Angina pectoris, or angina, is chest pain caused by underlying coronary heart
disease resulting in myocardial ischemia. Different types include the
- Stable angina ("classic") occurs with exercise, emotional stress, or
extreme temperatures. It seldom is associated with permanent damage to the heart
- 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
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
- Elevated blood cholesterol
- Sedentary lifestyle
- Emotional stress
|Signs and Symptoms|
- 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.,
- Abnormal electrocardiogram (ECG) including transient abnormality
during pain, QRS notching or slurring, ST-segment depression, and T-wave
- Chest wall musculoskeletal conditions
- Aortic stenosis
- Hypertrophic obstructive cardiomyopathy
- 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
- A recent study indicates elevated levels of basic fibroglast growth
factor (BFGF) in urine are associated with exercise-induced
- 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
- Ultrafast CT scan can image calcium in atherosclerotic
- 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
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
- 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
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.
|Complementary and Alternative
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
- 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
- Vitamin E (400 to 800 IU/day) inhibits platelet
- 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
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
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
- Glonoine for rapid pulse, violent palpitations, cardiac pains
that radiate to arms, and waves of pounding
Helpful for some patients with angina. Acupuncture may be useful for both
symptomatic relief and addressing underlying or concurrent
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
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
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.
Ballegard S, et al. Acupuncture in angina pectoris: does acupuncture have a
specific effect? J Intern Med. 1991; 229:357-362.
Caligiuri G, et al. Immune system activation follows inflammation in unstable
angina: pathogenetic implications. J Am Coll Cardiol.
Cohen M, et al. A comparison of low-molecular weight heparin with
unfractionated heparin for unstable coronary artery disease. N Engl J Med.
Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:58-60.
Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Zhou XP, Liu JX. Metrological analysis for efficacy of acupuncture on angina
pectoris [in Chinese]. Chung-Kuo Chung His I Chieh Ho Tsa Chih.
Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
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The reader is advised to check product information (including package inserts)
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interactions, and contraindications before administering any drug, herb, or
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