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Angina

What Type Of Treatment Is Available?

Last modified: 
16/03/2012 - 14:25

Contributing Author: Guy Slowik FRCS

The first step in angina treatment is to eliminate risk factors that are likely to hasten the progression of heart disease. This means that people with angina should stop smoking, lose excess weight, eat a "heart-healthy" diet, and exercise regularly, if possible.

Although physicians do not know everything about the causes of angina and atheroma (fatty deposits, or plaques, within the blood vessels), they do know enough to offer effective medical therapy. Such therapy will depend upon the results of exercise tolerance and other tests, the presence or absence of symptoms, and the individual's personal preferences.

In general, most angina treatment involves medication, with or without an operative procedure such as

  • Angioplasty (blood vessel repair) or
  • Coronary artery bypass surgery (surgically made arterial pathways that bypass [go around] diseased arteries in the heart)

Individuals with angina may consider:

Smoking cessation

If the person with angina is a smoker, the most important thing that he or she can do is to stop smoking. Smoking damages the heart in many ways. Tobacco smoke contains substances that speed up the heart, prevent oxygen from binding to the red blood cells, make the arteries tighten up, and hasten the development of atherosclerosis (gradual buildup and hardening of fatty deposits within the arterial walls).

Research indicates that heart attack survivors who stop smoking live longer and have fewer complications than those who continue to smoke.Therefore, it is never too late to stop smoking!

All types of cigarettes are dangerous. There is no good evidence that low-tar products are any safer than those with high tar.

Anyone who wants to quit smoking should ask a physician for help. Nicotine gum and nicotine patches can be very beneficial, especially when the individual participates in other supportive measures, such as smoking cessation programs or counseling.

Weight loss and proper nutrition

Many people with angina are overweight. Weight loss is recommended, since it can:

  • reduce symptoms
  • improve a person's overall sense of well-being
  • decrease the likelihood of developing diabetes (which may lead to heart disease)

A nutritionist can help to develop a diet that is "heart-healthy," but does not take all the pleasure out of food. Most nutritional programs have the objectives of cutting down on saturated fats, while increasing polyunsaturated fats in the diet.

Eating habits generally can be improved by following a few simple steps, such as:

Eat fewer portions of

  • Fatty dairy products (such as butter, margarine, cream, cheese). These foods are rich in saturated fatty acids. Saturated fats are a type of fat that has been linked with high cholesterol levels in the blood and also with the development of atheroma. Substitute low-fat dairy products (skim milk, low-fat cheese, etc.) whenever possible.
  • Red meat (such as beef, lamb)

Eat more portions of

  • Unsaturated cooking fats (such as canola oil, sunflower oil, corn oil)
  • White meat (such as chicken, turkey)
  • Fish
  • Grains, cereals, fruits and vegetables

Nice To Know:

Although fish contains fat, it is rich in polyunsaturated fatty acids known as omega-3 fatty acids. Omega-3s may help to reduce the risk of heart attack by preventing blood from clotting and sticking to the artery walls. Some types of fish - especially cold water varieties like herring, mackerel, and salmon - are very high in omega-3s. Soybean and canola oils contain some omega-3s, too. For the most benefit, fish should be eaten two or three times a week.

Regular exercise

Many people with angina can and should exercise regularly, provided that exercise is not carried out to the point of exhaustion. Exercise helps to keep weight down, reduces clotting tendencies, improves heart function, and improves the blood lipid profile (fatty substances in the blood). Perhaps most importantly - exercise lessens depression and anxiety, since people feel better when they are fit.

Very inactive or sedentary individuals should begin to exercise slowly. To avoid injury, it is important to stretch the muscles before exercise.

The easiest form of exercise is simple: brisk walking. Other suitable activities include swimming, slow jogging, golf, or bicycling.

A typical cardiorespiratory (heart/lung) fitness program calls for 15 to 30 minutes of low-intensity aerobic exercise (oxygen-using, endurance-building exercise) every other day. Alternative programs may recommend more frequent exercise (for example, five days a week).

