Can Angina be Relieved by Rest?

What is angina?

Angina pectoris, known more commonly as angina, is a type of chest pain or discomfort caused by reduced blood flow and oxygen to the heart.

The blood is responsible for circulating oxygen and nutrients. Hence this reduced blood flow leads to the heart getting inadequate amounts of oxygen and nutrients, which are needed by the heart muscles to perform their function. At rest, the oxygen demand is low. Thus the heart muscle may still be able to work with the decreased blood supply it gets without triggering angina symptoms except in the case of unstable angina, However, during times of high oxygen demand — when exercising, for example — the blood supply to the heart muscle becomes inadequate, this leads to angina. 

Angina is not a disease, but rather, it is the most common symptom of ischaemic heart disease, which is a primary cause of morbidity and mortality globally.

Angina has four main types

• Stable
• Unstable
• Prinzmetal(Variant)
• Microvascular

Here are the tips that could help you differentiate which type of angina you may be suffering from

Stable

You have stable angina if you experience angina symptoms only upon physical exertion. It may feel like gas or indigestion.

It is predictable and doesn't come as a surprise, the episodes are similar. It lasts a short time, and you get relieved when you rest or take medicine,

Triggers 

• Emotional stress
• Very hot or cold temperatures 
• Large/Heavy meals
• Smoking

Unstable

Angina symptoms are present when you have light physical activity and even at rest, this requires more prompt management and treatment

It is not predictable, it lasts longer than stable angina.  Rest or medications usually won't give you relief. It may get worse over time and might lead to a heart attack; hence it is a medical emergency.

They are caused by clots/plaque that blocks the flow of blood in the coronary artery

Variant

This type of angina is not common, you may experience it at rest or at night. it is caused by coronary artery spasm

Triggers

• Exposure to very cold weather
• Stress
• Drugs that constrict or narrow blood vessels
• Smoking
• Recreational/street drug use

Microvascular angina

This type of angina is a symptom of coronary microvascular disease. It is usually more severe and lasts longer than other types, it can last up to 10 to 30 minutes

It may present with Fatigue, shortness of breath, and inability to sleep.

Triggers

• Usually during daily routine activities
• Emotional stress

Causes and risk factors (Briefly)

Angina is primarily caused by a shortage of blood flow to the heart.  

Angina could be symptom of;

Coronary artery disease (CAD); This is the most common cause of angina It is when plaque (a fatty wax-like substance) builds up and narrows or blocks the coronary artery. Myocardial ischemia results when the heart can't get enough oxygen and nutrients due to plaque buildup, this leads to chest tightness or discomfort (angina) CAD can also be referred to as ischaemic heart disease or coronary heart disease.

Coronary microvascular disease is when the tiny arteries that branch from your coronary artery are damaged. It doesn't lead to blockage but affects the blood flow to the heart, leading to microvascular angina. Females are at higher risk for this disease than males.

Coronary artery spasm: This may affect large or small coronary arteries, damage to these coronary arteries can cause them to spasm(to tighten and then open up repeatedly) which narrows the artery, temporarily reduce blood flow, and can cause angina, coronary spasm can occur in the absence of coronary artery disease its risk factors are high blood pressure. Atherosclerosis and hyperlipidemia

Risk factors of angina

Angina have quite a lot of risk factors. Some factors can worsen heart problems that cause angina or increase its risk

Other factors directly reduce blood flow or oxygen to the heart

While some factors cannot be controlled e.g, genetics, and old age. Fortunately, some factors can be controlled through diet and lifestyle modifications e.g, tobacco use, diabetes, and obesity.

