ANGINA
What is Unstable Angina?
Unstable angina is a type of coronary
artery disease. The coronary arteries bring oxygen-rich blood to your heart.
Because your heart is a muscle, it needs oxygen to work well. In coronary artery
disease, one or more of these arteries may be partially or even completely
blocked. The type of coronary artery disease you have usually depends on the
amount of blockage in your arteries. A heart attack, called a myocardial
infarction, means the heart muscle has been damaged by not getting enough blood.
Stable angina usually does not damage the heart. Unstable angina is worse than
stable angina and may progress to a heart attack if not treated. Angina is
caused by a lack of oxygen in the heart muscle. The symptoms of angina include
pain or discomfort in the chest, arms, back, neck, or jaw. Sometimes, anginal
pain may feel like a tightness or crushing sensation, or it may be a stabbing
pain or seem like numbness. Some people mistake anginal pain as indigestion or
gas pain. Having either stable or unstable angina does not always mean you will
have a heart attack. But, unstable angina can be serious and should be treated
by a doctor.
How are
Stable and Unstable Angina Different?
Anginal discomfort may be different
for different people. Some people have anginal discomfort when they over-exert
themselves (for example, when they shovel snow). Other people feel anginal pain
when they get very upset or excited. Over time, they can usually tell which
activities will give them discomfort. Usually, the discomfort will go away in a
few minutes. This type of chest discomfort is called stable angina. Stable
angina attacks usually have a regular pattern. But in some people the pattern of
angina is different-it becomes unstable. People with unstable angina include
those who: Have anginal discomfort when they are resting or that awakens them
from sleep. Suddenly develop moderate or severe discomfort on exertion when they
have never had angina before. Have a marked increase in the frequency or
severity of their discomfort. Unstable angina is more serious than stable angina
because the risk of having a heart attack is greater.
What Causes Unstable Angina?
In
coronary artery disease, blockages -- made up of fats, such as cholesterol, and
other debris -- form on the inside walls of the coronary arteries. In patients
who have stable angina, the blockages may not seriously block the flow of blood.
In unstable angina, the blockages may be large. Sometimes, the blockage cracks
open. When this happens, your body tries to heal the crack in the blockage by
making a blood clot around the damage. If the clot is big enough to block the
artery, the clot will keep blood flow from getting through. This can cause a
heart attack.
When Do I
Need to See a Doctor?
This may depend on whether or not your
doctor
has ever told you that you have coronary artery disease.
People Without Known Coronary Artery
Disease
Many people do not know if they have heart disease. Any new or
severe chest discomfort that is not related to an injury, such as a pulled
muscle, could be unstable angina or a heart attack. Unstable angina is not
dangerous to most people who get medical care right away, but it can be very
serious if it is not treated. Even anginal pain that goes away with rest can be
serious. Only your doctor will be able to tell how serious it is and what should
be done.
People with Known Coronary Artery Disease
If you have
coronary artery disease, your past symptoms are the best guide to whether you
should call your doctor about new symptoms. Call your doctor if the discomfort
you are having is more severe or lasts longer than the discomfort you have had
before, has begun to happen more frequently or with less effort, or happens when
you are resting or asleep.
Chest Pain Can Be An
Emergency
Here are some signs that your angina is very serious and you
should go to the hospital right away: Pain or discomfort that is very bad, gets
worse, and lasts longer than 20 minutes. Pain or discomfort along with weakness,
feeling sick to your stomach, or fainting. Pain or discomfort that does not go
away when you take three nitroglycerin tablets. Pain or discomfort that is worse
than you have ever had before. If you live in an area where ambulance service is
not quickly available, have someone drive you to the nearest hospital. You
should not drive yourself to the hospital. It is a good idea to talk with your
family, friends, or neighbors about your heart condition and have them read
this. They should be familiar with warning signs that signal when you should go
to the hospital. You also may want to tell them which medicines you are taking
and where you keep them.
What Will Happen in the Emergency
Room?
At your hospital emergency room, the doctors and nurses will decide
if you have unstable angina. If you do have unstable angina, they will give you
medicines through a vein in your arm to stop your pain and prevent injury to
your heart. These medicines will help prevent blood clots and help your heart
work more easily. You probably will be given oxygen to help you breathe and get
more oxygen in your blood. The doctors and nurses will ask how you are feeling
and if the medicines have stopped your discomfort. It is important to tell them
how you really feel. If the medicines do not stop your discomfort, there are
other things they can do to help you. These things need to be done quickly. The
doctors and nurses may not be able to explain everything as it is happening.
There will be time for you to ask questions after your doctor finds out how
serious your condition is.
