Angina is a cardiovascular symptom characterised primarily by chest pain and is caused by insufficient perfusion of heart tissue, also known as ischaemia.
Understanding angina
Angina, also referred to as Angina pectoris, which translates from the original Latin as ‘choking sensation in the chest’ (1), was originally seen to be evidenced in the late 18th century. An English physician of the time, William Heberden, described it as “a disorder of the breast, marked with strong peculiar symptoms… the sense of strangling… those affected with it are seized while they are walking, but the moment they stand still, all this uneasiness vanishes”(2).
In the world of today, angina is now recognised as in itself not a disease but the most common initial symptom of an underlying problem with the heart often as a result of ischaemic heart disease (IHD) (2,3). Worldwide, ischaemic heart disease remains a leading cause of death and disability. Whilst the symptoms of angina may be distressing to the individual experiencing them it is usually not immediately life-threatening; however, it has been shown to significantly increase the future risk of major cardiovascular events such as myocardial infarction (heart attack) and cerebrovascular accident (CVA or stroke) (3,4).
The World Heart Federation estimates that between 30–40,000 people per million in Western countries experience symptoms of angina and yet it has been reported that 43% of angina patients may remain undiagnosed (5). The true prevalence is considered difficult to assess as it is based on many factors including accurate diagnosis, whether patients actively seek medical attention for their symptoms and the availability of accessible and affordable healthcare provision, which may be impacted by issues such as social exclusion or inequality. Taking these factors into account, it is suggested that 3% of the population experience angina symptoms that are sufficiently debilitating to negatively impact on their quality of life (6). The prevalence of angina is reported by some sources to be slightly higher in women, however annual incidence of angina increases with age in all genders. Between the ages of 45–64 years it is considered to have a prevalence of 5–7% in women compared to 4–7% in men. However, by the age of 65–84 years it has increased to 10–12% in women in contrast to 12–14% of men in this age group (6,7).
There are also differences in both prevalence and presentation due to ethnicity. Individuals from African American descent are at higher risk of developing angina than the Caucasian population. In the UK, both men and women of South Asian origins are 1.5 times more likely to be diagnosed with IHD than the population as a whole with these differences being greatest within younger age groups. Angina due to spasm of the coronary vessels is reported to be more common in Japan compared with in Western populations (2,8).
The negative impact of angina on an individual’s life may not be limited to the more apparent risks of increased mortality and morbidity. Angina is associated with a significantly higher incidence of depression and loss of employment(9). Despite medical advances in coronary care, it is anticipated that the number of patients with angina will continue to rise as a result of contributory factors including increasing levels of obesity and metabolic diseases such as diabetes (10).
How does angina work?
Angina is caused when the necessary demand for oxygen and nutrients by the heart cannot be met, particularly on increased exertion, resulting in ischaemia. Ischaemia is defined as insufficient blood circulation to the tissues or an organ of the body as a result of changes to the blood vessels supplying that area. In ischaemic heart disease, this frequently involves the coronary arteries or the microvasculature, the much smaller blood vessels, that branch off the main coronary arteries of the heart (11). Although this is most commonly associated with atherosclerosis (the development of plaques in the endothelium) in the large coronary arteries, angina may also be caused by coronary or microvascular spasm, cardiomyopathy, value disease or high blood pressure, inflammation, metabolic syndrome or anaemia (6).
Typically angina is classified as either stable or unstable. Of these, stable angina is more common and generally episodes will have an obvious trigger, such as exertion or stress with symptoms resolving with rest or medication. However, stable angina has the potential to develop into unstable angina, which is more serious partly owing to its unpredictability, absence of an obvious trigger or resolution, and lack or alleviation from rest. It is encompassed as a form of acute coronary syndrome along with ST elevation myocardial infarction (STEMI) and non-STEMI heart attacks. The pathophysiology of both these conditions usually involves the obstruction of the main coronary arteries; however, unstable angina can be distinguished from a heart attack through blood tests; cardiac markers such as elevated troponin that reflect damage to the heart muscle are detected following heart attack, but not angina (12,13).
Understanding the root
The type of angina a person has along with the symptoms they experience is dependent on the underlying condition that is causing it. This may include;
Coronary artery disease (CAD) or atherosclerosis
In these circumstances the main coronary arteries supplying blood flow to the heart are narrowed by the presence of plaque, reducing oxygen and nutrients to the muscle. On occasion pieces of this plaque may become detached from the wall of the blood vessel causing total or partial blockage of the artery (2).
Coronary microvascular disease
The much smaller arteries, arterioles, that form the microvasculature of the heart are too small to constrict, but damage or the effects of normal ageing may result in them losing the ability to expand when required at times of increased oxygen demand by the heart. The resultant reduction in blood flow in these microvessels may result in microvascular angina (14,15).
