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Angina

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Also indexed as: Angina pectoris, Breast Pain, Stenocardia

Illustration

Ease the pain in your chest by paying closer attention to your coronary arteries. According to research or other evidence, the following self-care steps may help you prevent or repair damage:

What you need to know

  • Understand the warning signs
  • Seek immediate medical attention if you develop symptoms of new or worsening chest pain
  • Add L-carnitine to your daily routine
  • Take 1 gram of this nutritional supplement two or three times a day to improve heart function and ease symptoms of angina
  • Mix in some magnesium
  • Take 200 to 300 mg of this mineral supplement twice a day to reduce the risk of exercise-induced chest pain
  • Get to know N-acetylcysteine
  • With a healthcare provider’s supervision, take 600 mg of this nutritional supplement three times a day to improve the effects of nitroglycerin
  • Make an appointment with an acupuncturist
  • Visit a qualified practitioner to see if treatments reduce angina attacks and the need for nitroglycerin, and improve exercise tolerance

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full angina article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About angina

Angina, or angina pectoris, is chest pain due either to reduced blood flow to the heart or to certain other abnormalities of heart function.

Hardening (atherosclerosis) of the coronary arteries that feed the heart is usually the underlying problem. Spasms of the coronary arteries may also cause angina.

There are three main types of angina. The first is called stable angina. This type of chest pain comes on during exercise and is both common and predictable. Stable angina is most often associated with atherosclerosis. A second type, called variant angina, can occur at rest or during exercise. This type is primarily due to sudden coronary artery spasm, though atherosclerosis may also be a component. The third, most severe type is called unstable angina. This angina occurs with no predictability and can quickly lead to a heart attack. Anyone with significant, new chest pain or a worsening of previously mild angina must seek medical care immediately.

It is important for treatment and prevention of angina (and for overall health) to learn more about atherosclerosis

Product ratings for angina

Science Ratings Nutritional Supplements Herbs
3Stars

Coenzyme Q10

L-carnitine

  
2Stars

Arginine

Magnesium

N-acetyl cysteine

Ribose

Vitamin E

Hawthorn
1Star

Bromelain

Fish oil (EPA/DHA)

Khella

Kudzu
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

Common symptoms of angina include a squeezing pressure, heaviness, ache, or burning pain (like indigestion) in the chest that occur for 5 to 30 minutes at a time. These sensations are usually felt behind the breastbone but may also be felt in the jaw, neck, arms, back, or upper abdomen. Some people may also have difficulty in breathing or may become pale and sweaty. Symptoms of angina usually appear during physical exertion, after heavy meals, and with heightened emotional states, such as anger, frustration, shock, and excitement.

Medical options

Aspirin (Bayer Low Adult Strength, Ecotrin Adult Low Strength) reduces the risk of death or nonfatal heart attack in patients with a previous history of heart attack or unstable angina.

Many classes of prescription drugs are use to treat angina. Calcium channel blocking agents, such as verapamil (Calan, Verelan), diltiazem (Cardizem, Tiazac), and amlodipine (Norvasc) are commonly prescribed. Nitrates, such as nitroglycerin, are available as tablets to be placed under the tongue (Nitrostat), applied topically as an ointment (Nitro-Bid), or as a patch to be applied to the skin (Nitro-Dur, Transderm-Nitro). Other nitrates include isosorbide dinitrate (Isordil) and isosorbide mononitrate (ISMO, Imdur). The last major category often used to treat angina is the beta-adrenergic blocking agents, such as atenolol (Tenormin), metoprolol (Lopressor, Toprol XL), and propranolol (Inderal).

Smoking is discouraged, since nicotine prevents proper blood flow. In advanced stages, surgical repair of the blood vessels in the heart may be recommended. Treatment may be directed toward underlying medical conditions, such as high cholesterol, high blood pressure, anemia, hyperthyroidism, obesity, or lung disease.

