Angina Pectoris — complete guide: from first symptoms to medication choices

Angina pectoris (Latin for "chest tightness") is a clinical syndrome in which the patient experiences pressing or squeezing chest pain caused by a temporary oxygen deficit in the heart muscle. It is not a disease per se but a manifestation of coronary artery disease (CAD) — the leading cause of death worldwide according to the WHO.

The heart muscle receives oxygen via the coronary arteries. In atherosclerosis, plaques of cholesterol and calcium narrow these arteries. When the lumen shrinks by 50–70%, blood flow is adequate at rest but insufficient during exertion, stress, or cold — causing ischemia: the heart temporarily "starves" and sends a pain signal.

Unlike myocardial infarction, angina ischemia is reversible — pain subsides at rest or after nitroglycerin.

The most common form. Attacks occur at a predictable workload — climbing stairs, walking uphill, emotional stress. Pain resolves in 3–5 minutes at rest or with nitroglycerin. The Canadian Cardiovascular Society (CCS) grades it from Class I (pain only with strenuous activity) to Class IV (pain at rest).

An emergency. Pain occurs at rest, lasts over 20 minutes, and responds poorly to nitroglycerin. It means the plaque has become unstable and may rupture, triggering a coronary thrombus (heart attack). Requires immediate hospitalization.

A rare form caused by coronary artery spasm rather than plaque. Attacks typically occur at night or early morning. Calcium channel blockers — verapamil, amlodipine — are effective.

Typical presentation:

- Pressing, squeezing, or burning chest pain behind the sternum

- Radiates to the left arm, shoulder, jaw, or back

- Lasts 2–15 minutes

- Triggered by exertion, stress, cold, or heavy meals

- Relieved by rest or nitroglycerin

Call emergency services if pain lasts over 15–20 minutes, does not respond to 3 doses of nitroglycerin (5-minute intervals), or is accompanied by sweating and fear.

Resting ECG — baseline method; changes in the ST segment during an attack are characteristic. Stress testing (treadmill, bicycle ergometry) — the gold standard for stable angina. Echocardiography — assesses heart muscle contractility. Coronary angiography — X-ray visualization with contrast to pinpoint narrowing; indicated for unstable angina or before stenting/bypass. Lab tests: lipid panel, fasting glucose, HbA1c, troponin (to rule out infarction).

1. Stop physical activity, sit or recline

2. Loosen tight clothing

3. Take 1 nitroglycerin tablet under the tongue

4. If pain persists after 5 minutes — repeat (up to 3 times, 5 min apart)

5. If pain persists after 3 doses — call emergency services

6. If no contraindications — chew 250 mg aspirin

Antiplatelets — aspirin 75–100 mg/day or clopidogrel 75 mg/day if aspirin-intolerant. Prevent clot formation on plaques.

Statins — atorvastatin 40–80 mg/day. Lower LDL cholesterol and stabilize plaques.

ACE inhibitors / ARBs — perindopril, ramipril, losartan. Protect vessels, especially with concurrent hypertension or diabetes.

Beta-blockers — metoprolol, bisoprolol. First-line therapy: reduce heart rate and myocardial oxygen demand. Target HR: 55–60 bpm.

Calcium channel blockers — amlodipine, verapamil, diltiazem. Dilate coronary arteries.

Nitrates — nitroglycerin for acute relief; isosorbide dinitrate for prevention. A nitrate-free interval of 10–12 hours daily is needed to prevent tolerance.

PCI (stenting) — a catheter-delivered balloon opens the narrowed artery and a stent holds it open.

CABG (bypass surgery) — surgeons create bypass routes using the patient's own vessels. Indicated for multi-vessel disease or left main stenosis.

Modifiable: smoking (doubles CAD risk), hypertension (target < 130/80), dyslipidemia (LDL target < 1.4 mmol/L for very high risk), diabetes, obesity, sedentary lifestyle, chronic stress.

Non-modifiable: age (men > 45, women > 55), male sex, family history of early CAD.

Angina is serious but manageable. Modern medicine offers a wide arsenal — from nitroglycerin for acute relief to statins and antiplatelets that demonstrably extend life. The key is early diagnosis, strict adherence to treatment, and lifestyle modification.

Learn more about these medications: nitroglycerin, metoprolol, amlodipine, atorvastatin, clopidogrel, aspirin. Always consult your physician before changing therapy.