Angina

Angina is tightness or pain in the chest that appears when the heart muscle is short of blood. The heart itself is not worn out or diseased: what has narrowed is the artery that feeds it. At rest the remaining channel is still enough; one flight of stairs and it is not. This is not a heart attack. It is the warning of one, the clearest warning the body knows how to give, and the reason to deal with your heart now rather than one day. If for the moment your chest simply hurts and it is not clear whether the heart is involved at all, start with the neighbouring page, chest pain, which goes through all the common causes and not only the cardiac ones.

Why the muscle runs short of blood

The heart does not take its own blood supply from the chambers it pumps; it takes it from a separate network of vessels running over its surface, the coronary arteries. Over the years cholesterol plaques build up in their walls and the channel narrows. While a person is sitting, the muscle's demand is small and the narrowed channel copes. The moment they speed up, the heart needs more oxygen and the artery cannot deliver it. That shortfall is what is felt as a weight in the chest.

Hence the defining feature of angina: it is tied to exertion. The episode arrives when the heart is working harder than usual and goes when the demand falls, which is why it lasts minutes rather than hours.

A heart attack works differently: the cap of the plaque tears, a clot grows on the tear, the flow stops altogether and a patch of muscle begins to die. Rest fixes nothing at that point. These are two stages of one process, and the whole point of this page is that the second stage should never arrive.

What it feels like

The word «pain» is used here less than you might expect. People say instead that something presses, burns or squeezes, as though a slab had been laid on the chest or a band drawn tight around it. Some describe the episode with no pain at all: as breathlessness, or as a sudden tiredness that makes them stop. That is why angina spends years being put down to age and poor fitness.

• the site is behind the breastbone, in the middle of the chest, not a spot on the left that a finger can pick out;
• it spreads to the left arm, to both arms, to the neck, the jaw, the back, under the shoulder blade and sometimes to the upper abdomen;
• it comes on with exertion: stairs, walking uphill, carrying shopping, stepping out into cold or wind, a heavy meal, an upset, hurrying;
• it lasts a few minutes, not seconds and not half a day;
• it eases with rest, or a minute or two after glyceryl trinitrate if that has been prescribed for you.

The most useful feature is that it is predictable. Someone with angina knows their own measure: two flights of stairs, a hundred metres uphill, and they have to stand still. As long as that measure stays put, the situation is one thing; once it shifts, it is quite another, and the next section is about it.

Stable and unstable: the distinction that matters

Everything this page has to settle is settled here. A picture that feels identical comes in two versions, and they call for opposite actions.

Stable angina. The episode comes on with a familiar, expected level of exertion, lasts a few minutes, reliably settles with rest or with glyceryl trinitrate, and the pattern does not change for months. It is not a reason for an ambulance, but it is an absolute reason to see a doctor and be investigated: this is the stage at which a heart attack can still be prevented.

Unstable angina is an emergency. The name covers any change of the familiar pattern for the worse:

• the episodes have become more frequent, stronger or longer;
• they come on with less exertion than before, in places where they never used to;
• they have started to appear at rest, at night or in the early hours;
• glyceryl trinitrate helps less, needs a repeat dose, or does not help at all;
• the episode is the first one you have ever had.

Behind this lies a torn plaque with a clot growing on it: the same thing as in a heart attack, except that the channel is not yet closed completely. So here you do not book an appointment and do not wait until morning: call an ambulance. In this situation the difference between going to hospital today and seeing a doctor next week is the difference between heart muscle saved and heart muscle lost.

When it is already a heart attack

Signs that mean calling an ambulance straight away:

• the pain or pressure in the chest lasts longer than fifteen to twenty minutes;
• it does not settle with rest and is not relieved by glyceryl trinitrate;
• the episode is stronger than any before it;
• cold clammy sweat, nausea or vomiting, sudden weakness, breathlessness or dizziness have joined it;
• a fear with no cause has appeared, a sense of something terrible closing in.

112 is the single European emergency number and works in Spain, Italy, Portugal, Poland and Ukraine; elsewhere dial your local emergency number. Calling and turning out to be wrong is nothing to be ashamed of; missing a heart attack cannot be undone.

And separately, the thing that most often makes help arrive late. In women, in older people and in people with diabetes a heart attack frequently runs without severe chest pain. In diabetes the nerves that carry pain are damaged, and the event can pass almost painlessly. What comes to the fore instead is breathlessness where there was none before, unexplained weakness, nausea, heaviness and burning in the upper abdomen that feels like indigestion, cold sweat, fainting, and in an older person sudden confusion. If something like that appears for the first time and you cannot account for it, treat it as a heart matter.

What to do during an episode

The order is simple, and it is worth knowing in advance: in the middle of an episode there is no time to work it out.