Need To Know:

Isometric exercise - in which the muscles are contracted (squeezed) over a long period of time - is not suitable for people with angina. Common forms of isometric exercise include weight-lifting and push-ups.

Isometric exercise should be avoided, since it can cause decompensation (inability to maintain circulation) in the heart's left ventricle (pumping chamber), as well as a sudden increase in blood pressure.

Unfortunately, angina is so severe in some individuals that their ability to exercise is greatly limited. Specifically, people with severe myocardial ischemia (insufficient blood in the heart muscle) should not begin exercise training until their coronary arteries have been repaired.

Medication

A variety of medicines now are available for the treatment of angina. There are five main types of medication, which help to control symptoms and increase blood flow to the heart muscle:

  1. Aspirin
  2. Nitrates
  3. Beta-blockers
  4. Calcium channel blockers
  5. Statin drugs

In addition, a physician may prescribe medicine for conditions such as high blood pressure (hypertension), arrhythmia (abnormal heart rhythm), high cholesterol, or other disorders (for example, lung disease) that can contribute to heart disease.

  1. Aspirin

    Aspirin is used to prevent blood clots within the coronary arteries or other blood vessels. Physicians advise most people with angina to take a small dose of aspirin every day, unless they cannot tolerate it because of allergy or gastrointestinal (GI) complaints such as stomach ulcer. Such patients may be able to tolerate other medications such as clopidogrel (Plavix).

    Note: Pain relievers like ibuprofen (Advil) and acetaminophen (Tylenoldonot have the same clot-preventing properties as aspirin and should not be taken for this purpose.

  2. Nitrates

    Nitrates - such as nitroglycerin - have been used to treat angina for many years. Nitrates open up the arteries, improving blood flow to the heart and the rest of the body. This makes the heart's work easier, since it can pump blood without as much resistance from narrow blood vessels. The reduced workload makes it less likely that angina will occur.

    Nitrate medications comes in a variety of forms:

    • Pills that dissolve under the tongue
    • Pills that are swallowed
    • Mouth sprays
    • Ointments or creams
    • Skin patches or plasters

    Nitroglycerin (also known as glyceryl trinitrate, or "GTN") often is administered as a pill that is placed under the tongue (for example,Nitrostat). The medication passes rapidly into the bloodstream and relieves angina symptoms within a few minutes. The individual may feel a "tingle" under the tongue and a slight "fullness" in the head, which indicates that the blood vessels are opening up.

    Nitroglycerin is used for sudden attacks of angina. It is also used as a preventive medicine to be taken before an individual engages in an activity known to bring on an attack. Longer-lasting sublingual (mouth-dissolving) pills are available for extended therapy (for example, Nitrogard).

    How To Information: How to take nitroglycerin tablets for sudden angina

    • Take one tablet as soon as angina-related discomfort occurs.
    • Wait five minutes. If discomfort does not go away, take a second tablet.
    • Wait five minutes.
    • If the discomfort persists, take a third tablet.
    • Wait five minutes.
    • If after taking three tablets in 15 minutes discomfort continues, go to the hospital immediately. Long-lasting discomfort that does not go away after 15 minutes may signal an approaching heart attack.

    Isosorbide dinitrate and all mononitrates (Imdur, Isordil, Sorbitrate) are other nitrate medicines that come in tablet form to be swallowed whole or chewed for extended prevention of angina attacks.

    Nitrate sprays (such as Nitrolingual) are fast-acting products that are used to relieve sudden angina attacks. The mouth should be closed after each dose, and care should be taken not to shake the container; it is flammable.

    Ointments, like Nitro-Bid, are used for preventive therapy. They are not suitable for sudden attacks of angina.

    Skin patches and plasters (for example, Transderm-Nitro, Minitran) slowly deliver medicine through the skin (the skin of the chest is the preferred site). These drug-delivery systems are used to prevent angina, especially in individuals who experience symptoms at night.

    All nitrate products have a limited shelf life, after which they will no longer work effectively. A pharmacist can provide information about how long each product lasts and when it should be replaced.

    Nitrates may cause headaches and faintness especially when first used, although these side effects usually diminish over time.

