Angina Versus Unstable Angina

  • 1st Revision: Emma Soopramanien
  • 2nd Revision: Olivia Sowerby
  • 3rd Revision: Pranitha Ven MuraliLinkedin

What is Angina?

Angina pectoris is the medical term for chest pain caused by reduced  oxygenated blood flow to our cardiac (heart) muscles. Over time, plaque can build up within our arteries, causing them to become narrower and less flexible, restricting oxygenated blood flow. When this occurs in our coronary arteries, blood flow to our cardiac muscle is restricted, causing angina pain. According to statistics published in the journal ‘circulation’, angina affects approximately 6.2% of the global population.1 Whilst the condition itself is not normally life-threatening, angina does require medical attention and is considered a warning sign of cardiovascular disease.

Stable vs Unstable Angina: What’s the Difference?

Stable Angina

Stable angina is the more common type of angina. The condition requires immediate medical attention; however, it can normally be helped with medication and lifestyle changes. Those with stable angina will likely experience the following.

  • Chest pain triggered when the heart is required to beat faster e.g. during physical activity or when stressed
  • Pain that lasts around 5 minutes (no more than 15 minutes)
  • Pain that normally subsides when you rest or take medication

Unstable Angina

Whilst less common, unstable angina is the more severe type of angina. Unstable angina is considered as a medical emergency and requires immediate medical treatment. Those with unstable angina will likely experience the following:

  • May not be triggered by anything, making angina attacks much less predictable
  • Angina pain may be more frequent, severe and last a longer duration of time
  • Pain does not normally subside after rest or medication

Signs and Symptoms

Whilst the triggers and duration of symptoms differ between stable and unstable angina, both share similar signs and symptoms. As discussed previously, the main symptom of angina is chest pain. According to the American Heart Association, sufferers of angina describe their pain as ‘pressure, squeezing and/or tightness in their chest.2 Additionally, it is also common for those with angina to suffer from the following symptoms:

  • Nausea
  • Breathing difficulties
  • Pain in both arms, shoulders, jaw, back and neck
  • Feeling dizzy or lightheaded
  • Tiredness

Causes and Risk Factors

The primary cause of angina is coronary artery disease (CAD), which develops as plaque builds up within our coronary arteries, reducing blood flow to the heart and causing us to experience angina pain. Whilst CAD is considered the most common cause of angina, other risk factors can increase our risk of developing the condition.

Sedentary lifestyle - Research shows that those who lead a sedentary lifestyle are at a greater risk of suffering from angina than those who lead an active lifestyle.3 Sedentary lifestyles allow for an increased build-up of plaque within the coronary arteries, thus increasing the risk of CAD and angina.

Poor Diet- A diet high in saturated fats and sugary products has been strongly linked with an increased risk of angina.4 Consuming a poor diet directly aids the narrowing of our arteries, increases plaque build up within the coronary arteries and raises blood pressure/sugar levels, all of which increase the risk of suffering from angina and CAD.

Age- As we age, research has established our risk of angina naturally increases. Throughout life, our arteries begin to become narrower, less flexible and accumulate plaque build-up.5 Resultantly, studies have found that we become significantly more prone to angina after the age of 60.

Smoking- The National Heart, Lung and Blood Institute report that smoking can significantly increase the risk of angina as well as a wide range of other cardiovascular diseases.6 The nicotine found within cigarettes causes damage to our artery walls and inflames our blood vessels. Consequently, our coronary arteries become narrower and more prone to plaque build-up, increasing the risk of angina.

Complications

Unfortunately, in addition to the disruptive chest pain, those with angina may be at an increased risk of further cardiovascular complications, especially if their condition remains untreated. Here are some of the complications that someone diagnosed with angina could suffer:

Myocardial Infarction - Unfortunately, those with angina are at an increased risk of suffering from a heart attack.7 Over time, a reduced supply of oxygenated blood (myocardial ischemia) to our cardiac muscles causes them to become damaged, which results in a higher risk of a heart attack.

Ischemic Stroke - Statistics indicate that those diagnosed with angina are 5.4% more likely to suffer a stroke within 4 years of diagnosis than those without the condition.8 As a result of plaque build-up, oxygenated blood flow to the brain can become restricted, significantly increasing the risk of a stroke.

Heart Failure - Research has found that those with angina are 11% more likely to suffer from heart failure within four years of their diagnosis than those who do not have the condition.8 In heart failure, the heart becomes weak and unable to pump sufficient amounts of blood around the body. Angina increases our risk of heart failure in two ways. The condition increases our risk of suffering a heart attack, which consequently damages our hearts muscles. Additionally, angina restricts blood flow to the heart's muscles which can cause them to become weaker, reducing their ability to pump sufficient amounts of blood.

