Angina: Pins and Needles

What are “Pins and Needles”?

“Pins and Needles” is the colloquial term for the medical condition Paresthesia. Paresthesia is the abnormal sensations of prickling, tickling, skin crawling, and numbness that may be felt in the arms, legs, hands, and feet. ⁽¹⁾ This sensation may radiate to other parts of the body. The sensation is similar to the feeling of when your arms or legs “fall asleep” following long periods of time in a fixed position. ⁽¹⁾  Chronic paresthesia may be a symptom of a diverse range of cardiovascular disorders.

What Can Cause Pins and Needles?

The Pins and Needles sensation is caused by insufficient blood flow to the blood vessels in the affected area. ⁽²⁾   Reduced blood flow causes the cells of the affected area to enter a state of ischaemia. Ischaemia is responsible for many physical symptoms of Pins and Needles, such as prickling and overall numbness in the affected area. ⁽²⁾ Ischaemia may occur in any area of the body but commonly occurs in the brain (cerebral ischemia), heart (cardiac ischemia), and legs (limb ischaemia). ⁽²⁾

Pins and Needles can also be caused by reduced blood flow to the peripheral nerves of the body.⁽³⁾ This is commonly experienced when a limb such as an arm or leg “falls asleep” from the pressure of one sitting or sleeping on the affected limb for long periods of time.⁽³⁾ The sensation usually ends once the pressure is taken off the affected area and the nerve’s blood supply is fully restored. Brachial plexus neuropathy, an injury of the group of nerves that innervate the shoulders, is also a common cause of the Pins and Needles sensation. ⁽³⁾

Chronic Pins and Needles may be a sign of a more serious condition depending on where it occurs. Pins and Needles may be a sign of cardiovascular conditions such as stroke, coronary artery disease, and angina pectoris. It also is a common symptom of multiple sclerosis, nerve disease, and hypothyroidism. ⁽²⁾

What is Angina?

Angina pectoris is a coronary medical condition characterised by severe chest pain that often radiates to other parts of the upper body. ⁽⁴⁾  Angina is caused by an imbalance in blood delivery to the heart. The blood supplies the heart with oxygen and other vital nutrients while also getting rid of metabolic waste products created as by-products from the heart’s functioning. ⁽⁴⁾  Insufficient blood flow causes a buildup of waste products and nutrient depletion, resulting in the condition’s characteristic chest pain.

The three major types of angina: Stable (typical angina), Prinzmetal variant angina, and Unstable angina. ⁽⁵⁾ 

Stable angina is the most common form of angina: it is caused by an imbalance in blood flow to the heart due to pathophysiological changes in the heart’s work demand. ⁽⁵⁾  Stable angina typically occurs during physical exertion such as exercise, stress, and excitement. Stable angina patients describe their symptoms as a crushing or squeezing sensation in the chest that may spread to areas near the heart, such as the left arm and left jaw. ⁽⁵⁾ 

Prinzmetal variant angina (also known as variant angina) is a rare form of angina that results from arterial spasms in the heart. ⁽⁵⁾  Prinzmetal variant angina patients commonly have occluded coronary arteries, which predisposes them to this form of angina. Prinzmetal variant angina attacks are not caused by physical activity as they commonly occur at rest. ⁽⁵⁾ 

Unstable angina is characterised by a pattern of frequent and persistent chest pain that lasts for longer than 20 minutes. ⁽⁵⁾ Unstable angina can occur with low physical activity levels and at rest. Unstable angina is associated with several cardiovascular conditions and is an important warning symptom of possible heart attack occurrence. ⁽⁵⁾

Signs and Symptoms 

A significant sign of stable angina is chest pain initiated from physical activity and/or emotional stress that usually is resolved following the end of these activities. Unstable angina may persist following the end of these activities. Prinzmetal variant angina may occur suddenly at rest, so one should immediately seek medical attention. ⁽⁵⁾  

The most common symptom of angina is chest pain; however, there are several others to look out for. These include:

• Nausea
• Heaviness
• Burning
• Pins and needles sensation in the chest and surrounding area
• Fatigue
• Sweating
• Breathlessness
• Squeezing
• Sharp chest pain
• Arm pain (typically on the left side of the body)
• Jaw pain (typically on the left side of the body)
• Dizziness
• Hyperventilation ^(6,7)  

The clinical presentation of angina differs between people assigned male at birth (AMAB) and people assigned female at birth (AFAB). People AFAB are more likely to develop less common symptoms such as stomach pain and nausea. They are also more likely to develop microvascular angina, which are spasms of the smallest coronary arteries. ^(6,7) 

Causes and Risk Factors

Angina is caused by an imbalance in blood flow to the heart and its surrounding blood vessels due to atherosclerosis occurrence in coronary artery disease. ⁽⁵⁾ Atherosclerosis is the thickening of the arteries due to plaque accumulation in the inner arterial wall.  ⁽⁸⁾ The plaque is composed of lipid, cholesterol, calcium, and cellular waste product deposits.  ⁽⁸⁾ As these compositions accumulate in the arterial wall, the arterial wall slowly thickens and stiffens. As the artery thickens, it progressively narrows, reducing the blood flow volume capacity of the artery. This results in reduced blood flow in the affected artery’s circulation areas within the heart.  ⁽⁸⁾   

According to the British Heart Foundation, risk factors of angina include:

• Chronic emotional stress
• Smoking (general tobacco use)
• Obesity
• Physical Inactivity
• Family history of cardiovascular disease
• Older age (>45 years old people AMAB and >55 years old people AFAB)
• High cholesterol intake
• Drug abuse: cocaine and other stimulant drugs can cause arterial spasms that trigger angina
• Cold temperature exposure ⁽⁶⁾  

Diagnostic Procedures

​​Angina is diagnosed through a physical exam by healthcare providers and questions regarding a patient’s symptoms. Patients are typically asked to describe their symptoms and identify their possible risk factors. Diagnostic procedures include:

• Electrocardiogram (ECG): ECG measures the heart’s electrical activity. Electrodes are placed on the chest and occasionally on the arms and legs. The electrodes are then connected to a computer. ECG identifies any possible abnormalities in the patient’s heart rate due to insufficient blood flow. ⁽⁷⁾
• X-Ray of the chest: A chest X-ray is used to image the heart and lungs to rule out other cardiovascular conditions that have similar symptoms as angina.  ⁽⁷⁾
• Blood Test: Blood tests detect the specific enzymes the heart muscle releases during damage. ⁽⁷⁾
• Echocardiogram: Echocardiogram uses sound waves to image the heart’s motile function. In angina diagnosis, an echocardiogram is used to image the heart’s blood flow to detect any areas with abnormal blood flow. ⁽⁷⁾
• Cardiac Computerised Tomography (CT): an X-ray tube inside the CT machine rotates around the body to image the heart and chest to produce a CT scan. The CT scan shows any changes in heart size and arterial diameter. ⁽⁷⁾

Treatment 

Angina requires a thorough treatment plan due to the serious nature of the condition. Treatment aims to improve the heart's blood flow imbalance and cardiac metabolism.

Nitrates

Nitrates relax and widen the thick, stiffened arteries to restore proper blood flow to the heart. The most common form of nitrate used in treatment is nitroglycerin. Nitroglycerin comes in pill form; it is placed under the tongue for oral ingestion. Medical providers may recommend taking nitrate before physical exerting activities. Nitrate can also be taken long-term to prevent  progression to more severe heart conditions such as stroke and heart attack. ⁽⁷⁾

Aspirin

Aspirin reduces blood clot production allowing easier blood flow through the narrowed arteries. Aspirin also reduces heart attack risk in angina patients. Medical providers should be consulted before aspirin use. ⁽⁷⁾

Beta-blockers

Beta-blockers dilate blood vessels, reduce blood pressure, and slow heart rate to improve blood flow in angina patients. ⁽⁷⁾

