Angina When Waking Up


What is angina?

Angina Pectoris is a sharp chest pain that arises when the blood supply that enriches the heart muscle walls with oxygen and nutrients is limited. The heart relies on its blood supply to grant the muscle enough energy to pump and spread blood around the body, keeping you alive. Partial inhibition of the blood flow to your heart means that it cannot pump as efficiently. This causes stress to the heart muscle, symptomatically manifesting as chest pain. Angina episodes are transient, only lasting a few minutes and can be relatively harmless. However, experiencing chest pain can panic most people and for good reason as it often mimics the pain of a heart attack. Angina is often a warning sign for potential future cardiac emergencies like heart attacks because the same mechanisms that limit the heart's blood supply can block it completely and result in cardiac arrest.

Symptoms of angina

Angina’s defining symptom is chest pain, which can be a dull ache or a tight gripping pain. Amongst different patients, symptoms can vary. Angina pain can also spread to your arms, neck, jaw, back or stomach. Patients suffering from angina can experience nausea, breathlessness, dizziness, light-headedness and sweating. These symptoms should ease after a few minutes of rest, or if you have been diagnosed with angina before, after taking prescribed nitrate (GTN) medicines.

What causes angina?

There are many different mechanisms by which the heart's blood supply can be constrained, causing angina. Angina most commonly presents itself as a repercussion of coronary heart disease (CHD). CHD sees an accumulation of fatty substances that are deposited on the inner arterial walls reducing their diameter, meaning less blood can be transported through them. The fatty blockages are formed in response to vessel wear and tear from high blood pressure or an unhealthy lifestyle, increasing the substances in the blood like cholesterol that makes up these fatty plaques. The more these vessels get blocked the more severe the angina experience will be and the more at risk you will be of a heart attack. Upon physical activity or stress, the heart's demand for blood is larger as it must pump harder and faster. Therefore, most angina cases occur when the arterial narrowing means the blood supply isn’t sufficient enough to keep up with the heart’s exercise-triggered high energy demand. These cases explained by this are called stable angina episodes, where the pain occurs at an expected time.

Causes of angina when waking up

This does not explain experiencing angina when waking up, however. In the morning, most people are in a state of rest and the heart and blood vessels are not under stress, so what is the explanation for angina at this time?

 Unstable angina is a condition that presents as unexpected chest pain when a person is resting. It is caused by CHD too, the fatty plaques that are blocking the arteries can spontaneously rupture, so a blood clot must form in response as a temporary fix.1 While this has a fixative intention, blood clots will cause much worse damage, further blocking the artery to limit blood supply to the heart and cause angina.

Risk factors for unstable angina include:2

  • Smoking
  • Dehydration
  • High cholesterol 
  • Unhealthy diet
  • Diabetes
  • Sedentary lifestyle
  • Stress
  • Drinking excess alcohol
  • Getting little sleep

Alternatively, vasospastic angina is a condition that could explain waking up in the morning with chest pain. This usually occurs at rest when the heart isn’t working hard or under stress. This occurs more randomly when there's spasm and constriction of the coronary arteries supplying your heart, limiting the blood supply to the heart and causing chest pain.3 CHD can make this condition worse, already narrowing the blood vessels and making them more susceptible to stress.

There is not one pinpointed cause of vasospastic angina but triggers can include:4

  • Magnesium deficiency
  • Mental stress
  • Anxiety
  • Extremely cold weather
  • Hyperventilation
  • Severe allergic reactions
  • Beta-blockers
  • Inflammation of arterial wall muscle
  • Smoking
  • Some antidepressants
  • Some anti-migraine drugs
  • Some chemotherapy drugs
  • Migraines
  • Cocaine use
  • Alcohol consumption
  • Adrenaline and noradrenaline release

Types of angina

The three main types of angina are stable angina, unstable angina and variable angina (vasospastic angina resides in this category).

