Angina Pectoris

Polyarteritis Nodosa

Angina Pectoris | Johns Hopkins Medicine

The first description of this disease dates back to 1866 when Kussmaul and Maier identified a condition that consisted of “focal, inflammatory, arterial nodules”. They termed this disorder “periarteritis nodosa” because of the inflammation they observed around the blood vessel wall.

The name was changed to polyarteritis nodosa (PAN) to underscore the fact that inflammation throughout the entire arterial wall – not just around the wall – is a major disease feature.

Polyarteritis nodosa is sometimes termed “systemic necrotizing vasculitis”, but this term is non-specific as other forms of vasculitis also have systemic and necrotizing features.

Who gets Polyarteritis Nodosa (the “typical” patient)?

Most cases of PAN occur in the 4th or 5th decade, although it can occur at any age. Men are twice as ly to be affected than women. A minority of patients with PAN have an active hepatitis B infection. In the rest of the cases, the cause(s) is presently unknown, and the disease is said to be “idiopathic” in nature.

Classic symptoms and signs of Polyarteritis Nodosa

PAN is a multisystem disease that may present with fever, sweats, weight loss, and severe muscle and joint aches/pains. PAN may develop in a subacute fashion, over several weeks or months.

Patients may have nonspecific complaints such as fever, malaise, weight loss, anorexia, and abdominal pain. The disease can affect nearly any site in the body, but it has a predisposition for organs such as the skin, kidney, nerves, and gastrointestinal tract.

Many patients with PAN have high blood pressure and elevated erythrocyte sedimentation rates (ESR).

The presentation of PAN may also include skin abnormalities (rash, ulcers) and peripheral neuropathy (pain, the sensations of burning, tingling, or numbness, or weakness in a hand or foot). However, the disease has a predilection for certain organs and tissues; these are described below.

  • Nerve
  • Skin
  • Kidney
  • Gastrointestinal tract
  • Heart
  • Eye
  • Genitals


  • Peripheral neuropathies are very common (50 to 70%). This includes tingling, numbness and/or pain in the hands, arms, feet, and legs.
  • Central nervous system (CNS) lesions may occur 2 to 3 years after the onset of PAN and may lead to cognitive dysfunction, decreased alertness, seizures and neurologic deficits.


  • Skin abnormalities are very common in PAN and may include purpura, livedo reticularis, ulcers, nodules or gangrene.
  • Skin involvement occurs most often on the legs and is very painful.


  • Renal artery vasculitis may lead to protein in the urine, impaired kidney function, and hypertension.
  • Small percentage of patients go on to require dialysis.

Gastrointestinal Tract

  • Abdominal pain, gastrointestinal bleeding (occasionally is mistaken for inflammatory bowel disease)
  • Hemorrhage, bowel infarction, and perforation are rare, but very serious


  • Clinical involvement of the heart does not usually cause symptoms.
  • However, some patients develop myocardial infarctions (heart attacks) or congestive heart failure.


  • Scleritis or inflammation in the sclera (white part of the eye)

What causes Polyarteritis Nodosa?

Hepatitis B causes a minority of cases of PAN. With the availability of hepatitis B vaccine now, cases of PAN caused by hepatitis B are now rare in the developed world. It is possible that other infections contribute to other cases of PAN, but links between other infections and this disease remain conjectural at the present time.

How is Polyarteritis Nodosa Diagnosed?

Routine laboratory tests may provide important clues to PAN, but there is no single blood test that is diagnostic of this disease. Most patients with PAN have elevated ESRs. Proteinuria (protein in the urine) is common among those with kidney involvement.

If there is skin or muscle/nerve involvement, a skin or muscle/nerve biopsy can be extremely helpful in coming to a definite diagnosis of PAN. Nerve conduction studies are a non-invasive way of identifying nerves that are involved by the inflammation. (These nerves can then be biopsied to confirm the diagnosis).

The diagnosis is confirmed by a biopsy showing pathologic changes in medium-sized arteries. The biopsy site may vary. Most biopsies are taken from skin, symptomatic nerve, or muscle. An angiogram of the abdominal blood vessels may also be very helpful in diagnosing PAN.

Aneurysms most often affect the arteries leading to the kidneys, liver or gastrointestinal tract.

The American College of Rheumatology (ACR) has established criteria that should be fulfilled if a patient is to be included in a research study of PAN. The criteria are designed to differentiate PAN from other forms of vasculitis. Not all patients have all criterion.

