Angina is chest pain caused by decreased blood flow to the heart (called ischemia). Angina is more likely to happen when blood and oxygen requirements of the heart increase and when the coronary arteries (blood vessels supplying blood and oxygen to the heart) constrict (become more narrow). Examples of such situations include exercise and stress.

Stable angina is when you have chest pain at a predictable time or predictable level of exertion - for example, walking 4 blocks or walking up 2 flights of stairs. Stable angina is relieved after a short period of time with rest or nitoglycerin. If angina occurs when you are resting, the pain doesn't go away after a few minutes with rest or nitroglycerin, or it begins at a lower level of activity than usual, this is considered unstable angina. In such circumstances, you should call 911 or equivalent local emergency number. Getting emergent care and getting to the hospital as soon as possible for unstable angina may prevent you from having a heart attack.

The key is to distinguish chest pain or discomfort due to angina from chest pain due to other causes like heartburn, a muscle strain, asthma, etc. This can be very tricky and, when in doubt, assume that it is related to your heart until proven otherwise, especially if you are experiencing pain that you have never felt before.

The classic chest pain from angina feels like significant pressure, squeezing, or tightness in the center of your chest, possibly radiating to your left arm and shoulder, neck, and jaw. Other possible feelings include indigestion, rapid or skipping heartbeat, or mild discomfort. If you have diabetes, you may not feel anything at all when blood flow to your heart is diminished.

Coronary heart disease is almost always the cause of angina. Other potential causes or contributing factors include:

• Congestive heart failure
• Anemia - when severe enough, anemia can lead to angina because not enough oxygen is getting to the heart, even if blood flow is normal.

The risk factors for angina are the same as the risk factors for developing heart disease including:

• Older age
• Male sex
• Menopause
• Family history of heart disease
• Diabetes
• Tobacco use or exposure to second hand smoke
• High cholesterol
• High blood pressure
• Obesity
• Sedentary lifestyle
• Stress

See articles on Atherosclerosis and Heart Attack for more information about risk factors.

You will have an electrocardiogram (EKG), during which electrodes will be fastened to your chest with a sticky gel. Your health care provider may also suggest a stress test, in which the EKG is taken while you walk on a treadmill or use a stationary bicycle. The stress test may be done with imaging (like thallium, sestimibi, or an echocardiogram) to look at the blood flow and muscle function of your heart.

Your health care provider may recommend coronary arteriography, where a catheter is inserted through a small incision to inject a dye that makes your blood flow visible on an x-ray image. Any blockages in your coronary blood vessels will appear.

Newer non-invasive ways to look at and evaluate the coronary blood vessels and the heart muscle include cardiovascular magnetic resonance imaging (MRI), electron beam angiography, and cardiac CT scans.

If you will be participating in an activity that generally triggers your angina, it often helps to take nitroglycerin a few minutes in advance to prevent the pain. Talk to your doctor about the safety and appropriateness of doing this for you.

In the long term, the best prevention for angina is to modify as many risk factors for heart disease as possible:

• Stop smoking
• Lose weight if you are overweight
• Control blood pressure, diabetes, and cholesterol
• Eat a diet low in saturated and hydrogenated fats and cholesterol, and high in starches, fiber, fruits, and vegetables
• Exercise 3 hours per week or more (such as 30 minutes per day, 6 days per week)
• Reduce stress

The main goal in treating angina is to treat the underlying heart disease and prevent it from getting worse. By doing this, blood flow to the heart improves and angina gets better. Lifestyle practices and certain medications can improve blood flow and make you feel better fairly quickly. Keep track of what causes your angina pain, what it feels like, how often you get it, and how long it lasts. If there's a change in your pattern for the worse (for example, increased frequency of you angina or lighter activities bring it on), let your health care provider know right away.

Changing your diet, exercising regularly, and practicing relaxation techniques to reduce your response to stress can help improve blood flow to your heart and reduce angina. These steps can also help treat your risk factors for heart disease, like high blood pressure, high cholesterol, and high homocysteine levels.

Diet

The AHA recommends that you do the following to prevent or treat heart disease:

• Eat a variety of fruits and vegetables (5 to 9 servings/day).
• Eat a variety of grain products, with an emphasis on whole grains (6 or more servings/day).
• Eat at least 2 servings of fish per week
• Limit total fat intake to <30% and saturated fat to <7% of energy. Replace dietary saturated fats and trans fatty acids with monounsaturated and polyunsaturated fats (including foods rich in omega-3 fatty acids). Food sources of omega-3 fatty acids include fatty fish (such as salmon), flaxseed and flaxseed oil, soybean oil, canola oil, and nuts.
• Limit amounts of dairy products to 2 to 4 servings of low-fat or fat free items per day.
• Limit sodium intake to 6 grams per day.
• Limit alcohol intake to 2 drinks per day for men and 1 drink per day for women.
• Maintain a healthy body weight by matching calorie intake to energy needs; this includes a moderate level of regular physical activity (30 to 60 minutes within your target heart range most days per week)

Relaxation

Many believe that relaxation techniques help alleviate feelings of stress, which is often a contributing factor to heart disease, and relieve chest pain. Such practices might include the use of meditation, progressive muscle relaxation, breathing exercises, yoga, self-hypnosis, or biofeedback to reduce your risk factors for heart disease and to stick with healthy lifestyle changes like quitting smoking and losing weight.

