AMAB). This could result in angina going undetected for some time. Chest pain is still present but may not be the major symptom.
Prevalent symptoms could include:
- Shortness of breath
- Abdominal pain
- Discomfort in the neck, jaw, or back
- Stabbing pain instead of chest pressure
Three Types of Angina
There are three types of angina and they vary in terms of the cause and treatment:
This is the most common form of angina and happens when the heart is working harder than usual, during activities such as walking upstairs. It has a regular, predictable pattern, lasts only for a few minutes, and is usually eased through a combination of rest and medicines. Besides physical exertion, other factors that can trigger stable angina include cold temperatures, emotional stress, smoking, and eating very heavy meals.
This is the most dangerous form of angina. It does not follow a set pattern and can happen without any physical exertion. It often occurs unexpectedly and attacks are more severe and longer than stable angina (30 minutes or more). Rest or medicine does not help. It is a sign that you could be about to have a heart attack (myocardial infarction) and constitutes a medical emergency.
Variant or Prinzmetal’s Angina
This is very rare and typically occurs overnight during rest. Symptoms are often severe but respond well to angina medication. This form of angina results from a spasm in a coronary artery, which temporarily narrows it, restricting the blood flow. Attacks tend to occur in clusters. Causes can include emotional stress, smoking, medications that tighten blood vessels (e.g. anti-migraine drugs), and the use of recreational drugs, like cocaine.(2)
Angina happens when your heart muscle does not get enough oxygen-rich blood. There are a number of causes, but the main one is ischaemic heart disease, of which there are two main types, either coronary artery disease or coronary microvascular disease.
Coronary artery disease is the result of atherosclerosis, where the arteries that supply blood to the heart are narrowed or blocked by a build-up of plaque.(3) Coronary microvascular disease is similar, but affects the tiny arteries that branch off the main coronary arteries instead. This reduces blood flow, and can lead to microvascular angina.(4)
The last cause of angina is a sudden spasm in the coronary arteries. Vascular spasms can occur whether or not you have ischemic heart disease and can affect large or small coronary arteries.
Damage to coronary arteries by ischaemia or other causes may worsen the problem by causing them to narrow instead of widen when the heart needs more oxygen.
The following risk factors increase your risk of coronary artery disease and angina:
- Tobacco use.
- High blood pressure.
- High blood cholesterol or triglyceride levels.
- Family history of heart disease.
- Older age: men older than 45 and women older than 55.
- Lack of exercise.
Can you Drive if you Have Angina?
The short answer is yes, you can. Angina sufferers may worry about what their diagnosis means for their driving. Driving can cause stress, which could induce an angina attack and make it difficult for you to drive.
The Driver and Vehicle Licensing Agency (DVLA) of the UK Government sets out guidelines for driving with cardiovascular conditions like angina. If you drive a car or a motorbike (Group 1), you do not need to inform the DVLA, even if your angina is severe enough to require medication.
However, if your angina occurs while resting, during times of emotional stress, or while driving, then you must stop driving until the symptoms are well under control.
If you are licensed to drive a bus, coach, or lorry (Group 2), you MUST inform the DVLA immediately and fill out a medical form (VOCH1). You must not drive when symptoms occur, and your licence may be revoked if symptoms continue.
You may then be relicensed/licensed if you have experienced no angina for at least 6 weeks or if you meet the DVLA requirements(see DVLA Guidance on Fitness to Drive, Appendix C).(5) In this case, licensing will be short term (maximum of 3 years) and renewal will be subject to further testing and reports.
Tips for Managing Attacks
If you have stable angina (the most common form), you will likely be given a medicine called glyceryl trinitrate (GTN) to manage the symptoms of an attack.
This comes as either a spray or tablets that dissolve under your tongue. Many feel the spray is more convenient because the tablets expire 8 weeks after the packaging is opened, while the spray lasts up to three years.
Other medications might be prescribed on a preventative basis. According to the Mayo Clinic, these include aspirin, which inhibits blood clot formation and improves flow through narrowed or damaged arteries, possibly reducing the risk of a heart attack. Other clot preventers used, especially in unstable angina, include clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta).(2)
You should always seek medical advice before starting a new medicine. Other angina preventers include: beta-blockers, which reduce blood pressure and cardiac effort; statins, which control cholesterol; and calcium channel blockers like verapamil, which relax and widen the blood vessels.
You may also be given drugs to lower your blood pressure if it is high.
Other drugs which prevent chest pain in angina are ivabradine, ranolazine, or nicorandil, all of which increase blood flow to the heart, and are prescribed when other antianginal medicines have not worked.
They are not suitable for everyone and may cause problems for those with low blood pressure or pulmonary oedema (fluid on the lungs). Therefore, it is recommended that you follow a doctor's advice and receive an appropriate prescription.
There are surgical procedures that may help with angina, particularly if you have unstable angina. These include angioplasty and stenting, where a small, stiff wire coil (a stent) is inserted into an artery to widen it. Below is an illustration of this:*Image credit by CC BY-SA 3.0, Link
Another surgical procedure is coronary artery bypass (CABG), where a blood vessel from elsewhere in your body is used as a graft to bypass a narrowed coronary artery, improving blood flow to the heart.
Doctors may also try a medical procedure called external counterpulsation (ECP), where blood pressure-type cuffs are placed around parts of the lower body and pulsed to improve blood flow to the heart.(2)
Angina is a warning sign that you are at risk of heart attacks and stroke. In addition to medicine and surgery, lifestyle changes and stress-reducing activities are also important in fighting angina.
A healthy weight and a healthy heart can be maintained by:
- Stopping smoking
- Minimising alcohol consumption
- Eating a healthy balanced diet low in saturated fat
- Becoming more physically active
When exercising, it is important to start at a low level of intensity and build up gradually, taking regular breaks to minimise the chances of causing an angina attack. You should have your GTN spray or pills with you and take them at the first sign of chest discomfort. You may also use them preventatively before exercise.
Stress is part of everyday life and is almost impossible to avoid, but there are things you can do to reduce its impact on your heart health. These include exercise, mindfulness techniques, yoga, meditation, and social activities such as chatting with friends and family. The British Heart Foundation recommends all these techniques as ways to reduce stress-causing hormones.(6)
Angina is usually a non-life-threatening chest pain caused by poor oxygen supply to the heart, which can be benign or may be a sign of much more serious cardiovascular problems, such as a heart attack or a stroke. There are many treatments available, and they can usually be managed with a combination of drugs and lifestyle factors. With the right precautions and adjustments, most sufferers are able to get their symptoms under control and lead normal lives.
- American Heart Association. Silent Ischemia and Ischemic Heart Disease [Internet]. [updated 2015 Jul 31; cited 2022 Feb 9].
- Mayo Clinic. Angina [Internet]. [updated 2020 Jun 12; cited 2022 Feb 9].
- CDC, Coronary Artery Disease (CAD) [Internet]. [updated 2021 Jul 19; cited 2022 Feb 9].
- American Heart Association. Coronary Microvascular Disease (MVD) [Internet]. [updated 2021 Feb 10; cited 2022 Feb 9].
- DVLA. Cardiovascular disorders: assessing fitness to drive [Internet]. [updated 2021 Mar 2; cited 2022 Feb 9].
- BHF. Stress [Internet]. [cited 2022 Feb 9].