Health A to Z
Angina is chest pain that occurs when the blood supply to the muscles of the heart is restricted. It usually happens because the arteries supplying the heart become hardened and narrowed.
The pain and discomfort of angina feels like a dull, heavy or tight pain in the chest that can sometimes spread to the left arm, neck, jaw or back.
The pain is usually triggered by physical activity or stress and typically only lasts for a few minutes. This is often referred to as an angina attack.
Read more about the symptoms of angina.
Dial 999 to request an ambulance if you experience chest pain and you haven't previously been diagnosed with a heart problem.
If you have an angina attack and you've previously been diagnosed with the condition, take the medication prescribed for you (glyceryl trinitrate). A second dose can be taken after five minutes if the first dose doesn't have any effect. If there's no improvement five minutes after the second dose, call 999 and ask for an ambulance.
The two main types of angina are stable angina and unstable angina.
Some people develop unstable angina after previously having stable angina, while others experience unstable angina with no history of having angina before.
Unstable angina should be regarded as a medical emergency, because it's a sign that the function of your heart has suddenly and rapidly deteriorated, increasing your risk of having a heart attack or stroke.
Read more about diagnosing angina.
Most cases of angina are caused by atherosclerosis, which is the hardening and narrowing of arteries as a result of a build-up of fatty substances known as plaques. This can restrict the blood supply to the heart and trigger the symptoms of angina.
Advanced age, smoking, obesity and eating a diet high in saturated fats all increase your risk of developing atherosclerosis.
Read more about the causes of angina.
Treatment for angina aims to relieve the symptoms during an angina attack, reduce the number of angina attacks that a person has, and reduce the risk of a heart attack or stroke happening.
A number of medications can be used to try to achieve this. Some of these are only taken when needed, while others are taken every day.
Surgery to widen or bypass the narrowed arteries may be recommended if the symptoms don't respond to medication.
Read more about treating angina.
A major concern for people with angina is that their atherosclerosis will continue to get worse. This can lead to the blood supply to their heart becoming blocked, which could trigger a heart attack. Similarly, a blockage of the blood supply to the brain could trigger a stroke.
Each year it's estimated that 1 in every 100 people with stable angina will have a fatal heart attack or stroke, and as many as 1 in 40 people will have a non-fatal heart attack or stroke.
You can considerably reduce your risk of developing these complications by making lifestyle changes. For example, if you're obese and you smoke, you can significantly reduce your risk by stopping smoking and maintaining a healthy weight.
Angina is a common condition among older adults.
In England, it's estimated that 1 in every 12 men and 1 in every 30 women between 55 and 64 years of age have angina. This figure rises to 1 in every 7 men and 1 in every 12 women who are over 65 years of age.
Angina is more common in men than women.
The most common symptom of angina is a feeling of pain or discomfort in your chest. The pain can feel tight, dull or heavy.
The pain can spread from your chest to your left arm, neck, jaw and back. In some cases, the pain is similar to indigestion.
Chest pain may also occur with:
Some people may experience breathlessness without any obvious chest pain.
There are two types of angina, called stable and unstable angina. The symptoms of these two types are similar, but there are some important differences.
Attacks of stable angina usually occur when the heart is forced to work harder – for example, during physical activity or emotional stress. In some cases, the pain can also develop after eating a meal or during cold weather. These are known as angina triggers. The symptoms of stable angina usually improve if you rest for a few minutes.
Unstable angina is more unpredictable. It can develop without any obvious triggers and can persist even when you're resting. Attacks of unstable angina may last longer than a few minutes and don't always respond to treatments used for stable angina.
Dial 999 to request an ambulance if you experience chest pain and you haven't previously been diagnosed with a heart problem.
If aspirin is easily available and you're not allergic to it, take one tablet while you are waiting for the ambulance to arrive. Chewable aspirin is best, because it works faster than other forms. Aspirin helps to prevent blood clots and reduces your risk of experiencing a heart attack or a stroke.