Statins

Statins prevent further angina progression by reducing cholesterol levels in the blood to prevent cholesterol deposition in the arterial walls. Statin also blocks the enzymes that the liver uses to make cholesterol. ⁽⁷⁾

Platelet Aggregation Inhibitors

Medications such as Clopidogrel and Ticagrelor prevent blood platelets from sticking together to form blood clots. Platelet aggregation inhibitors are typically used as aspirin alternatives. ⁽⁷⁾

Calcium channel blockers

Calcium channel blockers are a class of drugs that interact with the muscular arterial wall to relax and widen occluded blood vessels for blood flow restoration. ⁽⁷⁾

Angina treatment also involves several lifestyle changes to prevent the condition from progressing further. ^(6-7) Patients are encouraged to adopt stress-management techniques such as yoga, meditation, and deep breathing exercises. Light exercise should be gradually introduced to progressively restore the balance between the heart’s blood supply and demand (along with medication). Patients should also reduce alcohol intake and stop using tobacco as both substances contribute to arterial thickening. Diet changes are also vital; patients should limit salt, fat, and sugar and focus on maintaining a diet high in fibre and lean protein foods to lower blood pressure and blood cholesterol levels.  ^(6-7)

Outlook 

Angina can be treated with a combination of lifestyle changes and medical treatment. Healthy life changes include regular and gentle exercise, reduced alcohol and tobacco intake, and reduced stress. If left untreated, angina increases the risk of a heart attack, cardiac arrest, and stroke. ⁽⁷⁾ However, angina is easily managed if medical treatment is sought immediately after noticing the symptoms. Treatment of angina is continuously improving; according to the British Journal of Cardiology, there will be an estimated 36,000 fewer deaths from coronary heart disease conditions (including angina) by 2030. ⁽⁹⁾

Is it Angina or a Heart Attack?  

Angina and heart attack have many similar symptoms; however, several symptoms differentiate the two conditions. A myocardial infarction, commonly called a heart attack, occurs when there is a blockage in blood flow to the heart. ⁽⁷⁾ The blockage is commonly caused by the buildup of lipids, cholesterol, and cellular waste products within the body. ⁽⁸⁾  A heart attack shares many of the same symptoms as angina. However, compared to stable angina, heart attack symptoms do not resolve upon rest. Heart attacks last long enough to cause significant long-term damage to the heart if left untreated. Unstable angina and Prinzmetal angina are more serious forms than stable angina as they may lead to a heart attack. You should immediately seek medical attention if you are experiencing strong chest pain that does not resolve upon rest.  ⁽⁵⁾ 

When to Dial 999

If you are experiencing significant chest pain during exercise that does not resolve upon rest, you should immediately dial 999. Angina symptoms have a significant overlap with heart attack symptoms. Dial emergency services if you experience:

• A squeezing, pinching, or crushing pressure in the chest area that lasts for several minutes or occurs in waves
• Pain in the arms, back, neck, jaw, stomach
• Breathlessness
• Nausea
• Cold sweats
• Lightheadedness/ Faintness
•   Like angina, people AFAB are more likely to experience more stomach area symptoms such as nausea, vomiting, and stomach pain ⁽¹⁰⁾

Summary

Angina pectoris is a cardiovascular condition characterised by chest pain at exercise, or in advanced cases, at rest due to imbalanced blood flow to the heart. Its most common cause is coronary artery disease, a condition in which arteries stiffen and thicken. These arterial structural changes are amplified by angina risk factors: smoking, physical inactivity and chronic stress. A family history of heart disease also increases the risk of angina. Angina's common symptoms include chest pain, pins and needles sensation in the arms, chest, legs, and stomach, breathlessness, and fatigue. Healthcare providers may use several diagnostic and treatment methods to diagnose the condition and determine prognosis and treatment plans. Treatment involves medical intervention and changes in lifestyle such as maintaining a healthy weight, regular low-intensity exercise, and reducing the use of alcohol and tobacco. As angina and heart attack share several symptoms, it is important to seek emergency medical attention if you notice that symptoms last for several minutes or occur in intervals.