The chest pain of angina comes in four flavours

There are four main types of anginawomen should know about, no matter how you pronounce it: ‘anj-EYE-nuh’ in Canada or Australia, or ‘AN-gin-uh’ in the U.S.  Angina is not the same as a heart attack – but it can lead to one. Here are the four types of angina you need to know:

• Stable angina: Mayo Clinic cardiologists define this as any pain/discomfort between neck and navelthat comes on with exertion and is relieved by rest. When you climb stairs, exercise or walk, your heart muscle demands more blood, but it’s harder for the muscle to get enough blood when your arteries have become narrowed. Stable angina can also be triggered by emotional stress, cold temperatures, heavy meals, smoking or other activities that can narrow arteries.

• Unstable angina can strike without any link to physical exertion and is not relieved by rest or your usual angina medications like nitroglycerin. If a fatty plaque deposit in a coronary artery ruptures or a blood clot forms, it can quickly block or reduce flow through a narrowed artery, severely decreasing blood flow to your heart muscle. If the blood flow doesn’t improve, heart muscle deprived of oxygen dies – and that’s a heart attack, or myocardial infarction. Unstable angina is a serious medical emergency and requires urgent treatment.
  * Stable angina (persistent, recurring chest pain that usually occurs with exertion)
  * Unstable angina (sudden, new chest pain — or a change in the pattern of previously stable angina — that may signal an impending heart attack)
  A third, a rare type of angina called variant angina (also called Prinzmetal’s angina) is caused by a coronary artery spasm.

• Variant angina (also called Prinzmetal’s angina) is relatively rare (only 2% of all angina cases).  It’s usually caused by a coronary artery spasm, and is more common in women (particularly younger women) than in men. The artery can momentarily narrow during this spasm, suddenly reducing blood flow to your heart and causing severe pain. It nearly always happens while you are at rest. It doesn’t follow physical exertion or emotional stress. Attacks may be very painful and usually happen between midnight and 8 a.m. You may also have a blockage in at least one major coronary artery, and the spasm usually happens very close to the blockage. According to the Canadian Society of Internal Medicine, patients with Prinzmetal’s typically have good exercise tolerance, often with no abnormal EKG changes during conventional cardiac treadmill stress testing. Tragically, even an invasive diagnostic angiogram can sometimes fail to identify heart disease in patients with Prinzmetal’s. Drugs such as cocaine can also cause such a life-threatening spasm, which is why paramedics and medical staff may ask if you’ve ingested cocaine when you present with cardiac symptoms.

• Microvascular angina causes chest pain, but without any apparent blockage in a coronary artery. This pain is caused by an improper functioning of the tiny microvascular blood vessels that feed your heart. This condition is sometimes also called Syndrome X. Coronary microvascular angina is also called non-obstructive coronary artery disease. Doctors don’t know yet whether coronary microvascular angina is the same as microvascular disease linked to other conditions such as diabetes.  Standard cardiac diagnostic tests look for coronary artery blockages that affect blood flow in your large coronary arteries, but these tests can’t detect plaque deposits that form, scatter, or build up in the smallest coronary arteries. And standard tests can’t detect when the arteries spasm or when the walls of the arteries are damaged or diseased.  See also: My Love-Hate Relationship With My Little Black Box

For many women, angina symptoms can feel very different from the classic angina symptoms of men.

For example, a woman may have chest pain that feels like a stabbing, pulsating, burning, heavy or  sharp form of chest discomfort rather than the more typical vise-like pressure and tightness of men. Women are also more likely to experience nausea, shortness of breath or abdominal symptoms. These differences may lead to delays in seeking treatment for many women.

Remember, too, that about 40% of women experience no chest symptoms at all during a heart attack.

