Angina That Is Worse After Eating

Overview

Have you ever experienced prolonged abdominal pain after eating? Have you tried to take an antacid like Bismuth subsalicylate, after eating to soothe your pain, but with no resolution? You may be experiencing a form of angina called abdominal angina. 

Angina is the name used for a condition where blood flow is reduced to the heart due to blockages in blood vessels, in turn causing pain through stimuli such as exercise or eating heavy meals.^1,2 Angina of the abdomen is similar in that blood vessels in the gut are unable to carry the required amount of oxygen to the digestive system- the stimulus here is not exercise, but a meal. As abdominal angina has symptoms which can be confused with Gastro-oesophageal Reflux Disease (GORD), it is important for patients to understand the differences and when specific symptoms should be reported to their doctor to get a proper diagnosis. 

What is angina?

The chest pain you experience as an angina sufferer is the most common symptom therefore very tiresome for anyone suffering from this condition.¹ Angina is diagnosed when the normal supply of oxygen, which is transported in your blood, to your heart is reduced hence the pain. Angina is a common symptom of Ischemic Heart Disease (IHD) or Coronary Artery Disease (CAD) common terms that are used in medicine to discuss the narrowing of some veins and arteries around your heart.² This narrowing of your veins and arteries is caused by a build-up of fatty substances (atherosclerosis) high cholesterol is one of the causes.¹ Angina can be divided into two types: stable also known as angina pectoris, and unstable angina. 

Signs and symptoms

The main sign of angina is chest pain below the sternum bone pain in the centre of the chest. It gets worse during exercise, anxiety or emotional and mental stress. It typically lasts longer than 30-60 seconds and goes away when you rest or use nitroglycerin.¹ The pain can start to go down your back, up into your neck and even into your jaw. It can go on for 5-15 minutes and sometimes feels like burning or aching.¹ 

Causes and risk factors

When the blood flow to your heart is reduced, the heart has to work harder to get oxygen and, in turn, chest pain happens. There are a few different causes of angina, with IHD or CAD being the main culprits. The others are:¹  

• Cardiomyopathy – Weakened heart muscles, sometimes this is genetic
• Valve disease – When the heart valves don’t work properly
• Aortic Stenosis – When the aortic valve, the plug that helps blood leave the heart to the rest of the body, gets smaller and blood can’t flow through properly³

These are all conditions that your doctor can diagnose and manage with you. 

The main lifestyle risk factors that you can alter, for angina, are as follows:

• Alcohol use – unstable angina
• Illegal drugs use – can cause damage to the blood vessels
• Lack of physical activity
• Smoking tobacco or secondhand smoke exposure
• Stress
• Unhealthy eating habits – high quantities of saturated fat and added sugars. A Heart Healthy diet is recommended to decrease your chance of developing CAD

Other risk factors, that are not altered by your lifestyle, are:

• Age – as you get older the chances get higher
• Family history or genetics – some people have angina that runs in their family or some people develop it with no risk factors purely through genetics
• Environment – This can be due to air pollution, specifically particle pollution dust, farms, construction sites or mines
• Occupation – A job that exposes you to radiation, high levels of stress or long periods of standing and sitting 

Angina attacks after eating

Some people can experience prolonged attacks of abdominal pain after eating. This is referred to as Abdominal Angina.⁴ 

How does eating cause angina symptoms?

In a typical person, when they eat, the food enters the stomach and then the gut and causes the need for oxygen in the gut to increase. The average person eats and is not aware of this process as no pain is felt after their meal.

However, someone with abdominal angina experiences abdominal pain, and lower back pain, in some cases, after eating. This pain occurs between 30 and 90 minutes after a meal and is also known as postprandial pain.  It can continue for up to 4 hours.⁵ A person with these symptoms, usually has some blood vessels in the gut which are partially blocked and thus the blood cannot flow properly to the stomach and intestines. This then means the gut is not receiving the oxygen it needs to digest your food. At the beginning of this condition, the pain is minimal but, after some weeks, it becomes severe.⁴ When this condition goes on for a while, the gut can become damaged and other symptoms can occur, such as diarrhoea, protein and fat loss in faeces (poo) and weight loss. 

