Preventing coronary artery disease
		Living with angina
		Life after a heart attack

Going Home

Some plaque is hard and stable and leads to narrowed and hardened arteries. Other plaque is soft and is more likely to break open and cause blood clots. The buildup of plaque on the inner walls of the arteries can cause angina in two ways:

		By narrowing the artery to the point where the flow of blood is greatly reduced
		By forming blood clots that partially or totally block the artery

Types of Angina

The three types of angina are stable, unstable, and variant (Prinzmetal's). It is very important to know the differences among the types.

More than 6 million people in the United States have angina.

People with coronary artery disease or who have had a heart attack are more likely to have angina.

Unstable angina occurs more often in older adults.

Variant angina is rare. It accounts for only about 2 out of 100 cases of angina. People with variant angina are often younger than those with other forms of angina.

What Are the Signs and Symptoms of Angina?

Pain and discomfort are the main symptoms of angina. These symptoms:

		Are often described as pressure, squeezing, burning, or tightness in the chest
		Usually start in the chest behind the breastbone
		May also occur in the arms, shoulders, neck, jaw, throat, or back
		May feel like indigestion

Some people say that angina discomfort is hard to describe or that they can't tell exactly where the pain is coming from. Symptoms such as nausea, fatigue, shortness of breath, sweating, light-headedness, or weakness may also occur.

Symptoms vary based on the type of angina.

Stable Angina

The pain or discomfort:

		Occurs when the heart must work harder, usually during physical exertion
		Is expected, and episodes of pain tend to be alike
		Usually lasts a short time (5 minutes or less)
		Is relieved by rest or angina medicine
		May feel like gas or indigestion
		May feel like chest pain that spreads to the arms, back, or other areas

Unstable Angina

The pain or discomfort:

		Often occurs at rest, while sleeping at night, or with little physical exertion
		Is unexpected
		Is more severe and lasts longer (as long as 30 minutes) than episodes of stable angina
		Is usually not relieved with rest or angina medicine
		May get continuously worse
		May signal that a heart attack is impending

Variant Angina

The pain or discomfort:

		Usually occurs at rest and during the night or early morning hours
		Tends to be severe
		Is relieved by angina medicine

Chest pain that lasts longer than a few minutes and is not relieved by rest or angina medicine may mean you are having—or are about to have—a heart attack. Call 9–1–1 right away.

How Is Angina Diagnosed?

To find out if you have angina, your doctor will:

		Do a physical exam
		Ask about your symptoms
		Ask about your risk factors and your family history of coronary artery disease (CAD) or other heart disease

Sometimes, your doctor can diagnose angina by noting your symptoms and how they occur. Your doctor may order one or more tests to help make a diagnosis of angina. The tests your doctor may order include:

EKG (electrocardiogram). This test measures the rate and regularity of your heartbeat. Some people with angina have a normal EKG.

Cardiac catheterization. A thin flexible tube (catheter) is passed through an artery in the groin (upper leg) or arm to reach the coronary arteries. Your doctor can determine pressure and blood flow in the heart's chambers, collect blood samples from the heart, and examine the arteries of the heart by x ray.

Coronary Angiography. This test is done during cardiac catheterization. A dye that can be seen by x ray is injected through the catheter into the coronary arteries. Your doctor can see the flow of blood through your heart and the location of blockages.

Your doctor may also order blood tests, such as:

		A fasting lipoprotein profile to check your cholesterol levels.
		Fasting glucose test to check your blood sugar level.
		C-reactive protein (CRP) test. This blood test measures CRP, a protein in the blood that shows the presence of inflammation. Inflammation is the body's response to injury. High levels of CRP may be a risk factor for CAD.
		A test to check for low hemoglobin in your blood. Hemoglobin is the part of red blood cells that carries oxygen to all parts of your body.

How Is Angina Treated?

Treatment for angina includes lifestyle changes, medicine, special procedures, and cardiac rehabilitation. The main goals of treatment are to:

		Reduce the frequency and severity of symptoms
		Prevent or lower the risk of heart attack and death

Lifestyle changes and medicine may be the only treatments needed if your symptoms are mild and are not getting worse. Unstable angina is an emergency condition that requires treatment in the hospital.

