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Angina

Angina is when you have chest pain or an uncomfortable tight feeling in your chest. The pain and discomfort can sometimes spread to your arms, jaw, neck and back. It develops when there is not enough blood getting to your heart muscle.

Many people live with angina and manage it well, but it can lead to serious health problems and can sometimes be life-threatening.

Angina
Dr Asif Qasim talks about angina

About angina

Angina is usually a symptom of coronary heart disease. This is when a fatty substance called atheroma develops in the walls of your blood vessels, which makes them narrower. When this happens, not enough blood and oxygen can get to your heart and that’s when angina develops. If the blood vessels become completely blocked, usually by a blood clot, this can lead to a heart attack.

You’re more likely to get angina as you get older, and men are more likely to get it than women.

Angina or heart attack?

It can be difficult to tell the difference between angina and a heart attack because the symptoms can be similar. If you have any of the following symptoms you may be having a heart attack, so you should call for an ambulance straightaway:

  • chest pain or discomfort that doesn’t go away
  • chest pain that spreads to your arms, neck or jaw
  • feeling sick or short of breath
  • feeling sweaty and light-headed

Types of angina

There are two main types of angina.

Stable angina

This type of angina usually comes on predictably after you have exercised or been active. It doesn’t happen when you are resting. The pain or discomfort usually goes after you’ve rested or taken medicines for chest pain.

Unstable angina

Unstable angina is when the chest pain happens more easily. The discomfort is more severe than with stable angina and lasts for longer. It starts to happen when you’re resting. It can be serious and needs treating quickly. If you have this type of chest pain, take the medicine that your doctor has prescribed you for angina. If the pain continues after 20 minutes and despite taking your medicine, dial 999. Explain that you have a history of angina and are having chest pains that won’t go away.

Symptoms of angina

Stable angina

The symptoms of stable angina are usually chest pain or discomfort. The chest discomfort can feel like heaviness or pressure, or like you’re being squeezed tightly. The discomfort or pain can be in the middle of your chest, and sometimes it can spread to your back, jaw, arms and neck. The pain doesn’t change when you move, breath in or out or cough.

Stable angina usually comes on when you’re being active, when you’re eating or when you’re upset or stressed. Some people also find that cold weather can bring it on. It usually lasts for around five minutes. It’s unusual to get other symptoms, such as feeling sweaty or short of breath.

These symptoms are not always caused by angina, but if you have them, see your GP. If your symptoms begin to change, for example, they come on after less exertion than before or are more severe, see your GP as soon as you can.

Unstable angina

With unstable angina, your chest pain is usually more severe. It’s more likely than stable angina to spread from your chest to your back, jaw, neck and arms. It can come on when you’re resting as well as when you’re active. Some people have other types of chest pain with it, for example discomfort that feels like indigestion, or a stabbing pain.

You may have other symptoms too, such as:

  • feeling sick
  • feeling sweaty with clammy skin
  • feeling light headed
  • being short of breath

If you have these symptoms and chest pain that isn’t going away, you should call 999 straightaway. You should mention that you have a history of angina.


Image showing a coronary artery affected by atherosclerosis

Diagnosis of angina

Your doctor will usually ask you about your symptoms, lifestyle, and you and your family’s medical history. They will also examine you, including taking your blood pressure and listening to your heart and chest with a stethoscope.

After that, your doctor may ask you to have some tests, including:

  • blood tests to check whether you have other health problems, and to check your glucose and cholesterol levels
  • an electrocardiogram (ECG) – this shows the electrical activity of your heart

Depending on what the tests show and how severe your symptoms are, your GP may refer you to a heart specialist (a cardiologist) for more tests or for treatment. The other tests you have may include the following.

  • An exercise EGC. This is when you have an EGC taken while you’re exercising. It’s usually done when you’re walking on a treadmill or pedalling an exercise bike.
  • A chest X-ray.
  • Imaging tests, such as a computer tomography (CT scan) or magnetic resonance imaging (MRI) scan of your chest, abdomen (tummy) and coronary arteries (the vessels that supply your heart with blood).
  • An echocardiogram, either when you’re resting or exercising. This test uses ultrasound to produce moving images of the structure of your heart.
  • Coronary angiogram. This is a procedure where a special dye is injected into your coronary arteries to make them show up on X-rays. It can show where a blood vessel is narrowed or blocked.