Coronary artery spasm
In some cases the protein contained in atherosclerotic plaques may stimulate the vascular wall to contract. This temporary spasm results in the temporary narrowing of the artery subsequently reducing the supply of blood to the heart muscle. Spasm may also be caused by damage to the arteries, however may occur in patients whose coronary arteries appear normal when viewed by angiogram. This cause of angina is described as vasospastic and may present with a variable pattern of symptoms, one of which is sudden onset of extreme fatigue (14,16).
Angina factors
Many factors may increase an individual’s likelihood of developing angina including age, gender, ethnicity, family history of heart disease or genetics. Risk factors including an unhealthy diet, alcohol consumption, recreational drug use and exposure to tobacco smoke, seen to both increase the primary risk of developing angina as well as worsen the severity of symptoms in established cases.
Issues connected to low-income and poverty are associated with a higher likelihood of the incidence and reporting of cardiovascular diseases such as angina (17). Furthermore, research indicates that individuals on lower incomes were demonstrated to have a greater level of stress-related brain activity, which was directly correlated with increased inflammation levels and suggested to contribute to the significantly increased risk of cardiovascular disease of all types in individuals from lower income brackets (18)
Stress has long been acknowledged as a major factor seen to provoke and increase the frequency of angina attacks. Recent research in 2022 indicated there was a direct correlation between stress-related activity in the inferior frontal lobe of the brain with the severity of angina as self-reported by patients (19). Many previous studies of the relationship between stress and cardiovascular diseases, such as angina, have been inconclusive regarding the mechanisms that explain the influence of stress on states of health. However, perceived or actual stress is now believed to initiate responses by body systems including the sympathetic adrenal system (SAS), hypothalamic-pituitary-adrenal (HPA) axis as well as physiological changes in the cardiovascular, endocrine, immune and nervous systems. Cumulative and repeated over-activation of these responses is considered to be a significant debilitating factor in a diversity of chronic health conditions and is suggested as a key contributor to the worsening of angina (20).
Signs and symptoms
- Chest pain
- Pain or discomfort in the neck, jaw, shoulders or arms
- Shortness of breath
- Sweating
- Fatigue
- Upper abdominal discomfort
The National Institute for Health and Care Excellence (NICE) guidance defines the typical presentation of angina as being a sensation of pain or discomfort in the chest, neck, jaw, shoulders or arms that occurs as a result of physical exertion and resolves within about five minutes with either rest or medications, such as glyceryl trinitrate (GTN) (21).
The character of cardiac pain may be described as constricting, heavy, dull or choking and may also be experienced as a sensation of breathlessness with patients often emphasising that it is more of an extreme discomfort than what they would normally associate with pain. Although characteristically precipitated by physical exertion, it may also occur, or be exacerbated by emotion, after eating or in a cold wind. In unstable angina these symptoms may occur with minimal or no exertion and are seen even when an individual is at rest. In particularly susceptible patients, even lying down may provoke the pain of angina due to increased venous return and preload (22,23).
Angina may also present atypically with the absence of any complaint of chest pain in some patients who instead report shortness of breath, increased or excessive sweating, fatigue along with digestive symptoms including upper abdominal discomfort and indigestion thus further complicating prompt diagnosis and appropriate treatment (24).
Herbal solutions
Any chest pain should be taken seriously and the appropriate medical attention sought, particularly if it is the first time such symptoms have been experienced. Angina is a sign of an underlying heart condition and as such is recommended to be treated under the guidance of a healthcare provider such as a GP, alongside a qualified and experienced medical herbalist who will also be able to advise on any potential interaction between herbs and prescribed medications commonly used for the management of angina such as sublingual glyceryl trinitrate (GTN) or beta-blockers such as atenolol, bisoprolol and propranolol (25).
Many herbs have a number of evidenced therapeutic actions that support heart health including being cardiac trophorestorative, cardioprotective, cardiac and vascular tonics, peripheral vasodilators, hypotensive, nervine and antispasmodic (1).
Traditionally herbs such as hawthorn (Crataegus spp.), motherwort (Leonurus cardiaca), limeflower (Tila spp.) and oats (Avena sativa) have all been used for their benefits in promoting healthy cardiovascular function and the management of conditions such as angina (26).
Hawthorn (Crataegus spp.)
Hawthorn is a key herb in the management of angina and is considered to be the closest to a specific for this and many other cardiovascular conditions including hypertension, arteriosclerosis and mild or early congestive heart failure. Its properties include being cardioprotective, antiarrhythmic, antioxidant and a coronary artery vasodilator. Studies have indicated that it may increase coronary perfusion, have positive effects on the contractile ability of the heart and is proven to reduce myocardial demand for oxygen. Further clinical trials have shown no interaction or adverse effects with conventionally prescribed medicines (1,27,28).