If you have an angina attack and you've previously been diagnosed with the condition, take the medication prescribed for you (called glyceryl trinitrate). A second dose can be taken after five minutes, if the first dose doesn't have any effect. If there's no improvement five minutes after the second dose, call 999 and ask for an ambulance.
Angina is caused by narrowing and hardening of the main blood vessels going to the heart, which limits blood supply to this major organ.
Like all of the body’s organs and tissues, your heart needs a constant supply of oxygen-rich blood to function normally.
Blood is supplied to the heart by two large blood vessels known as the coronary arteries. Over time, the walls of these arteries can become furred up with fatty deposits. This process is known as atherosclerosis and the fatty deposits are called atheroma.
Coronary heart disease is the term that describes what happens when your heart's blood supply is blocked or interrupted by this build-up of fatty substances.
When you're resting, the muscles of your heart only need a relatively small supply of blood. However, when you exercise or feel stressed, your heart muscles have to work harder and the demand for blood increases. If the coronary arteries are narrowed, the required amount of blood is unable to reach the heart in time, triggering the symptoms of angina.
Anything that causes the coronary arteries to narrow can increase your risk of angina. This can include:
These risk factors can often be inter-related. They're explained below in more detail.
Your arteries are designed to pump blood at a certain pressure. If that pressure is exceeded, the artery walls may become damaged. High blood pressure can be caused by:
For reasons that aren't fully understood, high blood pressure is more common among people of Afro-Caribbean and south Asian (Indian, Pakistani and Bangladeshi) origin. A tendency to develop high blood pressure also often runs in families.
Read more about preventing high blood pressure.
Cholesterol is a type of fat that's essential for the functioning of the body. It helps to produce hormones, protects nerve endings and makes up cell membranes (the walls that protect individual cells). There are two main types of cholesterol:
Most of the cholesterol the body needs is manufactured by the liver. However, eating foods high in saturated fat increases the levels of bad cholesterol in your blood.
Read more about lowering your cholesterol.
A lack of regular exercise can raise your blood pressure and increase your risk of developing type 2 diabetes. Both of these increase your risk of developing angina.
Smoking can damage the walls of your arteries. If your arteries are damaged by smoking, blood cells called platelets form at the site of the damage in an attempt to repair it. This can cause your arteries to narrow.
Smoking also decreases your blood's ability to carry oxygen around your body, which increases the chances of a blood clot occurring.
Read more about stopping smoking.
If you have poorly controlled diabetes, the excess glucose in your blood can damage the walls of your arteries.
As you get older, your risk of developing angina increases, as your arteries are more likely to have narrowed over time.
Heart disease can run in families, so if you have a first-degree relative (mother, father, brother or sister) with a history of heart disease or angina, your risk of developing angina is increased.
If you see your GP after experiencing chest pain, they'll probably ask about the pattern of your symptoms – for example, if you've noticed any particular triggers.
Your GP will then assess whether you're at increased risk of developing atherosclerosis. This is where the arteries become clogged by fatty substances, which can lead to the symptoms of angina.
As part of the assessment you'll have:
Tests are necessary because some angina medications aren't suitable for people with liver or kidney disease.
You're also likely to discuss whether you smoke, if you drink and how much, whether you have a high-fat diet, and any family history of heart disease.
You may be prescribed a medication called glyceryl trinitrate to provide immediate relief for any angina while you wait to see a specialist (see treating angina for more information).
The assessment involves a series of tests that are explained below.
An ECG records the rhythms and electrical activity of your heart. A number of electrodes (small metallic discs) are placed on your arms, legs and chest. The electrodes are connected to a machine that records the electrical signals of each heartbeat.
An abnormal ECG reading may indicate that the muscles of your heart aren't receiving enough blood.
An ETT is similar to an ECG, but it's carried out when you're exercising, usually on a treadmill or an exercise bike.
An ETT can be used to measure how much exercise your heart is able to tolerate before the symptoms of angina are triggered. This information is useful for assessing how severe your angina is likely to be.
An MPS is an alternative test to an ETT used if a person is unable to exercise or when the results of an ETT are unclear.
