Angina Pectoris: Chest Pain as a Key Symptom

Angina pectoris refers to a typical symptom caused by a temporary reduction in blood flow to the heart muscle. The term “angina pectoris” comes from Latin and means “chest pain,” thus describing the characteristic feeling of tightness in the chest area.

Angina pectoris usually causes pain behind the breastbone that is described as pressing, burning, or constricting. This chest pain occurs when part of the heart muscle is no longer receiving an adequate supply of blood and oxygen. These symptoms occur more frequently precisely when more blood and oxygen are needed, such as during physical exertion or stress.

In most patients, coronary heart disease (CHD) is the underlying cause. Arteriosclerosis leads to the buildup of deposits and plaques that affect the coronary arteries, causing them to narrow progressively.

Angina pectoris often occurs when a blood vessel is narrowed by deposits and plaques. This narrowing is usually caused by atherosclerotic deposits, which lead to constriction of the coronary arteries.

Symptoms of angina pectoris often manifest as chest pain. Typically, these symptoms occur during physical exertion or stress and improve at rest.

In most patients, coronary artery disease is the underlying cause. The coronary arteries are narrowed by plaques, preventing the heart muscle from receiving an adequate blood supply.

In addition to classic coronary heart disease, other forms may also play a role. These include Prinzmetal angina, in which an artery spasms and narrows, leading to impaired blood flow. Microvascular angina pectoris may also be present, in which only the small blood vessels are affected. 

However, chest pain can also be caused by numerous other conditions, such as those affecting

• the cardiovascular system,
• the lungs,
• the gastrointestinal tract, and
• the musculoskeletal system.

High blood pressure, diabetes, smoking, and a lack of physical activity also significantly increase the risk.

The symptoms of angina pectoris usually manifest as a feeling of tightness and severe pain in the chest area around the heart. 

Typical symptoms include chest pain that radiates to the left arm, the lower jaw, or the upper abdomen and back.

These symptoms often occur during physical exertion, such as climbing stairs or engaging in strenuous physical activity. In some cases, they can also occur at rest.

An episode usually lasts only a few minutes. If an episode lasts longer, a medical evaluation is necessary.

Angina pectoris can be classified based on

• the way the pain is triggered and
• its course,

into stable and unstable forms.

Stable angina pectoris

The term “stable” means that the symptoms always occur under the same circumstances. The course of the disease is therefore consistent.

The severity of angina pectoris is not determined by the intensity of the pain, but by the way in which the pain is triggered.

Angina pectoris whose symptoms only become noticeable during strenuous physical activity is therefore a milder form of the condition. In contrast, angina pectoris that occurs even at rest or during light physical activity is classified as a more severe form.

The chest pain usually lasts from a few minutes to about 15 minutes.

According to the Canadian Heart Society (CSS), stable angina pectoris is classified into four severity grades:

• Grade 1 (CSS1) is a very mild form. In this case, angina pectoris does not cause any discomfort in daily life (walking, climbing stairs), but only becomes noticeable during sudden or prolonged physical exertion.
• In Grade 2 (CSS2), daily activities are only slightly limited by the condition. The symptoms of angina pectoris become noticeable during
  • walking briskly,
  • climbing stairs after a meal,
  • walking in cold weather or against a headwind, or
  • emotional stress.
• At Grade 3 (CSS3), the person affected finds activities of daily living significantly more difficult. Symptoms caused by the disease occur even with mild physical exertion, such as normal walking or getting dressed. 
• Stage 4 (CSS4) describes a very severe form of the disease. At this stage, symptoms occur even with the slightest physical exertion or at rest.

Unstable angina

The term “unstable” indicates that the nature of the symptoms has changed from what was previously typical.

If the symptoms initially occurred only during strenuous activity but are now noticeable even during light activity or even at rest, this change is referred to as unstable angina. 

A diagnosis can only be made by a doctor, typically a cardiologist. The doctor will first ask about the patient’s symptoms and when they typically occur. In some cases, this alone may reveal a trigger for the symptoms.

The doctor also needs to know whether the symptoms improve after administering nitroglycerin spray. This helps determine whether the symptoms described by the patient are actually related to a heart condition.

As part of the physical examination, the doctor will listen to the patient’s heart. It is also advisable to measure blood pressure in this case to diagnose possible hypertension. High blood pressure increases the risk of atherosclerosis and damages the inner lining of blood vessels.

An electrocardiogram (ECG) is performed at rest and during exercise to record the heart’s electrical signals. However, in more than half of patients suffering from angina pectoris, the resting ECG is normal.