Dietary changes that may be helpful

Coffee should probably be avoided. Drinking five or more cups of coffee per day has been shown to increase the risk of angina, although effects of different forms of coffee on angina are unclear.1

Lifestyle changes that may be helpful

Cigarette smoking causes damage to the coronary arteries and, in this way, can contribute to angina. It is critical for anyone with angina who smokes to stop smoking. Smoking has also been shown to reduce the effectiveness of treatments for angina.2 Secondhand smoke should be avoided as well.3

Increasing physical exercise has been clearly demonstrated to reduce symptoms of angina, as well as to relieve its underlying causes. One study found that intense exercise for ten minutes daily was as effective as beta-blocker drugs in a group of patients with angina.4 Anyone with angina or any other heart condition, as well as anyone over the age of 40, should consult a doctor before beginning an exercise program.

Vitamins that may be helpful

L-carnitine is an amino acid needed to transport fats into the mitochondria (the place in the cell where fats are turned into energy). Adequate energy production is essential for normal heart function. Several studies using 1 gram of L-carnitine two to three times per day showed an improvement in heart function and a reduction in symptoms of angina.5 6 7 Coenzyme Q10 also contributes to the energy-making mechanisms of the heart. Angina patients given 150 mg of coenzyme Q10 each day have experienced greater ability to exercise without experiencing chest pain.8 This has been confirmed in independent investigations.9

Low levels of antioxidant vitamins in the blood, particularly vitamin E, are associated with greater rates of angina.10 This is true even when smoking and other risk factors for angina are taken into account. Early short-term studies using 300 IU (International Units) per day of vitamin E could not find a beneficial action on angina.11 A later study supplementing small amounts of vitamin E (50 IU per day) for longer periods of time showed a minor benefit in people suffering angina.12 Those affected by variant angina have been found to have the greatest deficiency of vitamin E compared with other angina patients.13

Nitroglycerin and similar drugs cause dilation of arteries by interacting with nitric oxide, a potent stimulus for dilation. Nitric oxide is made from arginine, a common amino acid. Blood cells in people with angina are known to make insufficient nitric oxide,14 which may in part be due to abnormalities of arginine metabolism. Taking 2 grams of arginine three times per day for as little as three days has improved the ability of angina sufferers to exercise.15 Seven of ten people with severe angina improved dramatically after taking 9 grams of arginine per day for three months in an uncontrolled study.16 Detailed studies have investigated the mechanism of arginine and have proven it operates by stimulating blood vessel dilation.17

N-acetyl cysteine (NAC) may improve the effects of nitroglycerin in people with angina.18 People with unstable angina who took 600 mg of NAC three times daily in combination with a nitroglycerin transdermal (skin) patch for four months had significantly lower rates of subsequent heart attacks than did people who used either therapy alone or placebo.19

Magnesium deficiency may be a contributing factor for spasms that occur in coronary arteries, particularly in variant angina.20 21 While studies have used injected magnesium to stop such attacks effectively,22 23 it is unclear whether oral magnesium would be effective in preventing or treating blood vessel spasms. One double-blind study of patients with exercise-induced angina, however, showed that oral magnesium supplementation (365 mg twice a day) for 6 months significantly reduced the incidence of exercise-induced chest pain, compared with a placebo.24

In a controlled study, men with severe coronary heart disease were given an exercise test, after which they took either 15 grams of ribose or a placebo four times daily for three days. Compared with the initial test, men taking ribose were able to exercise significantly longer before experiencing chest pain and before abnormalities appeared on their electrocardiogram (ECG), but only the ECG changes were significantly improved compared with those in the placebo group.25 Sports supplement manufacturers recommend 1 to 10 grams per day of ribose, while heart disease patients and people with rare enzyme deficiencies have been given up to 60 grams per day.

Bromelain has been reported in a preliminary study to relieve angina. In that study, 600 people with cancer were receiving bromelain (400 to 1,000 mg per day). Fourteen of those individuals had been suffering from angina. In all 14 cases, the angina disappeared within 4 to 90 days after starting bromelain.26 However, as there was no control group in the study, the possibility of a placebo effect cannot be ruled out. Bromelain is known to prevent excessive stickiness of blood platelets,27 which is believed to be one of the triggering factors for angina.

