Angina That Comes And Goes

Angina (also known as angina pectoris) refers to chest pain related to the heart, and usually has a fluctuating pattern. There are varying types of angina, which we will go on to explore in this article!

Understanding angina

Angina (aka angina pectoris) is the name of a symptom. When we talk about angina, we are talking about chest pain originating from the heart that is sudden in onset and only lasts for a short time. Angina is usually a precursor, or a warning sign, of problems with the blood flow to the heart. Certain conditions are linked with angina, including coronary heart disease (aka coronary artery disease or ischaemic heart disease), heart failure, and acute coronary syndrome. 

A restriction of blood flow to the heart muscle causes angina. In a healthy heart, the coronary arteries supply the tissue with oxygen-rich blood, which is essential for the heart muscle to function correctly. If this supply is interrupted, the heart will suffer, and one of the ways it signals that to us is through pain. There are four categories of angina: stable, unstable, variant, and microvascular. 

Stable angina

Stable angina refers to angina that occurs on exertion. This can be triggered by various things, including

• Exercise
• Cold weather
• Stress (including emotional stress)

Stable angina occurs only after a trigger (as described above). It usually settles once you remove the triggering event. For example, if the trigger was exercise, having a short break from working out would help resolve the chest pain. Stable angina usually occurs for a few minutes and will resolve by itself within a similar time frame. 

Unstable angina

Unstable angina refers to angina that occurs with no trigger. This is also referred to as angina that occurs ‘at rest’ because there is no identifiable cause. This form of angina is more serious than stable because it means that the heart struggles to get oxygen-rich blood even when there are no stressors. Someone can have stable angina that becomes unstable over time. 

Variant angina

Variant angina is a less common form of angina caused by a coronary artery spasm. A coronary artery spasm is when the blood vessels supply the heart suffers a temporary tightening or narrowing. Variant angina occurs at rest and does not usually have a specific trigger.  There can be varying causes for this, such as:

• Stress (including emotional stress)
• Cold weather
• Drug use (e.g. cocaine and heroin)
• Heavy smoking

Microvascular angina

Microvascular angina is caused by non-obstructive coronary artery disease. This is when the blockage, or coronary spasm, occurs in tiny blood vessels. This form of angina is a relatively new concept in the medical world.¹ The exact cause or trigger for microvascular angina has not been empirically identified. However likely causes include

• Damage to the lining of the small blood vessels, leading to the formation of a small blood clot in the area that reduces blood flow
• Spasm of the smaller blood vessels

Angina signs and symptoms 

The signs and symptoms for angina are largely the same. The main difference between stable and unstable angina is that unstable angina has no identifiable trigger. Signs and symptoms include

• Sudden chest pain or chest discomfort - this can feel dull, tight, or be a sharp pain
• Pain that radiates down left arm or up to your jaw
• Exercise intolerance due to pain
• Breathlessness or shortness of breath
• Dizziness 
• Nausea 
• Fatigue 

Does the pain come and go 

Anginal pain comes and goes when you have stable angina. The pain felt during a stable angina attack is short-lived and will come and go. If the pain is ongoing and not resolving, it is likely to be something else (such as acute coronary syndrome or a heart attack). 

In the case of unstable angina, the pain is likely to be long-lasting and may not fully resolve. Unstable angina can often be a precursor to a heart attack and should be taken seriously. If there is ongoing chest pain, you should seek medical attention from a healthcare provider as soon as possible. 

Causes of angina

There are various causes of angina. Angina occurs when there is a restriction of oxygen-rich blood flow to the heart, which a variety of conditions can cause can. These can be split into medical conditions that cause angina and risk factors that can increase the chances of developing angina. Medical conditions that are associated with angina include

• Coronary heart disease
• Heart failure
• Problems with the valves in the heart
• Coronary artery spasm
• Imbalance of hormones in the blood (e.g. thyroid hormone levels)
• High blood pressure
• Diabetes 
• Hypercholesterolaemia (high levels of cholesterol in the blood)

Risk factors

When thinking about risk factors for any condition we should look at the risk factors we can control (modifiable), and those that we can’t (non-modifiable). The modifiable risk factors for angina include:

• Smoking
• Alcohol intake
• High blood pressure
• High level of cholesterol in the blood
• Sedentary lifestyle 
• High-fat percentage in your body mass 

Non-modifiable risk factors include:

• Gender - those who are born male have a higher risk of developing problems with their heart health
• Age 
• Family history of cardiovascular disease

Complications 

So we understand that when angina is occurring, it’s our heart’s way of saying ‘hey, I need more oxygen please’! As such, angina is often considered a warning sign or an indicator that we need to reassess our heart health. If left unaddressed, complications canoccur due to the worsening of the situation. Examples of complications that can occur include:

