Life Expectancy With Angina: Living A Long, Fulfilling Life With Angina

Angina 101

What is it?

Angina is chest pain that is caused by reduced blood flow to the heart.¹ Angina is not a life-threatening condition however, it can be a warning sign for developing a more dangerous disease,  such as a heart attack or stroke. It is important to note that angina is not a disease, but merely a symptom of underlying heart disease, commonly known as coronary heart disease (CHD). ¹

There are several types of angina²

Stable angina: predictable chest pain often caused by physical exertion or stress causing an increase in how much oxygen the heart requires. 

Unstable angina: usually occurs whilst resting and is difficult to predict when it occurs. It can be caused by a sudden blockage of the vessels in the heart. Unstable angina is less common than stable angina but more serious as it can lead to a heart attack. 

Microvascular angina: As the name suggests, this type of angina is caused by tiny blood vessels within the heart muscle. When these tiny blood vessels don’t widen up as they should they cause a lack of supply of oxygen to the heart muscle. This type is more prevalent in women who are undergoing or have undergone menopause. 

Variant angina: This rare type of angina almost always occurs when the patient is at rest and is caused by the spasm of the blood vessels that supply the heart's oxygen.

Symptoms²

The main symptom of angina is chest pain that can occur at rest or when exercising depending on the type of angina. The chest pain usually feels heavy and tight and can spread to the arms, neck and jaw; however, some people (in particular people assigned female at birth) may experience sharp and stabbing pain instead.

Other symptoms include:

Breathlessness 

Dizziness 

Restlessness

Causes

The cause of angina varies depending on the type of angina. 

Atherosclerotic plaques, where fatty substances and cholesterol build up, narrow the artery so less blood is able to pass through. Whilst exercising, more blood needs to pass through the narrow blood vessel which puts more strain on the heart and hence the chest pain (stable angina). ³ 

In unstable angina, the plaques rupture and form a temporary blood clot which partially or intermittently blocks the blood vessels which causes the chest pain hence why the pain experienced is unpredictable. If the blood clot is not dissolved, it can lead to a heart attack. ³   

Microvascular angina is caused by the inability of micro-vessels to dilate and that leads to less blood flow. ⁴ 

Variant angina, also known as prinzmetal angina, is caused when the arteries that supply the heart with oxygenated blood spasm and constrict, which leads to intense pain and less blood flow. ² 

Triggers

Physical activity, including low impact exercises (climbing stairs or walking), can trigger an angina attack in patients suffering from stable angina and after resting for a few minutes the chest pain may go away. Unlike stable angina, unstable angina has no known triggers and can occur even at rest and the pain can persist even after rest. Unstable angina is a medical emergency and treatment needs to be sought immediately if it occurs. ⁵ 

Risk factors

There are two types of risk factors for developing angina: risk factors that can be decreased by modifying lifestyle and non-modifiable risk factors which cannot be changed.  

Modifiable factors

High blood pressure is a modifiable factor, the increased pressure in the arteries damages the arteries and makes the arteries less elastic which prevents them from dilating when the heart needs more oxygen. ² 

Atherosclerosis is the build-up of the fatty deposit within the walls of their arteries that has developed over years is the cause of angina in many people, this fatty deposit makes the arteries narrow and eventually leads to less blood getting through to them. When this fatty deposit dislodges from the walls of the arteries, a blood clot subsequently forms, thus blocking the arteries. This is a trigger of unstable angina. ^2,3 

Cholesterol is an essential component to the function of cells around the body; however, in large quantities cholesterol can contribute to atherosclerosis. Exercising regularly and eating a balanced diet can reduce cholesterol levels which reduces the risk of developing angina. Drugs such as statins (e.g simvastatin, atorvastatin ….) are also used to reduce the amount of cholesterol that the liver produces. ⁶

Overweight and obese people tend to have higher blood pressure and higher levels of cholesterol which in turn increases the risk of developing angina. ²

Non-Modifiable factors

Age: simply because the arteries narrow over time, the older you are, the higher risk of developing angina. ² 

Ethnicity: South Asians are twice as likely to develop coronary heart diseases than the rest of the population in the UK. ⁷

Family history: certain genes can increase the risk of developing angina and at the time of writing genetics cannot be changed. ²  

Living with Angina

Prognosis

Prognosis of angina tends to be quite good and with appropriate lifestyle changes and with use of medications, more than half of people with angina tend to be symptom free within a year of starting treatment. However, it is crucial to keep in mind that coronary artery diseases tend to progress over time and the patient can experience angina attacks even with appropriate treatment. ⁸ 

Treatments to manage symptoms

There are two aspects of treating angina with medications: first, reducing the frequency of attacks and preventing the progression of the disease; second, treating the attacks when they happen. 

Medications such as statins tend to reduce circulating cholesterol around the body. Therefore, they reduce the increase of plaque in the arteries and hence lower the risk of angina worsening.² Ranolazine, beta-blockers, and calcium channel blockers tend to reduce the heart rate and reduce the oxygen demand of the heart which can prevent angina attacks. 

Glyceryl trinitrate (GTN), a compound historically used to produce explosives, is used to treat angina attacks. GTN tends to dilate the blood vessels and that helps the blood flow through the arteries hence improving the symptoms. GTN is usually used as a form of spray for under the tongue which has an immediate effect. Long-acting nitrates work in a similar way to GTN; however, as the name suggests, their effects last longer and therefore are used to prevent angina attacks. ⁹

Low dose aspirin and other blood thinners (e.g. clopidogrel) also have a role in treating angina, especially unstable angina.

Surgical interventions

If the medications fail to control the blockage caused by plaques, surgeries such as percutaneous coronary intervention (aka angioplasty) can be performed where a stent (a tiny hollow tube) is placed in the arteries and opens the passage for the blood flow. ⁸ 

Coronary artery bypass is another surgery where a piece of healthy blood vessel from the patient's leg or arm is used to replace the blocked blood vessel in the heart. ⁸ 

Improving your outcomes through Lifestyle Changes

Diet, exercise reduce smoking and alcohol

Patients with angina are capable of exercising; however, it is important to know its limits. Regular aerobic exercise is beneficial and improves the ability of the body to take in and use oxygen and can reduce the symptoms of angina. It is important to start exercising slowly and increase the intensity of it over time. ¹¹

It is advised to know that when exercising, your GTN spray should be handy as there is a risk of triggering angina symptoms if over-exercising.  

Life expectancy is at least 10 years shorter for smokers than non-smokers in general and smoking has detrimental effects which increase the risk of coronary heart disease by increasing the risk of blood clots, increasing blood pressure and reducing the amount of oxygen delivered to the heart muscle. ^13,14

Alcohol, another contributing factor to developing angina can increase cardiovascular disease (conditions affecting the heart and/or blood vessels). Long term consumption or binge drinking (consumption of more than 8 units for men and 6 units for women in one sitting) increases the blood pressure which in turn increases the risk of developing angina. ¹⁵

Patients with angina tend to have underlying CHD which puts them at a higher risk of myocardial infarction (aka heart attack). However, if the patient is at an age of over 70 years, their life expectancy is reduced by about 2 years if they only suffer from angina. However, if they also suffer/suffered from a heart attack as well, their life expectancy is reduced further by 6 years. ¹⁶

Summary

In conclusion, angina does affect the life expectancy of those who suffer from it. Angina is not “curable” but with appropriate treatment the progression of it can be reduced and most patients experience a symptom-free life.