Fish oil, which contains the fatty acids known as EPA and DHA, has been studied in the treatment of angina. In some studies, enough fish oil to provide a total of about 3 grams of EPA and 2 grams of DHA has reduced chest pain as well as the need for nitroglycerin;28 other investigators could not confirm these findings.29 People who take fish oil may also need to take vitamin E to protect the oil from undergoing potentially damaging oxidation in the body.30 It is not known how much vitamin E is needed to prevent such oxidation; the amount required would presumably depend on the amount of fish oil used. In one study, 300 IU of vitamin E per day prevented oxidation damage in individuals taking 6 grams of fish oil per day.31

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

The fruit, leaves, and flowers of the hawthorn tree contain flavonoids, including oligomeric procyanidins, which may protect blood vessels from damage. A 60 mg hawthorn extract containing 18.75% oligomeric procyanidins taken three times per day improved heart function and exercise tolerance in angina patients in a small clinical trial.32

Khella is an African plant that contains spasm-relieving compounds, including khellin. Purified khellin was shown to be helpful in relieving angina in preliminary studies in the 1940s and 1950s.33 34 It is unknown whether the whole herb would have the same effects. Due to the potential side effects of khella, people with angina should consult with a physician knowledgeable in botanical medicine before taking it.

Kudzu is used in modern Chinese medicine as a treatment for angina. Standardized root tablets (10 mg tablet is equivalent to 1.5 grams of the crude root) are sometimes used for angina pectoris in the amount of 30 to 120 mg per day.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

Holistic approaches that may be helpful

People suffering from angina may find acupuncture to reduce symptoms, the need for medication, and even the need for invasive surgery. While some studies of acupuncture treatment for angina found no benefit,35 others have demonstrated positive results. An uncontrolled trial of 49 angina patients found that acupuncture resulted in 58% less nitroglycerin use and a 38% decrease in the number of angina attacks.36 In another study, 69 patients suffering with severe angina were treated with a combination of acupuncture, shiatsu (acupressure), and lifestyle changes. The results were compared to patients with severe angina treated with coronary artery bypass grafting (CABG). The incidence of heart attack and death was 21% among those treated with CABG and 7% among those treated with the combined therapy including acupuncture. In addition, 61% of those treated with the combination therapy, because of their improved health, postponed any further invasive treatment.37 In a single-blind study of 26 patients, a reduction in angina attack rate and nitroglycerin use, as well as an improvement in exercise performance, occurred in the treatment group compared to a sham (fake) acupuncture group.38 Findings from a controlled trial comparing acupuncture treatment (three treatments per week for four weeks) to placebo tablets support these results, demonstrating a reduction in the number of angina attacks, improved exercise performance, and corresponding improvements in ECG readings.39

Transcendental meditation (20 minutes twice daily of silently chanting a mantra with eyes closed) was found in a small controlled trial to reduce angina-like chest pain and to normalize electrocardiograms (ECGs) in patients with cardiac syndrome X, a form of angina in people with otherwise normal coronary arteries.40 While these patients did not have angina in the classic sense, their chest pain was thought to result from anxiety, which may reduce blood flow to the heart, and their ECGs resembled those of classic angina patients. It is not yet known whether transcendental meditation would have the same effect on patients with angina pectoris.

Evidence from preliminary41 42 43 and controlled44 studies suggests that there may be a relationship between the presence of heart disease and changes to the muscles and joints of the spine that are detectable by practitioners of spinal manipulation. In a double-blind study, patients with proven coronary disease were more likely to have specific changes in their spine detectable by palpating or “feeling” their backs than were subjects who were healthy.45 Controlled studies have demonstrated that manipulation of the joints in the middle of the neck can increase heart rate, respiratory rate, and blood pressure,46 47 but manipulation of the lower neck does not appear to have the same effect.48 Despite these intriguing findings, there is no research investigating whether manipulation reduces angina symptoms or otherwise benefits the heart and cardiovascular system.

References:

1. LaCroix AZ, Mead LA, Liang KY, et al. Coffee consumption and the incidence of coronary heart disease. N Engl J Med 1986;315:977–82.

2. Deanfield J, Wright C, Krikler S, et al. Cigarette smoking and the treatment of angina with propranolol, atenolol, and nifedipine. N Engl J Med 1984;310:951–4.

3. Glantz SA, Parmley WW. Passive smoking and heart disease. JAMA 1995;273:1047–53 [review].

4. Todd IC, Ballantyne D. Antianginal efficacy of exercise training: A comparison with beta blockade. Br Heart J 1990;64:14–9.