• Smoking or using other tobacco products
• Too much Alcohol
• Metabolic syndrome
• Increasing Age (The risk increases over 45 years of age for men and 55 years of age for women)
• Genetics (Family history of early heart disease)
• Anemia (low red blood cells)
• Stress
• High Cholesterol level
• Diabetes.
• Unhealthy Diet 
• Air pollution (Long-term exposure to secondhand smoke)
• Heart valve disease
• Heart failure.
• Hypertrophic cardiomyopathy (enlarged heart)
• Inflammation.
• Physical inactivity
• Obesity
• Smoking
• Recreational/street drugs
• High blood pressure

Signs and symptoms (Briefly)

Triggers of angina are physical activity, chronic stress, emotional state (anger, fear), large meals, and exposure to cold or wind. It can also occur at rest when arteries are severely narrowed, in the case of Unstable angina. Stable angina could progressively become Unstable as the coronary artery gets narrower. Unstable angina could also lead to a heart attack.

When you have an angina attack, it feels like pain or discomfort (in the form of tightness, pressure, burning, fullness, squeezing) in your chest, this discomfort or pain may radiate to your back, belly, shoulder, arm, neck, and jaw. 

Some other people experience angina as a feeling of indigestion or a feeling of uncomfortability or anxiousness.

Some other symptoms caused by lack of oxygen that are not felt in the chest area include

• Dizziness
• Fatigue
• Nausea
• Shortness of breath

These other symptoms are called angina equivalents.

Rest and recovery

Rest is the first step in the management of angina. It offers relief within 5 minutes, especially when used with nitrates. It is advisable to stop any activity, relax and rest, you can lie down if possible, use your nitrate medicine, wait for five minutes and use it again if symptoms persist. Rest offers immediate relief from an angina episode but shouldn't be used as a substitute for long-term treatment, visit your doctor for assessment and treatment recommendations for your angina.

However, this is not the case for Unstable angina, which does not ease with rest, it might even get worse and needs urgent medical attention.

Diagnostic procedures (Briefly)

To diagnose angina or the underlying heart diseases that could be causing your angina, your doctor might perform the following tests

Electrocardiogram (ECG): To diagnose abnormalities or show lack of oxygen (ischemia)

Standard Exercise stress test without imaging: you might have a normal ECG despite having angina, this is because ECG may not show abnormalities for Unstable and stable angina, your doctor will require you to perform the physical exercise while he records your ECG. The result then assesses how your heart performs well with activity. Alternatively, drugs that mimic the effect of physical activity on the heart can be used if you can not perform the exercise.

Heart imaging: These are tests that provide an image of the heart, they can also help to detect the extent of the blockage. Examples include Echocardiogram, Catheter Angiography, Coronary Computed Tomography Angiography, Magnetic Resonance Imaging. Chest X Ray can also be done to rule out other causes of chest pain.

Blood Tests: Some enzymes e.g troponin, can be detected in your blood (after the heart has suffered angina) through blood tests.

Treatment and prevention

The treatment goal for angina is to reduce the frequency of angina attacks, relieve symptoms and reduce your risk of a heart attack.

This can be achieved by:

• Diet and Lifestyle modifications
• Medications to control Risk factors
• Medications for angina( Antianginal agents)
• Revascularization either by Angioplasty and stenting procedure or Bypass surgery
• EECP Therapy

Diet and lifestyle modifications

Diet and lifestyle modifications that will improve your heart health including foods with low trans fat, saturated fat, sugar and sodium and lifestyle changes such as the incorporation of mild exercises, weight control, and smoking cessation. These will prevent more plaque from forming in your arteries.

Medications to control risk factors

They are medications that are used to manage other conditions that could be responsible for your angina. This will help to reduce how often angina attacks occur.

They include medications to reduce blood pressure, cholesterol, or blood sugar.

Your doctor can prescribe

Statins

Aspirin

ACE inhibitors or ARB's

Medications to control risk factors

This will help control your symptoms and reduce the risk for further atherosclerosis and cardiac events

Medications that your doctor might suggest for your angina to help keep your heart arteries open are 

• Nitrates; Sublingual or oral spray nitroglycerin can help you relieve acute Angina episodes within 5-10minutes. You can also use it prophylactically if you have frequent angina, as it can be helpful. 
• Anticoagulants
• beta blockers
• calcium-channel blockers
• ranolazine