Other herbs that may be combined within a herbal prescription for angina include;
Dan shen (Salvia miltiorrhiza)
The cardioprotective, vasodilator and antiplatelet actions of dan shen have been shown in clinical trials to be of benefit in the treatment of angina (27). In TCM, it is considered to be a cooling circulatory stimulant and its effects have been demonstrated to include the vasodilation of the coronary arteries. Furthermore, is has been suggested that it is protective against myocardial ischaemia (1).
Crampbark (Viburnum opulus)
The vasodilating, relaxant and antispasmodic acids of crampbark result in it often being included in herbal formulas involving spasm or tension (1).
Cayenne (Capsicum spp.)
Cayenne is a circulatory stimulant and has been traditionally used to improve the blood supply to the heart as well as in conditions where there is seen to be insufficient blood supply to the peripheral circulation (27,28).
Ginkgo (Ginkgo biloba)
A systemic review in 2015 found evidence to suggest that Ginkgo biloba (ginkgo) demonstrated a statistically significantly effect on relieving angina including overall cardiac improvement, cardiac output and stroke volume. Some of the subjects involved in the trial reported mild adverse effects such as nausea, stomach discomfort and dislike of the bitter taste however none of these were considered severe and all resolved within a short time frame (29).
Adaptogenic herbs may be useful in the treatment of angina due to their ability to increase resilience to stressors.
Siberian ginseng (Eleutherococcus senticosus)
Siberian ginseng is a mild, non-stimulating adaptogen which clinical studies have shown to help relieve angina particularly when this is triggered by stress. It has a relaxing effect on the arteries and increases the heart’s resistance to oxygen deprivation. Additionally, Siberian ginseng has also demonstrated antihyperlipidaemic effects, helping to counter the risks posed by high cholesterol in the development of angina and other cardiovascular related conditions (1,30).
Reishi (Ganoderma lucidum)
Reishi is a medicinal mushroom considered to be a mild calming adaptogen with anti-inflammatory, immune amphoteric, nervine, antihypercholesterolaemic, antioxidant and cardiac tonic properties. It has been demonstrated in clinical studies to improve cardiac function and reduce the pain of angina (30).
Holistic solutions
It is said that diet, sufficient good quality sleep and rest, exercise and fresh air, efficient digestion and elimination combined with balanced relationships with others and the world around us and emotional equilibrium, are the foundations of good health — all of which are acknowledged as being beneficial for the prevention or management of cardiovascular conditions such as angina (31).
Many eating patterns such as the Mediterranean diet or the DASH (Dietary Approaches to stop Hypertension) eating pattern have been demonstrated to be of value to cardiovascular health (32,33,34). Consumption of a wide range of vegetables and other fibre rich foods, such as legumes or wholegrains, is encouraged along with healthy fats such as those contained in nuts and seeds or oils such as olive, hemp and linseed. Highly processed foods and excessive sugar should be avoided or limited as far as possible (1,27).
Some sources advise adopting a protocol that includes daily intake of green leafy vegetables, beetroot, cocoa or chocolate of 85% or above, dark berries such as blueberries, bilberries or blackberries, ½–1 clove of raw garlic and the inclusion of herbs and spices in cooking especially turmeric, ginger and green tea. This may be of particular benefit to individuals with damage affecting the microcirculation, such as in microvascular angina (35). Additionally some sources recommend supplements such as magnesium, coenzyme Q10 and the equivalent of 4 g of fresh garlic daily as a capsule (1). Alcohol intake is best kept light, with binge drinking, smoking tobacco or the use of recreational drugs avoided (1,27).
A healthy weight and moderate physical activity enhances many realms of life including positive mood and nourishing sleep at night and is seen to be of particular benefit to cardiovascular health. A lifestyle or work pattern that reduces the opportunity for sleep, involves long intervals of sitting, limits the amount of time available to be spent outdoors in the fresh air and sunlight or involves high stress is not conducive to good cardiovascular health (2).
The benefits of sufficient good quality sleep, and the risks of not doing, have been demonstrated by numerous studies concluding that short sleep of less than six hours was associated with a significantly higher risk of experiencing a cardiovascular or cardiac event than individuals who were getting between 7–8 hours every night, suggesting that unhealthy sleep does indeed contribute to an unhealthy heart (36).
Stress is increasingly seen as endemic in today’s fast-paced technological culture and, a continued demand on the endocrine and nervous systems (30). Aiming to achieve work–life balance, spending time outside in nature, having support systems in place along with practices such as yoga, meditation or mindfulness are all evidenced as being beneficial to maintaining healthy levels of stress in our lives.
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