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
Signs and Symptoms
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
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
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
The risk factors for angina are the same as the risk factors for developing
heart disease including:
Family history of heart disease
Tobacco use or exposure to second hand smoke
High blood pressure
See articles on Atherosclerosis and Heart Attack for more information about
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
In the long term, the best prevention for angina is to modify as many risk
factors for heart disease as possible:
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
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
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
The AHA recommends that you do the following to prevent or treat heart
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
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)
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
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
Surgery and Other Procedures
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.
Nutrition and Dietary Supplements
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
Hawthorn (Crataegus monogyna) may be especially helpful in
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.
Massage and Physical Therapy
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.
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.
Kastrup J. Therapeutic angiogenesis in ischemic heart disease: gene or
recombinant vascular growth factor protein therapy? Curr Gene Ther.
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
Mashour NH, Lin GI, Frishman WH. Herbal medicine for the treatment of
cardiovascular disease. Arch Intern Med.
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.
Muhling O, Jerosch-Herold M, Nabauer M, Wilke N. Assessment of ischemic heart
disease using magnetic resonance first-pass perfusion imaging. Herz.
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.
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.
Reviewed By: Participants in the review process include: Jacqueline A. Hart, M.D.,
Department of Internal Medicine, Newton-Wellesley Hospital, Newton, Ma., and
Senior Medical Editor, A.D.A.M., Inc.; Richard A. Lippin, MD, President, The
Lippin Group, Southampton, PA; Tom Wolfe, P.AHG, Smile Herb Shop, College Park,
MD; Leonard Wisneski, MD, FACP, George Washington University, Rockville,
The publisher does not accept any responsibility for the accuracy of
the information or the consequences arising from the application, use, or misuse
of any of the information contained herein, including any injury and/or damage
to any person or property as a matter of product liability, negligence, or
otherwise. No warranty, expressed or implied, is made in regard to the contents
of this material. No claims or endorsements are made for any drugs or compounds
currently marketed or in investigative use. This material is not intended as a
guide to self-medication. The reader is advised to discuss the information
provided here with a doctor, pharmacist, nurse, or other authorized healthcare
practitioner and to check product information (including package inserts)
regarding dosage, precautions, warnings, interactions, and contraindications
before administering any drug, herb, or supplement discussed