Angina (Coronary Artery Disease)
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Learn About Angina (Coronary Artery Disease)

What is Angina?   
Key Symptoms
What Causes Angina?
Conventional Treatments
Medications
Tests and Procedures 
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor 


Evidence Based Rating Scale
References

What is Angina?

Angina (or angina pectoris, to give the disorder its full medical name) is the intense crushing or squeezing chest pain that results when the heart receives an insufficient amount of blood and oxygen. Also characterized as a tightness, heaviness or aching in the chest, the pain of angina is usually located under the breastbone and may radiate to the shoulders, neck, arms (often the left one), or jaw. Lasting anywhere from 30 seconds to 15 minutes, an attack is generally triggered by physical exertion or stress, which increases the heart's need for oxygen, and is relieved by rest. The pain generally builds in intensity, hits a plateau, and then subsides. 

Angina is a primary symptom of coronary artery disease (CAD), the gradual narrowing of the arteries that supply heart muscles with oxygenated blood. Coronary artery disease develops slowly, often with no symptoms at first. In time, and especially if the disease is not controlled through lifestyle changes and medications, angina attacks may increase in frequency, intensity, or duration, or they may be triggered by less exertion. Such changes in the pattern of angina attacks may signal an impending heart attack.  

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Key Symptoms 
 

  • an intense crushing or squeezing pain in the chest, generally triggered by exertion and relieved by rest. Pain may also radiate to the shoulders, arms (usually the left one), neck, and jaw. Women may have these symptoms, but are also more likely to have atypical angina.

  • Sweating

  • Palpitations

  • Shortness of breath

  • General weakness and lightheadedness

  • Nausea

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What Causes Angina?

Angina is most often a result of the narrowing of the coronary arteries caused by atherosclerosis--the buildup of cholesterol-rich fatty deposits, or plaques, on the inside of arterial walls. As plaques develop, the coronary arteries thicken and narrow over time, impeding the flow of oxygenated blood to the heart muscles. During rest, the narrowed arteries may still be wide enough to supply the heart with the oxygen it requires. But when physical activity, such as running or climbing stairs, increases the heart's need for oxygen, the narrowed arteries now fail to meet the demand, and angina results.

In some cases, angina attacks are not triggered by physical activity, but occur instead when a small blood clot forms on plaque-damaged arterial walls, temporarily blocking a coronary artery. Arterial wall spasms, possibly induced by smoking, extreme emotional stress, or exposure to cold air, may also produce angina.

High blood cholesterol is the primary cause of atherosclerosis. Other factors that promote plaque formation include high blood pressure, smoking, obesity, lack of exercise, family history, diabetes, and stress.

Conventional Treatments

The traditional treatment for angina pain is nitroglycerin, a prescription drug that helps dilate blood vessels. Cardiologists use other medications as well to reduce the workload of the heart. Angina medications typically treat the symptom, not the cause of the problem. Dietary and lifestyle changes combined with drugs – if necessary – to lower cholesterol and blood pressure are the keys to slowing or halting the arterial damage that causes angina. Supplements can also play a role in the treatment of angina by helping to improve arterial health and heart function. 

Medications

Taking one aspirin daily is often recommended for patients with angina and other symptoms of CAD in order to decrease inflammation and clot formation.

Nitroglycerin products are a mainstay for the relief of angina: they come in a variety of short and long-acting forms that may be taken sub-lingually (under the tongue), orally, or transdermally (through the skin). Using a fast-acting nitroglycerin tablet (Nitrostat, Nitroquick, Nitrolingual, Nitro-Dur) under the tongue at the start of an attack usually eases pain within minutes. Other types of nitrate drugs (Isordil, Imdur, Monoket) also help to dilate blood vessels throughout the body and immediately reduce the workload of the heart. Because the activities that trigger angina soon become predictable, a patient can also take fast-acting nitroglycerin before engaging in such activities to ward off an attack. Nitroglycerin and other nitrates also come in various other forms for treatment and prevention, such as ointments, IV, patches and oral sprays (Nitrolingual Pump Spray, Natispray). The spray, which is rapidly absorbed through the lining of the mouth for immediate efficacy, can also be administered prior to activities that trigger attacks. The ointment and patch forms of nitrates, as well as long-acting nitroglycerin capsules, are used continually to prevent angina attacks because they act too slowly to relieve pain during an attack.