• Heart attack - angina pain is similar in pathophysiology to that of a heart attack
• Coronary heart disease - this is a condition in which there is a blockage of the blood supply due to there being a narrowing in the coronary arteries 
• Heart failure - this refers to long-term damage to the heart muscle which makes the heart function at suboptimal levels, therefore decreasing the amount of blood the heart can pump to the rest of the body
• Stroke - this is when there is a blockage to the blood supply to the brain, causing damage to the brain tissue

How can I reduce the pain 

The pain that originates from most types of angina can be resolved by resting and removal of the trigger. So, for example, if you are taking a walk and you notice that you are getting chest pain, you could sit down for a few minutes to allow your heart to flow more blood. After a few minutes of rest, angina should resolve. Regular exercise and maintaining a healthy lifestyle will also help decrease the heart load. 

If you have been diagnosed with any form of angina, your healthcare provider should have prescribed certain medications. Medication that can help with an angina attack include

• Glyceryl trinitrate (GTN) - this can come as either a spray or a tablet placed under the tongue and dissolves (sublingual). This is used during the angina attack to help the coronary arteries dilate, therefore supplying the heart with more oxygen-rich blood
• Aspirin - helps to thin the blood and can reduce the risk of a blood clot forming

Tips to prevent and manage angina

As mentioned earlier, there are modifiable risk factors that can be addressed to decrease the likelihood of someone suffering angina and decrease the risk of angina progressing to more serious complications. Things you can alter in your lifestyle include:

• Stop smoking - smoking is a massive risk factor for cardiovascular disease
• Reduce alcohol intake
• Exercise frequently, as recommended by the British Heart Foundation 
  • 150 minutes of exercise a week²
  • Remember to warm up slowly to allow your heart to adjust to the exercise
  • Try not to push yourself too much, start slow and build up from there over time
  • Stop exercising if you are experiencing chest pain, or if there is chest pain at rest
• Ensure you do not have too much salt in your diet - the recommended amount is no more than 6g/day for adults
• Reduce the number of saturated fats in your diet

Other ways of preventing angina is through medication:

• Beta-blockers (such as bisoprolol) - this is a preventative medication for those with a diagnosis of angina. Beta-blockers help to slow down the heart rate and allow the heart to beat with less force, therefore reducing the strain on the heart
• Calcium channel blockers (such as verapamil) - this is a preventative medication for those diagnosed with angina. Calcium channel blockers help to relax blood vessels, therefore causing an increase in the amount of blood reaching the heart tissue
• ACE inhibitors (such as ramipril) - these are designed to help lower your blood pressure

Alongside the prevention of further angina attacks, your doctor may consider preventative treatment to reduce the risk of any complications occurring. This can include:

• Anti-coagulation medication (such as clopidogrel) - these medications reduce the risk of a blood clot forming, therefore reducing the risk of a blockage caused by blood clots
• Low-dose aspirin 
• Medication for high blood pressure - various medications can be used to treat high blood pressure; if you are concerned about having high blood pressure speak to your healthcare provider for an assessment and further management options
• Statins (such as atorvastatin) - statins are used to reduce the level of cholesterol in your blood, therefore reducing the risk of a blockage being created by them in the coronary arteries

Sometimes medical management doesn’t work, and angina can persist even with pharmaceutical intervention. In this case, you may be offered surgical options, which can include:

• Coronary artery bypass grafting
• Coronary angioplasty and stenting

When to seek medical attention 

Understandably, when we think about a sudden, sharp chest pain, most of us will be concerned about heart attack. If you experience sudden onset chest pain out of the blue, it is important to get urgent medical attention, as there is no way of knowing what is going on until you have been assessed. Angina is one of the many causes of chest pain, and without assessment, it is impossible to know what the cause of the chest pain is!

For those who have had a diagnosis of angina in the past and have GTN spray/tablets handy, it is recommended to use those. If the pain is not resolving despite using these interventions, then it is important to seek urgent medical advice as it could mean the angina is progressing to a more serious acute coronary syndrome. 

Summary

There are varying forms of angina; some angina that comes and goes and some that persists. It is important to remember that most forms of angina are a warning sign that there is some level of blockage to the blood supply of the heart. That could be in the form of coronary artery disease, spasms or other causes for blockage. Either way, it is important that if you are suffering from chest pain that comes and goes you should consult with your healthcare provider urgently. If you are suffering from angina then there are ways to optimise your heart health and reduce the risk of suffering from complications. 

If you experience chest pain that doesn’t resolve through rest or medication then you must seek medical attention straight away. Even if you experience angina that comes and goes it is really important to be seen by a doctor in order to best manage the angina, and to prevent any complications.