Self-help

There are many things you can do to help you control your symptoms, manage your condition and stop your angina from causing further heart problems.

  • Talk to your doctor to find out what you should do if you have chest pain. Make sure you always have pain relieving medicine with you.
  • Where you can, plan your activities to prevent any chest pain. You may need to pace yourself and spread your activity to prevent chest pain. You can also take pain-relieving medicines before exercise too, to prevent an attack if you are going to do something that might bring this on.
  • If your angina starts to get gradually worse, the pain becomes more severe, or you’re getting an attack of angina more often, make sure you see your GP.
  • If you smoke, stop. Ask your GP or pharmacist for advice.
  • If you’re overweight, try to lose the extra weight.
  • Eat a healthy, balanced diet that is low in saturated fat, salt and sugar and high in fibre, fruit and vegetables.
  • Be physically active . Talk to your GP or nurse (who may be a cardiac rehabilitation nurse) about how to exercise safely. See our frequently asked questions for more information.
  • Stick to recommended limits for the amount of alcohol you drink. The current guidelines are for adults to drink no more than 14 units of alcohol a week, and to spread this out over the week.
  • Go for regular check-ups with your GP to check your blood pressure and cholesterol levels.

What to do if you have an angina attack

Your GP will prescribe a medicine called glyceryl trinitrate (GTN) that you can take as soon as you get angina. GTN usually comes as either a spray or a small tablet that you put under your tongue. It works quickly, within a few minutes, and should help to ease the pain. You can also take GTN before doing activities that you know may trigger an angina attack.

GTN works by making your coronary arteries wider so that more blood can flow to your heart. Because GTN opens up your blood vessels, it can cause side-effects in other parts of your body when that happens. So, your face might look and feel flushed, you might have a headache or feel light-headed.

When you have an angina attack, you should:

  • stop what you’re doing and rest
  • use your glyceryl trinitrate spray or tablets
  • take a second dose of GTN after five minutes if the pain hasn’t eased
  • call for an ambulance if your pain hasn’t eased five minutes after the second dose, or earlier if you pain is getting worse and you’re feeling unwell

Treatment options for angina

There are several treatment options for angina, depending on what type you have and whether you have other health conditions as well. Your GP or cardiologist will talk to you about your treatment choices and help you to make a decision that’s right for you.

Medicines

Medicines for the symptoms of angina

If you’re having an angina attack then glyceryl trinitrate (GTN) usually helps to ease chest pain and other symptoms. If you’re having a severe angina attack, and GTN under your tongue isn’t working, your doctor may give the GTN via a drip in your arm instead – this would be done in hospital. You will probably be given a strong painkiller, such as morphine as well. In some cases, you doctor may also give you oxygen using a face mask or thin tubes inside your nostrils.

Medicines to prevent angina attacks and further heart problems

Your doctor may prescribe medicines for you to take regularly to help prevent an angina attack and reduce your chance of having further heart problems. You may be offered one or more of the following medicines.

  • An anti-clotting medicine, such as aspirin or clopidogrel. If you have unstable angina and are being treated in hospital, you may also be given a medicine called heparin or something similar. These medicines help to prevent blood clots developing and can reduce the chance of having a heart attack.
  • Medicines to lower and control your blood pressure.
  • Anti-angina medicines, such as beta-blockers and calcium channel blockers. These help to reduce the symptoms of angina and prevent angina attacks.
  • Statins (eg simvastatin). These help to lower your cholesterol level and prevent fatty deposits building up in the blood vessels in your heart. This could reduce your risk of experiencing angina in the future. There are other medicines that your doctor may suggest you try, which work in similar ways to those listed above. They will talk to you about how these medicines may help, and any potential side-effects of taking them. Always ask your GP for advice and read the patient information leaflet that comes with your medicine.

Surgery

If your symptoms aren’t getting better using medicines, your doctor may suggest an operation to either widen or bypass the narrowed blood vessels in your heart.

The two main procedures are:

  • A coronary angioplasty (also called percutaneous coronary intervention) can widen your narrowed coronary artery. In this procedure, your doctor will pass a thin tube into your artery. When it reaches the narrow part, your doctor will usually place a stent inside the blood vessel. The stent will be attached to a balloon that your doctor can blow up to open it up. This helps to widen the blood vessel.
  • A coronary artery bypass graft (CABG) operation. This is where your surgeon takes a piece of a blood vessel from your leg, arm or chest and uses it to bypass the narrowed blood vessel. This can improve the flow of blood to your heart.