Other classes of medications used for angina are beta-blockers and calcium channel blockers. By separate mechanisms, each of these kinds of medication prevents angina attacks by reducing the work performed by the heart muscle. When the load is reduced, so is the heart’s oxygen requirement. Examples of beta-blockers commonly prescribed to treat angina include atenolol (Tenormin), metoprolol (Lopressor or Toprol-XL), and propranol (Inderal). Calcium-channel blockers include nifedipine (Procardia), amlodipine (Norvasc), and diltiazem (Cardizem). These drugs also reduce high blood pressure (associated with atherosclerosis and angina) because the rate and force with which the heart pumps is lowered. Other medications called statins are used to help reduce elevated  cholesterol levels to reduce the risk of CAD. Examples of statins commonly prescribed to treat angina include atorvastatin (Lipitor), simvastatin (Zocor), and pravastatin (Pravachol). Because these medications deplete the body's stores of the compound coenzyme Q10, supplementation is recommended.(45)

Tests and Procedures

Physical examination and blood tests may determine if risk factors – such as high blood pressure, diabetes and high cholesterol – are present. An imaging scan, called computed tomography (CT), uses a type of X-ray and a computer to make detailed pictures of the heart and coronary arteries. This scan can be used to measure the amount of calcium deposits found in the plaque in the coronary arteries, which may indicate a risk for CAD before symptoms develop. This technique remains investigational and is typically not covered by insurance.

An electrocardiogram (ECG), which records heart activity through electrodes fastened to the chest, may be performed to measure the overall condition of the heart. An ECG also is performed as part of a stress test, which measures how the heart performs during exercise, typically on a treadmill or stationary bicycle. An imaging test, such as an echocardiogram (ECHO), to look at alterations in blood flow and muscle function of the heart may also be done before and after the exercise component. An alternative to a standard exercise test for patients who cannot perform a treadmill test is a thallium scintigram, during which medication is used to stimulate the effects of exercise

Another type of procedure, called percutaneous transluminal coronary angiography (PTCA), also known as coronary catheterization, involves injecting dye into the arteries through a catheter to see if the arteries are narrowed or blocked. After a preliminary diagnosis is made, this procedure may used to specifically which arteries are affected and to determine the best course of treatment.

If lifestyle changes and medications are not effective or if unstable angina develops, procedures such as angioplasty or coronary artery bypass graft (CABG) may be required to treat angina. Angioplasty involves inserting a tiny balloon into a narrowed or obstructed artery or vein and inflating the balloon to widen the opening, thereby improving blood flow to the heart. In this type of angioplasty, the balloon is deflated and removed after the procedure. Sometimes a permanent wire stent may be left in the widened opening to help prevent it from narrowing again. Some stents, called drug-eluting stents, also are coated with medication believed to help keep the artery open; however the safety and efficacy of some of these has lately been questioned.

If CABG surgery is required, healthy arteries or veins from the patient's body are grafted to the coronary arteries to bypass the narrowed openings and improve blood flow to regions of the heart. This type of bypass surgery typically requires open-chest surgery and the use of a heart-lung bypass machine during the surgical procedure to continue to add oxygen and circulate the blood.

Some newer, less invasive techniques for bypass surgery are gradually being introduced as alternatives to open-chest surgery. In one such technique, medicine is used to slow the heart, eliminating the need for a heart-lung bypass machine. Other minimally invasive procedures, such as keyhole procedures, use several small openings in the chest and may not require a heart-lung machine. Research with these techniques is continuing.

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Treatment and Prevention

To slow, halt, or even begin to reverse the coronary artery disease that causes angina, patients need to make fundamental dietary and lifestyle changes--stop smoking, lose weight, eat a healthy diet, start exercising, reduce stressors  (or your reaction to them)--and be vigilant about taking any medications prescribed to lower cholesterol and blood pressure. In addition, supplements that benefit the heart and help keep arteries in good repair can be used (in combination or singly, but always under a doctor's supervision) to complement angina and other cardiovascular medications.

