Angina pectoris, or angina, is chest pain caused by underlying coronary heart disease resulting in myocardial ischemia. Different types include the following.

• Stable angina ("classic") occurs with exercise, emotional stress, or extreme temperatures. It seldom is associated with permanent damage to the heart muscle.
• Unstable angina occurs even at rest. Patients may present with symptoms resembling a myocardial infarction but with no evidence of heart muscle damage. Unstable angina may progress to acute myocardial infarction and should be treated as an emergency.
• Prinzmetal's or variant angina is a rare condition that occurs at rest and is caused by coronary artery spasm with electrocardiographic changes. This type of angina should be treated as a medical emergency, because it is often associated with acute myocardial infarction, ventricular tachycardia and fibrillation, and sudden cardiac death.
• Microvascular angina is chest pain in patients with no apparent coronary artery blockages and is caused by poor functioning of smaller blood vessels.

Coronary atherosclerosis and/or coronary artery spasms are usually the root causes of angina. Episodes may be precipitated by exertion, emotional stress, smoking, extreme temperatures, overeating, alcohol, or a combination of these. Unstable angina is associated with inflammatory markers indicating possible immune system involvement.

• Older age
• Male gender
• Postmenopausal women
• Family history of angina
• Diabetes
• Smoking
• Elevated blood cholesterol
• Hypertension
• Obesity
• Sedentary lifestyle
• Emotional stress

• Pressing or squeezing pain under the breastbone, or less often, in the shoulders, arms, neck, jaws, or back, generally brought on by exertion and relieved within a few minutes by rest and/or medication (e.g., nitroglycerin).
• Abnormal electrocardiogram (ECG) including transient abnormality during pain, QRS notching or slurring, ST-segment depression, and T-wave inversion

• Chest wall musculoskeletal conditions
• Aortic stenosis
• Hypertrophic obstructive cardiomyopathy
• Esophagitis
• Gastritis
• Pulmonary embolus
• Panic attack
• Hiatal hernia

Blood pressure monitoring.

Measure serum cholesterol, test for diabetes (blood glucose), test for underlying anemia (hemoglobin), measure thyroid function to detect underlying thyroid disease, CPK isoenzymes if myocardial infarction must be ruled out or in unstable angina.

• Atherosclerosis
• A recent study indicates elevated levels of basic fibroglast growth factor (BFGF) in urine are associated with exercise-induced ischemia.

• Thallium stress test involves injecting radioactive thallium into a vein during a treadmill stress test. Radiation detectors are then used to evaluate the pattern of uptake into the heart muscle.
• Stress echocardiography involves imaging heart contractions during a stress test.
• Ultrafast CT scan can image calcium in atherosclerotic plaque.
• Coronary arteriography, to determine the need for angioplasty or coronary-artery bypass, involves injecting liquid dye that is opaque to X rays into coronary arteries. X-ray video is then used to detect blockages in the arteries.

Resting 12-lead electrocardiography should be performed. Approximately 15% of patients with coronary artery disease have a normal ECG. Since stable angina manifests itself during exertion, a stress test (treadmill or bicycle) often is performed if a patient has a normal ECG.

The goals of managing angina are to relieve pain, increase exercise tolerance before the onset of pain, and treat any underlying coronary heart disease (and/or retard its development or progression). One or more of the following are recommended.

• Surgical treatment—Transcatheter revascularization, balloon angioplasty, stent, rotoblator
• Coronary-artery bypass surgery—Surgery presents a larger initial risk but is more effective in relieving angina and preventing recurrence. Surgery improves survival in patients with coronary disease involving the left main coronary artery, multivessel disease involving the proximal left anterior descending artery, or three-vessel disease with impaired left ventricular systolic performance.

For chronic stable angina:

• Nitrates: Vasodilators. Glyceryl trinitrate in sublingual spray or tablets (10 mg), or buccal preparations, is used to treat pain or before performing activities that bring on pain. Also used as regular symptomatic treatment in the form of isosorbide mononitrate (40 to 180 mg/day). Transdermal glyceryl nitrate (10 to 20 mg patch) is effective if used intermittently; tolerance effects are likely with continuous use.
• Beta-blockers, used for regular symptomatic treatment of angina, inhibit the action of adrenaline, and thereby reduce blood pressure, heart rate, and pumping force. If beta-blockers are stopped suddenly, coronary events have been shown to increase fourfold over the subsequent month. Thus, patients using beta-blockers must be warned not to run out. If the drugs must be stopped, a gradual reduction over a period of two to four weeks should be done. Common beta-blockers are metoprolol (100 to 200 mg/day), atenolol (50 to 100 mg/day) and carvedilol (50 mg/day).
• Calcium-channel blockers, used for regular symptomatic treatment of angina, reduce blood pressure and heart pumping force; some also reduce heart rate. Common calcium-channel blockers include nicardipine (90 mg/day), nifedipine (30 to 120 mg/day), isradipine (5 to 10 mg/day), amlodipine (2.5 to 10 mg/day), and diltiazem (60 to 480 mg/day).