Lifestyle Changes

The first thing that you need to do is change your living habits to avoid bringing on an episode of angina.

		Slow down or take rest breaks, if angina comes on with exertion.
		Avoid large meals and rich foods that leave you feeling stuffed, if angina comes on after a heavy meal.
		Try to avoid situations that make you upset or stressed, if angina comes on with stress. Learn techniques to handle stress that can't be avoided.

You can also make other lifestyle changes, for example:

		Eat a healthy diet to prevent or reduce high blood pressure, high blood cholesterol, and obesity
		Quit smoking, If you smoke
		Be physically active, as directed by your doctor
		Lose weight, if you are overweight or obese.
		Follow your doctor's orders and take all medicines as directed, especially if you have diabetes

Medications

Nitrates are the most commonly used medicines to treat angina. Fast-acting preparations are taken when angina occurs or is expected to occur. Nitrates relax and widen blood vessels, allowing more blood to flow to the heart while reducing its workload.

You can use nitrates in different forms to:

		Relieve an episode that is occurring by using the medicine when the pain begins
		Prevent an episode from occurring by using the medicine just before pain or discomfort is expected to occur
		Reduce the number of episodes that occur by using the medicine regularly on a long-term basis

Nitroglycerin is the most commonly used nitrate for angina. Nitroglycerin that dissolves under your tongue or between your cheeks and gum is used to relieve an angina episode. Nitroglycerin in the form of pills and skin patches is used to prevent attacks of angina. These forms of nitroglycerin act too slowly to relieve pain during an angina attack.

Other medicines can be used to treat angina:

		Beta blockers slow the heart rate and lower blood pressure. They can delay or prevent the onset of angina.
		Calcium channel blockers relax blood vessels so that more blood flows to the heart, reducing pain from angina. Calcium channel blockers also lower blood pressure.
		ACE (angiotensin-converting enzyme) inhibitors lower blood pressure and reduce the strain on the heart. They also reduce the risk of a future heart attack and heart failure.

People who have angina may also use:

		Medicines to lower cholesterol levels.
		Medicines to lower high blood pressure.
		Oral antiplatelet (an-ty-PLAYT-lit) medicines (such as aspirin and clopidigrel), taken daily, to stop platelets from clumping together to form blood clots. Platelets are small blood cells that circulate through your blood vessels and help stop bleeding by sticking together to seal small cuts or breaks in tiny blood vessels. Antiplatelet medicines may not be appropriate for some people because they increase the risk of bleeding. Discuss the benefits and risks with your doctor before starting therapy with aspirin or the other antiplatelet medicines.
		Glycoprotein IIb-IIIa inhibitors are potent antiplatelet medicines that prevent clots from forming in your arteries. They are given intravenously in hospitals for the treatment of angina or during and after angioplasty.
		Anticoagulants (an-ty-ko-AG-u-lants) to prevent clots from forming in your arteries and blocking blood flow.

Special Procedures

When medicines and other treatments do not control angina, special (invasive) procedures may be needed. Two commonly used procedures are:

		Angioplasty. This procedure opens blocked or narrowed coronary arteries. It can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a stent is placed in the artery to keep it propped open after the procedure.
		Coronary artery bypass surgery. This procedure uses arteries or veins from other areas in your body to bypass your blocked coronary arteries. Bypass surgery improves blood flow to your heart, relieves chest pain, and can prevent a heart attack.

Cardiac Rehabilitation

Your doctor may prescribe cardiac rehabilitation (rehab) for angina or after bypass surgery, angioplasty, or a heart attack.

The cardiac rehab team may include:

		Doctors
		Your family doctor
		A heart specialist
		A surgeon
		Nurses
		Exercise specialists
		Physical therapists and occupational therapists
		Dietitians
		Psychologists or other behavioral therapists

Rehab has two parts:

		Exercise training. This helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual ability, needs, and interests.
		Education, counseling, and training. This helps you understand your heart condition and find ways to reduce your risk of future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.

How Can Angina Be Prevented?

You can prevent or lower your risk for heart disease and angina by making lifestyle changes and getting treatment for related conditions.

