Angina is pain (or constricting discomfort) in the chest, neck, shoulders,…
Angina is pain
(or constricting discomfort) in the chest, neck, shoulders, jaw, or arms caused by an insufficient blood supply to the myocardium.
Angina is usually caused by coronary artery disease — atherosclerotic plaques in the coronary arteries cause progressive narrowing of the lumen, and symptoms occur when blood flow does not provide adequate amounts of oxygen to the myocardium at times when oxygen demand increases (such as during exercise).
Less commonly, angina is caused by valvular disease (for example aortic stenosis), hypertrophic obstructive cardiomyopathy, or hypertensive heart disease. The management of angina associated with non-coronary artery disease is beyond the scope of this CKS topic.
Stable angina usually occurs predictably with physical exertion or emotional stress, lasts for no more than 10 minutes (usually less), and is relieved within minutes of rest, as well as sublingual nitrates.
Unstable angina is new onset angina or abrupt deterioration in previously stable angina, often occurring at rest. Unstable angina usually requires immediate admission or referral to hospital. See the CKS topic on Chest pain for more information on the assessment, diagnosis, and management of unstable angina.
Non-modifiable risk factors include older age, being male, family history of CVD, and ethnic background (for example, people of South Asian origin have an increased risk of CVD compared with people of European origin).
Modifiable risk factors include smoking, high blood level of non-high density lipoprotein cholesterol, lack of physical activity, unhealthy diet, alcohol intake above recommended levels, overweight and obesity.
Comorbidities that can increase the risk of developing CVD include: hypertension, diabetes mellitus, chronic kidney disease, dyslipidaemia, rheumatoid arthritis, influenza, serious mental health problems, and periodontitis
Statin treatment should be offered for the primary prevention of CVD to people with an estimated 10 year CVD risk of 10% or more if lifestyle interventions have not proved effective.
Atorvastatin 20 mg a day is the recommended statin if the person decides to take drug treatment after an informed discussion about benefits and harms, after having been provided with lifestyle advice, and if there are no contraindications.
Exclude a diagnosis of stable angina if clinical assessment indicates non-anginal chest pain, unless clinical suspicion is raised based on other aspects of the history and risk factors.
If the person has typical or atypical anginal pain, refer them to a specialist chest pain service to confirm, or exclude the diagnosis of stable angina. For more information, see the section on managing chest pain in a person who does not require hospital admission, in the CKS topic on Chest pain.
Include a description of the features of anginal chest pain in all requests for diagnostic investigations.
For people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, organize a resting 12-lead ECG as soon as possible after presentation, depending on local availability.
An abnormal ECG makes the diagnosis of coronary artery disease more likely, but does not confirm that the chest pain is stable angina.
ECG changes that may indicate ischaemia or previous myocardial infarction include:
Pathological Q waves (in particular).
Left bundle branch block (LBBB).
ST-segment and T-wave abnormalities (for example T-wave flattening or elevation, or T-wave inversion).
Do not rule out stable angina on the basis of a normal resting 12-lead ECG.
Do not use exercise ECG to diagnose or exclude stable angina for people without known coronary artery disease (CAD).
If the person has confirmed coronary artery disease (CAD), but a diagnosis of stable angina cannot be excluded from clinical assessment, refer for diagnostic testing.
CVD RISK FACTORS
Cardiovascular disease (CVD) is an umbrella term that describes a range of conditions that affect the heart, the blood vessels, or both. It is caused by blood clots (thrombosis), or atherosclerosis.
CVD is a significant cause of mortality and morbidity, accounting for almost a quarter of all deaths in the UK
A person's 10 year CVD risk should be assessed using the QRISK assessment tool every 5 years (apart from people who already have CVD or are at high risk of developing it, or people aged 85 years or over).
People with type 1 diabetes mellitus or chronic kidney disease (CKD) stages 3, 4, or 5 are considered at high risk, and so a CVD risk assessment is not required. However, it may help some people with these conditions to make an informed choice on whether to take a statin.
The calculated CVD risk is an estimate. Clinical judgement is required to adjust for factors that the risk calculator does not take into account.
ASSESSMENT FOR STABLE CHEST PAIN
Stable angina should be suspected on the basis of the clinical assessment, and the typicality of chest pain.