The most significant research demonstrating reversal of heart disease was developed by Dean Ornish, M.D. in the Lifestyle Heart Trial and is ongoing. Ornish and others believe treatment should include prevention or reversal of the disease rather than temporary fixes. The Lifestyle Heart Trial showed that a diet low in fat and high in fruits and vegetables combined with aerobic exercise, smoking cessation, stress management (usually through meditation), and social support can lead to the regression of coronary atherosclerosis even in those who have recurrent symptoms after previous CABG— especially when the lifestyle changes are followed for five years or more. By contrast, when the lifestyle changes are not followed, coronary atherosclerosis progresses and leads to twice as many cardiac events. (28), In early studies, patients following the Ornish program reported near complete relief from angina after one year of follow-up most likely due to increased blood flow to the heart. (29) Further follow-up studies found that the amount of regression of atherosclerosis is associated with the extent of lifestyle change – small changes are associated with a slowing the progression of heart disease, while a complete change in lifestyle can reverse or halt the disease process. (29-31)

The same dietary and lifestyle changes recommended for the treatment of CAD are recommended for its prevention, along with regular monitoring of cholesterol and blood pressure levels.

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How Supplements Can Help

Just a reminder: Anyone with a serious medical condition should always check with a doctor before beginning a supplement program.

Vitamins C and E are both antioxidants that can help to prevent cell damage. Several studies have linked the presence of low levels of vitamin C to a greater risk of angina and heart attacks in people with existing heart disease. (1-5) In fact, two further analyses have shown the plasma level of antioxidants to be more indicative of unstable angina than the severity of atherosclerosis. (6, 7) Other research also indicates that, when taken together, vitamin C increases the effectiveness of vitamin E and vice versa. A population study of more than 11,000 people over age 67 found that when taken with vitamin E, vitamin C seems to help protect LDL ("bad") cholesterol from oxidation, thus reducing plaque buildup in coronary arteries. The combination also helped to reduce the risk of death from all causes and was most effective in guarding against death from CAD. (8) However, while studies have linked the combination of vitamins E and C with reducing risk factors for angina, results are conflicting regarding the effects of these antioxidants in treating cardiovascular events, such as angina. Results from major clinical studies, such as the Women's Antioxidant Cardiovascular Study, involving more then 80,000 subjects, may shed more light in this area. (9) Take vitamin C to help repair plaque-damaged arteries.

Taking magnesium supplements may help to prevent the coronary artery spasms responsible for some angina attacks. During heart attacks, magnesium works by helping to improve energy production in the heart; dilate the coronary arteries, thus improving the flow of oxygen to the heart; reduce peripheral vascular resistance and the demand on the heart; and inhibit platelets from aggregating and forming blood clots; reduce the size of any blockages; and improve heart rate and arrhythmias. These properties may be useful in treating spasms during angina attacks, which have been shown to result from a magnesium deficiency. (10) In 1994, a six-month pilot study of nine ischemic heart disease patients – meaning blockages cause a shortage of oxygen containing blood in the heart – found that taking magnesium supplementation reduced angina attacks and nitrate consumption in these patients. (11) And in a 1997 study, 61 patients with unstable angina were randomized to receive a 24-hour IV infusion of magnesium or placebo within twelve hours of admission to the hospital and were evaluated for the following month. Compared to the control group, the magnesium group, had fewer ischemic episodes, shorter duration of ischemia, and excreted less stress hormone compared to the control group. (12) However, a later study found that while intravenous administration of magnesium suppressed exercise-induced coronary spasms in some patients with unstable angina, magnesium did not suppress elevation of the ST segment (the portion of the ECG exam that indicates ischemia).Thus it’s unclear whether the reduction in symptoms correlates with reduced damage to the heart. (13) More research is needed regarding the role of magnesium in treating angina.

Take one or more of the following amino acids, all of which have beneficial effects on the heart. Arginine is involved in the formation of nitric oxide, an arterial wall relaxant. Carnitine is an amino acid-like substance that improves the energy efficiency of heart muscle cells. The amino acid taurine helps to regulate abnormal heart rhythm. An early study also demonstrated decreased heart muscle damage when it was given intravenously prior to CABG surgery. (44) Several studies have shown taking arginine supplementation decreases symptoms of angina and improves exercise tolerance and quality of life in patients with class II-IV angina. (14-16) One of these studies found arginine may also help patients with class IV angina who have frequent attacks at rest and who have not had success with conventional medications. (15) However, a 2000 study of patients with CAD who were also undergoing conventional medical treatment found arginine supplementation did not improve blood vessel dilation or increase nitric oxide and, therefore, may not benefit these patients. (17) Small controlled studies also have shown that carnitine supplementation may improve exercise tolerance in people with chronic stable angina. (18, 19) When taken with arginine, the amino acid taurine may be more effective in dilating blood vessels and increasing nitric acid. Few studies have examined this use, but preliminary evidence indicates taurine supplementation may help to prevent cardiac arrhythmias. (20)

