Chest pain & angina: what does it feel like and what causes it?

Chest pain & angina: what does it feel like and what causes it?

January 6, 2020 27 By Bertrand Dibbert


Heart pain classically comes on with exercise,
such as walking uphill or rushing. There are other typical features such as a constriction
or tightness in the chest and that the symptom can be relieved by rest. Some patients however,
don’t have the typical symptom and their symptom may occur in the shoulders or in the arms
or in the jaw or the teeth. So diagnosing angina or heart pain can be difficult. There
are some people who feel it like an indigestion. And that’s a really common situation. But
when walking, they describe a feeling of indigestion. And of course, to the patient they don’t naturally
think immediately of the heart. Well, the first step in trying to establish
whether it’s heart related pain is based upon the history as we’ve discussed. And classically,
the symptom can come on with exercise. If the symptom is classical, then it’s highly
likely that the symptom is angina based upon the history alone, but in most cases, we’ll
require investigations to truly establish whether there’s underlying coronary artery
disease. These days we have a fantastic set of non-invasive
investigations to initiate the diagnosis of coronary artery disease. The mainstay in my
practise is a CT coronary angiogram. This is a non-invasive test which takes ten minutes
to do and involves small x-ray doses and the use of some contrast. And we can obtain superb
images of the coronary arteries in a rapid non-invasive fashion. This is really helpful.
This has developed rapidly over the last few years with the latest machines being fantastic
at diagnosing coronary disease. The second form of a non-invasive test which I use is
a stress MRI scan, which looks to see if there’s any problem with the blood flow in the heart
arteries. The next step which is my area of expertise is with invasive angiography. That’s
the gold standard really for diagnosing coronary artery disease. This is a procedure performed
under local anaesthetic as a day case. And in my hands, from the radial artery. And this
is the best method to evaluate the true level of coronary artery disease. The main risk factors that we know about are quite well-known publicly. Those are of course
smoking but also hypertension, raised blood pressure, and importantly a high cholesterol.
There are others such as diabetes and carrying extra weight. The main risk factor that is
often under looked and which we really do need to focus on is the family history or
the genetics of coronary artery disease. So, I see many patients either to treat symptoms
or for screening who’ve got a strong family history of heart attacks or cardiac events
under the age of 60. So, the genetics is really, really important. Angina is classically a stable condition which occurs with exercise. So, patients will describe
that after walking maybe 400 yards or walking uphill or briskly, they develop a discomfort
and then they have to rest. The important feature of a stable symptom, angina, is that
when they rest, the symptom goes within five or ten minutes. A heart attack can be quite
difficult to diagnose, but typically or classically, this occurs at rest. Sometimes in the middle
of the night but lasts longer than five or ten minutes and can make the patient feel
generally unwell with breathlessness or exhaustion. The classic symptom is a well-described tight
band across the chest; which can be a life-threatening condition. Sadly, there are some people who
have a heart attack which is much more difficult to diagnose with rather subtle symptoms of
mild discomfort at rest. And even more difficult, there are some people who have a heart attack
with no discomfort whatsoever. And that’s quite common in the elderly and in diabetic
patients. So those patients who don’t have any discomfort may just feel generally unwell
or feel exhausted or have nausea or feel faint. And in elderly diabetic patients, this is
a common picture. And in those circumstances, heart attacks are frequently missed. A heart
attack is sadly still a very, very common condition. It’s one of the commonest causes
of death in the United Kingdom at this stage. There are 200,000 heart attacks each year
and about 66,000 patients die from a heart attack every year, and maybe 22,000
of those are under the age of 75. So, despite a lot of the progress we’ve got for the treatment
of heart attack which involves opening the artery very quickly using balloons and metal
tubes called stents, despite all of this, sadly there are still a lot of people who
die from heart attacks. And so, detecting coronary disease and giving the prevention
that will help reduce the incidence of heart attacks is probably one of the most crucial
things we do as cardiologists. There are two main aspect of the treatment
of coronary artery disease. The first is the use of medication to reduce the risk of a
heart attack. And that would be aspirin, the use of a tablet called Astatine which lowers
cholesterol, and a Beta Blocker tablet which protects the heart. The next treatment of
coronary artery disease is to open up narrowings using a balloon and a metal tube called a
stent. That’s a procedure which I perform via the radial artery which is the pulse at
the wrist. From there, passing a tube up to the heart to open up the artery and put in
this metal scaffold which helps the blood flow down the heart arteries to relieve all
of the symptoms. That’s treatment for angina, but also an emergency treatment for patients
who are having a heart attack.