Just as I sat down to write this article, I got a call from a friend about angina. Evidently, he had some pain in his chest when he went for a walk this morning. Originally I was planning to talk about cancer but after this call I thought that talking about angina and why it happens and what to do about it might be more useful.
For us physicians angina ‘pectoris’ (of the chest) is any pain or discomfort in the chest or adjacent areas that occurs because of heart not getting enough blood. Like any other muscle in the body the heart also needs blood to work and it receives blood through arteries that run into it. The harder the heart works the more blood it needs.
When there is a mismatch in the supply of blood and the demand for blood usually due to blockages in the heart arteries, heart muscle produces pain or discomfort that is called angina. This angina that occurs when the work of the heart increases as during physical exertion and then subsides when the exertion is over is called angina of effort or exertion. This sort of angina that occurs predictably and subsides predictably is called ‘stable’ angina’.
What is the pain of angina like? The word angina comes from a Latin word that means ‘strangling’. The common form of angina is then a feeling of pressure or crushing pain in the centre of the chest. However angina can also present in other ways.
Herman Tarnower, the chief of cardiology in the hospital where I first trained in the United States way back in the seventies, used to say that angina could be any pain above the belly button. Tarnower later on became famous for writing a best-selling diet book and then being murdered by a jilted girlfriend.
So how else can angina be felt? In medicine, we call it ‘referred’ pain or pain hat is felt in a place that shares sensations. Angina can often be felt as pain that goes down the left arm, or up in the neck or into the jaw. It can also be felt as a pain similar to heartburn. There are reported cases where patients went to a dentist because of recurrent pain in the ‘teeth’ that turned out to be angina.
In patients with severe heart artery blockages or those with diabetes, angina can be felt just as sudden shortness of breath. The bottom line is that any ‘new’ ache or pain in the chest area or sudden shortness of breath that comes on with exertion and subsides when exertion is stopped could be angina. Women especially have to be careful since in them the pain might be less typical and doctors less likely to suspect them for having heart artery blockages.
Not every pain in the chest area is angina. A lot depends on the person. Certain types of people are more likely to get heart artery problems and are therefore more likely to develop angina. Men and women in their sixties that have a family history of heart problems are at risk. As also are people that are overweight, not physically active; who smoke and have diabetes. So people with the above problems should be more careful and seek medical help promptly when they get pains suggestive of angina.
What about angina that is not stable? Unpredictable angina and prolonged angina are referred to as unstable angina. That term however has now been replaced by ‘Acute Coronary Syndrome’ (ACS) that suggests that a heart attack might be imminent or might actually be going on.
So how do we know whether that pain is actually angina? A doctor will make that determination. The first thing the doctor will do is determine if the person complaining of chest pains fits the picture of somebody that could have heart artery blockages. Certain basic tests including blood lipid (fat) levels might be done as well as an ECG.
If angina is suspected further testing might be needed. The primary doctor might then choose to refer the person to a heart medicine specialist (cardiologist). Depending on the severity and frequency of the angina symptoms the cardiologist might decide to treat with medicines or go for further tests. For relatively short and infrequent episodes medicines might be prescribed but also ‘life style’ changes will be suggested especially to stop smoking, lose weight and cut back on salt.
Medicines will include those to keep the blood pressure at normal levels, keep the heart working slower and less forcefully. Certain medicines called ‘nitrates’ might also be added especially to use during episodes of angina. If all this controls the angina and allows the person to live a normal life, then fine. Also people that are too old or have other serious medical problems to tolerate extensive treatment might receive medical treatment alone.
If the cardiologist feels that the angina is severe enough to warrant further tests, some form of a ‘stress test’ might be done that reproduces the angina under controlled circumstances and ECG monitoring. If the test suggests inadequate blood supply then it is clear that blockages in the heart arteries exist and are producing the angina. Now a decision will be made about what to do next.
Based upon medical literature concerning the treatment of patients with stable angina, the evidence suggests that medical treatment alone is adequate for most of them. In spite of such evidence many patients with stable angina will undergo further testing culminating in a coronary angiogram (heart artery-picture) and then depending on the nature and the extent of the artery blockages will undergo some form of ‘percutaneous catheter intervention’(PCI). The types of interventions are many and include fancy stuff like intravascular ultra sound (IVUS), lasers, rotablators, atherectomy catheters, and other such stuff.
The commonest intervention however is an angioplasty (artery reconfiguration) combined with a stent procedure. What that means is that a catheter is passed through a leg or arm artery back into the heart arteries and then a wire is passed through this catheter to cross the artery blockage. A balloon cater is passed over this wire and is used to open up the blockage. Once the blockage is open a medicated metal mesh or stent is placed to keep the artery open.
There are many finer points in the discussion about what sort of patients should have medical treatment or an angioplasty-stent procedure or something more. However, stent placement has become much too common and in the US every year some cardiologist is hauled up for performing unnecessary stent procedures and billing the insurance companies or the government for them.
One of the problems with getting a stent is that these patients will need to take blood thinning medicines for the rest of their lives. In spite of taking these medicines some stents will close down and cannot be reopened. And some patients have arteries that are so severely blocked that stents cannot be inserted in them. In some of these patients, members of my specialty of cardiac surgery get involved to perform what is called coronary artery bypass surgery.