Make Lifestyle Changes

		Eat a healthy diet to prevent or reduce high blood pressure, high blood cholesterol, and obesity.
		Quit smoking, if you smoke
		Be physically active, as directed by your doctor
		Lose weight, if you are overweight or obese

Treat Related Conditions

In addition to making lifestyle changes, you can help prevent angina and heart disease by treating related conditions, such as:

		High blood cholesterol. If you have high cholesterol, follow your doctor's advice about lowering it. Take medications to lower your cholesterol as directed.
		High blood pressure. If you have high blood pressure, follow your doctor's advice about keeping your blood pressure under control. Take blood pressure medications as directed.
		Diabetes (high blood sugar). If you have diabetes, follow your doctor's advice about keeping your blood sugar levels under control. Take medicines as directed.
		Overweight or obesity. If you are overweight or obese, talk to your doctor about how to lose weight safely.

Living With Angina

Angina is not a heart attack, but it does mean that you are at greater risk of having a heart attack than someone who does not have angina. The risk is even higher if you have unstable angina. For these reasons, it is important that you know:

		The usual pattern of your angina, if you have it on a regular basis
		About your medicine
		How to control your angina
		The limits of your physical activity
		How and when to seek medical attention

Know the Pattern of Your Angina

Stable angina usually occurs in a pattern. You should know:

		What causes the pain to occur
		What it feels like
		How long it usually lasts
		Whether it is relieved by rest or medicine

After several episodes, you will learn to recognize when you are having angina. It is important for you to notice if the pattern starts to change. Changes in the pattern to look for may include:

		Occurring more often
		Lasting longer
		Being more severe
		Occurring without exertion
		Not going away with rest or medicine

These changes in the pattern may be a sign that your symptoms are getting worse or becoming unstable. You should seek medical attention. Unstable angina suggests that you are at high risk for a heart attack very soon.

Know Your Medicines

You should know what medicines you are taking, the purpose of each, how and when to take them, and possible side effects. It is very important that you know exactly when and how to take fast-acting nitroglycerin or other nitrates to relieve chest pain. They should be taken:

		Immediately when pain begins or before stressful activity
		Three times spaced 5 minutes apart if pain does not go away
		Always sit down before taking nitroglycerin.
		Long-acting nitrate preparations should be used regularly as prescribed by your doctor.

Men with impotence (erectile dysfunction) who take sildenafil (Viagra®) should talk with their doctor. Taking sildenafil and nitroglycerin or other nitrates within 24 hours of each other can cause serious problems. Ask your doctor about your other medicines. Also, see the Treatment section to read descriptions of the medicines that you are taking.

Know How To Control Your Angina

After several episodes, you will know the level of activity, stress, and other things that can bring on your angina. By knowing this, you can take steps to prevent or lessen the severity of episodes. Physical exertion. Know what level of activity brings on your angina and try to stop and rest before chest pain starts. For example, if walking up a flight of stairs leads to chest pain, then stop halfway and rest before continuing. When chest pain occurs during exertion, stop and rest or take your angina medicine. The pain should go away in a few minutes. If the pain does not go away or lasts longer than usual, call 9–1–1 and get emergency care. Emotional stress. Anger, arguing, and worrying are examples of emotional stress that can bring on an angina episode. Try to avoid or limit exposure to situations that cause these emotions. Exercise and relaxation can help relieve stress. Alcohol and drug use play a part in causing stress and do not relieve it. If stress is a problem for you, talk with your doctor about getting counseling to help you deal with stress. Eating large meals. If this leads to chest pain, eat smaller meals. Also, avoid eating rich foods.

Know the Limits of Your Physical Activity

Most people with stable angina can continue their normal activities. This includes work, hobbies, and sexual relations. However, if you engage in very strenuous activity or have a stressful job, you may need to discuss this with your doctor.

Know How and When To Seek Medical Attention

If you have angina, you are at high risk of having a heart attack. Therefore, it is very important that you and your family know how and when to seek medical attention. Talk to your doctor about making an emergency action plan. The plan should include:

		The signs and symptoms of a heart attack
		Instructions for the prompt use of aspirin and nitroglycerin
		How to access emergency medical services in your community
		The location of the nearest hospital that offers 24-hour emergency heart care

Be sure to discuss your emergency plan with your family members. Take action quickly if your chest pain becomes severe, lasts longer, or is not relieved by rest or medicine.

