Angina, Angina Pectoris
Angina pectoris is a pain usually felt in the chest coming from the heart which is not receiving enough oxygen. The most common causes narrowing in the arteries fitting blood to the heart (coronary arteries, but it can also sometimes happen with severe anaemia, shock and low oxygen at very high altitudes. We will only discuss on this page angina caused by narrowing of the coronary arteries.
Blockages (plaques) develop can in the coronary arteries made up of cholesterol, fibrous tissue and calcium. When the plaques are big enough to reduce the blood flow, the patient experiences angina. This usually happens when the heart requires more oxygen such as exercise, cold, high blood pressure, stress, rapid heart rate.
Symptoms – angina is more a discomfort than a pain, patients describing a heavy, tight, squeezing, crushing feeling in the chest often indicated by a clenched fist, rather than pointing to a specific spot. The 8 can also be felt in the upper chest and lower jaw, down the left arm and occasionally the right. It can also go through to the back.
The pain usually gradually increases rather than is maximal initially, and can slowly fade away. It does not change with breathing or position and pressure on the chest makes no effect on it. Sometimes patients feel they would like to belch, but this doesn't usually make any difference.
Types of angina – there are 3 important different types of angina, and it is important to recognise these:
1. Stable angina – this is due to a stable narrowed artery, the pain consistently comes on with exercise stress etc., and then goes away when the cause is removed. It does not happen at rest but and is really prolonged.
2. Unstable angina – this is when the plaque in the artery is beginning to expand or rupture, and can be the forerunner of a heart attack. In the situation the angina occurs without any cause, can be more prolonged, and is often associated with sweating or feeling unwell. This is an emergency and when it happens the patient should be taken straight to hospital.
3. Coronary artery spasm, Prinzmetal angina. – This tends to occur more in middle-aged to older women, when part of one of the coronary arteries goes into spasm (like crap) causing anginal pain. The pain is identical to normal angina, but usually comes on at rest, or with stress or cold. It often needs investigations to separate this from angina due to a plaque blockage.
What doctors can do
1 Stable angina – Your doctor will usually arrange for a number of investigations including a thorough physical examination, electrocardiogram, possibly a stress ECG and an echocardiogram. He will also want a number of blood tests including your cholesterol, glucose levels etc. Depending on these results he may send you to a cardiologist who would probably arrange for an angiogram. (In some centres CT angiography and CT scoring for calcium can be done instead of a conventional angiogram, and is very much less invasive).
You'll then be put on a number of drugs to relieve the chest pain – a beta-blocker (metoprolol), or calcium channel blocker (diltiazem or verapamil). He will also give you a spray (Nitrolingual spray) which you spray one or 2 puffs under the tongue to relieve the pain. It is important to do this sitting down rather than standing as it can make you faint. A long acting nitrate which can open up the arteries (Imdur.) In addition he will put you on aspirin at a low dose and almost certainly a statin drug* to reduce the risk of the plaque in the artery increasing or rupturing. He will also recommended diet (see below).
If this controls the angina, then no further action need to be taken, but if the angina pain starts getting worse it's important to see your doctor to see whether further investigations are needed. This may include angiography and angioplasty and stenting to dilate the arteries, and in some cases coronary artery bypass surgery. There are other drugs as well (perhexalene, nicorandil, ranolozine).
2. Unstable angina – if you angina is becoming worse, the only place to be is in hospital where they can investigate this with angiography, angioplasty and stenting, or coronary artery bypass surgery. This is an emergency, and should not be delayed.
3. Coronary artery spasm (Prinzmetal angina) – the treatment of this is either nitrates sprayed under the tongue (Nitrolingual) and for prevention the best drugs are the calcium channel blockers – diltiazem, nifedipine or verapamil. Magnesium 800 to 1600 mg a day can often also be beneficial.
What you can do
- exercise is important, as not only doesn't open up the normal coronary arteries, but encourages the development of bypass arteries (collaterals) to improve the blood supply. It is important however to stop when the angina pain comes on, take a puff of spray and then resume the exercise. It is crucial to warm up before doing any vigorous exercise.
- Diet is very important, but unfortunately very few people give you the same answer to this question. There is no doubt that lots of fruit vegetables grains and fish and limited red meat is probably the way to go, the information about saturated fat is now being debated, and although monounsaturated fats like olive oil are still good, the main fats that are damaging our the trans-fats found in margarines and many processed foods. Probably the best diet for heart patients is the Mediterranean diet, and it is certainly the easiest one to follow.
EECP - Enhanced, external counter pulsation - this is described more fully on this site (here). It is a painless non invasiive techhnique where BP type cuffs are placed round the legs and lower abdomen, these inflate between heart beats greatly increasing blood flow to the coronary arteries. it is believed thet encourage the development of new bypass (collateral) blood vessels and have been shown to reduce angina. In patients who have angina and cannot have or do not want more procedures, EECP is well worth considering. Howevver it is not available in many places and also requires 15 - 20 one hour treatments.
