Acute Coronary Syndrome

Also known as Angina Pectoris, Acute Coronary Syndrome, Microvascular Angina, Prinzmetal’s Angina, Stable Angina, Unstable Angina, Variant Angina, Vasospastic Angina, Cardiac Syndrome X.

Angina pectoris

Angina is chest pain or discomfort that occurs if an area of your heart muscle does not get enough oxygen-rich blood. It is a common symptom of ischemic heart disease, which limits or cuts off blood flow to the heart.

Introduction

There are several types of angina, and the signs and symptoms depend on which type you have. Angina chest pain, called an angina event, can happen when your heart is working hard. It can go away when you stop to rest again, or it can happen at rest. This pain can feel like pressure or squeezing in your chest. It also can spread to your shoulders, arms, neck, jaw, or back, just like a heart attack. Angina pain can even feel like an upset stomach. Symptoms can be different for women and men.

Warning sign

Angina can be a warning sign that you are at increased risk for a heart attack. If you have chest pain that does not go away, call 9-1-1 immediately. To diagnose angina, your doctor will ask you about your signs and symptoms and may run blood tests, take an X-ray, or order tests, such as an electrocardiogram (EKG), an exercise stress test, or cardiac catheterization, to determine how well your heart is working. With some types of angina, you may need emergency medical treatment to try to prevent a heart attack. To control your condition, your doctor may recommend heart-healthy lifestyle changes, medicines, medical procedures, and cardiac rehabilitation.

Types of angina

Stable angina

Stable angina follows a pattern that has been consistent for at least 2 months. That means the following factors have not changed:

• How long your angina events last
• How often your angina events occur
• How well the angina responds to rest or medicines
• The causes or triggers of your angina

If you have stable angina, you can learn its pattern and predict when an event will occur, such as during physical exertion or mental stress. The pain usually goes away a few minutes after you rest or take your angina medicine. If the condition causing your angina gets worse, stable angina can become unstable angina.

Unstable angina

Unstable angina does not follow a pattern. It may be new or occur more often and be more severe than stable angina. Unstable angina can also occur with or without physical exertion. Rest or medicine may not relieve the pain.

Unstable angina is a medical emergency, since it can progress to a heart attack. Medical attention may be needed right away to restore blood flow to the heart muscle.

Microvascular angina

Microvascular angina is a sign of ischemic heart disease affecting the tiny arteries of the heart. Microvascular angina events can be stable or unstable. They can be more painful and last longer than other types of angina, and symptoms can occur during exercise or at rest. Medicine may not relieve symptoms of this type of angina.

Variant angina

Variant angina, also known as Prinzmetal’s angina, is rare. It occurs when a spasm—a sudden tightening of the muscles within the arteries of your heart—causes the angina rather than a blockage. This type of angina usually occurs while you are at rest, and the pain can be severe. It usually happens between midnight and early morning and in a pattern. Medicine can ease symptoms of variant angina.

Causes of angina pectoris

Angina happens when your heart muscle does not get enough oxygen-rich blood. Medical conditions, particularly ischemic heart disease, or lifestyle habits can cause angina. To understand the causes of angina, it helps to understand how the heart works.

Acute coronary disease

Ischemic heart disease

Two types of ischemic heart disease can cause angina.

• Coronary artery disease happens when plaque builds up inside the large arteries that supply blood to the heart. This is called atherosclerosis. Plaque narrows or blocks the arteries, reducing blood flow to the heart muscle. Sometimes plaque breaks open and causes blood clots to form. Blood clots can partially or totally block the coronary arteries.
• Coronary microvascular disease affects the tiny arteries that branch off the larger coronary arteries. Reduced blood flow in these arteries causes microvascular angina. The arteries may be damaged and unable to expand as usual when the heart needs more oxygen-rich blood.

Spasm of the coronary arteries

A spasm that tightens your coronary arteries can cause angina. Spasms can occur whether or not you have ischemic heart disease and can affect large or small coronary arteries. Damage to your heart’s arteries may cause them to narrow instead of widen when the heart needs more oxygen-rich blood.

What happens in the heart during an angina event?