Sometimes, it may be difficult to tell the difference between unstable angina and a heart attack. Most heart attack victims wait 2 hours or more after their symptoms begin before they seek medical help. This delay can result in death or lasting heart damage.

Key Points

		Angina is chest pain or discomfort that occurs when your heart muscle does not get enough blood. Angina may feel like pressure or a squeezing pain in your chest. The pain may also occur in your shoulders, arms, neck, jaw, or back.
		Most people with angina have coronary artery disease, with narrowed arteries due to atherosclerosis. When arteries are narrowed, blood flow to the heart is reduced.
		More than 6 million people in the United States have angina.
		The most common types of angina are stable angina and unstable angina. A less common type of angina is called variant angina.
		Stable angina is chest pain or discomfort that occurs when the heart is working harder than usual. Pain from stable angina goes away when you rest or take your angina medicine. Angina medicine, such as nitroglycerin, helps widen and relax the arteries so that more blood can flow to the heart.
		Unstable angina is a very dangerous condition that requires emergency treatment. Unstable angina is a sign that a heart attack could occur soon. Unstable angina can occur without physical exertion. It is not relieved by rest or medicine.
		Variant angina is caused by a spasm in a coronary artery. The spasm causes the walls of the artery to tighten. This narrowing of the artery slows or stops blood flow to the heart.
		Doctors diagnose angina based on your health history, your family’s health history, a physical exam, and the results of various tests.
		Angina is usually treated with medicines such as nitrates (nitroglycerin). People with angina may need to take other medicines to lower their blood pressure or cholesterol. They also may take medicine to prevent blood clots.
		To prevent and treat angina, it is important to make changes to improve your health. Get regular physical activity, maintain a healthy weight, don't smoke, and eat a healthy diet that is low in saturated fat and cholesterol. A cardiac rehab program can be helpful for many people with angina.
		When medicines and lifestyle changes do not control angina, special procedures may be needed. Angioplasty and coronary artery bypass surgery are two common procedures used to treat angina.
		If you have angina, it is important to know the pattern of your angina, about your medicine, how to control your angina, and the limits on your physical activity. You should know how and when to seek medical help.

Minimally Invasive Heart Surgery

Recent advances in surgical techniques and equipment allow surgeons to perform Coronary Artery Bypass Surgery in a less traumatic way. Minimally Invasive Coronary Artery Surgery is also called Limited Access Coronary Artery Surgery. It is as an alternative to the standard methods of Coronary Artery Bypass Graft Surgery. Unlike conventional surgery, which utilizes a 10-12" incision and requires the patient to be placed on the heart-lung machine, new minimally invasive surgery may avoid placing the patient on the machine, and can be performed through a 3-5" incision placed between the ribs, or may be done with several small incisions. Like conventional surgery, the surgery is done to reroute, or bypass, blood around coronary arteries clogged by fatty buildups of plaque and improve the supply of blood and oxygen to the heart.

Minimally Invasive Coronary Artery Bypass—also called MIDCAB—is used to avoid the heart-lung machine. It's done while your heart is still beating and is intended for use when only one or two arteries will be bypassed. MIDCAB uses a combination of small holes, or ports, in your chest and a small incision made directly over the coronary artery to be bypassed. The heart surgeon usually detaches an artery from inside the chest wall and re-attaches it to the clogged coronary artery farthest from the occlusion. The surgeon views and performs the attachment directly, so the artery to be bypassed must be right under the incision.

Minimally Invasive Bypass Surgery has the same beneficial results as conventional bypass surgery. It restores adequate blood flow and normal delivery of oxygen and nutrients to the heart. This type of surgery has additional advantages, including the ability of the surgeon to work on a beating heart or through smaller incisions.

This surgery is available to more patients. Many patients are poor candidates for traditional bypass surgery because their illness is too widespread or their heart is too weak. Some patients are able to receive this life-saving surgery through minimally invasive techniques. 

