angina and chest pain
by Jenny Bryan
Report a gripping pain in your chest to your GP that comes on when you're active and goes away after about 20 minutes and you should quickly be referred to a specialist to have your ECG checked while doing an exercise test.
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Rapid-access chest pain clinics, set up as part of the government's millennial initiative to beat heart disease, are cutting the time people have to wait to find out if they have angina – a painful and potentially serious problem that affects 1 in 20 of the population.
Gloucestershire GP, Dr Kevin Barraclough, explains that anybody with unexplained chest pain needs an exercise ECG (see abc of body under 'ECG') to check for heart damage, and that's not something a GP can do in the surgery.
'We should have had the rapid access clinics before, but at least we've got them now. Some of my patients are seen within 48 hours and the rest within seven days,' he says.
crushing, gripping pain
Most people complain of chest pain at some time, but usually it's the burning pain of indigestion which responds to drugs that block or neutralise stomach acid. Angina pain can sometimes be confused with indigestion, but it's a crushing, gripping pain in the chest that may spread down your left arm, usually lasts for 15 or 20 minutes, and then gradually disappears.
Angina is due to permanent narrowing of one or more of the coronary arteries (see abc of body under 'coronary') that supply the heart muscle with blood. If you have stable angina, your heart muscle gets enough blood to keep it supplied with nutrients and oxygen when you aren't doing anything strenuous. But when you're active – walking up a hill, running to catch a bus, digging the garden – the demands on your heart exceed the blood supply.
stable or unstable?
Stable angina is quite different from unstable angina, which people get without any exertion, even when they are sitting down. This is due to a sudden, dangerous narrowing of a coronary artery which may re-open so that the pain goes away, or stay blocked and lead to a full-blown heart attack.
'If someone comes to me saying they've had sudden, severe chest pain with relatively mild exercise or no exercise at all, they may look all right but I send them to hospital straight away because they may have unstable angina,' Dr Barraclough explains.
In hospital, they too will have an exercise test and ECG and a series of blood checks to assess their risk of a heart attack. Those at highest risk will be referred for further investigations and surgery, either to unblock their diseased coronary artery with a small inflatable balloon (see abc of body under 'angioplasty') or to bypass the blockage altogether (see abc of body under 'coronary bypass surgery').
protecting your heart
In the last few years, research has shown that people with angina may need to take a number of drugs to protect them from heart attacks and other serious circulatory problems.
For those with stable angina, that means aspirin (see abc of body under 'aspirin') to prevent blood clots, a statin (see abc of body under 'statin') to lower their cholesterol if it's raised and possibly a beta blocker (see abc of body under 'beta blocker') and an angiotensin converting enzyme (ACE) inhibitor (see abc of body under 'ACE inhibitor').
Dr Barraclough explains that many people use nitrate tablets or a nitrate spray (see abc of body under 'nitrate') to relieve or prevent bouts of chest pain but he stresses the importance of an 8-12 hour nitrate-free period each day. Take a nitrate throughout a 24-hour period and it won't work very well.
'Anyone who finds they need to use a nitrate a lot or are using it more frequently should tell their doctor as they may need to consider angioplasty or surgery to improve the blood supply to their heart,' he says.
for unstable angina only...
Recent studies have shown that people with unstable angina are likely to benefit from additional drugs to reduce their risk of heart attacks and strokes. Most of these drugs are aimed, like heparin (see abc of body under 'heparin') and aspirin, at preventing blood clots in vulnerable arteries and they work at different stages in the complex pathway of clot formation. For example, taking the combination of clopidogrel (Plavix) and aspirin for an average of nine months was recently shown to reduce the risk of dying from heart disease or having a heart attack or stroke by about 20%. This was in people at the milder end of unstable angina.
For those at higher risk, particularly if they are about to have angioplasty, heart specialists use one of a relatively new group of drugs, called glycoprotein IIb/IIIa receptor antagonists, in addition to heparin. These drugs are also designed to prevent clots forming but, unlike aspirin and clopidogrel which can be taken as tablets, they can only be given intravenously, and are much more expensive. However, they are only used for a few days after the episode of unstable angina.
Clearly, a pain in the chest isn't something to keep quiet and be brave about. It needs rapid assessment and effective treatment. But a combination of drugs and sometimes surgery means that angina should be a warning of, not an inevitable prelude to, a heart attack.
if you have angina …
- don't smoke
- take regular exercise
- if possible, protect your heart by taking aspirin, a beta blocker, a statin and an ACE inhibitor
- keep your cholesterol below 5
- if your angina becomes more frequent, tell your GP
- if your chest pain lasts more than 20-30 minutes, dial 999.
help and info
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organisations
British Heart Foundation
14 Fitzhardinge Street
London W1H 6DH
Heart Information Line: 08450 70 80 70 (Mon-Fri 9am-5pm)
Website: www.bhf.org.uk
Plays a leading role in the fight against heart disease and provides a range of information about the causes, prevention and treatment of the problem. Website contains a glossary, details of publications, plus practical advice on how to protect yourself from heart disease.
Stroke Association
240 City Road
London EC1V 2PR
Stroke Information Service Helpline: 0845 30 33 100 (Mon-Fri 9am-5pm)
E-mail: info@stroke.org.uk
Website: www.stroke.org.uk
Provides information and support for people affected by stroke and funds research into stroke prevention, diagnosis, treatment, rehabilitation, and care. Also produces a wide range of publications.
websites
BBC Health's Heart Disease Guide
www.bbc.co.uk/health/heart
Discusses coronary heart disease, its causes and the treatments available, and how to reduce the risks of heart disease. Also lists details of heart disease organisations and support services.
ECG
www.netdoctor.co.uk/health_advice/examinations/ecg.htm
Briefly describes what an ECG is, what it is used for, and how it is performed.
Healthy Heart
www.healthyheart.nhs.uk
Provides information for people who are interested in reducing their risk of developing heart disease and keeps patients informed of the latest developments in the treatment and prevention of heart disease. Looks at how to keep your heart healthy, risk factors, and medications.
Hearts for Life
www.heartsforlife.co.uk
A comprehensive website focusing on heart attack, angina and heart failure. Looks at causes, treatment and preventative measures. Has a useful glossary and range of links.
NHS Direct
www.nhsdirect.nhs.uk
Contains extensive healthcare advice, information and resources, including information on angina and heart disease.
Northenden Group Practice – Understanding Angina
www.norgp.freeserve.co.uk/angina.htm
Part of the Northenden Group Practice website describing what angina is, how to reduce the chances of developing coronary heart disease, treatment options, an explanation of drugs, and commonly asked questions.
X-Plain Online, Angina
www.nlm.nih.gov/medlineplus/tutorials/angina/htm/index.htm
An interactive website on angina, produced by the American Patient Education Institute. The tutorial covers the signs of angina, what causes it, treatment options, and how to prevent the serious diseases that angina may be a sign of. Requires Flash plug-in.
reading
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Angina (Medical Pocketbooks) by Graham Jackson (Martin Dunitz, 2000) |
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Living with Angina by Dr Tom Smith (Sheldon Press, 1996) |
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(October 2001, resources updated January 2005)
