Angina: When is it serious?

While angina symptoms of chest pain and tightness may cause alarm, it is in fact the underlying associated coronary artery disease which should be taken in to account when looking to address heart attack risk. In this informative guide to angina, heart attack risk and coronary artery disease, revered consultant interventional and general cardiologist Dr Dwayne Conway shares his expert insight on how angina relates to cardiovascular health and heart attack risk and also discusses the most appropriate forms of treatment and lifestyle measures which can impact on prognosis.

Should I be worried if I have angina?

A lot of people worry about angina but may not understand what the term angina actually refers to. Angina is really the description of the symptom that people feel, which is typically a constricting feeling across the chest (like a band tightening), although some people feel it differently. Angina is not a description of the disease process itself and therefore, when people express concern about their angina, this may need to be unpicked so we can establish if they are worried about the symptoms that they are experiencing, or rather the underlying condition.

Overall, most patients who suffer from angina do so because of coronary artery disease, where the heart’s arteries have become narrowed due to atherosclerotic plaques building up in the arteries, resulting in restricted blood flow. Although this is the most common cause, there are also other ways that people can experience angina. Angina can lead to very serious complications, including heart attack, but the majority of patients live for many years with stable angina, particularly if they take steps to control the progression of the underlying disease.

Does angina always lead to a heart attack?

Angina does not always lead to a heart attack. Long term outcomes and life expectancy with angina depend on your individual underlying risk factors. There are a number of medical conditions and other factors which make people more prone to heart attacks, including cigarette smoking, lack of exercise, obesity, diabetes and poorly controlled blood pressure or cholesterol levels. While each of these factors will increase a person’s risk of having a heart attack, fortunately, many can be controlled.

There are a lot of medications and dietary changes which can help to control diabetes and cholesterol, along with other types of medications and exercise plans which can lower blood pressure. Similarly, exercise and diet can also be used to help weight management.

Several years ago, a large trial called the ISCHEMIA trial was conducted to look at the difference between treating narrow blood vessels with stents versus treatment with medications in patients with angina, coronary artery disease and significant blood flow problems. If we look at the outcomes with medication, which is fairly standard treatment, the rate of heart attack per year amongst those patients was about three per cent per year – meaning that three people out of a hundred had a heart attack every twelve months.

For this minority, a heart attack is obviously a major life changing event. However, ninety-seven per cent of people didn't not suffer a heart attack that year, despite living with coronary artery disease and angina. If you extrapolate that out to ten, fifteen or twenty years, even at that stage, the majority of patients have not had a heart attack. Therefore, although heart attacks do happen and they are significant, it’s actually the minority who are affected, while most patients are able to live will with stable angina and coronary artery disease.

Importantly, this study included patients with all of the associated risk factors I have discussed and so the prognosis in terms of long term outcomes from stable coronary artery disease is not bad.

The most important thing is to recognise the full effects of the underlying heart disease so that heart attack risk can be managed. As such, it’s essential to have an expert review which establishes the cause of a patient’s angina and what can be done to reduce their risk of heart attack. This allows patients to focus on what can be done to help to reduce the risk and should also give them the understanding that the sensation of the angina (chest tightness and discomfort), is not in itself a sign that the heart is being damaged but rather an awareness of the underlying problem.

Can you live a long life with angina?

Yes, indeed most people do live a long life with angina. As I mentioned earlier, a minority of people will suffer a heart attack but the majority will not, despite living with angina and coronary artery disease. In cases where patients do suffer a heart attack, treatment is really excellent these days and as such, the outcomes after a heart attack are fairly good.

Heart attacks are clearly a significant problem and they can be fatal, sometimes even instantly, so this means that for some patients, heart disease can be deadly. However, considering patients with angina, the vast majority will not die from their heart disease over the next ten or twenty years, and in that time, it’s probably just as likely that other conditions like cancers or unexpected illnesses might come into play as well.

According to the ISCHEMA trial that I previously discussed, if we look at all causes of death (including cancers, heart disease and everything else), at five years from the start of the trial, eight per cent of the patients had died. This means that ninety-two per cent of patients were still alive five years on, regardless of the fact they were living with heart disease. At that same point of five years, eleven to twelve per cent had had a heart attack. The rate of heart attack is higher than the rate of fatality as many people survive a heart attack without any problem. This shows that most people will live a good long, healthy life with angina so long as they treat it and manage it appropriately.

Does angina come and go?

Yes, angina will normally come and go in relation to physical activity. Classical angina occurs on physical effort. In coronary artery disease, the arteries have narrowings which develop over time rather than coming on quickly.

When the patient is resting, they are not demanding much work from their heart and so the blood flow down those narrowed arteries is enough for their activity level, meaning that they don’t feel any symptoms. However, when the patient exerts themselves - typically by walking up an incline, going up the stairs or carrying heavy objects - they are increasing the workload of the heart and as such they start to feel angina symptoms. Patients normally find that when they stop and rest, the angina symptoms settle off within about five minutes but may recur again when they resume exercise.

It would be unusual for angina to come and go spontaneously, with chest pains that come one randomly without relation to physical effort. This is not a typical way for angina to behave unless it has a cause other than underlying coronary artery disease, like a change in heart rhythm.

In terms of symptoms which come and go over a long period of time, it is certainly the case that with good treatment, patients can be rendered free from angina and can resume their activities and be able to exercise without symptoms, sometimes even for many years. Later in life, as the arteries may become more narrowed with time in this biological process, the patient may feel their angina coming back.

How is it angina treated?

There are a lot of different treatments for angina. As discussed earlier, angina is the symptom rather than the condition and this chest discomfort occurs as a response to the underlying heart disease. The treatments for angina can be divided into those that relieve the symptoms, so people can feel better and do more physical activity without feeling discomfort, and those treatments which reduce the risk of the condition getting worse and the likelihood of developing a heart attack, or of dying from heart disease. Some medications are excellent and cover both of those areas and will reduce both the symptoms of angina and the risk of further problems in the future but often medications have different roles.

A classic type of medication for somebody with angina is statin drugs which don’t help to relieve angina symptoms but make a huge difference to the chance of having a heart attack and the likelihood of the underlying disease from worsening. Statins are indeed probably the most effective drug at preventing worsening of the heart condition.

On the other hand, there are medications like GTN (Glyceryl trinitrate) spray, which is a rapid reliever of angina symptoms that is sprayed under the tongue, but it doesn’t alter the underlying heart condition. Additionally, there are many other different medications such as beta blockers, calcium channel antagonists, vasodilator drugs and blood pressure reduction medications, among others, which can be helpful in the management of coronary artery disease and associated angina.

If you are concerned about angina or coronary artery disease and wish to schedule a consultation with Dr Conway, you can do so by visiting his Top Doctors profile.