MPS involves injecting a small amount of a radioactive substance into your blood. A special camera, known as a gamma camera, is used to track the substance as it moves through your blood vessels and into your heart. This allows healthcare professionals to determine how well blood is reaching your heart.
MPS is usually carried out both at rest and when you're exercising. If you're unable to exercise, medication can be used to replicate the effects of exercise on your heart.
A coronary angiography is a test to identify whether your coronary arteries are narrowed and determine how severe any blockages are.
During an angiography, a thin, flexible tube called a catheter is passed into a vein or artery in your groin or arm, and X-rays are used to guide it into your coronary arteries. A dye is injected into the catheter to highlight the arteries supplying blood to your heart. A number of X-ray images (angiograms) are taken, which highlight any blockages.
Coronary angiographies carry a small risk of serious complications, such as a stroke or a heart attack, which is estimated to be around 1 in 1,000. Although this risk is small, healthcare professionals are usually unwilling to perform an angiogram unless the benefits of the procedure outweigh potential risks.
Therefore, it's likely you'll only be referred for a coronary angiogram if:
If it's thought you may have unstable angina, you'll be admitted to hospital. Depending on the severity of your symptoms, you may be placed in a general ward or in the coronary care unit (CCU).
You'll be given an ECG as soon as you arrive at hospital to quickly assess whether your heart has been significantly damaged.
Blood tests will also be carried out to help identify increased enzyme levels (these are released when the heart is damaged). A coronary angiography may also be performed to assess the size and location of the blockage in your coronary artery.
Treatment may be started urgently, before all of the test results are known, to prevent serious complications arising from unstable angina.
After receiving suitable treatment for unstable angina, doctors will want to assess how likely you are to develop another angina attack, or possibly the symptoms of a heart attack, in the next six months. The outcome will have an important bearing on your recommended treatment plan.
GRACE is a widely used method of assessing the risk of further heart problems occurring. GRACE is a scoring system based on factors such as:
Your GRACE score provides a relatively accurate predictor of your risk of developing further heart problems. The score can range from very low (less than 1 in 65) to the highest (more than 1 in 10).
Surgery is usually recommended as a precaution if you have at least a 1 in 33 chance of developing further problems.
Read more about treating unstable angina.
If your risk is thought to be high, a combination of surgery and medication will probably be recommended. Surgery may also be recommended if medication doesn't work.
If your risk of having a heart attack or stroke is thought to be low, it should be possible to significantly reduce the risk by using a combination of medication and lifestyle changes (see preventing angina for more about lifestyle changes).
The various treatments for angina are outlined below. You can also read a summary of the pros and cons of the treatments for angina, allowing you to compare your treatment options.
Glyceryl trinitrate is a medication widely used to provide immediate relief from symptoms of angina. It can also be used as a preventative measure before doing activities known to trigger angina, such as exercise.
Glyceryl trinitrate belongs to a group of medication called nitrates. Nitrates work by relaxing and widening the blood vessels that increase the blood supply to the heart.
Glyceryl trinitrate is available in tablet form, which you dissolve under your tongue, or as a spray. You may experience headaches, flushing and dizziness soon after taking glyceryl trinitrate.
You should avoid drinking alcohol while taking glyceryl trinitrate, because it can make the side effects worse. If you experience dizziness, avoid driving and operating complex or heavy machinery.
One dose of glyceryl trinitrate usually eases the pain within two to three minutes. If the first dose does not work, a second dose can be taken after five minutes.
You should dial 999 to request an ambulance if the pain continues for five minutes after taking a second dose of glyceryl trinitrate.
Glyceryl trinitrate tablets usually expire after about eight weeks, at which point you will need a new supply. Therefore, you may prefer to use glyceryl trinitrate spray, as it lasts for longer.
Medication is also used to prevent angina attacks. This usually involves taking at least one type of medicine every day for the rest of your life.
Your GP or cardiologist (an expert in treating heart conditions) will usually try one medication first to see if it helps to prevent your symptoms (monotherapy). If this isn't effective, two medications may be recommended (combination therapy).