Some, in fact, may have only 2 or 3 criteria, yet their physicians are still comfortable classifying their disease as PAN. A committee of ACR physicians selected 10 disease features (criteria) as being those that best distinguish PAN from other vasculitides.

In order to be classified as a PAN patient – for the purpose of research studies – a patient should have at least 3 of the 10 ACR criteria.

The American College of Rheumatology 1990 criteria for the classification of Polyarteritis Nodosa

  1. Weight loss of > 4 kg since beginning of illness
  2. Livedo reticularis
  3. Testicular pain or tenderness
  4. Myalgias, weakness, or leg tenderness
  5. Mononeuropathy or polyneuropathy
  6. Development of hypertension
  7. Elevated BUN or creatinine unrelated to dehydration or obstruction
  8. Presence of hepatitis B surface antigen or antibody in serum
  9. Arteriogram demonstrating aneurysms or occlusions of the visceral arteries
  10. Biopsy of small or medium-sized artery containing granulocytes

Treatment and Course of Polyarteritis Nodosa

Treatment of PAN has improved dramatically in the past couple of decades. Before the availability of effective therapy, untreated PAN was usually fatal within weeks to months. Most deaths occurred as a result of kidney failure, heart or gastrointestinal complications.

However, effective treatment is now available for PAN. After diagnosis, patients are treated with high doses of corticosteroids. Other immunosuppressive drugs are also added for patients who are especially ill.

In most cases of PAN now, if diagnosed early enough the disease can be controlled, and often cured.

In medical terms, by David Hellmann, M.D

A discussion of Polyarteritis Nodosa written in medical terms by David Hellmann, M.D. (F.A.C.P.

), for the Rheumatology Section of the Medical Knowledge Self–Assessment Program published and copyrighted by the American College of Physicians (Edition 11, 1998).

The American College of Physicians has given us permission to make this information available to patients contacting our Website.

Polyarteritis nodosa is a small– and medium–sized arteritis affecting multiple organs, especially the skin, peripheral nerve, gut, kidney, and heart. The age of onset ranges from childhood to late adulthood but averages 40 years. Polyarteritis nodosa has been associated with active hepatitis B, hepatitis C, or both; therefore, the disease is more common in injection drug users.

Polyarteritis nodosa is probably mediated by deposition of immune complexes.

Evidence includes the observation that patients with polyarteritis nodosa associated with hepatitis B or hepatitis C have immune complexes consisting of immunoglobulin and viral antigens circulating in the blood and deposited in inflamed vessels. Moreover, antiviral therapy can remit the vasculitis in some of these patients.

The onset is gradual over weeks to months, and the initial symptoms are often nonspecific.

The earliest clues that the patient has vasculitis come usually from the skin (where vasculitis may appear as palpable purpura, livedo reticularis, digital gangrene, or tender nodules), or the peripheral nervous system (where infarction of one mixed motor and sensory nerve after another results in mononeuritis multiplex, one of the most specific clues that a patient has vasculitis). Renal involvement eventually develops in most and is accompanied by hypertension in half of patients, whereas Granulomatosis with Polyangiitis
rarely elevates the blood pressure. Polyarteritis nodosa also commonly involves the gut (abdominal angina, hemorrhage, perforation), heart (myocarditis, myocardial infarction), or eye (scleritis). Rupture of renal or mesenteric micoaneurysms can simulate an acute abdomen.

Confirming the diagnosis requires either biopsy specimen showing small– or medium–sized arteries, or mesenteric arteriography showing microaneurysms or alternating areas of stenosis and dilation.

Biopsy of a symptomatic nerve or a symptomatic muscle is 65% sensitive, whereas biopsy of an asymptomatic site is less than 30% sensitive. Because mesenteric angiography is 60% sensitive, it should be done when there is not a symptomatic site to biopsy.

Renal biopsy should be avoided unless angiography rules out microaneurysms susceptible to rupture.

Without treatment, almost all affected patients die within 2 to 5 years.

Treatment with prednisone (starting at 1 mg/kg daily) and cyclophosphamide (2 mg/kg daily) appeared to revolutionize the outcome of polyarteritis nodosa by achieving 70% 10–year survivals and established this combination of agents as the standard therapy.

However, newer studies suggest that prednisone alone may achieve the same high survival as prednisone and cyclophosphamide, although flares were less frequent in patients taking cyclophosphamide.

