Angina

Diagnosis

To diagnose angina, a healthcare professional examines you and asks questions about your symptoms. You are usually asked about any risk factors, including whether you have a family history of heart disease.

Tests

Tests used to diagnose and confirm angina include:

• Electrocardiogram (ECG or EKG). This quick and painless test measures the electrical activity of the heart. Sticky patches called electrodes are placed on the chest and sometimes the arms and legs. Wires connect the electrodes to a computer, which displays the test results. An ECG can show if the heart is beating too fast or too slow. The test can show if you are having or have had a heart attack.
• Chest X-ray. A chest X-ray shows the condition of the heart and lungs. A chest X-ray may be done to determine if other conditions are causing chest pain symptoms and to see if the heart is enlarged.
• Blood tests. Certain heart proteins slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these proteins, called cardiac enzymes.
• Stress test. Sometimes angina is easier to diagnose when the heart is working harder. A stress test typically involves walking on a treadmill or riding a stationary bike while the heart is checked. Other tests may be done at the same time as a stress test. If you can’t exercise, you might get medicines that affect the heart like exercise does.
• Echocardiogram. This test uses sound waves to create images of the heart in motion. These images can show how blood flows through the heart. An echocardiogram may be done during a stress test.
• Nuclear stress test. A nuclear stress test helps measure blood flow to the heart muscle at rest and during stress. It is similar to a routine stress test, but during a nuclear stress test, a radioactive tracer is injected into the bloodstream. A special scanner shows how the tracer moves through the heart arteries. Areas that have small amounts or none of the tracer are likely to have poor blood flow.
• Cardiac computed tomography (CT) or magnetic resonance imaging (MRI). These tests create images of the heart and chest. Cardiac CT scans use X-rays. Cardiac MRI uses a magnetic field and radio waves to create images of the heart. For both tests, you usually lie on a table that slides inside a long tubelike machine. Each test can be used to diagnose heart problems. The tests can help show the severity of heart damage.
• Coronary angiogram. This test uses X-ray imaging to check the inside of the heart’s blood vessels. It’s part of a general group of procedures known as cardiac catheterization.

  A healthcare professional inserts a flexible tube called a catheter into a blood vessel, usually in the groin. It’s guided to the heart. Dye flows through the catheter. The dye makes the heart arteries show up more clearly on an X-ray. The X-ray is called an angiogram.

Treatment

Options for angina treatment include:

• Lifestyle changes such as eating a healthy diet and exercising.
• Medicines.
• Angioplasty and stenting.
• Open-heart surgery called coronary artery bypass grafting (CABG).

The goals of angina treatment are to:

• Reduce the number of angina episodes.
• Make symptoms less severe.
• Lower the risk of a heart attack and death.

You will need immediate treatment if you have unstable angina or chest pain that’s different from what you usually have.

Medications

If lifestyle changes don’t improve heart health and relieve angina, you may need medicines. Medicines to treat angina may include:

• Nitrates. These medicines are often used to treat angina. Nitrates relax and widen the blood vessels so more blood goes to the heart. The most common form of nitrate used to treat angina is nitroglycerin (Nitrostat). The nitroglycerin pill is placed under the tongue. Your healthcare team might recommend taking a nitrate before activities that typically trigger angina, such as exercise. Some people need to take nitrates on a long-term, preventive basis.
• Aspirin. Aspirin reduces blood clotting, making it easier for blood to go through narrowed heart arteries. Preventing blood clots can reduce the risk of a heart attack. Don’t start taking a daily aspirin without talking to your care team first.
• Clot-preventing drugs. Certain medicines such as clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta) make blood platelets less likely to stick together so blood doesn’t clot. One of these medicines may be recommended if you can’t take aspirin.
• Beta blockers. Beta blockers slow the heartbeat. The heart beats with less force, which lowers blood pressure. These medicines also relax blood vessels, which improves blood flow.
• Statins. Statins are drugs used to lower blood cholesterol. High cholesterol is a risk factor for heart disease and angina. Statins block a substance that the body needs to make cholesterol. They help prevent blockages in the blood vessels.
• Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels to improve blood flow.
• Other blood pressure medicines. Other drugs to lower blood pressure include angiotensin-converting enzyme (ACE) inhibitors and angiotensin 2 receptor blockers (ARBs). If you have high blood pressure, diabetes, symptoms of heart failure or chronic kidney disease, your healthcare team may prescribe one of these types of medicines.
• Ranolazine. This treatment may be prescribed for chronic stable angina that doesn’t get better with other medicines. It may be used alone or with other angina medicines.

Therapies

Sometimes, a nondrug option called enhanced external counterpulsation (EECP) may be done to increase blood flow to the heart. With EECP, blood pressure-type cuffs are placed around the calves, thighs and pelvis. EECP requires multiple treatment sessions. EECP may help reduce symptoms in
people with frequent, uncontrolled angina, called refractory angina.

Surgery and procedures

If lifestyle changes, medicines or other therapies don’t reduce angina pain, a catheter procedure or open-heart surgery may be needed.

Surgeries and procedures used to treat angina and coronary artery disease include:

• Angioplasty with stenting. This treatment also is called percutaneous coronary intervention. A tiny balloon is inserted into the narrowed artery. The balloon is inflated to widen the artery. Then a small wire mesh coil called a stent is usually inserted to keep the artery open.Angioplasty with stenting improves blood flow in the heart, reducing or eliminating angina. The treatment may be a good option for those with unstable angina or if lifestyle changes and medicines don’t effectively treat chronic, stable angina.
• Coronary artery bypass grafting (CABG). This is a type of open-heart surgery. During CABG, a vein or artery from somewhere else in the body is used to bypass a blocked or narrowed heart artery. The surgery increases blood flow to the heart. It’s a treatment option for both unstable angina and stable angina that has not improved with other treatments.