In one day, your heart beats about 100,000 times and pumps about 2,400 gallons of blood throughout your body. To meet this demand, your heart’s cells needs a great deal of oxygen, which is supplied by the large coronary arteries and the tiny arteries that branch off the large arteries. When your heart is working hard, such as during physical activity or emotional stress, its demand for oxygen increases. Angina occurs when there is an imbalance between the heart’s need for oxygen-rich blood and the ability of the arteries to deliver blood to all areas of the heart.

Risk factors

You may have an increased risk for angina because of your age, environment or occupation, family history and genetics, lifestyle, other medical conditions, race, or sex.

• Age - Genetic or lifestyle factors can cause plaque to build up in your arteries as you age. This means that your risk for ischemic heart disease and angina increases as you get older. Variant angina is rare, but people who have variant angina often are younger than those who have other types of angina.
• Environment or occupation - Angina may be linked to a type of air pollution called particle pollution. Particle pollution can include dust from roads, farms, dry riverbeds, construction sites, and mines. Your work life can increase your risk of angina. Examples include work that limits your time available for sleep, involves high stress, requires long periods of sitting or standing, is noisy, or exposes you to potential hazards such as radiation.
• Family history and genetics - Ischemic heart disease often runs in families. Also, people who have no lifestyle-related risk factors can develop ischemic heart disease. These factors suggest that genes are involved in ischemic heart disease and can influence a person’s risk of developing angina. Variant angina has also been linked to specific DNA changes.
• Lifestyle habits - The more heart disease risk factors you have, the greater your risk of developing angina. The main lifestyle risk factors for angina include:
  • Alcohol use, for variant angina
  • Illegal drug use
  • Lack of physical activityAlcohol
  • Smoking tobacco or long-term exposure to secondhand smoke
  • Stress
  • Unhealthy eating patterns
• Other medical conditions

Medical conditions in which your heart needs more oxygen-rich blood than your body can supply increase your risk for angina. They include:

• • Anemia
  • A racing heart rate or blood vessel damage due to cocaine or methamphetamine use
  • Cardiomyopathy, or disease of the heart muscle
  • Damage to the heart caused by injury
  • Heart failure
  • Heart valve disease
  • High blood pressure
  • Inflammation
  • Insulin resistance or diabetes
  • Low blood pressure
  • Metabolic syndrome
  • Overweight or obesity
  • Unhealthy cholesterol levels
• Medical procedures - Heart procedures such as stent placement, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) can trigger coronary spasms and angina. Although rare, noncardiac surgery can also trigger unstable angina or variant angina.
• Race or ethnicity - Some groups of people are at higher risk for developing ischemic heart disease and one of its main symptoms, angina. African Americans who have already had a heart attack are more likely than whites to develop angina. Variant angina is more common among people living in Japan, especially men, than among people living in Western countries.
• Sex - Angina affects both men and women, but at different ages based on men and women’s risk of developing ischemic heart disease. In men, ischemic heart disease risk starts to increase at age 45. Before age 55, women have a lower risk for heart disease than men. After age 55, the risk rises in both women and men. Women who have already had a heart attack are more likely to develop angina compared with men. Microvascular angina most often begins in women around the time of menopause.

Cardiac stress test

Screening and prevention

Typically, doctors screen for angina only when you have symptoms. However, your doctor may assess your risk factors for ischemic heart disease every few years as part of your regular office visits. If you have two or more risk factors, then your doctor may estimate the chance that you will develop ischemic heart disease, which may include angina, over the next 10 years.

Prevention

To prevent angina, your doctor may recommend that you adopt heart-healthy lifestyle changes to lower your risk of ischemic heart disease, the most common cause of angina. Heart-healthy lifestyle changes include choosing a heart-healthy eating pattern such as the DASH eating plan, being physically active, aiming for a healthy weight, quitting smoking, and managing stress. You should also avoid using illegal drugs.

Signs and symptoms

Signs and symptoms vary based on the type of angina you have and on whether you are a man or a woman. Angina symptoms can differ in severity, location in the body, timing, and how much relief you may feel with rest or medicines. Since symptoms of angina and of heart attack can be the same, call 9-1-1 if you feel chest discomfort that does not go away with rest or medicine. Angina can also lead to a heart attack and other complications that can be life-threatening.