    Need To Know:

    Nitrate tolerance - the ineffectiveness of a nitrate drug after it has been used for a while - is a well-known hazard of angina therapy. Researchers suggest that nitrate tolerance is caused by the depletion of certain chemicals within the body's cells. These chemicals are needed to convert the drug into its active form.

    • Sublingual products (pills or sprays that dissolve under the tongue) are less likely to cause nitrate tolerance because of the limited length of time that they are active.
    • By contrast, longer-acting products (such as pills that are swallowed, skin patches) may cause or provoke tolerance when used with sublingual preparations.

    Nitrate tolerance usually can be prevented by intermittent delivery of the lowest effective dosage and is generally avoided by ensuring a 12-hour nitrate-free interval.

  3. Beta-blockers

    Beta-blockers have been used for over 35 years to treat both angina and high blood pressure (hypertension). These medications act as a "brake" that slows down the heart rate. Beta-blockers reduce the heart's work, so that it needs less oxygen and fuel.

    When taken regularly, beta-blockers can reduce the frequency of angina attacks.

    • "Combination therapy" with a beta-blocker and nitrate is a good choice for people who suffer from high blood pressure as well as angina.
    • Beta-blockers also are a good choice for people who have tachycardia (rapid heart rate).

    Sometimes beta-blockers cause side effects like cold hands, cold feet, or fatigue. About one in ten men may experience erectile dysfunction, or impotence (inability to achieve or maintain an erection), which sometimes is remedied by lowering the beta-blocker dose.

    Because of their effects on the respiratory system, beta-blockers are unsuitable for angina sufferers who have asthma or bronchitis. Cardiologists (heart specialists) generally advise against beta-blocker use by people who have variant angina.

    Beta-blockers are not to be used if the heart rate is excessively slow (or, if necessary, need to be used with great caution).

  4. Calcium channel blockers

    Calcium channel blockers (CCBs), also known as calcium antagonists, are muscle relaxants that also relax arteries. They are particularly beneficial if angina is caused by arterial spasms rather than blockage.

    Calcium channel blockers act like nitrates by opening up the arteries in the heart. They improve the blood supply in the heart muscle and relax the arteries within the body, making it easier for the heart to pump blood. Some calcium channel blockers also slow the heart like beta-blockers.

    Calcium channel blockers, when combined with nitrates, provide excellent control of angina and hypertension. They also are useful in angina patients who have lung disease.

    Certain calcium channel blockers are preferred when a person with angina experiences bradycardia - an abnormally slow heart beat.

    • In such cases, calcium channel blockers like amlodipine (Norvasc) or nifedipine (Procardia) are preferred.
    • The calcium channel blockers verapamil HCl (Calan, Isoptin) and diltiazem HCl (Cardizem) are not recommended when there is a slow heart rate (bradycardia).
  5. Statin Drugs

    Statins are the newest and the most powerful of the prescription drugs used to lower cholesterol. They work by interrupting the final step in the chemical pathway that creates cholesterol in the liver.

    Recent research shows statins can dramatically reduce the risk for a heart attack, stroke, or death, even in people who have normal cholesterol levels and do not have heart disease. In people with heart disease, statins prevent a first or second heart attack.

    Statins are safe and well tolerated. Their mild side effects include headaches, abdominal pain, constipation, diarrhea, and gas. They occasionally can cause muscle or joint pain. In rare cases, they can cause liver damage.

    Common statins are atorvastatin (Lipitor), fluvastatin (Lescol),lovastatin (Mevacor), pravastatin (Pravachol), and simvastatin (Zocor).

Surgery

Some people with angina have extensive narrowing of the heart's blood vessels. If atheromas (plaques; fatty deposits within an artery) block an individual's coronary arteries by more than 70%, the physician usually will recommend surgery to improve blood flow to the heart muscle. Surgical procedures relieve angina symptoms and also help to prevent heart attack.

The two main surgeries for angina are:

  1. Angioplasty
  2. Coronary artery bypass
  1. Angioplasty

    Angioplasty is an interventional procedure to widen a blood vessel. It is commonly used for individuals who have short obstructions within one or two coronary arteries. People with three-vessel disease (obstructions in three coronary arteries) also may benefit from angioplasty if they do not have high-risk features such as severe impairment of the heart's ventricle (pumping chamber).

