Angina

What is Angina?

Angina is chest pain or discomfort caused by a temporary mismatch between the heart muscle's need for oxygen and the blood supply it receives.^{[1, 2]} It is a symptom of heart disease, most often coronary artery disease, and it needs evaluation by a physician. This page covers stable (predictable) angina and explains why unstable angina is an emergency.

Common symptoms

Typical angina is pressure, squeezing or heaviness in the chest that comes with exertion or stress and eases with rest or nitroglycerin.^[2] It can spread to the arm, jaw, neck, back or shoulder, and some people feel breathless, sweaty or nauseated instead of having obvious pain.

Stable angina follows a pattern. Unstable angina is new, more frequent, more severe or occurs at rest, and it is part of acute coronary syndrome, which also includes heart attack.^{[1, 3]}

Causes and risk factors

Most angina comes from atherosclerosis, in which plaque narrows the coronary arteries and limits blood flow when the heart works harder.^[1] Spasm of a coronary artery or dysfunction of the smallest blood vessels can cause the same imbalance, even when the large arteries are open.^{[1, 4]}

Risk factors include older age, high blood pressure, high cholesterol, diabetes, smoking and a family history of heart disease.^[1]

How it is diagnosed and treated conventionally

Angina is diagnosed by a physician using your history, an examination, an electrocardiogram and tests such as stress testing or coronary CT angiography.^[2] Chest pain should never be self-diagnosed.

Treatment has two goals: preventing heart attacks and death, and relieving symptoms. Lifestyle changes and preventive medicines such as lipid-lowering drugs and antiplatelet drugs reduce risk, while beta-blockers, nitrates or calcium channel blockers relieve angina.^{[2, 5]} Stenting or bypass surgery is considered mainly when symptoms continue despite medication.^[2] Smoking cessation, weight management, a Mediterranean-style diet and exercise therapy, often in cardiac rehabilitation, are part of care.^[4]

Why Angina calls for a whole-person approach

Angina is driven mainly by the condition of the coronary arteries, and that is treated by your cardiology team. Other factors affect how much angina a person feels and how well they cope with it.

Stress, mood, sleep and lifestyle are reasonable targets for supportive care. They sit alongside medical treatment and do not replace it.

Lifestyle and risk factors

Blood pressure, cholesterol, diabetes, smoking and activity level all shape coronary risk, which is why guidelines place lifestyle measures and preventive medicines at the center of care.^{[4, 5]}

Anxiety and depression

Anxiety and depression are common in people with chronic stable angina. A review of seven trials with 893 participants found that acupuncture added to standard care was linked to lower anxiety and depression scores. The quality of the evidence ranged from low to moderate.^[6]

Brain and pain processing

Angina is a pain syndrome as well as a heart problem. A small imaging study found that people with chronic stable angina had different resting activity in several brain regions than healthy people, and that acupuncture was associated with changes in some of those regions. This is early research and it cannot show how acupuncture works in practice.^[7]

Acupuncture as supportive care in Angina

What the research shows

Acupuncture, added to standard antianginal medicine, may reduce how often angina attacks occur. The best evidence is a trial of 404 people in five Chinese centers, all of whom kept taking guideline-based angina medicines. Those given 12 sessions of acupuncture on points on the heart-related meridian had fewer attacks at 16 weeks than those given acupuncture on other meridians, sham acupuncture or no acupuncture.^[8]

Reviews of smaller trials are more cautious. A 2019 meta-analysis of 12 trials found better symptom and electrocardiogram results when acupuncture was used with or without medicine, compared with medicine alone. It also found no clear difference in nitroglycerin use between acupuncture alone and medicine alone.^[9] A 2015 review of 25 trials concluded the evidence was very low quality: acupuncture plus medicine did better than medicine alone, but acupuncture alone did not beat antianginal drugs.^[10] A 2023 meta-analysis of seven trials with 1,042 patients found electroacupuncture combined with drugs improved symptoms more than drugs alone, with publication bias likely and few high-quality studies.^[11]

Nearly all of this research was done in China, and none of it shows that acupuncture lowers the risk of heart attack or death.