Pain and discomfort are the main symptoms of angina. Angina is often described as pressure, squeezing, burning, indigestion, or tightness in the chest. The pain or discomfort usually starts behind the breastbone. Some people say that angina pain is hard to describe or that they cannot tell exactly where the pain is coming from.

Other symptoms include:

• Fatigue
• Light-headedness or fainting
• Nausea, or feeling sick in the stomach
• Shortness of breath
• Sweating
• Weakness

Symptoms of angina can be different for women and men. Instead of chest pain, or in addition to it, women may feel pain in the neck, jaw, throat, abdomen, or back. Sometimes this pain is not recognized as a symptom of a heart condition. As a result, treatment for women can be delayed.

Because angina has so many possible symptoms and causes, all chest pain should be checked by a doctor.

Each type of angina has certain typical symptoms. Learn more about the symptoms that are characteristic of each type.

Stable angina

• Discomfort that feels like gas or indigestion
• Pain during physical exertion or mental stress
• Pain that spreads from your breastbone to your arms or back
• Pain that is relieved by medicines
• Pattern of symptoms that has not changed in the last 2 months
• Symptoms that go away within 5 minutes

Unstable angina

• Changes in your stable angina symptoms
• Pain that grows worse
• Pain that is not relieved by rest or medicines
• Pain that lasts longer than 20 minutes or goes away and then comes back
• Pain while you are resting or sleeping
• Severe pain
• Shortness of breath

Microvascular angina

• Pain after physical or emotional stress
• Pain that is not immediately relieved by medicines
• Pain that lasts a long time
• Pain that you feel while doing regular daily activities
• Severe pain
• Shortness of breath

Variant angina

• Cold sweats
• Fainting
• Numbness or weakness of the left shoulder and upper arm
• Pain that is relieved by medicines
• Pain that occurs during rest or while sleeping
• Pain that starts in the early morning hours
• Severe pain
• Vague pain with a feeling of pressure in the lower chest, perhaps spreading to the neck, jaw, or left shoulder

Complications

Angina is not a heart attack, but it suggests that a heart attack or other life-threatening complications are more likely to happen in the future.

The following are other possible complications of angina:

• Arrhythmia
• Cardiomyopathy
• Sudden cardiac arrest

Diagnosis and Treatment

Your doctor may diagnose angina based on your medical history, a physical exam, and diagnostic tests and procedures. These tests can help assess whether you need immediate treatment for a heart attack. Some of these tests may help rule out other conditions.

Medical history

Your doctor will want to learn about your signs and symptoms, risk factors, personal health history, and family health history to determine whether your chest pain is angina or is caused by something else. Other heart and blood vessel problems or problems with your chest muscles, lungs, or digestive system can cause chest pain.

Tell your doctor if you notice a pattern to your symptoms. Ask yourself these questions:

• How long does the pain or discomfort last?
• How often does the pain occur?
• How severe is the pain or discomfort?
• What brings on the pain or discomfort, and what makes it better?
• Where do you feel the pain or discomfort?
• What does the pain or discomfort feel like?

Your doctor will also need information about ischemic heart disease risk factors and other medical conditions you might have, including diabetes and kidney disease. Even if your chest pain is not angina, it can still be a symptom of a serious medical problem. Your doctor can recommend steps you need to take to get medical care.

Physical examination

As part of a physical examination, your doctor will measure your blood pressure and heart rate, feel your chest and belly, take your temperature, listen to your heart and lungs, and feel your pulse.

Diagnostic tests

Your doctor may have you undergo some of the following tests and procedures.