First, a beta-blocker or a calcium channel blocker is used to reduce the frequency of angina attacks. Which medication is prescribed may depend on your level of health and, in some cases, your personal preference.
Beta-blockers make the heart beat slower and with less force. This means the heart needs less blood and oxygen after exercise, which can either prevent angina or lower its frequency.
Common side effects of beta-blockers include tiredness, cold hands and feet, diarrhoea and feeling sick.
Beta-blockers can also interact with other medicines, causing adverse side effects. Check with your GP or pharmacist before taking other medicines in combination with beta-blockers, including those available over the counter.
Calcium channel blockers work by relaxing the muscles that make up the walls of your arteries, increasing blood supply to the heart.
Side effects of calcium channel blockers include flushed face, headaches, dizziness, tiredness and skin rashes. However, these side effects should pass within a few days once your body gets used to the medicine.
You should never drink grapefruit juice if you're taking calcium channel blockers, because they can cause a drop in your blood pressure.
If you're unable to take beta-blockers or calcium channel blockers for medical reasons, or if you find the side effects too unpleasant, your GP or cardiologist may recommend alternative medication.
Long-acting nitrates are similar to glyceryl trinitrate, except they're designed for the long-term prevention of symptoms.
Side effects include headache and a flushed face, although these should improve with time.
If you're taking long-acting nitrates, you shouldn't take sildenafil (Viagra). This is because the combination of the two can lead to a dangerous drop in blood pressure.
Ivabradine is a newer type of medication that has a similar effect to beta-blockers in that it slows down the speed of your heart beat.
However, it works in a different way to beta-blockers, which means it can often be used in people unable to take beta-blockers for medical reasons, such as those with a lung infection.
A common side effect of ivabradine is that people experience temporary flashes of brightness in their field of vision. If you have this side-effect, it may not be safe for you to drive at night. You should ask your GP for advice.
Nicorandil is a potassium channel activator that widens the coronary arteries to increase blood flow to the heart.
Potassium channel activators can often be used by people who are unable to take calcium channel blockers for medical reasons.
Side effects of nicorandil include dizziness, headaches and feeling sick.
Ranolazine works by relaxing the muscles of the heart to improve blood flow and prevent angina attacks.
Unlike the other medications used to prevent angina attacks, ranolazine doesn't affect the speed at which the heart beats, so it may be a more suitable alternative treatment for people with heart failure or an abnormal heart rhythm.
Common side effects of ranolazine include constipation, dizziness and feeling weak.
If a single medication doesn't work for you, a combination of medications will probably be recommended. This is known as combination therapy.
If combination therapy doesn't work, you may be referred for surgical treatment (see below).
In some cases, where people are unable or unwilling to have surgery, or you are waiting for surgery, three different medications may be prescribed.
Three medications are available to help reduce the risk of a heart attack and stroke in people with angina. They are:
Statins work by blocking the effects of an enzyme in your liver used to make cholesterol. Reducing blood cholesterol levels should prevent further damage to your coronary arteries and should reduce the risk of a heart attack or stroke occurring.
Statins sometimes have mild side effects that can include constipation, diarrhoea and abdominal pain.
Low-dose aspirin is a type of medication called an antiplatelet. It's used to reduce the "stickiness" of your blood to prevent blood clots, which can reduce your risk of having a heart attack.
Side effects of low-dose aspirin are uncommon, but can include irritation of the stomach or bowel, indigestion and feeling sick.
If you're allergic to aspirin, or you're unable to take it because of another health condition that may be aggravated by it, such as a stomach ulcer, alternative antiplatelet medicines are available.
ACE inhibitors are medicines that can be used to reduce your blood pressure.
ACE inhibitors block the activity of a hormone called angiotensin II, which narrows blood vessels. As well as stopping the heart working so hard, ACE inhibitors improve the blood flow around the body.
ACE inhibitors have been known to reduce the supply of blood to the kidneys, which can reduce their efficiency. Therefore, blood and urine tests may be carried out before you start taking ACE inhibitors to make sure there are no pre-existing problems with your kidneys.