For patients taking beta-blockers, calcium-channel blockers or nitrates may be added as second-line agents for increased effectiveness. Aspirin (75 to 300 mg/day) is generally used for its antiplatelet properties as a secondary prophylaxis. Other antiplatelet drugs such as heparin or eptifibatide may be given during an episode of unstable angina to reduce the risk of myocardial infarction or sudden death. Cholesterol-lowering medications are often prescribed to retard the process of atherosclerosis.

Specific herbs and nutrients can be helpful in strengthening the contractility of the heart and increasing oxygenation of tissues. Meditation, yoga, and relaxation techniques may be helpful in reducing stress, increasing circulation, and reducing frequency and severity of angina episodes.

• Minimize intake of saturated animal fats (meat and dairy products), refined foods, caffeine, and alcohol.
• Increase fresh vegetables, whole grains, and essential fatty acids (cold-water fish, nuts, and seeds).
• Coenzyme Q10 (50 to 100 mg one to two times/day) helps to oxygenate tissues and strengthen cardiac muscle.
• L-carnitine (330 mg bid to tid) enhances the contractility of cardiac muscle.
• Vitamin E (400 to 800 IU/day) inhibits platelet aggregation.
• Essential fatty acids (1,000 to 1,500 mg one to two times/day) to reduce inflammation and lower cholesterol.
• L-taurine (100 mg bid) and magnesium (200 mg bid to tid) help to normalize cardiac muscle contractility.
• Vitamin C (1,000 mg bid to tid) helps to support connective tissue and is an antioxidant.
• Bromelain (400 to 1,000 mg/day) reduces platelet aggregation and relieves symptoms.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Hawthorn (Crataegus monogyna), linden flowers (Tilia cordata), and motherwort (Leonurus cardiaca) may be used as teas long-term with a high degree of safety. The rest of the herbs listed in this section should be used only with the supervision of a qualified practitioner as their use may produce toxic side effects.

A cardiac tonic that contains herbs to stimulate circulation and strengthen the cardiovascular system includes hawthorn, ginkgo (Ginkgo biloba), linden flowers, mistletoe (Viscum album), Indian tobacco (Lobelia inflata), and motherwort. A tincture made from equal parts of these herbs should be taken 20 drops tid.

For acute relief of symptoms use a tincture made from equal parts of the following herbs: yellow jasmine (Gelsemium sempervirens), Indian tobacco (Lobelia inflata), monkshood (Aconite napellus), night-blooming cereus (Selenicereus grandiflorus), and ginger (Zingiber officinale). Take 10 to 20 drops every 15 minutes when necessary, up to eight consecutive doses.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Aconite for panic and fear of death with tachycardia
• Cactus for constriction in chest and pains that shoot down the left arm
• Glonoine for rapid pulse, violent palpitations, cardiac pains that radiate to arms, and waves of pounding headache

Helpful for some patients with angina. Acupuncture may be useful for both symptomatic relief and addressing underlying or concurrent pathologies.

Therapeutic massage has been shown to be effective in reducing stress and improving general well-being. Massage also helps to improve circulation and nourishment to peripheral tissues.

Patients and their providers should monitor the pattern of angina for changes in symptoms, frequency, length, and response to medication, which may indicate imminent myocardial infarction. Patients who have undergone coronary-artery bypass surgery must be monitored for the redevelopment of atherosclerosis in the graft; likewise, after transmyocardial revascularization, irritation may result in restenosis.

Lifestyle changes (such as quitting smoking, reducing stress, and eating a low-fat diet) should be recommended as necessary to slow the progression of the underlying disease. Studies have shown that eating an extremely low-fat diet coupled with exercise and meditation (the Ornish program) reduces cardiac events and coronary artery stenosis as compared to the normally recommended diet. Hormone replacement therapy for postmenopausal women seems to mitigate their increased risk of atherosclerosis.

Coronary heart disease may progress to arrhythmias and acute myocardial infarction, with resultant damage to the heart muscle and the risk of sudden death.

A patient with angina is at greater than average risk for myocardial infarction and other coronary events. The most reliable predictors of mortality are the number of diseased coronary arteries and the left ventricular contraction pattern. In the stress test, ST-segment depression greater than 1 mm, decreased ejection fraction, or angina pain during exercise, and exercise tolerance less than 120 watts are indicative of a higher risk. Annual mortality is 3% to 4% overall.

Hawthorn, linden, and motherwort are safe in pregnancy. Stronger herbs should not be used without physician supervision.

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