• Blood tests to check the level of cardiac troponins. Troponin levels can help doctors tell unstable angina from heart attacks. Your doctor may also check levels of certain fats, cholesterol, sugar, and proteins in your blood.
• Chest X-ray to look for lung disorders and other causes of chest pain not related to ischemic heart disease. A chest X-ray alone is not enough to diagnose angina or ischemic heart disease, but it can help rule out other causes.
• Computed tomography angiography to examine blood flow through the coronary arteries. This test can rapidly diagnose ischemic heart disease as the source of your chest pain and help your doctor decide whether a procedure to improve blood flow will benefit your future health.
• Coronary angiography with cardiac catheterization to see if ischemic heart disease is the cause of your chest pain. This test lets your doctor study the flow of blood through your heart and blood vessels to confirm whether plaque buildup is the problem. The results of the scan can also help your doctor assess whether unstable angina might be relieved by surgery or other procedures.
• Echocardiogram to assess the strength of your heart beating, to help the doctor determine your risk of future heart problems.
• Electrocardiogram (EKG) to check for the possibility of a heart attack. Certain EKG patterns are associated with variant angina and unstable angina. These patterns may indicate serious ischemic heart disease or prior heart damage as a cause of angina. However, some people who have angina have normal EKGs.
• Hyperventilation testing to diagnose variant angina. Rapid breathing under controlled conditions with careful medical monitoring may bring on EKG changes that help your doctor diagnose variant angina.
• Magnetic resonance imaging or other noninvasive tests to check for problems with the heart’s movement or with blood flow in the heart’s small blood vessels.
• Provocation tests to diagnose variant angina. Your doctor may give you a medicine such as acetylcholine during coronary angiography to see if the coronary arteries start to spasm.
• Stress testing to assess your heart’s function during exercise. A stress test can show possible signs and symptoms of ischemic heart disease causing your angina. Stress testing in the early morning can help diagnose variant angina. Stress echocardiography tests can help your doctor diagnose the cause of your angina.

Treatment

Your doctor will decide on a treatment approach based on the type of angina you have, your symptoms, test results, and risk of complications. Unstable angina is a medical emergency that requires immediate treatment in a hospital. If your angina is stable and your symptoms are not getting worse, you may be able to control your angina with heart-healthy lifestyle changes and medicines. If lifestyle changes and medicines cannot control your angina, you may need a medical procedure to improve blood flow and relieve your angina.

Medicines

If you are diagnosed with angina, your doctor will prescribe fast-acting medicines you can take to control angina events and relieve pain. Often other medicines are also prescribed to help control angina long-term. The choice of medicines may depend on what type of angina you have.

• Anticoagulant medicines, or blood thinners, such as heparin, to prevent dangerous blood clots and future complications, such as a heart attack or another angina event.
• Antiplatelet medicines to prevent blood clots from forming. If you have stable or unstable angina, your doctor may recommend aspirin to treat angina and reduce the risk of complications of ischemic heart disease. Other platelet inhibitors, such as clopidogrel, may also be prescribed.
• Beta blockers to help your heart beat slower and with less force. These drugs are often prescribed to help relieve angina. If you cannot take beta-blockers for some reason, long-acting nitrates are the preferred alternative.
• Calcium channel blockers to keep calcium from entering the muscle cells of your heart and blood vessels. This allows blood vessels to relax. Calcium channel blockers may be an alternative medicine if you are unable to take beta blockers or nitrates. For variant angina, your doctor is likely to order calcium channel blockers and avoid giving you beta blockers.
• Nitrates to widen and relax blood vessels, which allows more blood to flow to the heart while reducing the heart’s workload. Nitrate pills or sprays, including nitroglycerin, act quickly and can relieve pain during an event. Long-acting nitrates are available as pills or skin patches. If you are hospitalized for chest pain, your doctor may order intravenous (IV) nitrates to relieve your angina pain.
• Statins to prevent plaque from forming and to relieve blood vessel spasms or inflammation, reducing the risk of a heart attack or other complications after emergency treatment.

If you still have symptoms or experience side effects, your doctor may prescribe other medicines, including:

• Morphine to relieve pain and help relax the blood vessels. Your doctor may suggest it if other medicines have not helped.
• Ranolazine to help you have angina symptoms less often. When given with other anti-angina medicines, ranolazine can also increase the length of time you can be physically active without pain. This medicine may work for coronary microvascular disease, which causes microvascular angina. Ranolazine may be a substitute for nitrates for men with stable angina who take drugs for erectile dysfunction.

Percutaneous coronary intervention

Procedures

If lifestyle changes and medicines do not control angina, you may need a medical procedure to treat the underlying heart disease.