Annual blood and urine tests may also be required if you continue to use ACE inhibitors.
Side effects of ACE inhibitors include dizziness, tiredness or weakness and a persistent, dry cough, although these should pass within a few days.
You should check with your GP or pharmacist before taking any other medication in combination with ACE inhibitors.
Surgery is usually recommended if your angina symptoms fail to respond to medication. However, you'll probably need to continue taking some medication after having surgery.
The two main types of surgery used to treat angina are:
In some circumstances it may not be possible to choose whether you have CABG or PCI. For example, PCI may not be suitable for people whose blood vessels have an unusual structure.
Both PCI and CAGB are broadly similar in their effectiveness in treating angina and preventing fatal complications in the long term, although each technique has its own set of pros and cons.
PCI doesn't involve making major incisions in the body, so the recovery time from surgery is much quicker and there's much less pain afterwards.
However, one main disadvantage of PCI is that there's a higher risk of the unblocked section of artery becoming blocked again, which would require further surgery to treat. The most recent data shows that further surgery is required in around 1 in 25 cases.
CABG is usually the preferred surgical option for people who:
Research indicates that using CABG in such circumstances is more likely to prolong lifespan than using angioplasty. There's also recent evidence that people who have had a CABG usually report a slightly better quality of life in the long term.
The disadvantage of CABG is that it causes more post-operative pain than PCI and it has a longer recovery time (usually around 12 weeks, compared to about one to two weeks for PCI).
If the symptoms of angina don't improve despite medication and surgery (or if surgery is unsuitable), a different approach may be used. This may involve the use of psychological or behavioural treatments, such as cognitive behavioural therapy (CBT).
Treatments such as CBT can help you develop skills to cope with your condition, manage your pain and improve your symptoms.
There are some treatments that the National Institute for Health and Care Excellence (NICE) says shouldn't be offered to help manage pain in people with stable angina:
These treatments aren't recommended, because there's a lack of evidence concerning their effectiveness and safety for people with stable angina.
If you have unstable angina (where symptoms develop unpredictably and persist even when resting), you'll immediately be given medication to prevent blood clots developing and reduce your risk of having a heart attack or stroke.
This will usually be aspirin to help thin your blood, unless there's a reason you're unable to take it, such as having a history of liver disease.
You'll probably also be prescribed another blood-thinning medication called clopidogrel, which you may need to take for at least 12 months (if you're unable to take aspirin, you'll just be prescribed clopidogrel).
You may also be given an injection of an additional blood thinning medication, such as fondaparinux or heparin.
It's likely you'll then have a series of tests to assess your risk of having a heart attack in the future (see diagnosing angina for more information).
If the risk is moderately high, an examination called a coronary angiography may be carried out to assess the size and location of the blockage in your coronary artery. If the blockage is significant, CABG or PCI can be performed.
Heart attacks and strokes are the most serious complications of angina.
The stress of living with a long-term condition can also have an impact on your emotional health.
Most cases of angina are caused by fatty deposits (plaques) building up on the inside walls of the blood vessels leading to the heart.
There's a small chance one of the plaques will break away, causing a blood clot to form. The blood clot can then block the supply of oxygen-rich blood to the muscles of the heart, causing extensive damage to the heart muscles and triggering a heart attack.
The risk of having a heart attack depends on a number of things, such as age, blood pressure and the extent of the blockage.
Depending on these factors, the risk of having a heart attack in any given year can range from less than 1 in 100 to 1 in 12. It's always possible to lower this risk by making lifestyle changes (see preventing angina for more information).
Symptoms of a heart attack include:
You should dial 999 immediately if you suspect a heart attack.
Heart attacks are treated using a combination of medication to improve the blood flow to the heart and surgery to bypass the blockage (coronary artery bypass graft) or widen the artery (percutaneous coronary intervention).
If you have fatty plaques clogging up the arteries to your heart, you may also have plaques clogging up the main blood vessel that supplies your brain with blood (the carotid artery).