Research has shown that 50 to 75 percent of people suffering from CAD have very low levels of coenzyme Q10 (CoQ10), a compound normally abundant in high-energy-demanding cells such as those found in the heart. (21, 22) In an early double-blind, cross-over trial study of 12 patients with stable angina treated with 150 mg of CoQ10 daily for four weeks, CoQ10 reduced the frequency of angina attacks by 53 percent and significantly increased treadmill exercise tolerance compared to placebo. (23) A 1998 review of studies evaluating the use of CoQ10 in cardiovascular disease indicates the compound's abilities to improve energy production and act as an antioxidant are useful in treating patients with angina. (24) Also in 1998, treatment with CoQ10 for 28 days significantly reduced angina in 73 patients after acute myocardial infarction compared to placebo (9.5 percent in the treatment group, compared to 28.1 percent). (25) However, a 2001 review of trials concluded CoQ10 may be best used in conjunction with conventional treatment. (26) Supplementation with CoQ10 is especially important in patients taking one of the statin class of drugs, as they can deplete CoQ10 levels.(45)

Preliminary evidence indicates the herb hawthorn may help to improve blood flow to the heart. A 2000 study of 102 patients diagnosed with mild cardiac insufficiency showed that preparation of hawthorn improved scores on seven measures of cardiac function as well as conventional treatment. (27) More research is needed. 

The essential fatty acids in flaxseed oil and fish oils promote arterial health and flexibility, and may help raise HDL ("good") cholesterol and reduce blood triglyceride levels, a risk factor for heart disease. In addition, fish oils reduce the risk of developing cardiac arrhythmias, which can occur when the circulation to the heart is threatened, as is the case with angina.

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Self-Care Remedies

  • Stop smoking immediately. Avoid smoke-filled places.

  • Watch what you eat. Stick with a diet that's low in saturated fat; processed and refined foods; and sugar and salt; and high in fiber. Use flaxseed, canola or olive oil instead of butter. Wine may be used in moderation, while other forms of alcohol are best avoided. Try to eat fish, especially an oily fish, such as salmon, mackerel, tuna, or sardines, at least two or three times a week.

  • Those who are overweight should trim the excess pounds.

  • Exercise regularly. At least 30 minutes a day of aerobic exercise three times a week is the usual recommendation. For those who have not been exercising regularly or are over 50, check with a doctor before starting an exercise program.

Alternative Therapies

The therapeutic effects of yoga have been shown not only to control symptoms of heart disease but also to help reverse many of the causes. (32) A 2000 study in India demonstrated a significant decrease in angina episodes per week, improved exercise capacity, decreased body weight, and lower cholesterol and triglyceride levels when subjects incorporated a yogic lifestyle intervention. These results lasted at least a year after the start of intervention. (33) More research is needed to confirm these initial findings.

Meditation, a mind-body technique used to induce a state of mental and physical tranquility, may help patients with angina deal with the pain associated with attacks. Mindfulness meditation was used in a 10-week stress reduction and relaxation program in 51 patients with chronic pain who had not improved with conventional treatment. At 10 weeks, more than half – who had reported lower back pain, neck and shoulder pain, angina, non-coronary chest pain, and gastrointestinal pains – showed a reduction of at least 50 percent in the mean total Pain Rating Index, (34) A 2002 review of stress reduction techniques found transcendental meditation (TM) shows promise as a preventive and treatment method for symptoms of CAD, but few studies have evaluated meditation for this use. More research is needed to determine efficacy. 

The ancient Chinese practice of tai chi, which uses meditation and deep breathing while moving through a series of continuous exercises, might enable the heart to pump more blood with each beat, thereby improving circulation, though this has not been specifically studied. Some studies have evaluated its use in reducing stress and cardiovascular risk factors. A 2006 study of 39 patients with cardiovascular risk factors including stress, who attended a 60-minute tai chi class three times a week for 12 weeks reported a reduction in perceived stress and improvements in mood. (35)

Depression has been strongly associated with CAD, both as a risk factor and as a condition resulting from diagnosis. (36, 37) Several alternative therapies such as acupuncture, massage, music and writing therapies have been shown to be effective in improving heart rate and blood pressure by promoting relaxation, relieving anxiety and stress, and treating depression. Individualized homeopathic treatment may address the specific nature of the depression. For more information on treating depression, see the WholeHealthMD library entry on Depression.