Revascularization

If your angina does not respond to lifestyle changes, medications, and other therapy your doctor can opt for a bypass surgery (open heart surgery) or a angioplasty and stenting procedure to help you open blocked arteries

Enhanced external counterpulsation (EECP)

Enhanced external counterpulsation (EECP); It is a non-invasive procedure Your doctor can recommend this if invasive procedures cannot be applied for you

Prevention

To prevent angina pain, lower your risk for its complications (such as heart attack) and ensure that you live a more healthy and productive life, You should

• Take your medications as advised by your physician
• Avoid smoking, other tobacco products as well as second-hand smoking
• Eat a healthy diet, the DASH diet and Mediterranean diet are advisable
• Avoid or reduce alcohol intake
• Exercising regularly, be active but do not exert yourself too much. Although exercise can trigger angina, a supervised program of exercise is safe. Your healthcare provider can put you through exercises that are safe for you to do. Long-acting nitrates can also be used to prolong exercise performance
• Maintain a healthy weight, set a goal with your physician, and ask for advice on how to reach it
• Manage other health conditions, especially ones related to heart disease.
• Know when to call for emergency help, for example, if your angina suddenly worsens or doesn't relieve you after rest and treatment
• Avoid the triggers that could lead to an angina attack e.g, strenuous activities, stress, and anger. You should be able to continue your normal routine, but you can also take medications such as nitroglycerin with you in case of an angina attack
• Manage your stress. Can adopt yoga, meditation, writing journals, or talking with a counselor or friend
• Manage the risk factors for coronary artery disease, such as high blood pressure, high cholesterol, high triglycerides, and diabetes

Outlook (Briefly)

Usually, you would get relief from angina quickly. But, it is important to determine what is causing it since it can be a sign of a life threatening heart disease and it can

raise your risk of having a heart attack. Fortunately, it is treatable if you follow the advice of your doctor on drugs to take as well as lifestyle and diet modifications to make

You can connect with other people who have the same condition and support groups which can help your loved ones and family understand angina so that they can help you get through it and offer help when you need it

Having angina doesn't mean you can't be active, however, if you feel the symptoms stop what you are doing and rest, 

Is it angina or a heart attack? when to dial 999

How to spot the difference

Angina and heart attack are both a result of coronary artery disease, and they both cause chest pain, discomfort, and tightness. However Angina is due to a temporary reduction of blood flow and does not cause permanent damage, while a heart attack is due to a longer reduction of blood flow which leads to the death of parts of your heart muscles and causes permanent damage

If you've been diagnosed with angina, you could be suffering from a heart attack when the chest discomfort you feel

• Does not follow the usual pattern you are used to
• Worsens
• Is more persistent/frequent

Another important sign is when your symptoms don't ease several minutes after rest and medications( after one or two dose of Nitrates), you could be having a heart attack, This is an emergency, heart attacks put you at an increased risk of severe arrhythmias and cardiac arrest that could cause sudden death.

What you should do;

• Let someone know how you are feeling
• Dial 999 and ask for urgent medical attention

You should also be familiar with what is 'usual' or 'normal' for you so that you can seek help when you notice symptoms that are out of ordinary

Summary

Angina is not a disease but rather It is usually a warning sign of other diseases, usually heart diseases. However, ischaemic heart disease is the most common cause of angina (chest pain). Ischemia is a reduction in blood flow due to obstruction. 

Triggers for angina are physical activity, chronic stress, emotional state(anger, fear), large meals, and exposure to cold or wind. It can also occur at rest when arteries are severely narrowed, in the case of Unstable angina. Stable angina could progressively become Unstable as the coronary artery gets narrower. Unstable angina could also lead to a heart attack.

Your doctor will use a series of tests to determine the cause of your angina, then the underlying disease or cardiovascular conditions can then be managed or treated, drugs would also be prescribed to relieve your angina symptoms. To live a healthy and productive life with angina, You should avoid triggers and other controllable factors that could worsen your angina and put you at risk of life threatening cardiac events such as heart attack. Seek urgent medical attention when you suspect you might be having a heart attack.