For the treatment of stable angina, your doctor will likely recommend daily aspirin as well as a combination of the following prescription medications:

• Nitroglycerin and oral nitrates—increase the size of blood vessels, thus allowing blood to flow more easily to the heart; tablets placed under the tongue can be used when you are having pain or to try to prevent pain when you are going to participate in an activity that triggers your angina. Nitrates in oral form or patches placed on the skin can be used on a regular basis to try to prevent angina. Tolerance (need for higher doses because usual amount is no longer effective) occurs with continued use and nitrates can cause significant headaches. Talk to your doctor about ways to avoid tolerance and headaches.
• Beta-blockers—reduce blood pressure, heart rate, and the work of the heart, which reduces the demand and need for blood flow. Common side effects from beta-blockers include sexual dysfunction and feelings of depression. DO NOT stop any medication from this class abruptly; serious side effects can occur. Talk to your doctor about how to slowly wean off of this drug.
• Calcium-channel blockers—reduce blood pressure and the force by which the heart pumps blood; some also reduce heart rate
• Cholesterol-lowering medications

If lifestyle changes and medications are not effective or if unstable angina develops, you may need bypass surgery, angioplasty with stent placement, or another type of procedure to improve blood flow to the compromised area of your heart. (See the monograph on atherosclerosis for details regarding bypass and angioplasty with stent.)

Some newer procedures to improve blood flow to the heart, called revascularization, include angiogenesis, arteriogenesis, and laser procedures. Although still under scientific investigation and not available at all hospitals or health centers, these may be of particular value to those who are not eligible for angioplasty or bypass surgery.

Angiogenesis and arteriogenesis involve administration of proteins that stimulate the growth of new blood vessels. Another approach is the use of gene therapy which causes your body to produce these same proteins on a more long-term basis. The idea is that new blood vessels bring greater blood flow and decreased pain if you have chronic stable angina that has not improved using all medications and approaches to lifestyle change available, particularly if you cannot have a reperfusion procedure like angioplasty or bypass.

Avoid saturated fats (meat and full-fat dairy products), refined foods, caffeine, and alcohol. Eat more fresh vegetables, whole grains, and omega-3 fatty acids (cold-water fish, nuts, and seeds). The AHA plan, outlined in the lifestyle section above, is an excellent way to include the foods that you need to protect your heart while eliminating those that harm your heart.

There are many supplements that can help reduce your chances of developing heart disease and its consequences, including angina. See monographs on atherosclerosis and heart attack for details.

Folic acid (vitamin B9) may be particularly helpful for reducing symptoms of angina. Also, bromelain, which has anti-inflammatory properties and antithrombotic properties (meaning that it may prevent blood clot formation), may prove to have a useful role in treating angina and preventing heart attacks.

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and ONLY under the supervision of a practitioner knowledgeable in the field of herbal medicine. Also, BE SURE to talk to your doctor about any herbs that you are considering.

There are several different herbs that may be helpful for the treatment and prevention of heart disease, including those that help you reduce your cholesterol, blood pressure, and other risk factors. See articles on atherosclerosis, heart attack, high blood pressure, and high cholesterol for more information.

Hawthorn (Crataegus monogyna) may be especially helpful in alleviating angina.

Used traditionally as a remedy for diseases related to the heart and circulation, some studies have shown that people with angina who take hawthorn berries experience fewer episodes of chest pain. In addition, animal and laboratory studies demonstrate that this herb has antioxidant properties that help protect against the formation of plaques in the coronary vessels and may help control high cholesterol and high blood pressure.

Homeopathy should NEVER be used instead of immediate medical attention for unstable angina, new onset chest pain, or chest pain that has changed in intensity, frequency, or other characteristics. Homeopathy may, however, be used to help reduce your risk factors for heart disease and its consequences. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for you as an individual.

Acupuncture may be useful for reducing risk factors for heart disease. It is considered an excellent treatment for people who wish to quit smoking and some studies indicate that it may aid in weight loss as well as cholesterol and blood pressure reduction. Acupuncture may also help relieve angina pain and lead to a faster recovery from bypass surgery.

Although few studies have examined the effectiveness of massage therapy for heart disease, massage has a relaxing effect and reduces stress-related hormone levels. Lowering stress hormone levels can lower cholesterol and blood pressure and may, therefore, prove to be beneficial for reducing your risk of heart disease. In addition, the relaxing effects of regular massage may help you comply with habits necessary to reduce the risk of heart disease, such as dieting, quitting smoking, and exercising. Also, at least one study has found that massage can lower blood pressure.