• Coronary artery bypass grafting (CABG) to treat ischemic heart disease and relieve angina. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.
• Percutaneous coronary intervention (PCI), also known as coronary angioplasty, to open narrowed or blocked blood vessels that supply blood to the heart. This procedure requires cardiac catheterization. If PCI includes certain medicines to expand coronary arteries, the procedure may be helpful for some people who have variant angina.

Living with Angina

Angina is not a heart attack, but it is a signal that you are at greater risk of having a heart attack. The risk is higher if you have unstable angina. For this reason, it is important that you receive follow-up care, monitor your condition, and understand your condition so you know when to get medical help. Your doctor may recommend heart-healthy lifestyle changes and cardiac rehabilitation to help manage angina.

Follow up

You may need follow-up visits every 4 to 6 months for the first year after diagnosis of angina and every 6 to 12 months as long as your condition is stable. Your care plan may be changed if your angina worsens or if stable angina becomes unstable. Unstable angina is a medical emergency.

• Your doctor may recommend cholesterol-lowering statins as part of your long-term treatment, especially if you have had a heart attack.
• Ask your doctor about when you can resume normal physical activity, such as climbing stairs.
• Ask your doctor whether sexual activity is safe for you. People who have unstable angina or angina that does not respond well to treatment should not engage in sexual activity until their heart condition and angina are stable and well managed.
• Talk to your medical team about vaccinations to prevent the flu and pneumonia.

Monitor your condition

To monitor your condition, your doctor may recommend the following tests or procedures:

• Blood pressure checks to ensure that your blood pressure is in a healthy range. Keeping your blood pressure under control can help your angina.
• EKGs to detect changes in heart health after treatment or for monitoring the heart during exercise as part of cardiac rehabilitation.
• Repeat lipid panels to see if blood cholesterol levels are at healthy levels. A lipid panel should be done every year and also 2 to 3 months after any change in treatment.
• Stress testing to assess your risk for complications either before or after starting angina medicines. Stress tests can also make sure your heart is strong enough for physical and sexual activity.

Change lifestyle

Angina is a symptom of ischemic heart disease. Your doctor may recommend the following heart-healthy lifestyle changes to help you manage angina:

• Heart-healthy eating. Following a healthy eating plan, including limiting alcohol, can prevent or reduce high blood pressure and high blood cholesterol, helping you reduce angina symptoms and maintain a healthy weight. You should avoid large meals and rich foods if heavy meals trigger your angina. If you have variant angina, drinking alcohol can also be a trigger.
• Aiming for a healthy weight. If you have overweight or obesity, work with your doctor to create a reasonable weight-loss plan. Controlling your weight helps you manage the risk factors for angina.
• Being physically active. Before starting any exercise program, ask your doctor about what level of physical activity is right for you. Slow down or take rest breaks if physical exertion triggers angina.
• Managing stress. If emotional stress triggers your angina, try to avoid situations that make you upset or stressed.
• Quitting smoking. Smoking can damage and tighten blood vessels, make angina worse, and raise the risk of life-threatening complications.

Prevent repeat events

Stable angina usually occurs in a pattern. After several events, you will learn what causes the pain to occur, what the pain feels like, and how long the pain usually lasts. To help learn your angina’s pattern and triggers, keep a log of when you feel pain. The log helps your doctor regulate your medicines and evaluate your need for future treatments. When you know what triggers your angina, you can take steps to prevent or lessen the severity of events.

• Know the limits of your physical activity. Most people who have stable angina can continue their normal activities. This includes work, hobbies, and sexual relations. Learn how much exertion triggers your angina so you can try to stop and rest before the chest pain starts.
• Learn how to reduce and manage stress. Try to avoid or limit situations that cause anger, arguments, and worry. Exercise and relaxation can help relieve stress. Alcohol and drug use play a part in causing stress and do not relieve it. If stress is a problem for you, talk with your doctor about getting help.
• Avoid exposure to very hot or cold conditions, because temperature extremes strain the heart.
• Eat smaller meals if large meals lead to chest pain.

Tell your doctor right away if your pattern changes. Pattern changes may include angina that occurs more often, lasts longer, is more severe, occurs without physical exertion, or does not go away with rest or medicines. These changes may be a sign that your symptoms are getting worse or becoming unstable.

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