When the heart doesn’t receive enough oxygen-rich blood, it can result in chest pain, or angina. Angina is a symptom of reduced blood flow to the heart from conditions affecting the blood vessels, such as coronary artery disease, rather than a stand-alone health condition.
About 10 million Americans experience angina each year, and it typically occurs in older adults. Women are more likely to be evaluated for angina than men, but the causes of angina may be different in men and women.
Different treatments are available for angina, which can eliminate pain and reduce its frequency.
What is angina?
Angina is the medical term for chest pain associated with various cardiovascular conditions, including coronary artery disease, coronary microvascular disease, and coronary vasospasm. The coronary arteries are blood vessels that provide oxygen-rich blood to the heart. In a healthy person, blood flows freely throughout the body. But when a person has a cardiovascular condition that results in narrowed arteries, the flow of oxygen-rich blood to the heart is restricted, which can cause chest pain (angina).
There are two types of angina:
- Stable angina is chest pain that occurs when the heart needs more oxygen than usual—for instance, during physical exertion, emotional distress, or when it’s cold outside. It’s typically the result of an underlying heart condition that is restricting blood flow. Stable angina is the most common type of angina and occurs in predictable intervals with the same intensity. This type of angina fades after a few moments of rest or after using prescription nitroglycerin (more on that below).
- Unstable angina is chest pain that starts suddenly or rapidly gets worse, including while a person is in motion or at rest. It’s a serious and potentially life-threatening type of angina that can lead to a heart attack if left untreated. It’s typically caused by a blockage in the coronary artery. Sometimes, unstable angina is an escalation from stable angina. Unstable angina is a medical emergency and must be treated immediately.
Other types of angina are used to describe specific conditions:
- Variant (Prinzmetal) angina, also known as coronary vasospasm, is chest pain that occurs when the coronary arteries spasm and restrict blood flow. This is unlike other forms of angina in that it often occurs when a person is resting or even asleep. It can affect younger, healthier individuals compared to those with stable angina.
- Microvascular angina is chest pain associated with issues in the smallest blood vessels of the coronary arteries. This type of angina is similar to stable angina, except for its cause: Stable angina is usually caused by issues with the heart’s large arteries; microvascular angina, however, is caused by narrowing in smaller blood vessels.
What causes angina?
Reduced blood flow to the heart, due to a narrowing or blockage of one of the coronary arteries, causes angina. Less frequently, it occurs when one of the coronary arteries spasms. In rare cases, it occurs when there is a shortage of red blood cells (anemia), which carry oxygen throughout the body.
Causes of angina include:
What does angina feel like?
People with angina experience one or more of the following:
- Chest pain and/or pressure
- A squeezing sensation within the chest
- Shortness of breath
- Shoulder or arm pain
- Jaw or neck pain
- A burning sensation in the shoulder, arm, jaw, or neck
- Abdominal pain
- Back pain
- Heart palpitations
What are the risk factors for angina?
Many of the risk factors for angina are the same as those for heart disease and coronary artery disease. They include:
How is angina diagnosed?
You may be diagnosed with angina after a doctor learns about your medical history, performs a physical examination, and offers diagnostic testing.
If you experience chest pain, let the doctor know how long you have experienced it, what it feels like, and how intense it is. If pain arises during certain activities, share that information with the doctor. Share details about your personal or family history of heart disease and related conditions, such as diabetes, high blood pressure, and high cholesterol levels.
During a physical exam, the doctor will listen to your heart and lungs with a stethoscope, take your blood pressure, and measure your heart rate.
Doctors may offer these diagnostic tests to confirm the presence of underlying heart conditions that are responsible for your angina:
- Blood tests, which look for different substances in the blood, including troponin, an indicator that a person is at increased risk for heart attack. High levels of troponin can indicate that a person is having or has had a heart attack.
- An electrocardiogram, which records the heart’s electrical activity and may also show whether a person is at an increased risk for heart attack
- An exercise stress test, during which a person walks on a treadmill to elevate their heart rate while also receiving an electrocardiogram; the test may reveal that the heart is not getting enough oxygen-rich blood when physically exerted.
- An echocardiogram, which uses ultrasound imaging to create moving images of the heart while the person is at rest and in motion; this test can reveal problems with the heart muscle or valves.
- A Holter monitor, a device worn for 24 hours or longer; it records the heart rhythm to look for abnormalities in the heart’s rhythm.
- Coronary angiography, during which contrast dye is injected into the bloodstream to reveal (on X-ray images) possible blockages within coronary arteries
- An X-ray, which can rule out other causes of chest pain
- A CT scan, which can look at the calcium build-up or blood flow in the coronary arteries
How is angina treated?
A variety of treatments are available to manage angina. Treatments vary, depending on the severity of symptoms, the patient’s overall health, and other factors.
Lifestyle changes. To help reduce the frequency of discomfort, doctors may recommend the following lifestyle changes:
- Getting 30 to 60 minutes of moderate-intensity exercise daily
- Eating a healthy diet, such as the Mediterranean diet
- Losing weight or maintaining a healthy weight
- Controlling other medical conditions, such as diabetes, high blood pressure, and high cholesterol
- Managing stress levels
- Quitting smoking
Medications. To relieve angina in the moment, doctors may prescribe one or more of the following medications:
- Nitroglycerin pills or sprays (nitrates). The pills are placed under the tongue or inside the cheek; the spray is placed on the tongue. This medication helps to widen blood vessels, which leads to better blood flow, thereby reducing pain. Some patients use nitroglycerin if they are about to participate in an activity that causes angina. Others may take long-acting nitrates.
- Beta-blockers or calcium channel blockers. Each of these medications helps reduce the frequency and intensity of angina.
- Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). These help to reduce blood pressure levels and reduce heart attack risk. These medications don’t directly impact angina, but they help to manage the underlying disease that leads to chest pain.
- Antiplatelet therapy, including aspirin usage. This may help minimize the incidence of angina. These therapies reduce the risk of blood clots, which could contribute to the narrowing of the coronary arteries, exacerbating angina. Antiplatelet therapy helps to reduce a patient’s risk of death from coronary artery disease.
Surgery. Some people with angina may require procedures, in addition to medication:
- Coronary angioplasty with stenting, a minimally invasive procedure during which a doctor inserts a narrow tube called a catheter through an artery in the groin or wrist, threading it through the blood vessels until it reaches the coronary arteries of the heart. When in place, if a blockage is found, doctors can inflate balloons to widen the blood vessel. Then, they will implant a stent to keep the artery open. This procedure won’t stop the progression of coronary artery disease, but it can improve a person’s symptoms.
- Coronary artery bypass grafting (CABG) is a surgical procedure that may be used to treat severely blocked coronary arteries. Surgeons remove a section of extra blood vessels (veins) from the legs, then connect them to the aorta (the major artery that brings oxygen-rich blood to the heart) as well as a section of coronary artery after the blockage, thereby bypassing the blockage that causes angina.
What is the outlook for people with angina?
While the management of angina may help ease chest discomfort, the treatment of the underlying heart condition, such as coronary artery disease, will determine the overall health outcome for each patient. It’s important to note that some heart conditions associated with angina may lead to heart attack or death if left untreated.
This article was medically reviewed by Yale Medicine interventional cardiologist Samit Shah, MD, PhD.