Prognosis and Complications

Stable angina can progress and become unstable and even lead to a heart attack. The good news, however, is that with proper treatment using proper diet, exercise, other aspects of lifestyle change, and medication, blood flow to the heart and, therefore angina, can dramatically improve.

Almeda FQ, Parrillo JE, Klein LW. Alternative therapeutic strategies for patients with severe end-stage coronary artery disease not amenable to conventional revascularization. Catheter Cardiovasc Interv. 2003;60(1):57-66.

Bahorun T, Trotin F, Pommery J, Vasseur J, Pinkas M. Antioxidant activities of Crataegus monogyna extracts. Planta Med. 1994;60:323-328.

Bahrke MS, Morgan WR. Evaluation of the ergogenic properties of ginseng: an update. Sports Med. 2000;29(2):113-133.

Bakloanov D, Simons M. Arteriogenesis: lessons learned from clinical trials. Endothelium. 2003;10(4-5):217-223.

Ballegard S, et al. Acupuncture in angina pectoris: does acupuncture have a specific effect? J Intern Med. 1991; 229:357-362.

Budoff MJ, Achenbach S, Duerinckx A. Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography. J Am Coll Cardiol. 2003;42(11):1867-1878.

Bueno EA, Mamtani R, Frishman Wh. Alternative approaches to the medical management of angina pectoris: acupuncture, electrical nerve stimulation, and spinal cord stimulation. Heart Dis. 2001;3(4):236-241.

Cunningham C, Brown S, Kaski JC. Effects of transcendental meditation on symptoms and electrocardiographic changes in patients with cardiac syndrome X. Am J Cardiol. 2000;85(5):653-655, A10.

Day W. Relaxation: a nursing therapy to help relieve cardiac chest pain. Aust J Adv Nurs. 2000;18(1):40-44.

Fugh-Berman A. Herbs and dietary supplements in the prevention and treatment of cardiovascular disease. Prev Cardiol. 2000;3(1):24-32.

Fujita M, Tambara K. Recent insights into human coronary collateral development. Heart. 2004;90(3):246-250.

Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina - summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). J Am Coll Cardiol. 2003;41(1):159-168.

Gilbert C. Clinical applications of breathing regulation. Beyond anxiety management. Behav Modif. 2003;27(5):692-709.

Goldman JP. New techniques and applications for magnetic resonance angiography. Mt Sinai J Med. 2003;70(6):375-385.

Heatlie GJ, Pointon K. Cardiac magnetic resonance imaging. Postgrad Med J. 2004;80(939):19-22.

Kastrup J. Therapeutic angiogenesis in ischemic heart disease: gene or recombinant vascular growth factor protein therapy? Curr Gene Ther. 2003;3(3):197-206.

King MS, Carr T, D'Cruz C. Transcendental meditation, hypertension and heart disease. Aust Fam Physician. 2002;31(2):164-168.

Kleiman NS, Patel NC, Allen KB, et al. Evolving revascularizaton approaches for myocardial ischemia. Am J Cardiol. 2003;92(9B):9N-17N.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:58-60.

Mashour NH, Lin GI, Frishman WH. Herbal medicine for the treatment of cardiovascular disease. Arch Intern Med. 1998;158:2225-2234.

Maurer HR. Bromelain: biochemistry, pharmacology, and medical use. Cell Mol Life Sci. 2001;58(9):1234-1245.

Miller AL. Botanical influences on cardiovascular disease. Altern Med Review. 1998;3(6):422-431.

Muhling O, Jerosch-Herold M, Nabauer M, Wilke N. Assessment of ischemic heart disease using magnetic resonance first-pass perfusion imaging. Herz. 2003;28(2):82-89.

Nikolaou K, PoonM, Sirol M, Becker CR, Fayad ZA. Complementary results of computed tomography and magnetic resonance imaging of the heart and coronary arteries: a review and future outlook. Cardiol Clin. 2003;21(4):639-655.

Rigelsky JM, Sweet BV. Hawthorn: pharmacology and therapeutic uses. Am J Health Syst Pharm. 2002;59(5):417-422.

Ruel M, Sellke FW. Angiogenic protein therapy. Semin Thorac Cardiovasc Surg. 2003;15(3):222-235.

Tackling tough-to-treat chest pain. Harv Health Lett. 2002;13(3):5-6.

Webster KA. Therapeutic angiogenesis: a complex problem requiring a sophisticated approach. Cardiovasc Toxicol. 2003;3(3):283-298.

Yeh JL, Giordano FJ. Gene-based therapeutic angiogenesis. Semin Thorac Cardiovasc Surg. 2003;15(3):236-249.