Angina overview

What is angina?

Angina is a common symptom of heart disease. It is most often described as an unpleasant feeling or discomfort, like a tightness or weight on the chest. It usually lasts only a few minutes and can be relieved by rest and/or medicines.

Angina can affect people in different ways and the symptoms may vary at different times. It is usually felt across the centre of the chest but may also be felt in either or both shoulders, the neck or jaw, down one or both arms and in the hands. Some people experience it in only one of these areas and not in the chest at all. Others, in particular people with diabetes, can get very little pain and may just complain of breathlessness.

Angina is usually brought on by exertion, by emotion, after a heavy meal or in cold weather. It may even occur at rest or during the night. Many people find they experience it more often at particular times of the day, the most common being first thing in the morning or late afternoon.

What causes angina?

In most cases, angina is caused by coronary artery disease. This occurs when fatty deposits build up under the inner lining of the coronary arteries, which supply the heart muscle.

As a result, these arteries become narrowed and the blood flow to the heart muscle is reduced. Angina occurs when the blood flow to the heart muscle is insufficient to meet the extra demands made on it. There is no permanent damage to the heart muscle from an episode of angina.

Angina is very occasionally caused by spasms of coronary arteries alone, without blockage.

Angina medicines

Several different types of medicines are used to treat angina. Nitrate spray or nitrate tablets that dissolve under your tongue are used when you first start to feel the symptoms of angina coming on. A number of other types of medicines, including other types of nitrates, are used to stop you from having further attacks of angina and to help lower your risk of having a heart attack.

Medicines used to treat angina symptoms

Nitrates are the most common way to treat angina when you have symptoms. They work quickly by relaxing the blood vessels, opening them wider so blood can flow more freely. A doctor must prescribe nitrates. Your doctor may prescribe a nitrate spray or tablet for you to take when you start to feel chest discomfort.

Nitrate spray

Your doctor may give you a nitrate spray called glyceryl trinitrate (also known as nitroglycerine; brand name Nitrolingual Pumpspray). The spray delivers a measured dose of nitrate into your mouth each time the nozzle is pressed. The spray droplets are absorbed quickly and give an almost immediate effect. Follow the instructions to ensure that you receive the correct dose.

Using glyceryl trinitrate spray effectively

  • Do not shake the canister.
  • You may need to prime the dosing chamber by spraying into the air first — refer to the instructions.
  • Hold the canister upright.
  • Spray the dose under your tongue and do not swallow or inhale the medicine immediately after.
  • Close your mouth.
  • For a second dose, repeat the above steps.
  • If the angina is not relieved after 2 doses (with a 5 minute interval between each spray), call an ambulance. Dial 000 immediately.

Nitrate tablets

The nitrate tablets that your doctor may prescribe for you to treat angina symptoms are glyceryl trinitrate tablets (brand names include Anginine) or isosorbide dinitrate tablets (brand name Isordil Sublingual Tablets). These tablets are absorbed into the bloodstream through the lining of your mouth. When taking the tablet, you should place it under your tongue or in your cheek. Do not swallow, chew or crush your tablet. The chemist’s label will tell you the correct dose, but check with your doctor if there’s something you don’t understand. Glyceryl trinitrate tablets start to lose their effectiveness 3 months after the bottle has been opened, so replace them at this time.

Using glyceryl trinitrate or isosorbide dinitrate tablets effectively

  • The tablet can be placed under your tongue or in your cheek and allowed to dissolve.
  • Avoid eating, drinking or smoking until the tablet has completely dissolved.
  • If the angina is not relieved by a total of 2 tablets and rest in 10 minutes, dial 000 immediately for an ambulance.

Storing your nitrate spray or tablets

  • Check the expiry date on all medicines. Always have enough medicine on hand, and carry the spray or tablets with you at all times.
  • Be aware that heat or dampness can adversely affect some medicines. Store nitrate spray and tablets in a cool, dry place below 25°C. Do not leave in a car on hot days.
  • Glyceryl trinitrate tablets must be changed every 3 months because they lose their effect if they are too old.
  • Keep nitrate tablets stored in the glass bottle in which they were dispensed. They should not be exposed to warmth, light or air. Don't place any other material, even cotton wool in your glyceryl trinitrate tablet bottle: use only the special packing provided.

