Angina Right-Sided Chest Pain

Causes of right-side chest pain

Pain in any area of the body is a very uncomfortable symptom. In the chest, it can go beyond simply being uncomfortable to be scared, especially because it involves the heart (the organ responsible for circulating blood to keep the body alive). Although most cardiac-related chest pains are associated with the left side, sometimes right-sided chest pain can also point to cardiac issues including angina. Pain in the right side of the chest may originate directly from organs in-situ including; the right portion of the heart, the right lung, the esophagus, ribs, and the spine. For instance, acid reflux, a condition in which the sphincter muscle at the lower end of the esophagus relaxes at the wrong time, allowing stomach acid to flow back into the stomach could cause right chest pain.^1,2 

Infection of the lungs such as pneumonia could also cause right-sided chest pain. Sometimes, the pain could be due to muscle strain or even anxiety shingles which is a viral infection that causes a unilateral rash and tingling feeling on the right side of the skin and can be a source of right-sided chest pain. The pain can also be caused by other parts of the body. As can be seen from the aforementioned conditions, the causes of right-sided chest pain can vary from serious conditions involving the heart and needing urgent care from a medical specialist to benign conditions such as anxiety which can be self-managed in some instances.¹ Given this variability, it is important that one is able to determine when chest pain might be a pointer to serious causes such as angina and when to see a doctor.

Angina and right chest pain

The main symptom of angina is chest pain although it is possible to have angina without experiencing chest pain. According to NHS England, chest pain could be angina if it: feels tight, dull, or heavy, spreads to arms, neck, jaw, or back, is triggered by physical exertion or stress, and stops within a few minutes of resting.³

When to see a doctor 

If you experience new, unexpected or unexplained chest discomfort, it is important to see your healthcare provider to determine its cause. 

If after being diagnosed with stable angina, it gets worse, it is important to see your doctor immediately. Importantly, if your chest pain lasts longer than a few minutes and doesn't go away when you rest or take your angina medications, it may be a sign you're having a heart attack. Therefore call for emergency medical help.⁴

Is it a heart attack?

Although angina is relatively common, it can still be hard to distinguish from other types of chest pain, such as the discomfort of indigestion.⁵ Equally, angina and a heart attack have similar symptoms, but a heart attack is life-threatening.³ It is therefore important that one gets an urgent medical appointment after an attack of chest pain that spreads to the arms, back, neck, or jaw associated with a feeling of tightness or heaviness, shortness of breath or sweating, and vomiting, and lasts more than fifteen minutes.⁵

What is angina?

According to NHS England, angina is chest pain caused by reduced blood flow to the heart muscles which is a symptom of coronary artery disease. It is not life-threatening, but it is a warning sign that one could be at risk of a heart attack.¹ Angina pain is often described as squeezing, pressure, heaviness, tightness, or pain in the chest. It may feel like a heavy weight lying on the chest. It is the main symptom of myocardial ischemia (which means reduced blood flow to the heart muscles). The pain happens following a blockage in the vessels supplying blood to the heart called the coronary arteries.⁵ This reduction in blood flow leads to reduced oxygen delivery to the heart muscle. Thus, during periods of stress or increased activity where the blood supply to the heart is expected to increase accordingly as the heart muscles are in greater need of oxygen, the reduction in blood flow caused by the blockage leads to myocardial ischemia and thus the experience of chest pain and other symptoms. Thus, angina is said to be brought on usually by physical exertion or emotional stress.  

Types of angina 

There are many types of angina depending on the cause and whether rest or medication relieves symptoms. However, stable and unstable angina are the two main types. Stable angina involves attacks that have a trigger (such as stress or exercise) and stops within a few minutes of resting and unstable angina involves attacks that may occur without a trigger and can continue despite resting.⁶ 

 Stable angina is the most common form of angina. It usually happens during activity (exertion) and goes away with rest or angina medication. For example, pain that comes on when you're walking uphill or in cold weather may be angina. It is predictable and usually similar to previous episodes of chest pain. The chest pain typically lasts a short time, perhaps five minutes or less.

Unstable angina is more severe, and unpredictable, it can occur at rest or the angina pain is worsening and occurs with less physical effort. It usually lasts longer than stable angina. The pain doesn't go away with rest or the usual angina medications. It lasts longer; sometimes persisting for up to twenty minutes. Persistent reduction in blood flow to the heart muscle can lead to the death of tissues in that portion of the heart resulting in a heart attack. Unstable angina is a medical emergency and requires urgent treatment.

