What is the Physical Exam for Angina?

What is Angina?

Angina Pectoris, more commonly referred to as angina, is the medical term for chest pain caused by a decrease in blood flow to the heart’s muscles. Angina is fairly common, with recent statistics indicating it is prevalent in over 100 million people worldwide. While often misunderstood, angina is actually a symptom of coronary artery disease, rather than a condition itself. Because of this, angina alone is not life-threatening.¹ However, research has found that angina is a clear warning sign that, without treatment and lifestyle changes, you may be at risk of serious and potentially fatal cardiovascular complications such as heart attacks, heart failure and strokes.^{2 Like many conditions, there are different types of angina. Below are the four main types of angina.}

Stable Angina

According to the NHS, stable angina is the most common type of angina.³ Stable angina refers to chest pain that has an obvious trigger (typically physical activity) and subsides once the individual rests. Stable angina patients can usually easily control their condition with medication and physical activity.

Unstable Angina

Unstable angina is considered a ‘medical emergency’ and is much more unpredictable than stable angina.⁴ Unstable angina refers to chest pain that does not have an obvious trigger, nor is the pain cured by rest. Unstable angina is much harder to manage with medication, and in some cases may require surgical interventions. 

Variant Angina

Unlike stable and unstable angina, variant angina does not occur due to blockages in our arteries. Variant angina pain is caused by spasms in our coronary arteries. During spasms, our arteries become narrower, thus temporarily restricting blood flow to the heart.

Microvascular Angina

Chest pain that is caused when the micro vessels that allow oxygenated blood into the heart are unable to open properly, therefore reducing blood flow into our cardiac muscles. 

Signs and Symptoms

The signs and symptoms an individual with angina experiences can differ depending on the type of angina they have. Below are some of the most common symptoms present in those with angina. If you regularly suffer from any of the following symptoms, ensure to book an appointment with your healthcare provider immediately.

• Chest pain (can be triggered by physical activity or have no obvious trigger)
• Chest pain that subsides with rest
• Feeling of pressure, tightness, or discomfort in the chest
• Nausea
• Bouts of dizziness and/or lightheadedness 
• Fatigued
• Breathlessness 

Causes and Risk Factors

In most instances of angina, chest pain is caused by a narrowing or blockage of the coronary arteries, the arteries responsible for the delivery of oxygenated blood and nutrients to the heart’s muscles. Over time, a combination of risk factors can cause plaque and fatty deposits to accumulate on the walls of our arteries, a process referred to as atherosclerosis. As the build-up continues, the space for blood to flow through the arteries begins to become narrower and, in some cases, completely blocked. As a result of this, the heart's muscles become deprived of the oxygen and nutrients it requires, causing them to become weaker and damaged. Eventually, this causes us to experience chest pain (angina). Below are some of the risk factors that have been identified by the National Heart, Lung and Blood Institute as the carrying the largest risk factor for angina.⁵

• Obesity
• Lack of physical activity
• Diet high in fat, sugars, and salt
• Overconsumption of alcohol
• Stress
• High blood pressure
• High blood cholesterol
• Diabetes
• Smoking
• Drug usage 

Diagnostic Procedures

To diagnose an individual with angina, your healthcare provider will need to conduct a physical exam. A physical exam will likely consist of a few quick and painless tests, which will all be explained to you by your doctor or GP. Whilst there is a wide range of tests designed to help angina diagnosis, certain tests are much more commonly used than others. 

Stages in a Physical Exam

When visiting your local doctor or GP about angina patients, your physical exam will likely consist of three sections. The first two sections look to assess a patient’s likelihood of having angina based on their symptoms, general health and medical history, whereas the final phase looks to provide the patient with a definitive diagnosis. Below is a more in-depth look at how medical professionals diagnose a patient with angina.

Health and symptoms questions

To begin with, your doctor will likely ask you a few questions regarding your general health and your symptoms. It is at this stage your doctor will begin to assess if your symptoms are angina symptoms and potentially the type of angina you have. You will likely be asked to discuss the following with your doctor.

• What symptoms you have suffered from
• Severity and frequency of symptoms
• When you suffer from the symptoms
• Whether there any obvious triggers to your symptoms
• Whether you have a family history of heart disease
• What sort of lifestyle you lead e.g. how much exercise you do, your diet and whether or not you smoke

General health testing

Your doctor will also likely run some basic health tests on you. This is done to assess if you have some of the key biological symptoms of an individual with cardiovascular complications. Some of the most commonly performed general health tests:

• Blood pressure test
• Blood cholesterol test
• Resting heart rate
• BMI testing
• Waist measurements

Further testing

If after the first two stages your doctor believes you may have angina or some form of cardiovascular complication, you will be referred to the hospital for further testing. The tests performed at a hospital are much more advanced and can provide a much more definitive diagnosis. 

What will a physical exam show?

