The chest pain of angina comes in four flavours

woman angina

by Carolyn Thomas    @HeartSisters

There are four main types of angina pectoris women should know about, no matter how you pronounce it: ‘anj-EYE-nuh’ in Canada or Australia, or AN-gin-uh’ in the U.S.   This term is translated as “strangling in the chest”.

The chest pain called angina is not the same as a heart attack – but it can feel like one and can in fact 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 navel that 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 coronary 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 considered relatively rare (only 2% of all angina cases).  It’s usually caused by a coronary artery spasm, and is more likely to affect younger women than in older women or 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 or small vessel 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

When angina symptoms fail to respond to the standard toolbox of medications or invasive cardiac procedures like bypass surgery or stenting, it’s known as refractory angina

The European Society of Cardiology Joint Study group on the Treatment of Refractory Angina (European Heart Journal 2002; 23: 355–370) describes refractory angina as a clinical diagnosis based on a combinations of history, examination and investigations) and states:

“Refractory angina pectoris is a chronic condition characterized by the presence of angina caused by coronary insufficiency in the presence of coronary artery disease which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. Chronic is defined as a duration of more than three months.”

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 dull 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 during a heart attack, at least 10% of women experience no chest symptoms at all.(1)

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 still experience angina one year after the major cardiac event, according to a study in the journal, Archives of Internal Medicine.(2) Denver researchers noted that those most likely to experience angina symptoms one year after heart attack included those who:

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

“Stretching pain” (or stretch pain) is commonly reported by about 30-40% of those who have recently had a coronary stent implanted. See also: Post-stent chest pain

Chest pain after angioplasty/stenting occurs frequently and is considered to be due to vasospasm or coronary artery stretch during the procedure, described in a study reported in the Journal of the American College of Cardiology.(3)  A significant increase in restenosis (or stent failure) 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/balloon angioplasty.

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 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.

Costochondritis causes chest pain that can be confused with heart attack (and vice versa). This is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone, or sternum. The condition causes localized chest pain that you can often reproduce by pushing on the cartilage in the front of your ribcage. Costochondritis is not associated with swelling, unlike Tietze’s syndrome, where swelling is characteristic.  In North America, treatment of both is typically limited to heat or ice, and medications to reduce inflammation.  Recent 2017 research published in the International Journal of Sports Physical Therapy confirms costo treatment as practiced in New Zealand by physiotherapists who treat the back, using manual therapy focused on jammed (or “frozen”) rib joint(s) around the back where they hinge onto the spine.  See more here.

Anecdotally, yoga aficionados also report may experience 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 U.K. 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 U.K. researchers also found that angina in women over age 45 is linked 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 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.

(1) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart  2009;95:1 2026.
(2) 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.
(3) 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
NOTE FROM CAROLYN:  My book A Woman’s Guide to Living with Heart Disease“. reads like the“Best Of” Heart Sisters blog archives.  You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon –  or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

See also:

85% of Hospital Admissions for Chest Pain are NOT Heart Attack

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?

When Chest Pain is “Just” Costochondritis

The Freakish Nature of Cardiac Pain (first of a three-part series on pain)

Brain Freeze, Heart Disease and Pain Self-Management (second of a three-part series on pain)

Chest Pain While Running Uphill (third of a three-part series on pain)

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

45 thoughts on “The chest pain of angina comes in four flavours

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  3. Am experiencing a continuous chest pain at the middle of my chest no matter exertion or rest and no other symptom – could that be angina?


      1. Hi Carolyn and thanks so much for the opportunity to ask a question that I seemingly can’t get an answer to. I had a heart attack 12 months ago and am still experiencing chest pain 24 hours a day, 7 days a week. Two stents were placed. There has been no relief since the incident. Cardiologist and gastroenterologist are unable to determine the source of my pain. The sensation is like extreme heartburn but it never subsides or goes away. Is this something you have heard of? Is there hope for me to be pain free? Any info you have would be greatly appreciated


        Liked by 1 person

        1. Hello Lisa – that sounds absolutely dreadful! 24/7 pain? Just awful! I’m not a physician so cannot comment on the specifics of your case of course, but generally, I’m wondering if you could be among that 20% of heart attack patients in that 2008 study who still experience angina one year after the major cardiac event?

          If you have a regional pain clinic in your area, please ask for a referral. Something is causing this pain, and you deserve to find out what that is, otherwise how can you come up with a treatment plan?

          You didn’t mention whether taking oral nitro is effective at all, or if you are on a nitro patch as many people living with chronic angina find helpful. Coronary microvascular disease may sometimes be the culprit in refractory angina (that means angina that does not respond to standard cardiac meds) and MVD does not show up on standard cardiac diagnostic tests that look for coronary artery blockages – as I have written about here and here.

          Best of luck to you in solving this medical mystery…


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