Other types of angina include: 

Variant angina (Prinzmetal angina): Which is caused by a spasm in the heart's arteries that temporarily reduces blood flow to the heart. Severe chest pain is the main symptom of variant angina. It most often occurs in cycles, typically at rest and overnight. The pain may be relieved by angina medication.

Refractory angina: This is an instance in which angina episodes are frequent despite medications and lifestyle changes.⁷

Signs and symptoms 

The classic angina symptoms include chest pain which could be sharp or stabbing, that spreads to the arms, neck, jaw, or back triggered by physical exertion or stress and stops with rest. Some people, especially women can have atypical symptoms in addition to chest pain, such as gastrointestinal discomfort or abdominal pain, breathlessness, or nausea. These can sometimes cause delays in seeking care.⁷

Causes and risk factors 

Angina is usually caused by the narrowing of the arteries supplying blood to the heart muscles due to a build-up of fatty substances which is called atherosclerosis. Several factors have been found to increase the risk of atherosclerosis.⁷ A risk factor is something that increases one’s chance of getting a disease. 

Some risk factors are called modifiable because you can do something about them. There are other risk factors, called non-modifiable, which you can’t change. Modifiable risk factors include smoking, high blood pressure, diabetes, physical inactivity, being overweight, and high blood cholesterol. Non-modifiable risk factors include age, ethnic background, and family history of heart disease. In spite of the presence of non-modifiable diseases, it is still possible to reduce the risk of having the condition if an individual controls the modifiable risk factors substantially.⁸

Research has shown that the older you are, the more likely you are to develop cardiac events such as angina. South Asians living in the UK were found to be twice as likely to develop coronary heart disease compared to the rest of the UK population. Also, people from African Caribbean backgrounds have a higher average risk of developing high blood pressure. Having a first-degree relative diagnosed with angina before age 55 can also increase one’s risk of angina.⁸

Stress is not considered to be a direct risk factor. However, the manner in which an individual handles stress can contribute to risk factors that can predispose to angina. For instance, some people adopt less healthy behaviors, such as smoking, drinking too much alcohol, and overeating which can lead to obesity thereby increasing their risk of angina.⁸

 Management and treatment

Angina can be managed medically. The aim is to stop or minimize symptoms, improve quality of life and reduce the risk of fatal complications. Management options include drug treatment and invasive/surgical options.

Medications can be used to treat angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular diseases such as heart attacks or strokes. Short-acting nitrates are used for preventing and treating acute episodes of angina. Beta-blockers or rate-limiting calcium channel blockers (diltiazem or verapamil) are recommended as initial therapy with the objective of improving symptoms. These are effective in reducing myocardial oxygen consumption, as a result of lowering heart rate, myocardial contractility, and blood pressure, together with increasing coronary blood flow and myocardial oxygen supply.⁴ 

In some cases, patients with stable angina due to atherosclerotic disease are given low-dose aspirin and a statin. For those living with diabetes, treatment with ACE inhibitors is also considered.

Invasive or surgical options such as revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI] are considered for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. Before this is offered, coronary angiography is carried out to assess the state of the coronary arteries. Additional non-invasive or invasive functional testing may also be required to evaluate angiographic findings and guide treatment decisions.⁴

Prevention

Adopting a healthy lifestyle can help to prevent angina to a certain extent. Important changes to make include; having a balanced diet, cutting down on alcohol, avoiding smoking, losing weight if overweight, and exercising regularly.⁷ 

The optimal management of comorbidities, including hypertension, diabetes, and renovascular disease is important in modifying the atherosclerotic disease process and improving outcomes.5 Regular screening is encouraged to prevent the development of risk factors or monitor progress in the event that an individual has already developed it. Screening means examining or checking a person for a disease. For angina, the measurements that you can check that affect your risk are waist measurement, weight, blood pressure, blood cholesterol level, and blood sugar level. 

Summary

In summary, angina is a condition caused by reduced blood flow to the heart muscles. It is often described as squeezing, pressure, heaviness, tightness, or pain in the chest although it may also present with atypical symptoms. There are two main types such as stable and unstable angina. Both are associated with modifiable risk factors such as obesity, smoking, and hypertension and non-modifiable risk factors such as family history, older age, and ethnic origin. Management options include medical options including the use of anti-anginal medications which can help to achieve control in mild to moderate cases. For severe cases, there may be a need for surgical options such as neovascularization. Having a balanced diet, cutting down on alcohol, avoiding smoking, losing weight if overweight, and exercising regularly can help to reduce the risk of angina. The optimal management of comorbidities, including hypertension, diabetes, and renovascular disease is important in modifying the atherosclerotic disease process and improving outcomes.