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Medical Author:

John P. Cunha, DO, FACOEP

John P. Cunha, DO, FACOEP

John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

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Medical Editor:

Daniel Lee Kulick, MD, FACC, FSCAI

Daniel Lee Kulick, MD, FACC, FSCAI

Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Angina is classified as one of the following two types:

• Stable angina
• Unstable angina

Stable Angina

Stable angina is the most common angina, and the type most people mean when they refer to angina.

• People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a pattern and are predictable.
• For most people, angina symptoms occur after short bursts of exertion.
• Stable angina symptoms usually last less than five minutes.
• They are usually relieved by rest or medication, such as nitroglycerin under the tongue.

Unstable Angina

Unstable angina is less common. Angina symptoms are unpredictable and often occur at rest.

• This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is already unstable.
• The symptoms are worse in unstable angina - the pains are more frequent, more severe, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue.
• Unstable angina is not the same as a heart attack, but it warrants an immediate visit to the healthcare provider or a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack.

If the patient has stable angina, any of the following may indicate worsening of the condition:

• An angina episode that is different from the regular pattern
• Being awakened at night by angina symptoms
• More severe symptoms than usual
• Having angina symptoms more often than usual
• Angina symptoms lasting longer than usual

Coronary Heart Disease

The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery disease.

• In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged.
• They can no longer supply the heart with all of the blood it needs.

Most cases of coronary heart disease are caused by atherosclerosis (hardening of the arteries).

• Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels.
• These buildups are called plaques, and they can block blood flow through the vessels partially or completely. Multiple risk factors, particularly:
• diabetes,
• high blood pressure,
• smoking,
• high cholesterol, and
• genetic
predisposition may accelerate this build up.

Coronary Artery Spasm

Another cause of unstable angina is coronary artery spasm.

• Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily. This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms.
• This is called variant angina or Prinzmetal angina.
• This is not the same as atherosclerosis, although some people have both conditions.
• The symptoms often come on at rest (or during sleep) and without apparent cause.
• Cocaine use/abuse can cause significant spasm of the coronary arteries and lead to a heart attack.

Other Causes

Other causes of angina symptoms include the following:

• Blockage of a coronary artery by a blood clot or by compression from something outside the artery
• Inflammation or infection of the coronary arteries
• Injury to one or more coronary arteries

• Poor functioning of the tiny blood vessels of the heart (microvascular angina)

When a person has underlying atherosclerosis, spasm, or damage to the coronary arteries, angina symptoms usually are set off by one of the following triggers:

• Physical exertion or exercise
• Emotional stress
• Exposure to cold
• Decreased oxygen content in the air you breathe (for example flying in an airplane or at high altitudes)
• Using a stimulant such as caffeine or smoking cigarettes (which lowers the amount of oxygen in the blood)

Risk Factors for Atherosclerosis and Angina

Risk factors for atherosclerosis and angina include the following. Some of these are reversible.

• High blood pressure (hypertension)
• High levels of cholesterol and other fats in the blood
• Diabetes
• Smoking
• Male gender
• Inactive (sedentary) lifestyle
• Family history of coronary heart disease
• Aging
• Regular use of stimulants, especially nicotine, cocaine, or amphetamines: Other stimulants include theophyllines, inhaled beta-agonists, caffeine, diet pills, and decongestants.

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