Angina Pectoris

    If you are having pain or pressure in the middle of your chest, left neck, left shoulder, or left arm, go immediately to the nearest hospital emergency department. Do not drive yourself. Call 911 for emergency transport.
Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the heart is not getting enough blood.
• The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries.
• Blood carries the oxygen and nutrients the heart muscle needs to keep pumping.
• When the heart does not get enough blood, it can no longer function at its full capacity.
• When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin.
• The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day.
An episode of angina is not a heart attack. Having angina means you have an increased risk of having a heart attack.
• A heart attack is when the blood supply to part of the heart is cut off and that part of the muscle dies (infarction).
• Angina can be a helpful warning sign if it makes the patient seek timely medical help and avoid a heart attack.
• Prolonged or unchecked angina can lead to a heart attack or increase the risk of having a heart rhythm abnormality. Either of those could lead to sudden death.
Time is very important in angina.
• The more time the heart is deprived of adequate blood flow (ischemia), and thus oxygen, the more the heart muscle is at risk of heart attack or heart rhythm abnormalities.
• The longer the patient experiences chest pain from angina, the more the heart muscle is at risk of dying or malfunctioning.
Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to very serious.
• For example, chest pain can be caused by:
 acid reflux (gastroesophageal reflux disease, GERD),
 upper respiratory infection,
 asthma, or
 sore muscles and ligaments in the chest (chest wall pain)
• If chest pain is severe and/or recurrent, the patient should see a healthcare provider.
• Go to a hospital emergency department if the patient has any of the following with chest pain:
 Other symptoms such as:
 sweating,
 weakness,
 faintness,
 numbness or tingling, or
 nausea
 Pain that does not go away after a few minutes
 Pain that is of concern in any way
 Symptoms
Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:
• An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest
• It may also feel like tightness, burning, or a heavy weight.
• The pain may spread to the shoulders, neck, or arms.
• It may be located in the upper abdomen, back, or jaw.
• The pain may be of any intensity from mild to severe.
Other symptoms may occur with an angina attack, as follows:
• Shortness of breath
• Lightheadedness
• Fainting
• Anxiety or nervousness
• Sweating or cold, sweaty skin
• Nausea
• Rapid or irregular heart beat
• Pallor (pale skin)
• Feeling of impending doom
These symptoms are identical to the signs of an impending heart attack described by the American Heart Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a few minutes and heart attack pain does not go away.
• If you have never had symptoms like this before, sit down. If you are able, call your healthcare provider, call 911, or go to the closest hospital emergency department.
• If you have had angina attacks before and this attack is similar to those, rest for a few minutes. Take your sublingual nitroglycerin. Your angina should be totally relieved in five minutes. If not, you may repeat the nitroglycerin dose and wait another five minutes. A third dose may be tried but if you still have no relief, call 911 or go to the nearest hospital emergency department.
Medical Treatment
If the patient has come to the hospital emergency department, they may be sent to another care area for further testing, treatment, or observation. On the basis of the provider's preliminary diagnosis, the patient may be sent to the following units:
• An observation unit pending test results or further testing
• A cardiac care unit
• A cardiac catheterization unit
Regardless of where the patient is sent, several basic treatments may be started. Which ones are given depends on the severity of the symptoms and the underlying disease.
• At least one IV line will be started. This line is used to give medication or fluids.
• Aspirin will probably be administered (unless the patient has already taken one)
• Oxygen will be administered through a face mask or a tube in the nose. This will help if the patient is having trouble breathing or feeling uncomfortably short of breath. The direct administration of oxygen raises the oxygen content of the blood.
Treatment will depend on the severity of the symptoms, severity of the underlying disease, and extent of damage to the heart muscle, if any.
• Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that the patient needs, if it is only angina.
• Medication may be administered to reduce anxiety.
• Medication may be administered to lower blood pressure or heart rate.
• Medication may be administered to reduce the risk of having a blood clot or to prevent further clotting.
• If the healthcare provider believes the chest pain actually represents a heart attack, the patient may be given a fibrinolytic (apowerful clot-buster medication).
After reviewing the patient's immediate test results, the hospital healthcare provider will make a decision about where the patient should be for the next hours and days.
• If the diagnosis of angina is made, and the patient is feeling better and their condition is stable they may be allowed to go home. The patient may be given medications to take. Follow-up with a primary healthcare provider within the next day or two will be recommended.
• The patient will be admitted o the hospital if the they are unstable with continuing symptoms. Further testing will be ordered, and if the arteries are critically blocked, the patient may undergo coronary angiography, coronary artery angioplasty, or even coronary artery bypass surgery.
Angioplasty is a treatment used for people whose angina does not get better with medication and/or who are at high risk of having a heart attack.
• Before angioplasty can be done, the area(s) of coronary artery narrowing is located with coronary arteriography.
• A thin plastic tube called a catheter is inserted into an artery in the arm or groin with local sedation. The catheter has a tiny balloon attached to the end.
• The catheter is threaded through the arteries and into the artery where the narrowing is.
• The balloon on the catheter is inflated, opening up the narrowing.
• Following ballon treatment, many patients require placement of a "stent," a small metal sleeve that is placed in the narrowed artery. The stent holds the artery open.
If the patient has had angina symptoms and is visiting their primary healthcare provider for evaluation, he or she will make a decision about how to proceed with the evaluation. The choices include going ahead with the evaluation on an outpatient basis, referring the patient to a specialist in heart disorders (cardiologist), or admitting the patient to the hospital for further workup.