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Angina literally means “strangulation” and is the word to describe the typical sensation of pain from the heart muscle. Heart pain may not be experienced as a true pain, but as a tightness, pressure or vice like constriction in the centre of the chest. It may be confined to the left or the right or even be felt across the back of the shoulders. It often radiates up into the throat and to the shoulders, armpits or down the arms to the wrist. Pain from the heart muscle is more likely to occur when the heart is asked to do more work and the term “angina of effort” describes the symptoms that occur during physical exercise such as walking quickly, running, climbing stairs, or carrying a heavy load. The symptoms may be associated with shortness of breath and often with sweating and usually subside with rest.
Some patients do not develop the classical symptoms and may have variations of it. Patient with angina may notice their symptoms are worse in the cold weather or if they walk after a meal. Unfortunately some people do not seek medical advice early enough as they put their symptoms down to “indigestion”. However, what should alert people to the possibility of heart pain is the relationship to physical exertion, the nature of the symptoms and the associated breathing difficulties.
Angina can present in more unusual ways including wrist pain, thumb pain or even tooth ache! A clever Dentist will refer the patient to a heart specialist if he or she complains of toothache on exercise!
Angina of effort is nearly always caused by narrowings or blockages in one or more of the coronary arteries which supply the heart with blood (see figure 1). Risk factors such as smoking, diabetes, high blood pressure, abnormally high cholesterol and family history can lead to narrowings that develop slowly over a period of years and when the arteries become severely narrowed or blocked, that is when they cut down the blood flow to the heart muscle and produce symptoms. Unfortunately mild angina which only occurs after a brisk walk on a cold day, does not always equate to mild narrowings and similarly severe angina on mild effort does not always mean life threatening disease. However, in 2005, no patient with angina should just be placed on tablets to control their symptoms without undergoing proper investigations to assess their condition fully. Not only will this include a full examination, which includes listening to the heart with a stethoscope and taking the blood pressure, but should always include a resting ECG, or possibly an exercise ECG (see figure 2) and there are other more sophisticated investigations which include radioactive scanning of the heart (figure 3), stress echocardiography, and nowadays even stress magnetic resonance scanning and coronary angiography. Cardiologists will be able to decide which tests are appropriate for each individual patient.
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Figure 1: Example of a coronary artery specimen from a heart attack victim who did not survive. The inside of the artery is completely blocked by a blood clot.
Figure 2: Traces from an Electrocardiogram Stress test. The top traces are heart beat traces with the patient resting, and the lower traces are recorded after 6 minutes of exercise. Note how the contours of the trace have changed after exercise, indicating shortage of blood from the heart muscle.
Figure 3: Pictures from a radioactive heart scan to image the blood flowing into the heart muscle. There are 3 pairs of horizontal rows of images. The top row of each pair is with heart beating under stress, and the lower row with the heart resting. In this example the flow is normal, as indicated by the yellow and red colours. There is hardly any difference between the images in each pair, and this person’s arteries were normal.
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