Which procedure your cardiologist recommends, if any, will depend on your symptoms and general health. They will discuss the benefits and risks with you to help you to decide whether to have the procedure.

Causes of angina

Angina is usually caused by coronary artery disease. This is when your arteries (blood vessels) become narrow, which reduces the amount of blood reaching your heart muscle. If less blood is reaching your heart muscle, it means that less oxygen is reaching it too, which is what causes the symptoms of angina. Sometimes a clot can partly block the arteries supplying your heart and that’s what causes unstable angina.

Blood vessels become narrowed because, over time, fatty deposits build up on the walls. This makes them narrow and hardened. This is called atherosclerosis, which is the cause of coronary heart disease. Atherosclerosis is more likely to develop if you:


Other health problems can also cause angina, such as heart valve disease and heart disease caused by high blood pressure. These are less likely causes of angina than coronary artery disease.

Complications of angina

Angina can lead to a number of complications, including:


Angina can also be associated with reduced general health and quality of life – you might find it harder to do everyday activities. This could lead to symptoms of depression.

Angina is also associated with a higher risk of stroke.

Prevention of angina

You may be able to prevent angina by having a healthy lifestyle. This includes:

  • not smoking
  • losing excess weight
  • being physically active
  • eating a healthy diet that’s low in fat and salt, while high in fruit, vegetables, grains, pulses and beans
  • staying within the recommended alcohol limits – the current guidelines are for adults to drink no more than 14 units of alcohol a week
  • eating a Mediterranean diet – this means eating less meat and having fish, fruit and vegetables, grains, nuts, pulses and beans



How atherosclerosis develops


Play video
Coronary heart disease happens when fatty deposits build up

FAQ: Can I drive if I have angina?

Many people with angina carry on driving. However, it’s best to tell the Driver and Vehicle Licensing Agency (DVLA) about your angina, in any case to check. In some cases you need to tell the DVLA.

You can drive a car or motorcycle if your angina is controlled and you don’t get symptoms brought on by emotion or when you’re resting or driving. If you have symptoms, then you must stop driving until your symptoms are under control. If you’ve had coronary angioplasty to treat your angina, you should stop driving for at least a week afterwards. If you’ve had a coronary artery bypass graft (CABG), you must stop driving for at least a month.

If you drive a bus or lorry, you need to tell the DVLA if you have angina, or if you’ve had heart surgery or an angioplasty. You won’t be able to drive any of these vehicles if you get symptoms. You can drive a bus or lorry again when you haven’t had symptoms of angina for at least six weeks and you have passed an exercise test. If you’ve had surgery to treat your angina, you must tell the DVLA. If you’ve had coronary angioplasty, you should stop driving your bus or lorry for at least six weeks afterwards. If you’ve had a coronary artery bypass graft (CABG), you must stop driving these vehicles for at least three months.

Speak to your GP or contact the DVLA for more information about when you’re allowed to drive again. You should also check with your insurance company to see whether having angina affects your policy.

FAQ: I have angina, can I travel by plane?

Most people with angina will be able to travel by plane. However, if you have severe symptoms or your symptoms or medicines have changed recently, you may need some help at the airport and on the flight. These are the recommendations for air travel if you have angina.

  • If you only get chest pain after a large amount of activity and your symptoms or medication haven’t changed, you can travel as normal.
  • If you get chest pain after a small amount of activity but your symptoms or medication haven’t changed, you should ask for help at the airport. You should also have oxygen available during your flight.
  • If you get chest pain when you’re resting or your symptoms and/or medication have changed recently, then you may want to postpone your flight. If you can’t do that, then you could travel with a medical escort and make sure you have oxygen available during your flight.

Talk to your doctor for more information. You should also let your travel insurer know about your condition, and keep them updated if your symptoms change before you travel. Otherwise you may not be covered by your insurance in the event that you become ill while you’re away.

FAQ: Can I exercise if I have angina?

Yes, you should be able to do physical activity if you have angina. In fact, your doctor will ask you to be regularly active to keep your heart healthy and to prevent any further heart problems.