How acupuncture may work

How acupuncture might ease angina is not known. One proposal is that it changes how the brain processes the pain signal. A small imaging study of people with chronic stable angina found that acupuncture was associated with changes in activity in the calcarine region of the visual cortex and in its connections with several pain-related brain areas.^[7] These are proposed explanations, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. The main trial gave 12 sessions over 4 weeks, three times a week.^[8] A course usually involves several visits with reassessment. Acupuncture is only appropriate after a physician has evaluated your chest pain and your heart condition is being managed.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners or antiplatelet drugs, are pregnant, or have a pacemaker or implanted defibrillator (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Angina

The Ayurvedic view

Ayurveda relates heart pain to a disorder of the heart region and to imbalance of Vata, Pitta and Kapha, described by the classical term Hridroga. These are traditional categories for choosing care, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally focuses on:

• Diet and daily routine, such as regular meals, steady sleep and gentle activity
• Stress-reducing practices, used only as an addition to your cardiac rehabilitation advice
• Herbs, most notably arjuna (Terminalia arjuna) bark, prescribed individually^[13]

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty. They are also not appropriate for people with unstable angina or a recent heart event.

What the research shows

The research on Ayurveda for angina is limited. A systematic review of studies of Terminalia arjuna in chronic stable angina found poor methodological quality. It found no significant difference from control treatment in the outcomes it could pool and concluded the evidence was insufficient for or against its use.^[13]

Yoga, a related Indian practice, has also been studied. A review of seven trials in heart disease found very low-quality evidence that yoga reduced angina episodes and low-quality evidence for fewer cardiac risk factors, and it did not show an effect on death.^[14] Whether this applies to your own heart condition is a question for your cardiologist.

Herbal medicine as supportive care in Angina

Herbs and formulas that have been studied

Chinese medicine uses many herbal products for angina, mostly in China as patent medicines. Studied examples include Danshen (Salvia miltiorrhiza) dripping pills and Suxiao Jiuxin Wan.^{[15, 16]} Terminalia arjuna is the main Ayurvedic herb studied.^[13]

What the research shows

The evidence is limited: the trials were mostly published in China, often compare against one older drug, and the reviews call for better-designed studies. A review of 60 Chinese trials with 6,931 participants found Danshen dripping pill to be more effective than isosorbide dinitrate for symptoms and electrocardiogram changes. The authors called for larger, higher-quality studies.^[15] A Cochrane review of 15 trials found weak evidence that Suxiao Jiuxin Wan was effective, with poor methodological quality in the included studies.^[16]

These are not proof that an herb can replace or add to your cardiac medicines. Anyone with angina should keep taking prescribed antianginal and preventive medicines.

Safety and herb-drug interactions

Heart patients take medicines that herbs can affect. Reviews report stronger blood thinning or bleeding when Danshen, ginkgo or garlic were taken with warfarin, and bleeding when ginkgo was taken with aspirin. In addition, a systematic review found many herbs and supplements can raise warfarin's effect.^{[17, 18]} Tell us about every medicine you take, especially blood thinners, antiplatelet drugs, blood pressure drugs and nitrates.

Licorice deserves a specific caution: a meta-analysis of 18 studies found that regular intake of products containing glycyrrhizic acid raised blood pressure and lowered potassium, which is of particular concern in people with heart disease.^[19] About one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic, so herbs should come from tested sources.^[20] Tell us if you are pregnant or breastfeeding or have liver or kidney disease. A herbal preparation applied to the skin through transdermal medication therapy has not been studied for angina, and we make no claim for it.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes angina as chest bi, a blockage of qi and blood flow in the chest, often called blood stasis. The biological research that has been done on acupuncture in angina looks at how the brain processes cardiac pain, and it is too early to say whether it matches this traditional picture.^[7]

In Ayurveda, Hridroga describes a disorder of the heart region with Vata, Pitta or Kapha features. No study has shown that a dosha corresponds to a particular biological process, or that these categories predict who will respond to a treatment.

How this care fits with your medical care

Angina needs medical treatment, and our role is supportive. Keep your cardiologist and primary care physician, keep taking your prescribed medicines, and do not stop or change them, including nitroglycerin, aspirin, statins, beta-blockers or other drugs, without your prescriber. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Please bring your diagnosis, recent test results, a full list of medicines and supplements, and details of any stents, bypass surgery or planned procedures.^[5]

When to seek urgent medical care

Chest pain can signal a heart attack or unstable angina, and these are emergencies.^[3]

• Chest pain, pressure or tightness that is new, comes on at rest, or lasts longer than usual
• Angina that is more frequent, more severe or easier to bring on than before
• Pain that does not ease within minutes of rest or your prescribed nitroglycerin
• Shortness of breath, sweating, nausea, lightheadedness or fainting with chest discomfort
• Pain spreading to the arm, jaw, neck or back
• Fast or irregular heartbeat with chest symptoms

If any of these occur, call 911 or go to the nearest emergency department. Do not drive yourself.