An ECG shows the activity of the heart muscle © jimmyan8511 | AdobeStock

The stress ECG, on the other hand, is somewhat more informative. If the doctor suspects cardiac arrhythmias, they will recommend a long-term ECG. For this, the patient is given a portable ECG device to wear for 24–48 hours during their daily activities.

During an echocardiogram, the doctor can detect changes in the heart using ultrasound. It is sometimes performed under physical stress, but more often under pharmacological stress (stress echocardiography).

In addition, this test allows the doctor to assess the function and condition of the heart valves and ventricles. This test can be performed quickly and is minimally invasive for the patient. It is one of the standard diagnostic tests for angina pectoris.

The standard procedure for assessing blood flow to the heart muscle is myocardial perfusion SPECT. This provides the doctor with information on

• blood flow,
• vitality, and
• function

of the heart muscle.

Other imaging techniques used to diagnose angina pectoris include

• contrast-enhanced computed tomography (CT) or
• a special type of magnetic resonance imaging (stress MRI).

The goal of these procedures is to identify areas of the heart muscle that are not receiving adequate blood flow. They also allow for the visualization of narrowed or blocked blood vessels.

A cardiac catheterization (coronary angiography) can definitively confirm or rule out coronary artery disease. During this procedure, a catheter is advanced through the vascular system into the coronary arteries, and the narrowings in the vessels are assessed.

Medications are available to treat an acute attack of angina pectoris. These so-called nitro preparations are taken in the form of sprays or capsules. These nitrates dilate the blood vessels, which relieves the strain on the heart.

In an emergency, anticoagulants (aspirin and heparin) and, if necessary, beta-blockers may also be administered.

Unstable angina pectoris is considered an acute medical emergency. It carries an increased risk of a heart attack. Therefore, if a patient experiences chest tightness for the first time or if the symptoms worsen due to

• nitroglycerin or
• rest

, an emergency medical service must be called immediately.

Treatment of Angina Pectoris Symptoms

Regardless of whether it is an acute emergency, the treatment for angina pectoris consists of

• alleviating the symptoms and
• preventing further episodes or life-threatening complications.

Various

• blood-thinning (or anticoagulant),
• vasodilators, and
• antihypertensive medications

are available for this purpose. These include

• aspirin and heparin (to prevent blood clotting),
• nitrates and calcium channel blockers (for vasodilation), as well as
• beta-blockers and ACE inhibitors (to lower blood pressure).

Statins or other lipid-lowering drugs (ezetimibe, PCSK9 inhibitors) reduce blood lipid levels. This lowers the risk of progressive vascular narrowing.

Treatment of Coronary Heart Disease

To provide long-term relief from symptoms, it is essential to treat the underlying condition, which is often coronary heart disease. In addition to the aforementioned medication, the primary focus is on reopening narrowed or blocked blood vessels. This allows an adequate amount of blood to flow through the vessels again (a process known as revascularization).

Depending on the condition of the coronary arteries and any comorbidities the patient may have, there are various methods:

• Widening the vessel via balloon dilation
• Implantation of a stent to keep the vessel open
• Bypassing the narrowed or blocked area through bypass surgery

Lifestyle changes can also reduce the risk of complications in patients with coronary heart disease. These include, for example:

• Weight loss if the patient is overweight
• Dietary changes, such as
  • reducing salt intake,
  • eating more vegetables, fruits, and fiber,
  • no sugar-sweetened beverages,
  • and less saturated fat.
• Physical activity or exercise programs
• Limit alcohol consumption to a maximum of 10 grams (women) or 20 grams (men) per day
• Avoid both active and passive smoking

The course of the disease depends heavily on the underlying cause. Without treatment, the narrowing of the blood vessels can worsen, resulting in the heart muscle no longer receiving an adequate supply of blood and oxygen.

In severe cases, this can lead to a heart attack.

What is angina pectoris?

Angina pectoris is a symptom in which the heart muscle does not receive an adequate supply of blood and oxygen.

When is angina pectoris dangerous?

Unstable angina pectoris is particularly dangerous, as it can be a warning sign of a heart attack.

What symptoms occur?

Typical symptoms include chest pain, a feeling of tightness, and pain radiating to the left arm or lower jaw.

What triggers angina pectoris?

Symptoms often occur during physical exertion or stress.

How is angina pectoris treated?

Angina pectoris is treated with medication and interventional procedures to improve blood flow.