The main risk factors for this condition, according to The Society for Vascular Surgery,  are:

• Gender – being assigned male at birth (AMAB)
• Smoking 
• High blood pressure
• High cholesterol
• Obesity
• Lack of physical activity
• Stress 

Effects of eating on the cardiovascular system

When we eat, our heart needs to work to provide blood to our digestive system, which then breaks down our food. This is a natural process which happens in our bodies every day, often without you noticing too much. However, if you eat a big meal or a meal full of more calories than you need, this can put pressure on your heart. When you overeat - especially meals full of fat, the amount of blood needed in the gut increases, as well as the expansion of your stomach. All in all, this causes the heart to work harder, and if you have a diagnosis of angina, this can lead to pain as blood flow is already reduced in important vessels. 

Postprandial angina vs GORD

Although abdominal angina causes pain after eating, it is not the most common cause. A more likely cause of discomfort after eating is gastroesophageal reflux disease (GORD). These two conditions are very different and it is important to understand the differences.^5.

What is GORD?

GORD is a condition where the contents of the stomach can rise up the gullet (oesophagus) and cause troublesome symptoms. In Western countries 10 % to 20% of adults experience GORD symptoms weekly – the main symptoms are regurgitation and heartburn.^5,6 Although swallowing difficulties can occur, this is a symptom that requires more investigation by your doctor. 

Other symptoms of GORD are:⁵

• Chest pain 
• Nausea
• Bloating
• Sore throat
• Stomach pain
• Sour, acidic taste in the mouth

It is the presence of undiagnosed chest pain, that requires a cardiac evaluation to rule out any other causes. 

What are the differences?

So, what are the main differences between postprandial angina and GORD?

GORD symptoms are likely to start soon after eating 5-15 minutes, unlike postprandial angina which takes around 30-90 minutes after eating to start. The type of pain can also be different as GORD is associated with acid reflux. Therefore a burning sensation occurs rather than abdominal pain in the lower quadrants.⁷

The other main symptoms of GORD, that differ from postprandial angina, are:

• Some food travelling up the gullet, but not necessarily vomiting
• Bringing up bitter-tasting fluids
• Feeling full
• Feeling bloated 

With regards to the duration of pain experienced in the two conditions, postprandial angina pain lasts longer, up to 4 hours, and the pain can become severe. GORD discomfort caused by acid reflux should, theoretically, respond to antacids.⁵

If a person experiencing postprandial angina for the first time were to take an antacid to relieve abdominal pain, it would not have any effect as acid is not one of the causes of pain in this condition.⁴ 

When to call a doctor

In general, the overlapping symptoms of GORD and abdominal angina mean that patients should pay special attention to the type of pain experienced. 

If you have no angina pectoris or abdominal angina diagnosis, you must make an urgent GP appointment when you have:

• An attack of chest pain that stops within a few minutes, or pain which occurs 30-90 mins after eating and remains for up to two hours

Other symptoms which require urgent medical attention that can be related to these two conditions are:

• Dysphagia- difficulty swallowing
• Blood in the stools or vomiting blood
• Inability to eat food

You must call an ambulance when you have:

• A sudden attack of chest pain, which does not resolve after a few minutes

If you do have a diagnosis of angina pectoris, abdominal angina or GERD, then urgent medical attention should be sought when you feel your condition, e.g. your pain has worsened to a point where you are unable to go about your normal daily life. Any presence of fever with confusion, or a rash, would also require medical attention. 

As with all diagnosed conditions, your GP will provide you with the information you need to understand if you should call an ambulance or call your doctor.

Summary

As well as angina pectoris being aggravated by a meal, another type of angina that is only exacerbated by meals is abdominal angina. This condition arises when the main blood vessels in the gut have reduced blood flow, often due to atherosclerosis (fatty deposits). 

This condition can present with similar symptoms to another condition known as GORD. The main similarity is chest and abdominal pain, which starts after eating. However, GORD pain normally starts much more quickly after a meal. 

With any severe chest or abdominal pain, it is important you seek urgent medical attention when you have severe pain that has not been previously diagnosed. If you have been diagnosed with angina or abdominal angina, and your pain becomes much worse or more debilitating than before, you should seek urgent medical attention.