Psychological Distress - Whilst not a direct effect of having angina, studies have indicated that those with the condition may be at an increased risk of psychological distress. A recent study found anxiety to be prevalent in 8.8% of those diagnosed with angina.9 If you are diagnosed with angina and become distressed about your condition, reach out to your local GP for reassurance.

Diagnosis

According to the NHS, medical professionals may need to conduct multiple tests to diagnose an individual with angina.10 Here are some of the tests commonly used by medical professionals to diagnose the condition:

Questions - To begin with, medical professionals may ask simple questions regarding your symptoms, lifestyle, and family medical history.

Basic Health Testing - a GP may conduct blood pressure, cholesterol, and BMI testing to assess the probability of cardiovascular complications.

Coronary Angiography - X-ray images are taken off the cardiovascular system once a dye has been injected into the bloodstream, helping medical professionals identify narrowed and blocked arteries.  

Electrocardiogram - Small plastic patches (electrodes) are placed on different parts of the body, passing a painless electrical current around the body, allowing the heart's electrical activity and rhythm to be recorded.

Treatment

There are various treatments available to individuals who are diagnosed with angina. Treatments will help reduce chest pain and the risk of future cardiovascular complications such as heart attacks and strokes. The type of treatment prescribed to those diagnosed with angina depends on their condition and the type of angina they have. Here are some of the most common treatments prescribed to angina patients.

Glyceryl Trinitrate (GTN) - Medication prescribed as a spray or tablet. Patients should take GTN when suffering from an angina attack to help stop the pain.

Beta - Blockers/Calcium Channel Blockers - Prescribed to help reduce heartbeat and relax the arteries, helping prevent or reduce future angina attacks.

Aspirin - Prescribed alongside other medication such as statins and ACE inhibitors to lower blood pressure, relax arteries and prevent blood clotting, lowering angina patients’ risk of heart attacks and stroke.

Angina Management Programmes - Depending on your condition, your GP may prescribe you an angina management programme consisting of exercises, diet and various other lifestyle changes. Some programmes have been proven to reduce chest pain by as much as 70%11.

Surgery - If necessary, angina patients may need to undergo surgery if their condition can not be treated by medication; there are two main types of surgery for angina patients

  • Coronary Angioplasty and Stent Insertion - A stent is used to widen a narrowed artery, increasing blood flow.
  • Coronary Artery Bypass Graft - Blood is redirected around a blocked or narrowed artery using a blood vessel taken from another part of the body.

When to See a Doctor vs When to Dial 999

If you have not previously been diagnosed with angina, ensure you visit your local GP as soon as possible if you suffer any of the following symptoms. A medical professional can help diagnose your condition and suggest ways it can be managed.

  • Chest pain that subsides with rest
  • Feeling of pressure, tightness or squeezing within the chest
  • Feeling lightheaded or nauseous after physical activity

In the event of an imminent serious cardiovascular issue, such as a heart attack or stroke, symptoms will likely be more severe and require immediate medical attention. If you or someone near you is suffering from the following symptoms, call 999 immediately.

  • Chest pain that lasts longer than 5 minutes
  • Pain that spreads to other parts of the body (especially arms, neck, back and jaw)

Tips for Living with Angina

Thanks to medication and some lifestyle alterations, many of those diagnosed with angina can lead a normal life despite having the condition. Here are some of the lifestyle advice commonly prescribed to those diagnosed with the condition.

Physical Activity

Whilst those with angina may be apprehensive at the thought of partaking in physical activity, the British Heart Foundation report that exercise is safe for those with the condition.12 Research also indicates that physical activity can significantly reduce certain angina symptoms and decrease the risk of further heart complications such as heart attacks.13

  • Perform 150 minutes of moderate aerobic exercise per week (walking, cycling, swimming, jogging)
  • Slowly build up the intensity of your exercise sessions over time
  • Perform a gradual 10-minute warm-up and cool down before and after each session

Diet

Research shows us that consuming a healthy and balanced diet can help us manage angina symptoms, allowing us to lead a normal life.14 To reduce angina symptoms and the risk of suffering from more severe cardiovascular conditions in the future, ensure to incorporate the following when planning your meals:

  • Eat at least 5 portions of fruit and vegetables per day
  • Regularly consume whole wheat products (Brown bread/pasta/rice, barley, oatmeal)
  • Avoid products high in sugar (confectionery, dairy desserts and fizzy drinks)
  • Avoid foods high in saturated and trans fats (takeaways, confectionery, fatty cuts of meat, cheeses)
  • Minimise salt intake as much as possible

Work

In most cases, angina symptoms should have little to no impact on your ability to go to work. However, if your occupation consists of regular manual labour, it may be safer to speak to your employer about changing your role or reducing your workload. No matter your occupation, it is important to inform your employer of your condition and ensure you take your GTN medication to work so you are well prepared in the event of an angina attack.