Side effects of nitrates

  • The most common side effects of short-acting nitrates are headache; low blood pressure (feeling faint or dizzy); flushing (redness of the face); and palpitations. Spitting out the nitrate tablet once symptoms are relieved may relieve these side effects. If you continue to experience side effects, check with your doctor.
  • Nitrate tablets and sprays temporarily lower your blood pressure. For this reason you may feel a bit faint if you are using them for the first time, if you take too much, or when you are hot (such as after a shower). It's best, therefore, to sit down when taking them.
  • You should be careful if you drink alcohol while taking nitrate medicines as it may increase the likelihood of faintness and dizziness.
  • If you are taking nitrates, do not take sildenafil (brand name Viagra), tadalafil (brand name Cialis) or vardenafil (brand name Levitra) as serious side effects may occur.
  • If you are concerned about the side effects of your medicines, consult your doctor.

Medicines used to prevent further attacks of angina

There are a number of different medicines that can be taken to prevent you from having further attacks of angina and to help lower your risk of having a heart attack.

Nitrates

Nitrate skin patches and tablets are often used for preventing chronic (ongoing) angina. Glyceryl trinitrate skin patches (brand names include Nitro-Dur and Transiderm-Nitro) are long-acting forms of nitrates that are absorbed through the skin. You should put the patch on your (hair-free) chest or upper arm and change the patch as prescribed by your doctor. Because tolerance (the body getting used to a medicine so that it is no longer so effective) can occur quite quickly with nitrates, it is often recommended that people using patches take them off for 8 hours each day, usually at night. Your doctor should discuss this with you.

Nitrate tablets that are taken to prevent you from getting further attacks of angina have a longer-acting effect than the nitrate spray or tablets that you take when you have angina symptoms. These nitrates are absorbed through the stomach instead of the mouth. They include isosorbide mononitrate (brand names include Duride, Imdur Durules and Isomonit).

Beta-blockers

Beta-blockers are also used to treat angina, as well as other conditions such as high blood pressure, heart failure and an irregular heart beat. They reduce the frequency of angina attacks and allow you to do more physical activity by slowing your heart rate and allowing it to pump more efficiently. Some of the beta-blockers used for angina are atenolol (brand names include Noten, Tenormin and Tensig) and metoprolol (brand names include Betaloc, Lopresor, Metrol and Minax).

Calcium antagonists

These medicines are also sometimes used to prevent angina symptoms. One way that calcium antagonists (also known as calcium channel blockers) can help is by relaxing (dilating) the arteries, allowing the blood to flow through more easily, reducing blood pressure and therefore reducing the workload on the heart. Some of the calcium antagonsits used for angina are amolidpine (brand names include Norvasc and Perivasc), diltiazem (brand names include Cardizem CD, Coras and Vasocardol), verapamil (brand names include Isoptin and Veracaps) and nifedipine (brand names include Adalat Oros, Addos XR and Adefin XL).

If you have moderate to severe angina that is not stopped by other medicines, you may be prescribed a calcium antagonist called perhexiline (brand name Pexsig). If you take this medicine you will need to have regular blood tests to check that the levels of the medicine in your blood are within acceptable levels.

Nicorandil

Nicorandil (brand name Ikorel) is a tablet that you may be prescribed for angina. It reduces angina by opening the coronary arteries and relaxing the muscle in the blood vessels.

Antiplatelet medicines

Antiplatelet medicines work by reducing the ability of blood to clot so that the blood flows more easily through narrowed arteries. They include aspirin and clopidogrel (brand names Iscover and Plavix).

Angiotensin converting enzyme (ACE) inhibitors

ACE inhibitors may be prescribed if you have angina to reduce your risk of having a heart attack or stroke. They help relax blood vessels and lower blood pressure.

