Angina

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Overview

Angina, also called angina pectoris, is a symptom of ischemic heart disease (IHD). Chest pain, pressure, and discomfort—commonly known as angina—result when the coronary arteries do not deliver an adequate amount of oxygen-rich blood to the heart (called ischemia).

Types

Angina is classified broadly as stable or unstable, depending on its pattern of occurrence and severity. Stable angina occurs when increased physical activity (e.g., hurrying across a street or climbing a long flight of stairs) creates a greater demand for oxygen-rich blood to reach heart tissue.

Unstable angina occurs with lesser degrees of exertion or while at rest. This type increases in frequency and duration and worsens in severity. Unstable angina is an acute coronary syndrome (ACS) that requires immediate medical attention.

Unstable angina that occurs at rest is the most serious form. This type usually is caused by the formation of a blood clot at the site of a ruptured plaque in a coronary artery. If left untreated, it can result in heart attack and irreversible damage to the heart.

Variant (or Prinzmetal's) angina—an uncommon form of unstable angina—is characterized by recurring prolonged attacks of severe ischemia that usually occur at rest.

Incidence and Prevalence

The American Heart Association reports that more than 6 million people in the United States experience angina and that more women than men are affected. Every year, coronary artery disease causes approximately 600,000 deaths in the United States, and the annual costs associated with the disease exceed $100 billion. Over 1 million heart attacks occur in the United States every year.

Risk Factors and Causes

Risk factors for ischemic heart disease (IHD) and angina include the following:

• Atherosclerosis
  
• Carotid artery intima-media thickness
  
• Chlamydial pneumonia, and other signs of infection
  
• Coronary calcification (detected by electron beam and helical-computed tomography)
  
• Elevated C-reactive protein (CRP)
  
• Elevated LDL ("bad") cholesterol
  
• Elevated levels of fats in the blood (hyperlipidemia)
  
• Elevated lipoprotein
  
• Tobacco use (including cigars)
  
• Diabetes mellitus
  
• Emotional stress (e.g., frustration, anger)
  
• Family history of ischemic heart disease
  
• Hypertension
• Obesity
  
• Reduced HDL ("good") cholesterol
  
• Sedentary lifestyle
  

Some risk factors can be reduced by making lifestyle modifications.

Cardiac ischemia—insufficient blood flow to heart tissue—and angina can be caused by the following:

• Blocked artery
  
• Aortic valve disease (e.g., aortic stenosis, aortic regurgitation)
  
• Hypertrophic cardiomyopathy
  
• Microvascular constriction
  
• Pulmonary hypertension
  
• Coronary artery spasm (in variant angina)
  

Atherosclerosis is the build-up of cholesterol deposits (plaques) in the wall of an artery. If the surface of a plaque ruptures, a blood clot (thrombus) may form on top of it and create a larger blockage. If the clot grows large enough, it can completely obstruct the artery. A 70% or greater blockage can deprive the heart of the volume of blood needed to meet an increased demand and cause angina.

Aortic valve disease causes the aortic valve to malfunction. This impairs the heart's ability to pump oxygen-rich blood out of the left ventricle and to the rest of the body.

In hypertrophic cardiomyopathy, an area of abnormally thick heart muscle impairs the heart's pumping action. This commonly causes angina during or shortly after exercise.

The pulmonary artery carries oxygen-depleted blood from the lower chamber in the right side of the heart (right ventricle) to the lungs, where it is oxygenated. Pulmonary hypertension is a rare disorder in which the pulmonary arteries are constricted, increasing pressure in the lung's blood vessels. Pulmonary hypertension makes it harder for the heart to pump blood out of the right ventricle.

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