5. Cherchi A, Lai C, Angelino F, et al. Effects of L-carnitine on exercise tolerance in chronic stable angina: A multicenter, double-blind, randomized, placebo-controlled crossover study. Int J Clin Pharmacol Ther Toxicol 1985;23:569–72.

6. Canale C, Terrachini V, Biagini A, et al. Bicycle ergometer and echocardiographic study in healthy subjects and patients with angina pectoris after administration of L-carnitine: Semiautomatic computerized analysis of M-mode tracing. Int J Clin Pharmacol Ther Toxicol 1988;26:221–4.

7. Cacciatore L, Cerio R, et al. The therapeutic effect of L-carnitine in patients with exercise-induced stable angina: A controlled study. Drugs Exp Clin Res 1991;17:225–35.

8. Kamikawa T, Kobayashi A, Yamashita T, et al. Effects of coenzyme Q10 on exercise tolerance in chronic stable angina pectoris. Am J Cardiol 1985;56:247.

9. Mortensen SA. Perspectives on therapy of cardiovascular diseases with coenzyme Q10 (ubiquinone). Clin Investig 1993;71:S116–23 [review].

10. Riemersma RA, Wood DA, Macintyre CC, et al. Risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene. Lancet 1991;337:1–5.

11. Rinzler SH, Bakst H, Benjamin ZH, et al. Failure of alpha-tocopherol to influence chest pain in patients with heart disease. Circulation 1950;1:288–90.

12. Rapola RM, Virtamo J, Haukka JK, et al. Effect of vitamin E and beta carotene on the incidence of angina pectoris. A randomized, double-blind, controlled trial. JAMA 1996;275:693–8.

13. Miwa K, Miyagi Y, Igawa A, et al. Vitamin E deficiency in variant angina. Circulation 1996;94:14–8.

14. Mollace V, Romeo F, Martuscelli E, et al. Low formation of nitric oxide in polymorphonuclear cells in unstable angina pectoris. Am J Cardiol 1994;74:65–8.

15. Ceremuzynski L, Chamiec T, Herbaczynska-Cedro K. Effect of supplemental oral L-arginine on exercise capacity in patients with stable angina pectoris. Am J Cardiol 1997;80:331–3.

16. Blum A, Porat R, Rosenschein U, et al. Clinical and inflammatory effects of dietary L-arginine in patients with intractable angina pectoris. Am J Cardiol 1999;83:1488–90.

17. Egashira K, Hirooka Y, Kuga T, et al. Effects of L-arginine supplementation on endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary arteriograms. Circulation 1996;94:130–4.

18. Marchetti G, Lodola E, Licciardello L, Colombo A. Use of N-acetylcysteine in the management of coronary artery diseases. Cardiologia 1999;44:633–7.

19. Ardissino D, Merlini PA, Savonitto S, et al. Effect of transdermal nitroglycerin or N-acetylcysteine, or both, in the long-term treatment of unstable angina pectoris. J Am Coll Cardiol 1997;29:941–7.

20. Turlapaty P, Altura B. Magnesium deficiency produces spasms of coronary arteries: Relationship to etiology of sudden death ischemic heart disease. Science 1980;208:199–200.

21. Goto K, Yasue H, Okumura K, et al. Magnesium deficiency detected by intravenous loading test in variant angina pectoris. Am J Cardiol 1990;65:709–12.

22. Cohen L, Kitzes R. Magnesium sulfate in the treatment of variant angina. Magnesium 1984;3:46–9.

23. Cohen L, Kitzes R. Prompt termination and/or prevention of cold-pressor-stimulus-induced vasoconstriction of different vascular beds by magnesium sulfate in patients with Prinzmetal’s angina. Magnesium 1986;5:144–9.

24. Shechter M, Bairey Merz CN, et al. Effects of oral magnesium therapy on exercise tolerance, exercise-induced chest pain, and quality of life in patients with coronary artery disease. Am J Cardiol 2003;91:517–21.

25. Pliml W, von Arnim T, Stablein A, et al. Effects of ribose on exercise-induced ischemia in stable coronary artery disease. Lancet 1992;340:507–10.