UPDATE
******Each year physicians evaluate more than 6 million Americans
with chest pain. One of the most important diagnostic steps is to rule out
myocardial damage through use of a cardiac blood test. The MB isoenzyme of
creatinine kinase (CK) was the traditional marker used to detect MI. But in fact
the CK-MB assay is not perfectly specific, and false-positive results may occur
for a variety of reasons. As a result, physicians sometimes disregarded the
test's results if the CK-MB assay results were inconsistent with other clinical
data.
In the past 4 years, however, new assays have become available that
offer a variety of other benefits. Among these are assays for the markers
troponin T, troponin I, and myoglobin. Myoglobin, for example, is an easily
measured cardiac protein released early in the course of an MI. Troponins, which
are proteins in the striated cell ultrastructure and part of the calcium-binding
complex of the thin myofilaments, are more sensitive than CK-MB. They are
extremely specific and sensitive markers of cardiac damage. While elevated CK-MB
levels return to normal levels within 24 hours, elevated troponin levels persist
for a week or longer. These assays are replacing the CK-MB, but it is important
to keep in mind that because troponin assays are more sensitive and more
specific, and because elevations persist for longer than CK-MB elevations do,
some patients will have elevations that are difficult to interpret.
******
What is an
Electrocardiogram?
When you are in the emergency room you may have an
electrocardiogram, called an ECG or EKG. An ECG records on paper the electrical
activity of your heart beat. The ECG may show your doctor if your heart muscle
is getting enough oxygen-rich blood.
Will I Have to Stay in the
Hospital?
Your ECG, past medical history, and the nature of your pain
tell your doctor how serious your problem is. If your doctor does not consider
your condition to be serious enough to admit you to the hospital, he or she may
make an appointment to see you in a day or two for more tests. If your chest
discomfort comes back before this appointment and is like that described on
"Chest Pain Can Be an Emergency," you should return immediately to the hospital.
It is not easy to accurately diagnose unstable angina, and your doctor may need
to see you more than once to be sure. If your doctor suggests admission to a
hospital, you may be put in a regular bed or in an intensive care unit. In
either case, treatment will continue while your doctor does more tests. The
tests you have will depend on how serious your condition is and how well the
medicines control your discomfort.
Stress Tests You may have an exercise
tolerance test. In this test you will be asked to ride a stationary bicycle or
walk on a treadmill while a doctor takes an ECG. Your doctor may give you an
injection of a radioactive drug that shows up on special cameras. This allows
your doctor to make pictures of how your heart moves and the way your blood
flows. This test will let the doctor see the changes that take place in your
heart when you exercise. Trained personnel or the doctor will watch your
condition by asking how you are feeling during the test. Be sure to follow their
instructions carefully and tell them exactly how you feel. If you have other
health problems, you may be given another kind of stress test that does not use
exercise. If you have this test, you will be given a special type of drug that
makes your heart beat faster and opens your coronary arteries. An ECG will be
taken at the same time. This test gives the doctor the same type of information
as the exercise tolerance test. The exercise tolerance test or other stress test
will help your doctor tell how well your heart is functioning. Although stress
tests are useful, they cannot tell your doctor exactly where your arteries are
blocked or how bad the blockages may be. Also, these tests are accurate no more
than 90 percent of the time. In some cases, doctors will want to do a cardiac
catheterization.
What Can These Tests Show?
Stress
testing may help your doctor decide how much of the heart could be in danger
from blockages in your arteries. An angiogram shows how severe the blockages are
and where they are. If you are told that you have single, two, or three-vessel
disease, it means that one, two, or three of the major coronary arteries have a
blockage. Your doctor may also talk about the percentage of blockage in the
vessel. The number of blocked arteries and the percentage of blockage are used
to measure the severity of your coronary artery disease. Generally, the greater
the number of vessels that are blocked, the higher the percentage of blockage,
and the more poorly your heart pumps blood, the more severe the disease. These
tests will give your doctor a lot of information about your condition. At this
point, he or she can start to give you more information about how serious your
condition is and the types of treatment available.
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Treatment of Unstable Angina
After
your tests, you and your doctor can decide on which treatment you should have.
The treatment that is best for you will depend on the results of your tests,
whether or not you are still having discomfort, and your own preferences. In
general you will have three choices: medical therapy, angioplasty, or bypass
surgery.
You may have been given medicine in the hospital or emergency room.
Some of these medicines, such as heparin which is used to decrease blood
clotting, are given to you only in the hospital. Many other medicines used to
treat unstable angina can be taken at home. They come in the form of pills or
creams that you can use by yourself. Many people do very well on medicine alone.