Risks  

Performing surgery on a beating heart is more difficult than working on a heart that has been stopped with the help of the heart-lung machine. In addition, the stress on the heart during the procedure may lead to more heart muscle damage, lower blood pressure, irregular heartbeat and potential brain injury if blood flow to the brain is reduced for too long during surgery. In some cases—usually less than 10 percent—it is necessary to convert to conventional methods on an emergency basis.

Weight Control

Weight control is an important part of our culture. We are reminded daily in our society that being overweight is not "in" or fashionable. Just look at TV or any type of media advertising and you will soon see that being thin and in good shape is what is popular.

Your primary goal should be to have a healthy body. Healthy bodies come in different shapes and sizes. Weight control is just a part of having a healthy body. Other factors include your diet, nutrition and the amount and kind of exercising you are getting. Displayed later on in this chapter is a height/weight chart that will serve as a guideline.

When you see your family doctor, they will check your height, weight, and blood pressure, blood lipids, (cholesterol, triglycerides), and blood sugar (for people with diabetes). All of these involve medical conditions related to weight. Proper weight control and weight management can help provide for a healthy body.

Obesity

Obesity is basically a medical condition that signifies the excess storage of body fat. It is normal for the body to store fat tissue under the skin and around joints and organs. Fat is essential for good health because it provides energy when the body demands it and provides insulation and protection for vital organs. It is the accumulation of too much fat that poses the health problems of obesity. These health problems include diabetes, hypertension, stroke, heart disease and arthritis.

The United States has one of the highest percentages of obese adults. It is estimated that over 36% of adults in America are obese. Obesity is most common among minorities, especially minority females. Over 50% of African-American and Mexican-American women are obese. Over 20% of children between the ages of 6 to 17 fit in the obese category.

A primary concern of obesity is the risk of developing disease. Obese people are twice as likely to develop high blood pressure and over 70% of heart disease cases are linked to excess body fat. Obese women are twice as likely to develop breast cancer and 40% more likely to develop colon cancer. Close to 80% of Type II or non-insulin dependent diabetics are obese.

Obesity is partially determined by genetic makeup. Research has revealed that basal metabolic rate and the size and number of a person's fat cells help in determining the amount of weight loss that is possible. When calories from food intake equal the amount of energy that the body requires to function the weight remains the same. However, when more calories are consumed than the body needs, the body will store the extra calories, resulting in weight gain.

Diet

Diets are the most common treatment for obesity. There seem to be countless diets that are promoted and it is recommended that your weight control diet be supervised by a your family doctor. Most health care professionals will recommend a diet that consists of 1200 - 1500 calories per day. People who are over 40 pounds overweight may require a more aggressive approach and may be put on a restricted diet of 500 to 800 calories per day.

There many types of weight loss medications on the market today but there are also many side effects that include insomnia, anxiety and irritability. Your family doctor can evaluate your particular condition, health issues and can  recommend weight-loss medications under the right circumstances. Used correctly, they can be very effective in the treatment of overweight people.

Exercise

Exercise should be an important part of your weight management plan. Calorie reduction alone is not a complete plan will not result in long-term weight loss. Regular exercise is a long-term plan for continuing weight reduction. Exercise will also improve some of the medical conditions associated with obesity which include high cholesterol levels, high blood pressure and diabetes.

A long-term exercise plan sometimes requires lifestyle and behavior modification, which can be hard for many obese people to accept. Successful weight management plans require strong discipline to control eating urges and to implement exercise plans. New habits need to be learned and many old bad habits need to changed, such as food types consumed and unproductive eating habits.

When choosing an exercise program, the person should consult their family doctor. The exercise program will be designed around the person's work capacity, which will be determined by your doctor. Exercise tests using the treadmill or stationary bicycle are the most common ways to determine and measure work capacity. Once your work capacity has been determined, an exercise program can be recommended. The formula will include what your training heart rate should be and how much intensity should be expended during your workout.

An exercise program can be the most important part of your weight management program because it will give you so many other added health benefits. Many studies show a direct correlation between physical fitness and mental achievement.

Weight Chart

The following charts provide healthy weight ranges for different body sizes and builds:

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