Overview

Chronic stable angina (angina pectoris) is a type of chest pain or discomfort that occurs when the heart muscle doesn’t receive enough blood. It is often a symptom of coronary artery disease (CAD), where the arteries supplying blood to the heart become narrowed or blocked due to plaque buildup.

Angina causes pain that's often described as crushing, squeezing, burning, or tight in the chest. Stable angina doesn't come as a surprise though. Symptoms are predictable to each individual and usually last less than 5 minutes.

While it is very uncomfortable, stable angina is not “dangerous” and can be managed with medication.

Stable vs. Unstable Angina

Stable angina is a predictable type of chest pain or discomfort that occurs when the heart muscle doesn't receive enough blood. It typically happens during physical activity or emotional stress. The pain is often described as a squeezing or crushing sensation in the chest. Stable angina can usually be managed with medications and lifestyle changes.

Unstable angian is a more serious condition where chest pain occurs suddenly, is more severe, or lasts longer than usual (more than 15 minutes). It can be a sign of a heart attack. Unlike stable angina, unstable angina is unpredictable and can occur even at rest. If you experience unstable angina, it's important to seek immediate medical attention as it can lead to a heart attack.

Prevalence

Stable angina is the most common form of angina. It affects millions of people worldwide, with about 10 million cases in the United States alone. It often affects individuals with underlying risk factors for heart disease, such as high blood pressure, high cholesterol, diabetes, and smoking.

The prevalence of stable angina increases with age. For women aged 45-64 years, the prevalence ranges from 5-7%, while for men in the same age group, it ranges from 4-7%3. The prevalence peaks between 55 and 65 years of age for men and then declines.

According to the Framingham Heart Study, approximately 500,000 new cases of stable angina occur each year in the United States.

Symptoms

Symptoms of stable angina include:

• The primary symptom of chronic stable angina is chest pain or discomfort. This pain can be described as: crushing, squeezing, burning, tight
• The pain typically occurs in the center of the chest but may radiate to the left arm, shoulder, jaw, or back
• Symptoms usually last less than 5 minutes
• The pain often occurs during physical activity or emotional stress, when the heart demands more blood.
• Fatigue, shortness of breath, neausea

These symptoms are predictable and usually occur during physical exertion or emotional stress, lasting less than 5 minutes.

Causes

The primary cause of chronic stable angina is coronary artery disease (CAD). This condition occurs when the arteries that supply the heart with blood become narrowed or blocked by a buildup of plaque, a substance composed of cholesterol, fatty deposits, and other cellular waste products.

As plaque accumulates in the coronary arteries, it can gradually reduce blood flow to the heart muscle. When the heart's demand for oxygen exceeds the supply due to narrowed arteries, angina pain occurs. This pain is a signal that the heart muscle is not receiving enough oxygen to function properly.

Other coases of stable angina include:

• Heart Failure: When the heart is unable to pump blood effectively, it can lead to reduced blood flow to the heart muscle.
• Heart Valve Problems: Conditions such as aortic stenosis can restrict blood flow and increase the heart’s workload.
• Arrhythmias: Abnormal heart rhythms can affect the heart’s ability to pump blood efficiently.
• Hyperthyroidism: An overactive thyroid gland can increase the heart’s workload and oxygen demand.
• Anemia: A lack of red blood cells can reduce the oxygen-carrying capacity of the blood, leading to insufficient oxygen supply to the heart.

Risk Factors

Several factors can increase an individual's risk of developing chronic stable angina. These factors often contribute to the development of coronary artery disease (CAD), the underlying cause of angina.

Lifestyle Factors

• Smoking: Smoking damages the blood vessels, leading to atherosclerosis and narrowing of the arteries.
• Diet: A diet high in saturated fats and cholesterol can contribute to plaque buildup in the arteries.
• Physical inactivity: Lack of regular physical activity can increase the risk of obesity, high blood pressure, and high cholesterol.
• Stress: Chronic stress can contribute to high blood pressure and other health problems.

Medical Conditions

• High blood pressure: Elevated blood pressure puts strain on the heart and arteries, increasing the risk of atherosclerosis.
• High cholesterol: High levels of LDL ("bad") cholesterol can contribute to plaque buildup in the arteries.
• Diabetes: People with diabetes have a higher risk of developing heart disease, including angina.
• Obesity: Excess weight can increase the risk of high blood pressure, high cholesterol, and diabetes.
• Family history: A family history of heart disease, particularly at a young age, can increase the risk of developing angina.