Chest pain in patients with stable angina may also be a result of musculo-skeletal dysfunction. Referred to as “cervicothoracic angina (CTA)”, the pain may be confused with coronary angina although it does not originate in the heart. Some evidence has shown that chiropractic doctors are often able to make this distinction by examining the spine and to relieve pain of non-cardiac origin with manual manipulation. In a 2005 non-randomized, open, prospective trial, 75 percent of 50 CTA-positive patients reported improvement of pain and general health after treatment while only 22 percent of 225 CTA-negative patients improved. (38) However, if you’re having angina-like chest pain, your first stop should be in the emergency room—not at the chiropractor’s office. Studies in osteopathic medicine find that a high proportion of patients with hypertension have consistent structural dysfunction patterns in the lower cervical and upper thoracic vertebrae. Osteopathic principles also suggest that treatment of the structural elements influencing chest excursion and the work of breathing may improve oxygen supply, blood and lymphatic flow and decrease peripheral resistance, thus both increasing heart function and decreasing its work load. (39)

Several studies demonstrate the additive benefit of acupuncture in treatment of angina and coronary disease. In one study in China, electroacupuncture treatment of otherwise healthy dogs with experimentally induced angina seemed to improve disorders in glucose and free fatty acid metabolism that result from decreased oxygenation. (40) In another study, acupuncture was reported to be more effective than isosorbide dinitrate. (41) And in a third, coronary dilatation was demonstrated with cardioangiography in a subset of patients after acupuncture. (42) All of these reports are in Chinese or Japanese; so it is difficult to assess the research methodology used. In a population based study done in Denmark, subjects with angina symptoms had improved medical status, decreased death rates, and lower costs for care when acupuncture and self-care measures were added to conventional pharmaceutical treatment. (43).

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When to Call a Doctor

  • At the first sign of any symptoms of angina

  • If patients with known angina notice a change in the usual pattern of angina attacks--for example, if they last longer or become more frequent or intense, or if they are triggered by less exertion or new activities

  • If an angina attack lasts more than 15 minutes. (This may be a heart attack. Call an ambulance immediately.)

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Evidence Based Rating Scale

The Evidence Based Rating Scale is a tool that helps consumers translate the findings of medical research studies with what our clinical advisors have found to be efficacious in their personal practice. This tool is meant to simplify which supplements and therapies demonstrate promise in the treatment of certain conditions. This scale does not take into account any possible interactions with any medication/ condition/ or therapy which you may be currently undertaking. It is therefore advisable to ask your doctor before starting any new treatment regimen.

 

Supplement/
Therapy

Rating

Explanation

 Acupuncture       Improved long-term outcomes when combined with self-help and conventional therapies.

 

 

 

 

 

 

 

 

 

 

 

 

Arginine

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

Several studies indicate efficacy in improving symptoms of angina, exercise tolerance and quality of life. Some conflicting evidence exists regarding use in patients who have not had success with conventional treatment. (14-17) 

 

L-Carnitine

   

Some studies indicate efficacy in improving exercise-tolerance in patients with chronic stable angina. (18, 19)

 Chiropractic   Benefit in treating chest pain originating from the spine rather than the heart. (38)
 Coenzyme Q10  

Studies indicates efficacy in improving energy production and exercise performance, and reducing angina attacks. More research is needed. (23-26)

 Hawthorn  
Preliminary evidence indicates efficacy in reducing several measures of cardiac insufficiency. More research is needed to confirm or refute efficacy. (27)
 

Magnesium  

Several studies indicate efficacy, but some conflicting evidence exists. More research is needed.
(10-13)

Meditation  
Preliminary evidence indicates efficacy in reducing stress that may result from or contribute to heart disease. More research is needed to determine efficacy specifically for angina. (34)
 Tai chi  
Some evidence indicates efficacy in treating risk factors, such as reducing stress and improving mood, and it is risk-free. Research evaluating tai chi specifically for treating angina is needed. (35)


 Taurine  
Preliminary evidence indicates potential efficacy in preventing arrhythmias, but few studies have evaluated its use in treating angina attacks. (20)


 Vitamin C  
Several high-quality studies have linked dietary vitamin C deficiency with angina attacks. Several studies indicate efficacy of supplementation when taken with vitamin E. Results from large studies are needed.  (1-9)
Vitamin E    


Several studies indicate efficacy when taken with vitamin E. Results from large studies are needed to confirm or refute evidence. (8-9)
 

 Yoga  
Preliminary evidence indicates improvement in risk factors for cardiac disease. More research in patients with stable angina is needed. (32, 33)

 

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