Understanding angina when waking up

Diagnosis and treatment

To diagnose angina, medical professionals can use an ECG to look for any irregularities in the heart's beating pattern due to damage from reduced blood flow. The “gold standard” diagnostic method is undertaking a coronary angiogram to image coronary arteries directly using x-ray imaging. This is used to observe where the arterial blockage is, how severe it is and what type of obstruction it is to diagnose the patient and differentiate the type of angina they have.5

With the aim of widening the arteries to increase blood flow to the heart and compensate for arterial blockage, you can treat angina cases using nitrate-based medicines like GTN spray and calcium channel blockers. These drugs act to relax the arterial muscle walls so that they dilate, increasing the heart's blood supply. Unstable angina patients are at risk of blood clots blocking their arteries so are recommended certain medicines to stop clotting, this includes aspirin and blood thinning injections. Unstable angina can be treated using surgical intervention, widening the blocked artery with a stent or balloon (a coronary angioplasty). Additionally, surgeons can reroute blood flow to the heart, avoiding the blocked artery to maintain optimal blood supply (coronary bypass).6


As with all coronary heart diseases, heart health depends on many environmental factors. Therefore, aiming for a healthy lifestyle will put you in the best position to prevent all types of angina. 

Steps to take for better heart health include:

  • Maintaining a balanced healthy diet
  • Increasing your physical activity habits
  • Managing day-to-day stress and anxiety
  • Stopping smoking
  • Limiting alcohol intake
  • Avoiding other mentioned angina risk factors

If you have already been diagnosed with angina, you can use nitrate-containing medicines in a preventative way, before an attack, not just to ameliorate the severity of episodes when they arise. 

When to consult a doctor

The symptoms of angina and a heart attack are very similar. So, you must know when to contact urgent medical attention. Angina chest pain is normally short-term, therefore if the pain goes on for over five minutes, contact an ambulance immediately, you may be having a heart attack. If you have already been diagnosed with angina, you should be able to manage your symptoms with prescribed nitrate medicines to ease an attack. Though, if this does not ease the discomfort or you notice symptoms worsening contact an ambulance briskly. Unstable angina from a blood clot appearing in your cardiovascular system should be treated as a medical emergency, however, you will not know what type of angina you have or if your symptoms are even due to angina at all unless you get diagnosed. Therefore, even if the pain passes quickly after an angina-like episode, contact your GP for medical advice and to arrange tests to illuminate your condition. Early detection puts you in the best position for cardiac emergency prevention.


This article was written to arm you with the proper understanding of your morning chest pain and hopefully push you to search for a diagnosis. Increasing your awareness of angina is important so you can distinguish not only between each angina subgroup but make the fine distinction between angina and a major cardiac event. The only way to rid some of the fear that surrounds experiencing chest pain is by being in the know, so let this article prompt you to take charge of your health by maintaining a healthy lifestyle and forming a good connection with your GP, should something worrying occur.


  1. Yeghiazarians Y, Braunstein JB, Askari A, Stone PH. Unstable angina pectoris. New England Journal of Medicine. 2000 Jan 13;342(2):101-14.
  2. Ford TJ, Berry C. Angina: contemporary diagnosis and management. Heart. 2020 Mar 1;106(5):387-98.
  3. Beltrame JF, Crea F, Kaski JC, Ogawa H, Ong P, Sechtem U, Shimokawa H, Merz CN, Coronary Vasomotion Disorders International Study Group. The who, what, why, when, how and where of vasospastic angina. Circulation Journal. 2016 Jan 25;80(2):289-98.
  4. Picard F, Sayah N, Spagnoli V, Adjedj J, Varenne O. Vasospastic angina: A literature review of current evidence. Archives of cardiovascular diseases. 2019 Jan 1;112(1):44-55.
  5. Kloner RA, Chaitman B. Angina and its management. Journal of Cardiovascular Pharmacology and Therapeutics. 2017 May;22(3):199-209.
  6. Participants RT. Coronary angioplasty versus coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial. The Lancet. 1993 Mar 6;341(8845):573-80.
This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Frankie Perrett

MSc Molecular Medicine and BSc Biological Sciences – University of East Anglia, Norwich

Frankie works in an NHS Hospital Pathology laboratory so has acquired excellent insight into many different diseases and their mechanisms of action.

Frankie’s Master’s course focused on key areas of biomedicine, centring around patient-first learning. In her degree, she specialised in Lung adenocarcinoma and its mechanisms of cell communication.

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