Driving

For most individuals, angina does not prevent you from driving. The DVLA report that drivers are safe to continue driving provided their condition is well controlled.15 However, if angina occurs while at rest or is triggered by emotion, you should stop driving immediately until your condition is controlled. If you are unsure whether you are allowed to drive or not, be sure to contact your GP for clarification.

Summary

If you suffer from any of the aforementioned angina symptoms, book an appointment with your local GP as soon as possible. Treating the condition will allow you to reduce the amount of chest pain you experience and significantly reduce your risk of suffering from further cardiovascular complications.

References

  1. Hemingway, Harry, et al. ‘Prevalence of Angina in Women Versus Men’. Circulation, vol. 117, no. 12, Mar. 2008, pp. 1526–36. ahajournals.org (Atypon), https://doi.org/10.1161/CIRCULATIONAHA.107.720953
  2. ‘Angina (Chest Pain)’. Www.Heart.Org, https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain
  3. Ahmadi‐Abhari, Sara, et al. ‘Physical Activity, Sedentary Behavior, and Long‐Term Changes in Aortic Stiffness: The Whitehall II Study’. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, vol. 6, no. 8, Aug. 2017, p. e005974. PubMed Central, https://doi.org/10.1161/JAHA.117.005974
  4. Feingold, Kenneth R. ‘The Effect of Diet on Cardiovascular Disease and Lipid and Lipoprotein Levels’. Endotext, edited by Kenneth R. Feingold et al., MDText.com, Inc., 2000. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK570127/
  5. Rodgers, Jennifer L., et al. ‘Cardiovascular Risks Associated with Gender and Aging’. Journal of Cardiovascular Development and Disease, vol. 6, no. 2, Apr. 2019, p. 19. PubMed Central, https://doi.org/10.3390/jcdd6020019
  6. Smoking and Your Heart - How Smoking Affects the Heart and Blood Vessels | NHLBI, NIH. https://www.nhlbi.nih.gov/health/heart/smoking
  7. Mentz, Robert J., et al. ‘Comparison of Clinical Characteristics and Long-Term Outcomes of Patients With Ischemic Cardiomyopathy With Versus Without Angina Pectoris (from the Duke Databank for Cardiovascular Disease)’. The American Journal of Cardiology, vol. 109, no. 9, May 2012, pp. 1272–77. ScienceDirect, https://doi.org/10.1016/j.amjcard.2011.12.021
  8. Eisen, Alon, et al. ‘Angina and Future Cardiovascular Events in Stable Patients With Coronary Artery Disease: Insights From the Reduction of Atherothrombosis for Continued Health (REACH) Registry’. Journal of the American Heart Association, vol. 5, no. 10, p. e004080. ahajournals.org (Atypon), https://doi.org/10.1161/JAHA.116.004080
  9. Tsai, Ching-Ching, et al. ‘The Association between Psychological Distress and Angina Pectoris: A Population-Based Study’. PLoS ONE, vol. 14, no. 11, Nov. 2019, p. e0224451. PubMed Central, https://doi.org/10.1371/journal.pone.0224451
  10. ‘Angina - Diagnosis’. Nhs.Uk, 20 Oct. 2017, https://www.nhs.uk/conditions/angina/diagnosis/
  11. Babu, Abraham S., et al. ‘Exercise Based Cardiac Rehabilitation for Unstable Angina: A Case Report’. Oman Medical Journal, vol. 27, no. 2, Mar. 2012, p. e034. PubMed Central, https://doi.org/10.5001/omj.2012.42
  12. How to Exercise When You Have Angina. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/activity/exercising-with-a-heart-condition/exercising-with-angina
  13. Winchester, David E., and Carl J. Pepine. ‘Angina Treatments and Prevention of Cardiac Events: An Appraisal of the Evidence’. European Heart Journal Supplements : Journal of the European Society of Cardiology, vol. 17, no. Suppl G, Dec. 2015, pp. G10–18. PubMed Central, https://doi.org/10.1093/eurheartj/suv054
  14. Maxwell, Andrew J., et al. ‘Randomized Trial of a Medical Food for the Dietary Management of Chronic, Stable Angina’. Journal of the American College of Cardiology, vol. 39, no. 1, Jan. 2002, pp. 37–45. PubMed, https://doi.org/10.1016/s0735-1097(01)01708-9
  15. ‘Angina and Driving’. GOV.UK, https://www.gov.uk/angina-and-driving

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