• Stop what you are doing. Not «finish the stairs first», but stop on the spot.
• Sit down. Do not stay standing and do not lie flat: standing up it is easy to faint, and lying flat makes the heart's work harder.
• Take glyceryl trinitrate if your doctor has prescribed it, and always sitting down. It opens the vessels abruptly, the blood pressure drops, and people do fall over with it on their feet.
• Loosen a tight collar, open a window, ask someone to stay with you.
• If it has not eased within a few minutes or after a repeat dose, ring for an ambulance.

Do not drive — not during the episode, not straight afterwards, and not to get yourself to hospital. You can lose consciousness on the way, whereas an ambulance records a heart tracing and starts treatment in the vehicle itself.

What not to do. Do not put up with it and do not try to walk it off: in angina exertion does not disperse the pain, it sustains it. Do not leave it until morning; chest pain at night is the worst possible reason to wait for daylight. Do not treat heartburn instead of the heart: a heart attack very often feels exactly like indigestion, and that is the commonest excuse people give themselves for not ringing. And do not take someone else's glyceryl trinitrate on the strength of «it helped the neighbour, it will help me»: with low blood pressure, with certain valve conditions, and alongside medicines for erectile dysfunction it is dangerous.

What narrows the arteries

The list is well known, and almost all of it can be worked on.

• Smoking comes first, vapes and daily exposure to other people's smoke included;
• high blood pressure;
• raised cholesterol;
• diabetes and prediabetes;
• excess weight, particularly around the middle;
• an inactive life;
• chronic kidney disease, sleep apnoea, chronic inflammatory conditions;
• heart attacks and strokes in parents or siblings at a young age.

That last point is worth raising with the doctor yourself, without waiting to be asked: early cardiac disasters in a family sometimes have familial hypercholesterolaemia behind them, an inherited disorder in which cholesterol is high from birth. It is treatable, and it usually goes unlooked for.

And the least welcome part. Stopping smoking does more than any of the tablets you will be prescribed, and it works faster than they do. It is worth doing at any age and after any number of years, including after a heart attack has already happened, and the doctor can help with medicines and not only with encouragement.

What the doctor usually does

The conversation decides most of it. The doctor will ask in detail where exactly it presses, what brings an episode on and what takes it away, how long it lasts, whether the pattern has changed in recent weeks. From that description alone an experienced doctor already knows whether this is angina and whether it is stable; everything else refines the answer.

The investigations are then chosen to fit: an electrocardiogram at rest and on exercise, blood tests for the cholesterol profile and glucose, an echocardiogram and, where needed, a study of the coronary arteries themselves. One thing is worth knowing: a normal resting tracing does not rule the diagnosis out. Between episodes in angina it usually looks entirely ordinary, and on that basis people have been sent home for years.

How it is treated

Treatment has three parts, and they only work together.

Medicines. Some cut short an episode that has already begun: they are taken under the tongue at the moment of the pain. Others are taken every day so that episodes do not arise, slowing the pulse and lowering the heart's oxygen demand, or widening the vessels. Separately there are medicines that lower cholesterol and medicines that make clots harder to form; these do not touch the pain, but they are the ones that push the heart attack away. Getting the combination right takes time, side effects are discussed with the doctor, and there is almost always an alternative.

This is the main warning of the section: prescribed medicines are not stopped on your own initiative once you feel better. «No more episodes, so I must be cured» is the commonest and most expensive mistake in angina. There are no episodes precisely because you are taking them; stopping puts everything back where it started, and a few of them, withdrawn abruptly, leave you worse than before treatment began. Any change to the regimen goes through the doctor.

Intervention on the vessels. Where medicines are not enough or the narrowing is too great, the artery is opened from inside with a balloon and a stent is placed; with extensive disease a bypass is done, stitching in a route around the narrowed segment. None of that replaces the tablets or stopping smoking.

Daily life. Regular activity within your capacity, vegetables, fish and wholegrains in place of processed meat and sugary drinks, weight down where there is excess, blood pressure and glucose under control. Ask separately what exertion to start with: with angina you do need to move, but by the rules.

Online consultation

Angina is one of those subjects where asking counts for more than examining, so a conversation with a doctor works well at a distance too. In an online consultation the doctor will go through in detail what your episodes resemble, tell cardiac pain apart from rib and muscle pain and from reflux, gather your risk factors, explain the tracings and blood tests you already have, and say which investigations are worth doing and in what order. Your medicines will be gone through separately: what each is for, what does not combine with what, how to take glyceryl trinitrate properly. And you will be given the signs that in your particular case mean calling an ambulance — that boundary is better known in advance.

What an online consultation does not replace: with chest pain that does not settle at rest you cannot wait for an appointment, you need an ambulance.

This material is for information only and does not replace medical advice.