If you have angina, regular exercise can help to keep your heart healthy by:

  • helping you keep a healthy weight
  • lowering your blood pressure
  • reducing your risk of getting diabetes
  • improving the way your blood vessels work
  • improving the way your body breaks down fats

Talk to your doctor or nurse on how much activity you should be doing. It’s important to increase the amount you’re doing gradually, to make sure you don’t put too much strain on your heart. Here are some tips.

  • Aim to do about half an hour of activity on four or five days of the week.
  • Do activity at a level that makes you feel warm and slightly out of breath.
  • Choose activities like walking, cycling and swimming. Don’t lift weights or do very vigorous sports like squash.
  • Pace yourself. Stop what you’re doing if you get chest pain, become very breathless or develop leg pain.
  • Don’t exercise outside when it’s cold, or very windy.

Your doctor may advise you to take glyceryl trinitrate (also known as GTN) before doing some activities.

If you can walk briskly up and down two flights of stairs, it should be safe for you to have sex. Speak to your GP if you have any questions or concerns.

Details

  • Heart treatment on demand

    You can access a range of our health and wellbeing services on a pay-as-you-go basis, including heart treatment.

  • Other helpful websites Other helpful websites

    Further information

    Sources

    • Angina. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised January 2017
    • Stable ischaemic heart disease. BMJ Best Practice. bestpractice.bmj.com, last updated July 2017
    • Angina pectoris. The MSD Manuals. www.msdmanuals.com, last full review September 2016
    • Acute myocardial infarction. PatientPlus. patient.info, last checked March 2017
    • Stable angina: management. National Institute for Health and Care Excellence (NICE). www.nice.org.uk, 2016
    • Stable angina. PatientPlus. patient.info, last checked May 2016
    • Angina. British Heart Foundation. www.bhf.org.uk, accessed 22 September 2017
    • Unstable angina. BMJ Best Practice. bestpractice.bmj.com, last updated April 2017
    • Acute coronary syndrome. PatientPlus. patient.info, last checked March 2017
    • Angina Pectoris Clinical Presentation. Medscape. emedicine.medscape.com, updated December 2016
    • Treadmill Stress Testing. Medscape. emedicine.medscape.com, updated December 2016
    • Exercise EGC. British Heart Foundation. www.bhf.org.uk, accessed 22 December 2017
    • Echocardiography. Medscape. emedicine.medscape.com, updated January 2014
    • Cardiac catheterization. The MSD Manuals. www.msdmanuals.com, last full review February 2016
    • CVD risk assessment and management. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised September 2014
    • UK Chief Medical Officers. Low Risk Drinking Guidelines. 2016 www.gov.uk
    • Glyceryl Trinitrate. NICE British National Formulary. bnf.nice.org.uk, accessed 25 September 2017
    • Unstable angina and NSTEMI: early management. National Institute for Health and Care Excellence (NICE) 2013. www.nice.org.uk
    • Lipid-regulating Drugs (including Statins). PatientPlus. patient.info, last checked July 2014
    • Percutaneous Coronary Intervention. PatientPlus. patient.info, last checked March 2017
    • Coronary Artery Bypass Grafting. PatientPlus. patient.info, last checked August 2016
    • Overview of Coronary Artery Disease. The MSD Manuals. www.msdmanuals.com, last full review September 2016
    • Atherosclerosis. The MSD Manuals. www.msdmanuals.com, last full review March 2017
    • Management of stable angina. Scottish Intercollegiate Guidelines Network (SIGN), 2007. www.sign.ac.uk
    • Prevention of cardiovascular disease. PatientPlus. patient.info, last checked August 2014
    • Car or motorcycle drivers with heart conditions. Driver and Vehicle Licensing Agency (DVLA) 2016 www.gov.uk
    • Report your medical condition. Driver and Vehicle Licensing Agency (DVLA) www.gov.uk, published April 2012
    • Cardiovascular disorders: assessing fitness to drive. Driver and Vehicle Licensing Agency (DVLA) www.gov.uk, last updated June 2017
    • British Cardiovascular Society. Fitness to fly for passengers with cardiovascular disease. Heart 2010;96:ii1eii16. doi:10.1136/hrt.2010.203091
    • Heart disease and physical activity. PatientPlus. patient.info, last checked December 2015
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    Reviewed by Graham Pembrey, Lead Health Editor, November 2017
    Expert reviewer, Dr Tim Cripps, Consultant Cardiologist
    Next review due November 2020

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