    To perform angioplasty, a physician makes an incision in a major artery of the forearm or leg and then threads a catheter (fine tube) through the blood vessels until it reaches the heart. A special dye is pumped into the bloodstream via the catheter, so that the coronary arteries are visible and the entire process can be watched on a video screen.

    Once the catheter reaches the blocked coronary artery, the physician removes the obstruction or flattens it against the inside of the artery by different methods. These methods include:

    • "Balloon angioplasty" (also known as percutaneous transluminal coronary angioplasty, or PTCA), in which a tiny balloon is attached to the end of a catheter. When the catheter reaches the blockage, the balloon is inflated, the plaque is flattened against the arterial lining, and the coronary artery is effectively widened.
    • Stent deployment, a newer technique being used to keep the coronary arteries open. A small, expandable metal sheath is slipped over the catheter and placed at the site where the artery has just been widened, to prevent it narrowing again.
    • Microsurgery, in which tiny surgical instruments are used to cut through plaque.
    • Laser surgery, in which a small laser (high-intensity, focused light beam) is used to clear out the obstruction. This procedure is known as transmyocardial revascularization, or TMR.

    Both angioplasty and bypass surgery are designed to achieve the same goal - that is, to increase blood flow within the heart muscle. Depending upon the severity of angina, an individual may have the opportunity to choose between the two procedures.

    Need To Know: Angioplasty or bypass surgery?

    In comparison to coronary artery bypass, angioplasty:

    • Is less invasive. Angioplasty is a much less complicated operation that involves comparatively small surgical incisions. Usually it is carried out under local anesthesia.
    • Requires a shorter hospital stay. The length of hospitalization for angioplasty is one to two days versus five to seven days for bypass surgery.
    • Results in a quicker recovery. Most people are back at work within a week.

    However, angioplasty:

    • Does not work in about 5% of cases, and emergency bypass surgery is necessary.
    • Must be repeated within six months in about 40% of cases. The coronary arteries become blocked again, and the individual must undergo another angioplasty or have bypass surgery.
  2. Coronary artery bypass surgery

    Coronary artery bypass surgery, like angioplasty, increases the amount of blood flow to the heart and eases discomfort. People with angina usually are candidates for coronary artery bypass surgery if they have:

    • Widespread obstruction to the left main coronary artery
    • "Three-vessel disease" (obstructions in three main coronary arteries)
    • Obstruction that is more diffuse and not felt suitable for angioplasty.

    Bypass surgery is especially recommended if the individual has significantly decreased heart function, or hazardous changes in the ECG (electrocardiogram).

    During the bypass operation:

    • A piece of blood vessel - usually a vein from the leg or an artery from the chest - is removed from the patient and is used to "bypass" the section of coronary artery that is blocked.
    • One end of the graft (transplanted vessel) is connected below the blockage in the coronary artery.
    • The other end is sewn into the aorta (major artery that carries blood away from the heart and into the body).
    • The bypass procedure is repeated for each obstructed coronary artery (for example, "triple bypass" means that three grafts have been made to skirt arterial blockages).
    • Increasingly, the artery from the chest (called the internal mammary artery) is being used, because this is easily accomplished and results are better.

    Bypass operations are now commonplace, but some risks remain. A cardiologist (heart specialist) will be able to explain the possible risks and benefits in each particular case. In many people, the surgical risk is less than that for gallbladder removal.

    After surgery, bypass patients need to spend a few days in intensive care, but they usually can go home in about a week. Most people can return to work after a few weeks, although the length of recovery is determined by factors such as age and the person's overall health and fitness.

    Bypass surgery does not completely cure angina, but most people experience total relief of discomfort for years. Also, specialists feel that the risk of a heart attack is reduced in many individuals.

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From Andrew Maynard - Chair of the University of Michigan Department of Environmental Health Sciences, with help from David Faulkner - 2013 Master of Public Health graduate.