The exact result of your physical exam is dependent on the tests your healthcare provider conducts. Different tests will provide an insight into different angina factors; for example, some may look at blood flow, whereas others may assess the damage sustained by the heart. Despite this, the end goal of a physical exam remains the same. A physical exam aims to answer the following questions:

• Does the patient have angina?
• What type of angina does the patient have?
• How severe is the patient’s angina?
• What sort of treatment does the patient require?

As previously mentioned, different tests can show slightly other things. Below are some of the most commonly used tests and what those tests show us.

Electrocardiogram (ECG)

An ECG is one of the more commonly used methods for diagnosing angina. ECGs are designed to show abnormalities in the electrical activity of a patient’s heart. The test only takes between 5-10 minutes and is completely painless. Tiny sticky patches known as electrodes are placed on the chest, arms, and legs. Once connected, the electrodes begin the analysis of the heart’s electrical activity before feeding the results back to a computer.

Exercise ECG

As physical activity is a common trigger of angina, it can be easier for medical professionals to diagnose a patient with angina whilst they are exercising. If the patient is deemed fit enough to perform the test, it is likely that an exercise ECG will be conducted. During an exercise ECG, electrodes are normally placed on the chest and shoulders of the patient. Exercise will then likely be performed on a treadmill or exercise bike. The electrical activity of the heart is then monitored as the intensity of the exercise is gradually increased. Do not worry if you do not regularly exercise, you will be closely monitored during the test and will not be asked to exercise beyond your level of fitness.  

Coronary Angiography

Coronary angiography is a slightly more invasive but still painless method for diagnosing angina. The test is designed to show blood flow into the heart, allowing medical professionals to identify areas that may be narrowed or blocked. An area of the body (normally the groin) will be placed under local anesthesia before a long and flexible tube, known as a catheter, is inserted. Using X-ray images, your doctor or GP will then direct the catheter towards the heart. Once in place, a contrast medium (a special type of dye that shows up on x-rays) is injected into the bloodstream via the catheter. Because the dye shows up on the x-ray images, doctors can utilize images to assess coronary blood flow.

Echocardiogram

An echocardiogram is a type of ultrasound that is used to create images of the heart via sound waves. An echocardiogram is designed to show blood flow, as well as highlight any damage to the heart’s muscles. The test is completely painless and takes between 15-60 minutes to complete. Images of the heart and surrounding blood vessels are created by soundwaves, which enter the body via a probe or electrode. As sound waves enter the body, they bounce off of different parts of the body, which helps a computer create an image. As this process continues, a moving image is created, which can be viewed on a computer. These moving images can then be used to watch blood flow through the heart, and any abnormalities in our cardiac muscles, e.g. any damage sustained.

Chest X-Ray

Unlike the other tests, a chest X-ray can not be used to diagnose a patient with angina. Instead, a doctor or GP will use a chest x-ray if they believe that a patient’s chest pain is being caused by another condition rather than angina. A chest X-ray allows your doctor to take an image of the major organs in your chest, for example, your heart and lungs. These images allow the doctor to look for key signs of alternative causes of chest pain, for example, an enlarged heart or fluid build-up within the chest.

What could a physical exam rule out?

Angina shares many of its signs and symptoms with other conditions, and therefore an individual may believe they suffer from angina but actually suffer from another condition. A physical exam helps rule out many other conditions, including the following.

• Muscle aches, strains, and tears
• Indigestion
• Stomach ulcers
• Acid reflux
• Gastroesophageal reflux disorder
• Gallstones
• Gallbladder disease
• Pleurisy
• Acute pericarditis
• Pulmonary embolism
• Heart Attack

Treatment

The treatment prescribed to an individual diagnosed with angina will depend greatly on the results of their physical exam. For those diagnosed with stable angina, the course of a patient’s treatment will likely consist of lifestyle changes and medication. However, those diagnosed with unstable angina may require some form of surgery to prevent serious complications such as heart attacks and strokes from occurring.

Lifestyle changes

• Physical activity
• Healthy and balanced diet
• Decrease consumption of alcohol
• Stress management and relaxation techniques
• Quit smoking

Medication

• Glyceryl Trinitrate (GTN)
• Aspirin
• Nitrates
• Beta Blockers

Surgical Intervention

• Coronary Angioplasty and Stent Insertion
• Coronary Artery Bypass Graft

Summary

While angina is not considered an immediate threat to our life, it is a warning sign that medical attention is required. Whilst visiting your healthcare provider about a potential heart-related issue can be extremely daunting, the British Heart Foundation describes angina diagnosis as potentially lifesaving. If you have angina, the sooner you are diagnosed, the quicker healthcare professionals can protect you from more severe cardiovascular issues.⁶ If you or someone you know regularly suffers from any of the aforementioned signs and symptoms of angina, ensure to book an appointment with your healthcare provider as soon as possible.