Angina and Physical Activity

Lifestyle has been suggested to be of big importance in the prevention of heart diseases, as well as cardiovascular rehabilitation and recovery. There is research implying that if appropriate lifestyle changes are applied successfully and followed consistently, the relative risk of heart failure can decrease.^3-5 This article will review and discuss the best approaches to lifestyle changes in preventing and living with cardiovascular disease with the focus on angina pectoris. 

What is Angina?

The most common type of heart inflammation, coronary artery disease, is caused by cholesterol or plaque clogging the arteries that maintain the heart muscle. We call this condition atherosclerosis. Its usual symptom is chest pain that happens during physical exercises, stress, or other things that make the heart work harder, which is known as angina pectoris or stable angina due to its predictable pattern.¹ 

The condition tends to appear as a heart pressure, aching, or burning in the middle of the chest, neck and shoulders. If the arteries are narrowed significantly, angina happens to additionally occur at rest or as a sense of anxiety or uneasiness; in which case is called unstable angina.⁸ The attacks of angina commonly last a few minutes. In the case when the incident was caused by physical exertion, the pain should stop within a few minutes of rest. If such pain lasts more than 10 minutes, it could indicate more serious heart disease, or even a heart attack.   

It has been a subject of many debates, whether the best way to approach this condition would be unblocking the artery (angioplasty and a stent) or sustainable medical therapy. The surgical solution, although seemingly more efficient, carries a lot of risks. On the other hand, optimal medical therapy means bringing all the factors that underlie the risk of angina (cholesterol, blood pressure, and blood sugar levels) into a healthy range. This however means taking many medications and taking several tests, thus making it a long way to overcome the issue.

 Sports medicine and exercise-based cardiac rehabilitation is likely to improve the condition of symptomatic patients with angina. Therefore, sports medicine could serve as an alternative treatment in the case when revascularization is not possible and aggressive medical management is pursued. In light of the above, we aim to provide a synopsis of the considerable effects of physical activity and sports medicine on life with angina pectoris and the risk of poor cardiovascular health.

For the clarity of the article, we define exercise as “a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness³.” This definition will help us to distinguish sports medicine from intentional but not structured physical activity. Before we begin the review one needs to consider that angina isn't the only originator of chest pains, so it's important to be able to distinguish angina from other types of chest discomforts because they are treated in varied ways and tend to affect long-term health differently. 

It may be a subject of concern for people who suffer from angina that physical exercise will affect the condition in a negative way. Yet, the research suggests that appropriate exercise is not only perfectly safe, but it improves the flow of oxygen and blood supply.⁷ It can also relieve angina symptoms such as chest pain and shortness of breath. It is through encouraging the body to use a network of small vessels that nourish the heart muscle. The principal goal of exercise rehabilitation in angina is to increase the ischemic threshold. It has been suggested that such sport medicine programs can decrease the episodes of chest pain and cardiovascular diseases by 70%, reduce nitrate use by 65%, and improve exercise tolerance by 57%.⁸ Therefore, recent guidelines⁷ support the reduced cardiac demands resulting from regular physical activity and sport medicine based rehabilitation in patients with angina pectoris.

Although physical exertion increases volume and rate of cardiac output, which together with a temporary increase in vascular resistance, results in the rise of mean arterial blood pressure (60), individuals who exercise consistently show lower resting heart rate and cardiac hypertrophy. Our analysis of numerous studies suggests that moderate physical activity performed regularly 3–5 times per week promoted a net reduction in blood pressure by an average of 3.4/2.4 mmHg.⁸ Although this may appear to be a small change, it has been shown that even a 1 mmHg decrease is associated with 20.3 fewer heart failure incidents per 100,000 people a year.¹¹ Lower ambulatory blood pressure is largely considered to be associated with a chronic reduction in systemic vascular resistance.¹⁰ Consequently, blood pressure could have an important influence on the treatment of all types of angina and incidence of other cardiovascular diseases. 

Animal models of aerobic exercise report that moderate but consistent exertion subdues atherogenesis and enhances the presence of nitric oxide and other vasodilatory mediators such as nitric oxide. As Howden et al.¹⁰ suggest, a consistent two-year exercise program decreases left ventricular stiffness within formerly sedentary middle-aged participants and implies that introducing moderate physical activity even later in life can reverse heart failure and chest discomfort.

As the above may suggest, it is recommended to introduce heart-healthy lifestyle changes for the sake of vascular and overall health by reducing the risk factors. Regarding exercise, research suggests 30 minutes of physical activity for 5 days a week but flagged fitness to be assessed before exertion. Interventions targeting behaviours, such as giving up smoking, keeping track of hydration or managing excess weight are thought to improve outcomes for cardiovascular disease patients. The results obtained with one multidisciplinary lifestyle intervention scheme of improvement in physical activity, BMI and exercise capacity have confirmed that these are the factors having a crucial impact on the improvement or deterioration of the patients with angina as well as other cardiovascular conditions.^{1, 7, 10}  

Dietary experts⁷ recommend whole foods rather than nutrients as a foundation of a heart-healthy diet. They proposed that supplementation of plant sterols at doses of 2–3g per day is beneficial due to their proven cholesterol-lowering effect¹¹. However, it remains just a guideline as there is no randomised clinical evidence to support this. The body of evidence suggests that a heart-healthy diet means a moderation in alcohol consumption should be considered; although everyday consumption is not recommended, wine or beer is suggested to positively affect one's cardiovascular health. 

Consequently, even in the present era with good clinical care and cardioprotective pharmacological treatments, comprehensive lifestyle intervention is crucial to maintaining cardiac health. The above paragraphs have confirmed the significance of risk factor control through lifestyle modification as an inherent part of the treatment in patients with angina.

Yet some questions remain unanswered in regards to mechanisms by which exercise impacts the remarkable benefits to cardiovascular health.  It is important to evaluate how physical exertion affects inflammation and immunity in patients with angina and it requires additional careful investigations. The remaining question is also whether the beneficial effects of physical activity demonstrate circadian or seasonal dependence such that exertion at a specific time of day or season benefits more than under other circumstances.

Further work is also needed to more robustly determine the effect of nutrition on endurance and how it affects the gut and the microbiome. It is crucial to determine the extent to which nutritional supplements enhance (or lower) the buffering capacity, growth, and hypertrophy of the heart muscle.^4-5 Such studies are necessary and valuable not only for a fundamental understanding of the mechanisms behind cardiac rehabilitation, but moreover for the development of successful exercise regimens and what follows the effectiveness of combined treatments involving lifestyle change, and for formulating relevant and effective pharmacological interventions for those who would not or cannot enhance physical activity.