Chest pain can also continue following treatment for heart attack – a distressing and frightening development just when you’re expecting that things should be back to normal. About 20% of heart attack patients experience angina one year after the major cardiac event, according to a study in the June 2008 issue of the journal, Archives of Internal Medicine.* Denver researchers noted that those most likely to experience angina symptoms one year after heart attack included those who:

• were younger
• were non-white
• were male
• had a previous history of coronary artery bypass graft surgery (CABG)
• had experienced chest pain while resting in hospital after heart attack
• were still smoking
• had undergone revascularization procedures (CABG, angioplasty, stents) after hospitalization
• had experienced significant new, persistent of fleeting symptoms of depression

“Stretching pain” is commonly reported by those who have had a coronary stent implanted. Chest pain after angioplasty/stenting occurs frequently and is considered to be due to vasospasm or coronary artery stretch during the procedure, according to a 2003 study reported in the Journal of the American College of Cardiology.**  A significant difference in restenosis of the newly-stented artery was noted at 6- to 9-month follow-up among those patients who reported post-procedure chest pain (29.5%) compared to patients who had not reported post-procedure chest pain (16.6%).  Researchers observed that these higher restenosis rates may have been associated with local vessel stretch and deep vessel wall injury during cardiac catheterization.

Dressler’s syndrome has also been identified as something that happens to a small number of people three to four weeks after a heart attack. The heart muscle that died during the attack sets the immune system in motion, calling on lymphocytes, one of the white blood cells, to infiltrate the coverings of the heart (pericardium) and the lungs (pleura). It also starts generating antibodies, which attack those two coverings. Chest pain is the predominant symptom. It can feel painful to take a deep breath or to twist the chest. The patient is often terrified that it’s another heart attack. Management of Dressler’s starts with the use of one of the anti-inflammatory drugs.

Angina can also occur in the absence of any coronary artery disease. Up to 30% of people with angina have a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart. People with severe anemia may also have angina because their blood doesn’t carry enough oxygen. And those with thickened heart muscles need more oxygen and can have angina when they don’t get enough.

Anecdotally, yoga afficianados can also report experiencing chest pain after doing yoga. The poses used in Bikram yoga, for example, can manipulate muscles, including those in the chest region. Overextending them or straining one of them while getting into and out of poses could cause chest pain after a session. Inflammation in the lungs, an embolism, and high blood pressure may be exacerbated by the practice. Injured ribs will likely produce chest pain, particularly after exercise, including yoga. Heartburn often mimics the chest pain associated with a heart attack, and may be aggravated by the changes in posture and position required during Bikram yoga. And if you suffer from asthma, the heat and humidity of hot yoga may make it difficult to breathe. Trying to get enough air in your lungs could make your chest hurt as well.

In a UK study of almost 100,000 people aged 45-89, epidemiologist Dr. Harry Hemingway of the University of London pointed out the difficulty in diagnosing angina in women, which is often missed by tests such as treadmill exercise electrocardiograms, compared to men. The UK researchers also found that angina in women over age 45 is connected with higher mortality rates.

Dr. Hemingway says:

“For women, angina is a more significant public health problem than many doctors, or indeed the general public, realise.  We need to ensure fair access to cardiac investigation and treatment services.” 

Dr. Peter Weissberg, medical director at the British Heart Foundation which funded the study published in the Journal of the American Medical Association, adds:

“Angina has traditionally been thought of as a male affliction. This study confirms that after age 45, women fare worse than men when they develop angina. Women with angina should receive prompt and appropriate treatment to reduce their risk of suffering a heart attack.”

There are several treatment options for these four types of angina ranging from medications alone to coronary bypass surgery in order to reduce the frequency or severity of your symptoms and to lower your risk of heart attack and death. Angina symptoms in women can be both physical and emotional.

Remember, all chest pain should be considered heart-related until proven otherwise.

Learn more about angina from the experts at Mayo Clinic.

See also:

• “How Does It Really Feel To Have A Heart Attack?  Women Survivors Tell Their Stories”
• The Myth of the “Hollywood Heart Attack” for Women
• What Is Causing My Chest Pain?
  

Please note: information on this website is not intended to replace medical advice.  Consult your physician for questions about your own personal health.

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* Maddox, T.M. et al: “Angina at 1 Year After Myocardial Infarction: Prevalence and Associated Findings”.  Archives of Internal Medicine (2008). 168[12]: pp. 1310 – 1316.

** Kini, A.S. et al:  “Postprocedure chest pain after coronary stenting: implications on clinical restenosis”.  J Am Coll Cardiol. (2003)  41(1):33-38. doi:10.1016/S0735-1097(02)02617-7

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Tags: angina, chest pain, health, heart attack, heart attack symptoms, medicine, microvascular disease, prinzmetal's angina