If you decide to use medicine to treat your unstable angina, and it does not
control all your discomfort, you can still have bypass surgery or angioplasty
later. Almost everyone who has unstable angina will be given some type of
medicine. The nurses or doctors caring for you will explain how and when to take
all your medicines. Several types of medicine can help to relieve the discomfort
of unstable angina. Many of these drugs also make it easier for the heart to
work. Medical therapy may be used alone or in combination with the other
treatments described later. Medical therapy alone also may be the right
treatment for people with other illnesses and people who do not want to have
surgery or other procedures. Medical therapy alone may benefit patients who:
Have a blockage or blockages in only one vessel Have a less severe blockage Do
not have severe anginal discomfort Have stabilized in the hospital Here are some
questions to ask your doctor about medical treatment. What side effects will I
have from the medicine? Will I have to take medicine for the rest of my life?
Some people have uncomfortable side effects from the medicine, but most people
feel better because they have less anginal discomfort. If you do have a reaction
to a medicine, be sure to tell your doctor about it. Often the reaction goes
away or becomes less severe with time. If not, your doctor may be able to change
your medicine to make you more comfortable. Remember, none of these drugs
removes any of the blockages from your arteries. They do relieve anginal
discomfort by bringing more blood to your heart or by making it easier for your
heart to work. Some of the most common medicines given to patients with unstable
angina include aspirin, nitrates, and beta blockers. Aspirin How it works: Most
people think of aspirin as something to relieve a headache or a fever. But
aspirin also can prevent blood clots from forming. These are the same kind of
blood clots that can block the coronary arteries and cause a heart attack.
Research in patients with unstable angina has proven that taking an aspirin
every day reduces the risk of heart attack or death. Acetaminophen (for example,
Tylenol [TM] ) and ibuprofen (for example, Advil [TM] ) are not the same as
aspirin and should not be used in place of aspirin. Side effects: Most patients
with unstable angina will be told to take aspirin every day. Your doctor will
tell you how much to take. When coated or buffered aspirin is used there are few
major side effects. Aspirin should not be used if you are allergic to it or if
you have had an ulcer or any other bleeding problem. Nitrates How they work:
Nitrates (usually nitroglycerin and isosorbide) are used to open blood vessels.
Nitrates increase blood flow to the heart muscle and the blood vessels and make
it easier for the heart to work. Nitrates can relieve most anginal discomfort
very quickly. Nitrates come in tablets that you put under your tongue or a
different type of tablet that you swallow, as a patch that you wear on your
skin, or as a cream that you apply on your skin. Nitrate tablets, cream, and
patches all have a limited shelf life after which they will no longer work. Ask
your pharmacist how long they will last and when you should replace them.
Nitrate cream and patches are for maintenance therapy only. If you are using a
nitrate patch or cream, you should still use nitrate tablets if you have anginal
discomfort. Take one nitroglycerin tablet as soon as you feel discomfort. If the
discomfort does not go away in 5 minutes, take a second tablet. If the
discomfort does not go away after 5 more minutes, take a third tablet. If the
discomfort has not gone away after taking three tablets in 15 minutes, go to the
hospital immediately. Do not wait! Persistent discomfort that does not go away
could be a sign that you are having a heart attack. You should see a doctor
immediately. Side effects: You may feel dizzy or lightheaded right after taking
nitrates. Patients are usually told to take nitrate tablets while sitting down.
Some people may also get a headache when they take nitrates. Beta Blockers How
they work: This drug decreases the amount of work your heart has to do and the
amount of oxygen your heart needs. Side effects: Beta blockers are very powerful
drugs that can have many side effects. About 10 percent of patients taking beta
blockers will feel tired or dizzy. Depression, diarrhea, or skin rash may also
happen in about 5 percent of patients. Mental confusion, headaches, heartburn,
and shortness of breath are much less common.
Angioplasty
This procedure is
done like an angiogram. A thin tube called a catheter is inserted into an artery
in the groin and threaded up to the blocked artery. This catheter has a very
small balloon attached on the end. When the catheter gets to the blockage, the
doctor inflates the balloon. When the balloon is deflated, the blockage should
be open enough for the blood to get through, stopping the anginal discomfort.
Possible benefits: Relieve anginal pain Increase activity/exercise Allow return
to former activities Reduce amount of medicine Decrease anxiety/fear Possible
risks: Worsened angina Emergency bypass surgery Heart attack Damage to the
artery Re-blockage of the artery Death Questions to ask your doctor about
angioplasty: Will I need additional angioplasty or bypass surgery in the future?
What will it feel like to have angioplasty? What is the chance that I might die
during the angioplasty procedure or have other problems?
