What is angina and why isn’t it the same for everybody?
Angina Pectoris, simply stated, is discomfort of the chest caused by lack of blood flow to heart muscle. There is a comprehensive article at Mayo Clinic which discusses the subject in great detail. For the basic, standard type of angina, it’s the place to go. What I’m going to talk about here is what people who do not have basic, standard angina experience. This subject is much more complex than most people (even health care providers) realize. Before my heart attack, I had no idea about any of this despite years of experience caring for cardiac patients in the hospital. Really, I think you have to experience it to truly understand though some doctors (or other health care providers) who have made a point of studying newer concepts in cardiology such as endothelial dysfunction, coronary microvascular disease, and coronary artery spasm are able to empathize.
Here is a picture of typical heart pain distribution on the front of the body. The dark red shows the most typical places people notice this pain. The pink shows other areas this pain may be felt. Pain may also be felt between the shoulder blades and further up the neck and into the jaw. This is a pretty fair representation, but don’t take it for absolute gospel. I saw a truly beautiful picture in an anatomy picture book my sister has that seemed more accurate. Unfortunately, I cannot remember the title so we’ll use this one.
Just like any other pain, each person’s experience is unique and can be difficult to put into words. Visceral pain (originating in internal organs) can be even more difficult to pin down. It tends to be elusive, sometimes seeming to shift from place to place or be in a general area but hard to point to. When I had my heart attack, I felt severe pain in the middle of my chest, milder pain in both armpits, and some numbness and tingling in my neck up to my chin and in both hands. My day to day angina is much milder and tends to start in a spot just to the left of my sternum (breast bone). Sometimes I feel it in my back to the left of the spine. Sometimes I feel twinges in my left armpit or elbow. It has taken a year of observation to fully realize these pains were coming from my heart. Like anything else, you have to learn through experience over time.
The education materials I received in the hospital described standard angina symptoms. These include pain or discomfort in the areas described above, triggered by exertion, resolving with rest and nitroglycerin, lasting an average of 1 to 15 minutes. I received the standard instruction to call EMS if pain lasted longer than that. Chest pain at rest may indicate unstable angina, a precursor to heart attack.
What I actually experienced was brief flashes of pain in my left chest if I felt strong emotion. As time went on, it seemed like my symptoms matched the descriptions in pamphlets, medical references, and from my doctor less and less and lasted much longer than 15 minutes. What I’ve come to realize is the information I was able to gather was more relevant to the gentleman pictured at right than to me, a 44 year old woman with coronary artery spasms and probable microvascular disease.
The issue here is that most of the research on heart disease done in the last few decades was done on middle aged men. Men tend to have earlier onset of atherosclerotic lesions (plaque) in the large coronary arteries than women do. They tend to have the symptoms that we have all heard about for heart attack. In recent years there has been more publicity of women’s “different” symptoms such as epigastric pain (over the stomach) or having predominantly nausea as a presenting symptom. These had not been previously recognized because only men were studied. Women also have a higher incidence of coronary artery spasm and spontaneous coronary artery dissection than men. These have been considered very rare conditions, but I suspect they have been underdiagnosed from the number of women I have met who have these problems. Until recently, little study has been done on these conditions.
We have made tremendous strides in medicine in the last century through use of the scientific method. Merriam-Webster dictionary defines scientific method as “principles and procedures for the systematic pursuit of knowledge involving the recognition and formulation of a problem, the collection of data through observation and experiment, and the formulation and testing of hypotheses.” One limitation of this practice that I have encountered is a tendency for doctors to deny the existence of phenomena which have not been rigorously proven in research even when slapped in the face with them. Rather than use critical thinking skills and consider the possibility that they are seeing something that has not been adequately researched, they tell patients it isn’t happening. Let me be clear, I am not saying that all doctors do this. I absolutely believe in the value of rigorous scientific study. I do, however, believe that we have to have the wisdom to admit we do not understand everything.
Coronary microvascular disease is a recent concept. There has been little research in this area, relative to disease of the large coronary arteries, because we just don’t have readily accessible technology to study these vessels. We can’t see them in a living organism. I have seen research articles discussing “filling deficits” in small vessels detected with MRI or PET scan, but these tests are not readily available in most places. Thus microvascular disease is usually treated empirically, that is the doctor thinks it is likely that it is there so uses treatments theorized to help this condition. This means there is quite a bit of trial and error involved. It can be a frustrating situation for both the doctor and the patient.
Angina caused by coronary artery spasm or microvascular disease is just not as well described in the literature as angina from mechanical blockage of coronary arteries. I mainly have to go by my own experience and that of the other women I have met who have been diagnosed with coronary microvascular disease. I have had several heart catheterizations verifying the absence of lesions in the large vessels since my heart attack and placement of stents in my LAD (left anterior descending artery). We know I have vasospasm as it has been seen in the cath lab. It has been a long process of elimination to figure things out.
So, after all this build up, what does this kind of angina feel like? What makes it different? The main thing I notice is the prolonged nature of episodes. Sometimes I have low level tightness or aching in my chest, back, and/or arm for several hours. The sensation is reduced by taking nitroglycerin, but either doesn’t go away completely or comes back as the nitro wears off in a few minutes or an hour or so. I also do not display EKG changes. People with severe spasm of large arteries will have changes on EKG similar to a heart attack. If the spasm is less intense or the ischemia is not affecting the full thickness of the heart wall, an EKG may look normal.
There are triggers that I know provoke angina for me. Strong emotion, like fear or surprise or anger, can trigger the chest pain. Exertion, fatigue, and stress also cause episodes. Like living with asthma, those of us with chronic angina have to learn what our usual triggers are and avoid them if possible. We have to carry our fast relief medication, sublingual nitroglycerin tablets or spray. We take our long acting medications daily, in my case a calcium channel blocker (diltiazem XT) and a long acting nitrate (Imdur). I have to rest a lot. I have to be careful about exertion and exercise and sometimes pre-treat with nitroglycerin.
Prinzmetal’s Angina, a type of coronary arterial spasm, is said to occur more often at rest and at night. I rarely have episodes at night myself.
Those of us with microvascular disease often experience delayed angina minutes to hours after activity. There have been times I thought I was tolerating my exercise well only to come home and notice heaviness and pain 20 minutes later. I had a severe episode a couple hours after my last treadmill stress test and nuclear perfusion scan. I only felt mild pressure during the test.
The lack of a strong body of research on microvascular and vasospastic angina make it challenging living with this disease. We encounter confusion and sometimes outright disbelief in many health care providers. We receive educational materials that don’t acknowledge and sometimes contradict our real life experience. Standard testing like stress tests seem to miss our symptoms. It was not until I met other women with the type of heart disease I have that I received validation of my experience and true support. I met these women through the WomenHeart group on Inspire.com.
Chronic angina is challenging to live with at times, but is definitely a problem that can be managed with proper treatment. Seeking support from others with this disease helps us feel less isolated. If you would like to share your story, please leave a comment. Also if there is something important that I left out, let me know. It’s a complex subject with many facets.