Choleserol-lowering medicines

Although they do not directly affect the symptoms of angina, cholesterol-lowering medicines reduce the build up of cholesterol in the coronary arteries and can reduce your risk of having a heart attack or stroke.

What else can be done for angina?

Serious angina that does not respond to medical therapy may be treated by physically re-opening the coronary arteries. Depending on where the blockages are, this can be done using balloon dilation (angioplasty), by a catheter fed through an artery in the groin, or traditional open cardiac bypass surgery. Following balloon dilation, a device like a mesh scaffold called a stent is often left in place to keep the artery open. An X-ray of the coronary arteries (angiogram) is required to decide whether surgery or angioplasty is necessary or possible.

Cardiac rehabilitation, a kind of exercise therapy designed to improve cardiac blood flow, can also help with angina.

Living with angina: an action plan

Occasional angina symptoms: action plan

  • Stop what you are doing, sit down, rest and wait until the feeling passes. If you have been given a nitrate spray or tablets, use them as instructed.
  • If you are using the spray, and the angina is persisting 5 minutes after the first dose, you can administer a second metered dose, however DO NOT take more than 2 doses during an angina attack. Resume your activities gently once the symptoms have passed.
  • If 2 doses don't relieve the attack, call an ambulance or the nearest hospital immediately.
  • If you are taking the nitrate tablets, you can use up to 2 tablets to relieve the angina pain. Always follow your doctor's instructions. These will usually be to use one tablet to start with — allow it to dissolve under your tongue or inside your cheek.
  • If the 2 tablets and rest do not relieve the angina after 10 minutes, call an ambulance or the nearest hospital immediately.
  • If your angina is accompanied by significant breathlessness, palpitations or a feeling that you are about to pass out, call an ambulance or the nearest hospital immediately.

Regular pattern angina symptoms: action plan

Some people get angina at predictable times. For example:

  • when it's cold;
  • when you are walking up hills or stairs;
  • while working or doing chores;
  • while showering; or
  • during sexual activity.

Use your nitrate spray or tablets a few minutes before attempting the activity that triggers your angina. If you are experiencing angina symptoms every day, consult your doctor within 24 hours so that further treatment can be planned.

Change in angina symptoms: action plan

The pattern of your angina may change significantly in the following ways. It may:

  • happen more often;
  • be more severe;
  • happen at rest or at night; or
  • not be relieved as easily as usual by your angina medicine.

This is called unstable angina. It may be a warning sign of impending heart attack. Consult your doctor within 24 hours or sooner if you feel faint or breathless. In the meantime, continue to use your nitrate spray or tablets. If an angina attack is not relieved within 10 minutes, call an ambulance by dialling 000 immediately.

Looking after yourself

You need to think about all the risk factors for coronary heart disease and how they apply to you. These include raised blood pressure, cigarette smoking, raised blood cholesterol, diabetes, excess weight and lack of physical activity.

Lifestyle changes that could improve your heart health include:

  • reducing your intake of saturated (animal) and trans fats and salt and increasing your intake of fruit and vegetables and wholegrain cereals;
  • not smoking;
  • having your blood pressure checked regularly;
  • enjoying regular physical activity according to your capacity, however, if you already have angina, consult your doctor before beginning any exercise programme;
  • maintaining a healthy body weight; and
  • developing ways to cope with stress.

What is the difference between angina and a heart attack?

Angina symptoms are associated with a temporary reduction in blood flow to part of the heart muscle leaving no damage to the muscle itself. Rest and medicines, including nitrate tablets or spray, can help relieve angina pain.

A heart attack results from a blockage in a coronary artery which causes permanent damage to the heart muscle. The pain associated with a heart attack usually lasts longer than 15 minutes and is not relieved by nitrate tablets or spray. However, some heart attacks, particularly in people with diabetes, may be painless. If you have significant risk factors for coronary artery disease it is a good idea to have regular tests to detect these silent episodes.

If your pattern of angina alters or worsens, discuss it with your doctor immediately.


 
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