Surgery is
usually recommended for patients who have severe blockages in the left main
coronary artery or disease in several vessels. Surgery is also an option when
medicines do not control anginal symptoms. Coronary artery bypass surgery can be
a very effective way to increase the amount of blood getting to your heart and
stop your discomfort. In this operation, a piece of a vein, usually from your
leg or an artery from your chest, is removed and used to "bypass" the section of
your artery that has the most blockage. One end of the blood vessel is placed
into your aorta. The aorta is the artery that supplies all the blood going out
of your heart into your body. The other end is sewn into the artery below the
blocked section to bypass the blockage. Possible benefits: Prolong life Relieve
anginal pain Increase activity/exercise Allow return to former activities Reduce
need for medicine Decrease anxiety/fear Possible risks: Bleeding, requiring more
surgery Wound infection Stroke Blood clots Organ failure (liver, kidney, lung)
Heart attack Death Here are some questions to ask your doctor about bypass
surgery: What will it feel like to have bypass surgery? Is it normal to be
afraid of having surgery? What is the chance that I might die during surgery or
have other problems? Will I need more surgery in the future? Angioplasty or
Bypass Surgery?
Both angioplasty and bypass surgery are designed to do
the same thing. They both can increase the supply of blood to your heart muscle.
Depending on the severity of your disease, you may have a choice between the
two. How will you know which one is right for you? Your doctor will help you
make this decision. But in general, angioplasty: Is not as major a procedure as
bypass surgery. Results in a shorter hospital stay. Will allow you to return to
normal activities sooner. You should also know that: In about 2 to 5 percent of
cases, angioplasty does not work, and emergency bypass surgery will be
necessary. About 40 percent of the time, the arteries become blocked again
within 6 months of the angioplasty. If this happens, you may have to have
angioplasty again or have bypass surgery. Talking with Your Health Care Team
Some people think that their doctors are too busy to answer questions. Other
people do not know how to ask their questions. But talking with the doctors,
nurses, and other health care providers is an important part of your care. Your
questions are important, and the people taking care of you should make the time
to answer your questions and listen to what you have to say. Your preferences
for the type of treatment you receive are very important. You may feel more
comfortable if a family member or friend is there when you talk to your doctors,
nurses, and other health care providers. This person can help to make sure that
you understand what is happening, ask questions, and tell the doctor your
concerns and preferences for care. Here are some questions to ask your doctor
before you decide what the best treatment might be for you. Am I a candidate for
medical treatment, angioplasty, or bypas surgery? What are the chances that my
arteries will become blocked again if I have angioplasty or bypass surgery? How
soon might this happen? Will I have to change my job or retire? How soon can I
resume my normal activities? What about resuming sexual activity? How much will
my treatment cost? Do I have to go on a low-sodium or low-fat diet? If so, for
how long? Will I have a heart attack? Will I always have chest pain? Can
Blockages Come Back? Neither angioplasty nor bypass surgery is a cure for
coronary artery disease. Blockages continue to build up on artery walls even
after angioplasty or bypass surgery. Both angioplasty and bypass surgery can be
repeated if the arteries become blocked again. The only way to stop coronary
artery disease is to prevent the blockages from building up. Although doctors do
not know for sure why blockages form, they do know, from studies of large
numbers of patients, that some people are more likely to have blocked arteries
than others. Your doctor may recommend that you attend a cardiac rehabilitation
program. These programs usually are offered by local hospitals and very often
they are covered by insurance. In a rehabilitation program, nurses, exercise
specialists, and doctors will help you to change behaviors that put you at
higher risk. They will also teach you how to exercise safely and help you gain
confidence in your ability to live with heart disease.
Preventing blockages:
The best
way to prevent blockages from forming is to: Take aspirin every day, under a
physicians care Stop smoking Eat foods that are lower in fat Keep weight down
Increase physical activity Control blood pressure if it is high Lower
stress
Living with Coronary
Artery Disease:
It is normal for you to worry about your health and your
future. But, you should know that most people with unstable angina do not have
heart attacks. Usually, angina becomes more stable within 8 weeks. In fact,
people who are treated for their unstable angina can live productive lives for
many years. Coronary artery disease does not go away. Your behavior and
lifestyle will affect your condition. This is why it is so important to follow
the advice of your doctor and the other health care professionals who treat you.
Every year, thousands of people are told they have coronary artery disease. This
may come as a shock, especially if they have never felt ill before. Often, they
become anxious about their future and wonder if they will still be able to take
care of their families or other responsibilities. It is normal to feel a loss of
control, as if something has taken over your life. Doctors, nurses, members of
the clergy, and counselors all have experience in helping people with coronary
artery disease. They can help you and your family. It is important to talk about
how you feel, not just physically, but emotionally. The best way to feel like
you are in control is to learn more about coronary artery disease-what it is and
the choices you have. When you see your doctor or other health care provider, be
prepared to ask questions.
For further information contact:
American Heart
Association
7272 Greenville Avenue
Dallas, TX 75231-4596
Phone: (800)
AHA-USA1
The Mended Hearts, Inc. 7272 Greenville Avenue Dallas, TX
75231-4596 Phone: (214) 373-6300
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