Ask The Doctors: December 2015
I have had stable angina for a couple of years. I know what brings on the pain and how to treat it. But what is the usual progression for angina? I know my heart attack risk is higher, but what can I do to prevent my condition from getting worse?
Angina is chest discomfort consisting of pain, pressure, or a squeezing sensation, classically felt under the breastbone or sternum, sometimes accompanied by radiation of discomfort to the arm, neck, jaw, or back. It is usually brought on by exercise and relieved by rest. Other factors which can trigger angina are cold weather, heavy meals, emotional stress, anemia, cardiac arrhythmias, and heart failure. Anginal symptoms occur when the heart muscle does not receive adequate oxygen, most commonly due to narrowing in the coronary arteries by coronary artery disease (CAD). From your description I must assume that your symptoms are known to be cardiac, and that you are receiving care from a physician. Stable angina is a chronic, long-term condition, in contrast to the medical emergency of unstable angina, which is characterized by new or progressive chest symptoms that can result in a myocardial infarction (MI, or heart attack).
People with angina should undergo a stress test, and will usually receive a heart catheterization as well, in order to assess their coronary anatomy. In that way, their doctor can determine if coronary revascularization—for example, by coronary artery bypass grafting (CABG)—is needed to reduce the risk of MI, and hopefully increase longevity. Unfortunately, there isn’t always a total “plumbing” solution for angina, and so it’s not unusual for patients who have experienced an MI, or undergone coronary stenting or CABG, to experience varying degrees of angina afterwards. As you mention, people with angina are at increased risk for another heart attack compared to the general population, but several approaches have been shown to reduce that risk. Quitting smoking, eating a heart-healthy diet, maintaining a normal weight, and exercising at least five days per week (as directed by your physician) are very important. As for medications, people with angina should take the following, if tolerated: aspirin, beta-blocker, ACE-inhibitor or ARB, statin, and nitroglycerin (taken under the tongue), as needed.
I’ve heard that if you have blockage in one artery, you may have it in other arteries. I have two stents in my heart, but when I see my cardiologist for checkups, he doesn’t check my carotid arteries or look for peripheral artery disease. What should a heart patient’s exam include?
What you’ve been told is partially correct. Atherosclerosis (cholesterol plaque buildup and inflammation) in one arterial system—for example, the coronary arteries—increases the probability of having it in other systems, such as the cerebrovascular arteries (which include the carotids) or the peripheral arteries supplying the limbs. However, at present no data exist to support doing routine imaging tests to screen for carotid or peripheral artery disease. In fact, it is more likely that overperformance of such tests would actually increase the risk of harm to patients (by triggering unnecessary invasive testing), rather than helping them. The most important single element when visiting your doctor is discussing your symptoms, which would include neurological abnormalities (suggesting transient ischemic attack or stroke) or claudication in the legs (suggesting narrowing in the peripheral arteries). As for the yearly physical examination, in addition to listening to the heart and lungs, it should include palpation (feeling) of pulses in the arms and legs, and listening for bruits (abnormal sounds) over the carotid arteries and femoral arteries. Although not particularly sensitive for detecting narrowings, bruits, once they are heard, can be the tip-off for finding a severely narrowed vessel.