Chelation therapy - iv infusions of EDTA are used to remove lead and other heavy metals from the body. Chelation clinics believe that by doing this they may also reduce the size of the plaque blockages in the coronary and other blood vessels. There is very little evidence for this. Only one trial ( The TACT trial) has been performed and found no benefit except in patients who have diabetes. So if you have diabetes and anngina,, then perhaps chelatioj may be worth considering. This is further discussed here.
it is crucial to stop the blockages of the arteries from getting worse, and thus in addition to diet it is essential to make certain that the body has all the assistance it can to repair and recover.
- A good multivitamin and multi mineral provides the heart tissue with all the nutrients required to be optimally, it can also contains vitamins B6, B12 and folic acid which lower the homocysteine which is believed to damage the artery walls. In areas where the selenium is low the soil, a good multivitamin should also contain selenium.
- Calcium and magnesium – calcium is required for the muscles to contract and magnesium for them to relax, and eliminate any spasm. 804,000 mg a day is the usual dose, and magnesium also has an additional effect of stabilising any heart rhythm abnormalities that might occur when the heart is starved of oxygen.
- Vitamin D – there is quite a lot of evidence that low vitamin D increases the risk of having a heart attack, sun exposure was good but this is difficult to achieve in many areas, and some vitamin D 5 to 8000 international units a day as a supplement seems wise.
- Omega-3 fish oils – these have numerous actions including improving cardiac function and slowing down the development of the plaque, but they also have quite a powerful rhythm controlling effect if any dangerous rhythm is occur during and anginal attack. Take at least 1 g a day, preferably 2 to 3 g a day but it is important to make sure that this is pure and does not contain mercury.
- Coenzyme Q 10 – this is an energy enzyme within the muscles in mitochondria of the heart and other tissues, and it is crucial for transporting energy around. Statin drugs block the development of coenzyme Q 10 which could lead to heart failure. All patients with heart disease should be taking coenzyme Q 10 supplements 100 to 200 mg daily.
- Hawthorne – although there are few studies on Hawthorne, it does appear that this is beneficial in patients with heart disease, and many practitioners are recommending this as well.
The Nutritional supplements I use and recommend to my patients
For Heart patients - USANA - Cellsentials *, Biomega, Active Calcium plus, Coquinone and vitamin D -
Other therapiesThere are a number of other therapies which you might like to look at. They have not been specifically included with this disease because some are a form of treatment which is applicable to most diseases and many focus on the mind, body, spirit, and the universe. These include - acupuncture, Ayurvedic medicine, energy healing, homeopathy, naturopathy, prayer, visualisation and some people with this condition might like to look at these topics (I have described them more fully on another page on this website click here .) With my personal experience and reading, I do not think that I can comment of whether one or a number of these might help. They fit well with most conventional and complementary treatments and I suspect some or even all of them can be extremely powerful - if performed by an experienced practitioner. My only caveat is that if in the course of one of these therapies, you are given potions or herbs, do check with your health practitioner that they will not interfere with other treatments or drugs you are receiving.
Nutritional supplementsI believe in today's world that nutritional supplements are so necessary as to be an essential component of any form of both prevention and treatment. Not only is today's food lacking in nutrients because of the way it was grown and processed, but also most of us make the wrong choices in diet. It is virtually impossible to obtain optimal levels of most of the vitamins, minerals and other nutrients although many people try to do so, and even then fresh produce is not available all year round. *There are many quality supplements available on the market, including –Thorne, NFS, Douglas Labs, Xtend Life, True Star Health, USANA, and Metagenics. There are others, but do your due diligence before choosing one. USANA Health Sciences has added a new adjunct to its multivitamin and multi mineral called CellSentials. These are a patented blend of phyto-nutrients which they believe affects cell signaling and growth, and increases the production of preventative antioxidants within the cell. These should add to the value of the multi, so these are the multivitamin/mineral preparation I recommend.
* There is a strong anti-statin lobby making people resistant to taking these drugs. In part this is reasonable, and there is no doubt the pharmaceutical industry and some medical authorities are pushing the use of statin drugs in many situations, and there is even a suggestion that everyone over the age of 50 should be taking a statin as part of a 'polypill'. However the evidence for many of the claims is not strong, and just because the cholesterol is lowered, this does not necessarily reduce heart and other diseases. The drugs also have significant side effects - muscle pain, mental blunting, abnormal liver function tests, nerve pains. However in patients who have definite heart disease, statins in many good trials have been shown to reduce the risk of further heart attack, stroke or death bu 10 - 20%. For a person who has had a heart attack, a 20% reduction for further events is significant, and my advice is to take a statin drug. If it causes side effects try another one (most doctors give simvastatin or atorvastatin - switch to Pravastatin which is water soluble). If the side effects are still present, then discuss with your doctor about stopping them.
I have also written in greater depth on this website - look under Statins.