26. Nieper H. Effect of bromelain on coronary heart diseases and angina pectoris. J Int Acad Prev Med 1976;3(2):62–3.

27. Heinicke R, van der Wal L, Yokoyama M. Effect of bromelain (Ananase) on human platelet aggregation. Experientia 1972;28:844–5.

28. Saynor R, Verel D, Gillott T. The long-term effect of dietary supplementation with fish lipid concentrate on serum lipids, bleeding time, platelets and angina. Atherosclerosis 1984;50:3–10.

29. Mehta JL, Lopez LM, Lawson D, et al. Dietary supplementation with omega-3 polyunsaturated fatty acids in patients with stable coronary heart disease. Effects on indices of platelet and neutrophil function and exercise performance. Am J Med 1988;84:45–52.

30. Wander RC, Du SH, Ketchum SO, Rowe KE. Alpha-tocopherol influences in vivo indices of lipid peroxidation in postmenopausal women given fish oil. J Nutr 1996;126:643–52.

31. Oostenbrug GS, Mensink RP, Hornstra G. A moderate in vivo vitamin E supplement counteracts the fish-oil-induced increase in in vitro oxidation of human low-density lipoproteins. Am J Clin Nutr 1993;57:827S.

32. Hanack T, Bruckel MH. The treatment of mild stable forms of angina pectoris using Crataegutt® novo. Therapiewoche 1983;33:4331–3 [in German].

33. Conn JJ, Kisane RW, Koons RA, Clark TE. Treatment of angina pectoris with khellin. Ann Intern Med 1952;36:1173–8.

34. Osher HL, Katz KH, Wagner DJ. Khellin in the treatment of angina pectoris. New Engl J Med 1951;244:315–21.

35. Ballegaard S, Pedersen F, Pietersen A, et al. Effects of acupuncture in moderate, stable angina pectoris: a controlled study. J Intern Med 1990;227:25–30.

36. Ballegaard S, Karpatschoff B, Holck JA, et al. Acupuncture in angina pectoris: do psychosocial and neurophysiological factors relate to the effect? Acupunct Electrother Res 1995;20:101–16.

37. Ballegaard S, Norrelund S, Smith DF. Cost-benefit of combined use of acupuncture, Shiatsu and lifestyle adjustment for treatment of patients with severe angina pectoris. Acupunct Electrother Res 1996;21:187–97.

38. Ballegaard S, Jensen G, Pedersen F, Nissen VH. Acupuncture in severe, stable angina pectoris: a randomized trial. Acta Med Scand 1986;220:307–13.

39. Richter A, Herlitz J, Hjalmarson A. Effect of acupuncture in patients with angina pectoris. Eur Heart J 1991;12:175–8.

40. Cunningham D, Brown S, Kaski JC. Effects of transcendental meditation on symptoms and electrocardiographic changes in patients with Cardiac Syndrome X. Am J of Cardiology 2000;85:653–5.

41. Burchett GC. Somatic manifestations of ischemic heart disease. Osteopathic Annals 1976;4:373–5.

42. Nicholas AS, DeBias, et al. A somatic component to myocardial infarction. Br Med J 1985;291:13–7.

43. Beal MC, Kleiber GE. Somatic dysfunction as a predictor of coronary artery disease. J Am Osteopath Assoc 1985; 85:70–5.

44. Beal MC Palpatory testing for somatic dysfunction in patients with cardiovascular disease. J Am Osteopath Assoc 1983;82:73–82.

45. Cox JM, Gorbis S, Dick LM, et al. Palpable musculoskeletal findings in coronary artery disease: results of a double blind study. J Am Osteopath Assoc 1983;82(11)832–6.

46. McGuiness J, Vicenzino B, Wright A. The influence of a cervical mobilization technique on respiratory and cardiovascular function. Man Ther 1997;2:216–20.

47. Vicenzino B, Cartwright T, Collins D. Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Man Ther 1998 3(2):67–71.

48. Nansel D, Jansen R, Cremata E, et al. Effects of cervical adjustments on lateral-flexion passive end-range asymmetry and on blood pressure, heart rate and plasma catecholamine levels. J Manip Physiol Ther 1991;14:450–6.
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