Classify the symptoms according to their typicality. People with:
Typical angina presents with all three of the following features:
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
Atypical angina presents with two of the above features.
In addition, atypical symptoms include gastrointestinal discomfort, and/or breathlessness, and/or nausea.
Factors that make a diagnosis of stable angina more likely include:
The presence of cardiovascular risk factors. For more information, see the CKS topic on CVD risk assessment and management.
A history of established coronary artery disease (for example previous myocardial infarction, coronary revascularization).
Factors that make a diagnosis of stable angina less likely include:
Pain that is continuous or prolonged.
Pain that is unrelated to activity.
Pain that is brought on by breathing.
Pain that is associated with dizziness, palpitations, tingling, or difficulty swallowing.
Chest pain refers to pain in the thorax. It can be classified by cause (cardiac or non-cardiac).
Cardiac causes of chest pain include:
Acute coronary syndrome (unstable angina and myocardial infarction).
Other cardiac causes, such as dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, or arrhythmias.
Respiratory causes of chest pain include:
Pulmonary embolus, pneumothorax or tension pneumothorax, community-acquired pneumonia, asthma, or pleural effusion.
Other causes of chest pain include:
Gastroenterological causes, such as acute pancreatitis, oesophageal rupture, peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis.
Musculoskeletal causes, such as rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), rheumatoid or psoriatic arthritis, fibromyalgia, or osteoporotic fracture.
Cancer (for example, lung cancer); herpes zoster; Bornholm disease; precordial catch (Texidor twinge); or psychogenic or non-specific chest pain.
Non-specific chest pain (no cause identified) is found in around 16% of people presenting to primary care with chest pain.
To determine the cause of chest pain, a medical history should be taken and an examination performed, with further investigations organized as appropriate based on the suspected cause.
Admission to hospital should be arranged for people with clinical features suggesting a serious cause such as:
Respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if no history of chronic hypoxia).
Altered level of consciousness.
Raised temperature (especially if more than 38.5°C).
Admission to hospital is also required if acute coronary syndrome (ACS) is suspected with the following features:
Current chest pain.
Signs of complications (such as pulmonary oedema).
Pain-free, but have had chest pain in the last 12 hours and have an abnormal electrocardiogram (ECG) or an ECG is not available.
If hospital admission or referral to a specialist is not required, investigations should be arranged where appropriate and the underlying cause managed.
People not requiring hospital admission should be appropriately referred:
For an urgent same-day assessment, if they have suspected ACS and are pain-free with chest pain in the last 12 hours and a normal electrocardiogram (ECG) and no complications (such as pulmonary oedema); or chest pain in the last 12–72 hours and no complications.
Within 2 weeks, if they have suspected ACS and are pain-free with chest pain more than 72 hours ago and no complications; a suspected underlying malignancy; a lung or lobar collapse or pleural effusion (if admission is not required) for investigation and treatment.
Routinely, if they have suspected stable angina, chest pain of unknown cause, or a clear diagnosis of the cause of chest pain but with persistent symptoms despite management in primary care.
Clearly explain the diagnosis of stable angina to the person. The explanation should include:
Factors which can provoke angina, such as exertion, emotional stress, exposure to cold, or eating a large meal.
The long-term progression and prognosis of angina.
Information on how angina is managed.
Encourage the person to ask questions about their angina and its management.
Explore and address any misconceptions the person might have about their angina. This includes:
Implications for daily activities.
Risk of myocardial infarction.
Advise the person to seek medical help if there is a sudden worsening in the frequency or severity of their angina.
Discuss the reasons for treatment, as well as the benefits and adverse effects (such as flushing, headache, and light-headedness). For more information, see the section on Prescribing information.
Provide information on how to use a short-acting sublingual nitrate and when to administer it.
Assess the person's need for lifestyle advice to manage their cardiovascular risk.
Explore and address issues according to the person's needs, which may include:
Self-management skills such as pacing their activities and goal setting.
Concerns about the impact of stress, anxiety, or depression on angina.
Advice about physical exertion including sexual activity.
Advice about other activities such as driving, flying, and work.
Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke.
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).