Diagnosis

Angina can be classified into many different classes. The most important classification is between stable and unstable angina.

Stable angina is more common and is predictable and short in duration. It will occur with the same activities and feel the same when it occurs.

Unstable angina, on the other hand, is unpredictable. This means that it will occur at rest, or during activities that normally do not bring on chest pain for you. This pain will not go away quickly, or even with typical medications that relive angina. If left untreated, unstable angina can result in a heart attack, and is therefore a medical emergency.

For a clear diagnosis, your healthcare provider will rely on your personally reported symptoms and tests such as blood work, imaging of your heart, and/or a stress test. A stress test measures how your heart works under physical stress, such as running on a treadmill. They will then rule out any other possible conditions or events such as heart failure or a heart attack before coming to a diagnosis.

Once your healthcare provider has classified your angina as stable, it can be further categorized based on how much it impacts your life.

Treatment

All patients with chronic stable angina will be recommended to make lifestyle adjustments and given short acting “rescue” medications to resolve symptoms. Lifestyle changes are very important to prevent angina from getting worse or developing into a more serious condition.

These changes can include:

• Cessation of dangerous activities, such as excessive drinking and smoking cigarettes.
• Exercise

  Regular exercise such as swimming jogging, or even walking can improve your heart’s health. It is important to continue exercising, though ensuring to pace yourself in order to prevent angina from interfering with exercise.

• Diet

  Eating a balanced diet full of fruits, vegetables, and grains is essential in order to maintain a healthy heart. It is also important to reduce salt intake from processed foods and beverages.

All patients with chronic angina should be given a short-acting nitroglycerin tablet or spray. This medication is often given to individuals following a heart-related event, such as a heart attack or stroke. However, it is also available over-the-counter to purchase without a prescription. If bought over the counter, it is important to ensure you have spoken to a healthcare provider about your angina and about the medication’s proper use before beginning self-treatment.

The purpose of a nitroglycerin spray is to quickly relieve the presence of angina when it is to occur. Other prescription medication treatments are preventative, and work to prevent the symptoms of angina before they occur.

If you have chronic angina, and the rescue medication such as nitroglycerin does not improve the chest pain after 5 minutes, seek emergency medical attention.

Medications for Chronic Stable Angina

There are 3 main medication types used to treat chronic statble angina. These include:

Beta-blockers

By hindering the release of these hormones that increase heart beat and blood pressure, beta-blockers reduce the stress placed on your heart and the force of heart muscle contractions. As a result, the blood vessels in your heart, brain, and the rest of your body are relieved of that pressure.

• Metoprolol (Lopressor)
• Bisoprolol (Zebeta)
• Propranolol (Inderal)
• Atenolol (Tenormin)
• Carvedilol (Coreg)

Calcium channel blockers (CCBs)

Calcium channel blockers decrease the amount of calcium that enter the heart and blood vessel walls. This relaxes the blood vessels and makes it easier for the heart to pump, resulting in decreased blood pressure.

• Amlodipine (Norvasc)
• Diltiazem (Cardizem, Tiazac)
• Verapamil (Calan, Verelan)

Nitroglycerin

The nitroglycerin works by opening up the blood vessels and increasing the blood flow to the heart, which reduces the pain of angina.

• Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Minitran)
• Isosorbide dinitrate (Isordil)
• Isosorbide mononitrate (Imdur)

Prevention

Chronic stable angina is a preventable condition. By making healthy lifestyle choices and working with your healthcare provider, you can significantly reduce your risk of developing this condition.

Lifestyle Modifications

A healthy diet plays a crucial role in preventing angina. Choose a diet rich in fruits, vegetables, whole grains, and lean proteins. Limit your intake of saturated fats, trans fats, cholesterol, and sodium.

Regular physical activity is another important factor in preventing angina. Aim for at least 30 minutes of moderate-intensity exercise most days of the week. If you're overweight or obese, working with your healthcare provider to develop a healthy weight loss plan can also help reduce your risk.

Smoking cessation is essential for preventing heart disease, including angina. Quitting smoking can significantly reduce your risk of developing this condition.

Stress management techniques like meditation, deep breathing, or yoga can help reduce stress levels, which can contribute to high blood pressure and other risk factors for angina.

Lifestyle Modifications

If you have high blood pressure, high cholesterol, or diabetes, working with your healthcare provider to manage these conditions is crucial. Medications and lifestyle changes can help control these risk factors.