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Unstable angina

Definition

Unstable angina is a condition in which your heart doesn't get enough blood flow and oxygen. It may lead to a heart attack.

Angina is a type of chest discomfort caused by poor blood flow through the blood vessels (coronary vessels) of the heart muscle (myocardium).

Alternative Names

Accelerating angina; New-onset angina; Angina - unstable; Progressive angina

Causes

Coronary artery disease due to atherosclerosis is the most common cause of unstable angina. Atherosclerosis is the buildup of fatty material, called plaque, along the walls of the arteries. This causes arteries to become narrowed and less flexible. The narrowing interrupts blood flow to the heart, causing chest pain.

People with unstable angina are at higher risk of having a heart attack.

Rare causes of angina are:

  • Abnormal function of tiny branch arteries without narrowing of larger arteries (called microvascular dysfunction or Syndrome X)
  • Coronary artery spasm

Risk factors for coronary artery disease include:

  • Diabetes
  • Family history of early coronary heart disease (a close relative such as a sibling or parent had heart disease before age 55 in a man or before age 65 in a woman)
  • High blood pressure
  • High LDL cholesterol
  • Low HDL cholesterol
  • Male gender
  • Not getting enough exercise
  • Obesity
  • Older age
  • Smoking

Symptoms

Symptoms of angina may include:

  • Chest pain that you may also feel in the shoulder, arm, jaw, neck, back, or other area
  • Discomfort that feels like tightness, squeezing, crushing, burning, choking, or aching
  • Discomfort that occurs at rest and does not easily go away when you take medicine
  • Shortness of breath
  • Sweating

With stable angina, the chest pain or other symptoms only occur with a certain amount of activity or stress. The pain does not occur more often or get worse over time.

Unstable angina is chest pain that is sudden and often gets worse over a short period of time. You may be developing unstable angina if the chest pain:

  • Starts to feel different, is more severe, comes more often, or occurs with less activity or while you are at rest
  • Lasts longer than 15 - 20 minutes
  • Occurs without cause (for example, while you are asleep or sitting quietly)
  • Does not respond well to a medicine called nitroglycerin
  • Occurs with a drop in blood pressure or shortness of breath

Unstable angina is a warning sign that a heart attack may happen soon and needs to be treated right away. See your doctor if you have any type of chest pain.

Exams and Tests

The doctor will do a physical exam and check your blood pressure. The doctor may hear abnormal sounds, such as a heart murmur or irregular heartbeat, when listening to your chest with a stethoscope.

Tests for angina include:

Treatment

Your doctor may want you to check into the hospital to get some rest, have more tests, and prevent complications.

Blood thinners (antiplatelet drugs) are used to treat and prevent unstable angina. You will receive these drugs as soon as possible if you can take them safely. Medicines include aspirin and the prescription drug clopidogrel or something similar. These medicines may be able to reduce the chance of a heart attack or the severity of a heart attack that occurs.

During an unstable angina event:

  • You may get heparin (or another blood thinner) and nitroglycerin (under the tongue or through an IV)
  • Other treatments may include medicines to control blood pressure, anxiety, abnormal heart rhythms, and cholesterol (such as a statin drug)

A procedure called angioplasty and stenting can often be done to open a blocked or narrowed artery

  • Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart.
  • A coronary artery stent is a small, metal mesh tube that opens up (expands) inside a coronary artery. A stent is often placed after angioplasty. It helps prevent the artery from closing up again. A drug-eluting stent has medicine in it that helps prevent the artery from closing.

Heart bypass surgery may be done for some people. The decision to have this surgery depends on:

  • Which arteries are blocked
  • How many arteries are involved
  • Which parts of the coronary arteries are narrowed
  • How severe the narrowings are

Outlook (Prognosis)

Unstable angina is a sign of more severe heart disease.

How well you do depends on many different things, including:

  • How many and which arteries in your heart are blocked, and how severe the blockage is
  • If you have ever had a heart attack
  • How well your heart muscle is able to pump blood out to your body

Abnormal heart rhythms and heart attacks can cause sudden death.

Possible Complications

Unstable angina may lead to:

  • Abnormal heart rhythms (arrhythmias)
  • A heart attack
  • Heart failure

When to Contact a Medical Professional

Seek medical attention if you have new, unexplained chest pain or pressure. If you have had angina before, call your doctor.

Call 911 if your angina pain:

  • Is not better 5 minutes after you take nitroglycerin (your health care provider may tell you to take three total doses)
  • Does not go away after three doses of nitroglycerin
  • Is getting worse
  • Returns after the nitroglycerin helped at first

Call your doctor if:

  • You are having angina symptoms more often
  • You are having angina when you are sitting (rest angina)
  • You are feeling tired more often
  • You are feeling faint or light-headed, or you pass out
  • Your heart is beating very slowly (less than 60 beats a minute) or very fast (more than 120 beats a minute), or it is not steady
  • You are having trouble taking your heart medicines
  • You have any other unusual symptoms

If you think you are having a heart attack, get medical treatment right away.

Prevention

Some studies have shown that making a few lifestyle changes can prevent blockages from getting worse and may actually improve them. Lifestyle changes can also help prevent some angina attacks. Your doctor may tell you to:

  • Lose weight if you are overweight.
  • Stop smoking.
  • Exercise regularly.
  • Drink alcohol in moderation only.
  • Eat a healthy diet that is high in vegetables, fruits, whole grains, fish, and lean meats.

Your doctor will also recommend that you keep other health conditions such as high blood pressure, diabetes, and high cholesterol levels under control.

If you have one or more risk factors for heart disease, talk to your doctor about taking aspirin or other medicines to help prevent a heart attack. Aspirin therapy (75 - 325 mg a day) or drugs such as clopidogrel, ticagrelor or prasugrel may help prevent heart attacks in some people. Aspirin therapy is recommended if the benefit is likely to outweigh the risk of side effects.

References

Cannon CP, Braunwald E. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 56.

Lange RA, Hillis LD. Acute coronary syndrome: unstable angina and non-ST elevation myocardial infarction. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 72.

Montalescot G, Cayla G, Collet JP, Elhadad S, Beyqui F, Le Breton H, et al. Immediate vs. delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA. 2009;302:947-954.

Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. J Am Coll Cardiol. 2013;61(23):e179-347.


Review Date: 5/13/2014
Reviewed By: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
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