If one of the plaques ruptures, it could cause a blood clot to develop, blocking the supply of blood to your brain and triggering a stroke.
As with a heart attack, you can reduce your risk of having a stroke by making lifestyle changes.
The main symptoms of a stroke can be remembered using the word FAST, which stands for Face-Arms-Speech-Time.
A stroke can be treated using medication to dissolve the blood clot, and surgery to unblock the carotid artery.
It's important to speak to your GP if you think you're depressed. Depression doesn't only affect your mental health, it can also have an adverse affect on your physical health as well.
Treatments for depression include antidepressant medications and a type of talking therapy called cognitive behavioural therapy (CBT).
Having a healthy lifestyle is the most effective way of reducing your risk of angina.
The best way to achieve this is to eat a healthy, balanced diet, try to keep your blood pressure at a healthy level, and avoid smoking. This will lower your blood pressure, reduce your cholesterol levels and strengthen your heart.
An unhealthy diet high in saturated fat and salt increases your risk of developing angina, and increases your risk of a heart attack or stroke.
A diet that includes plenty of fruit and vegetables and lots of fibre, such as wholegrain rice, bread and pasta, can help reduce this risk.
Fruit and vegetables are full of vitamins, minerals and fibre, and help keep your body in good condition. You should aim to eat five 80g portions of fruit and vegetables every day.
Eating high-fat foods can cause fatty plaques to build up in your arteries. You can help prevent this by avoiding foods that contain saturated fats.
Foods high in saturated fat include:
Eating a small amount of unsaturated fat increases the level of good cholesterol and helps reduce any blockage in your arteries. Foods high in unsaturated fat include:
You should also cut down on the amount of salt in your food, as it can raise your blood pressure.
You should aim to eat less than 6g (0.2oz) of salt a day, which is about a teaspoonful. For more information, see tips for a lower-salt diet.
Smoking can significantly increase your risk of both heart attacks and strokes, as it causes your arteries to narrow and raises your blood pressure.
If you decide to stop smoking, your GP can refer you to the NHS Smokefree service, which provides you with dedicated help and advice about the best ways to give up smoking.
You can also call the Smokefree National Helpline on 0300 123 1044. The specially trained helpline staff will offer you free expert advice and encouragement.
If you're committed to giving up smoking but don't want to be referred to a stop smoking service, your GP should be able to prescribe medical treatment to help with any withdrawal symptoms you may experience after giving up.
Regularly drinking alcohol above the maximum recommended limits can raise your blood pressure.
Alcohol is also high in calories, so you'll gain weight if you drink regularly, which can further increase your blood pressure.
Staying within the recommended levels is the best way to reduce your risk of developing high blood pressure:
Being overweight forces your heart to work harder to pump blood around your body, which can raise your blood pressure. Find out if you need to lose weight with the BMI healthy weight calculator.
If you do need to lose weight, it's worth remembering that just losing a few pounds will make a big difference to your blood pressure and overall health. Get tips on losing weight safely.
Being active and taking regular exercise helps keep your heart and blood vessels in good condition. Regular exercise can also help you lose weight and lower your blood pressure.
Starting an exercise programme when you have angina can be challenging as physical activity may trigger the symptoms of an angina attack. But the more you exercise, the less likely it is you'll have an angina attack.
Low-impact activities, such as walking, swimming and cycling, are recommended, whereas more strenuous activities, such as playing football and squash, should be avoided.
The list below is a combination of the and brand names of medicines available in the UK. Each name provides a link to a separate website (Medicine Guides) where you can find detailed information about the medicine. The information is provided as part of an on-going medicine information project between NHS Direct, Datapharm Communications Ltd and other organisations.
The medicines listed below hold a UK licence to allow their use in the treatment of this condition. medicines are not included.
The list is continually reviewed and updated but it may not be complete as the project is still in progress and guides for new medicines may still be in development.
If you are taking one of these medicines for a different condition, or your medicine for this condition is not mentioned here at all, speak to your prescriber, GP or pharmacist, or contact NHS Direct on 0845 46 47.