Other studies indicate that the traditional therapy with prednisone and cyclophosphamide should be abandoned in patients with polyarteritis nodosa associated with hepatitis B.

Patients treated with the traditional combination respond, but almost all survivors become chronic carriers of hepatitis B and may die later of cirrhosis or variceal bleeding. The newly propsed regimen consists of 2 weeks of prednisone to control the vasculitis, followed by plasmapheresis to remove immune complexes, and accompanied by antiviral therapy with lamivudine to rid the patient of the hepatitis B infection. The long–term value of anti–viral therapy for polyarteritis nodosa associated with hepatitis C is not established.


Angina (Ischemic Chest Pain)

Angina Pectoris | Johns Hopkins Medicine

Angina is chest pain that happens because there isn't enough blood going to part of your heart. It can feel a heart attack, with pressure or squeezing in your chest. It’s sometimes called angina pectoris or ischemic chest pain.

It's a symptom of heart disease, and it happens when something blocks your arteries or there's not enough blood flow in the arteries that bring oxygen-rich blood to your heart.

Angina usually goes away quickly. Still, it can be a sign of a life-threatening heart problem. It's important to find out what's going on and what you can do to avoid a heart attack.

Usually, medicine and lifestyle changes can control angina. If it's more severe, you may need surgery, too. Or you may need what’s called a stent, a tiny tube that props open arteries.

There are different types of angina:

Stable angina. This is the most common. Physical activity or stress can trigger it. It usually lasts a few minutes, and it goes away when you rest. It isn't a heart attack, but it can be a sign that you're more ly to have one. Tell your doctor if this happens to you.

Unstable angina. You can have this while you're at rest or not very active. The pain can be strong and long-lasting, and it may come back again and again. It can be a signal that you're about to have a heart attack, so see a doctor right away.

Microvascular angina. With this type, you have chest pain but no coronary artery blockage. Instead, it happens because your smallest coronary arteries aren’t working the way they should, so your heart doesn’t get the blood it needs. The chest pain usually lasts more than 10 minutes. This type is more common in women.

Prinzmetal's angina (variant angina). This type is rare. It might happen at night while you're sleeping or resting. Your heart arteries suddenly tighten or narrow. It can cause a lot of pain, and you should get it treated.

Chest pain is the symptom, but it affects people differently. You may have:

  • Aching
  • Burning
  • Discomfort
  • Dizziness
  • Fatigue
  • Feeling of fullness in your chest
  • Feeling of heaviness or pressure
  • Upset stomach or vomiting
  • Shortness of breath
  • Squeezing
  • Sweating

You might mistake an aching or burning for heartburn or gas.

You’re ly to have pain behind your breastbone, which can spread to your shoulders, arms, neck, throat, jaw, or back.

Stable angina often gets better with rest. Unstable angina may not, and it could get worse. It’s an emergency that needs medical help right away.

Men often feel pain in their chest, neck, and shoulders. Women may feel discomfort in their belly, neck, jaw, throat, or back. You may also have shortness of breath, sweating, or dizziness.

One study found that women were more ly to use the words “pressing” or “crushing” to describe the feeling.

Angina usually happens because of heart disease. A fatty substance called plaque builds up in your arteries, blocking blood flow to your heart muscle. This forces your heart to work with less oxygen. That causes pain. You may also have blood clots in the arteries of your heart, which can cause heart attacks.

Less common causes of chest pain include:

Some things about you or your lifestyle could put you at higher risk of angina, including:

Your doctor will do a physical exam and ask about your symptoms, risk factors, and family history. They might need to do tests including:

  • EKG. This test measures your heart’s electrical activity and rhythm.
  • Stress test. This checks how your heart is working while you exercise.
  • Blood tests. Your doctor will check for proteins called troponins. Lots of them are released when your heart muscle is damaged, as in a heart attack. Your doctor may also do more general tests a metabolic panel or complete blood count (CBC).
  • Imaging tests. Chest X-rays can rule out other things that might be causing your chest pain, lung conditions. Echocardiograms and CT and MRI scans can create images of your heart to help your doctor spot problems.
  • Cardiac catheterization. Your doctor inserts a long, thin tube into an artery in your leg and threads it up to your heart to check your blood flow and pressure.
  • Coronary angiography. Your doctor injects dye into the blood vessels of your heart. The dye shows up on an X-ray, creating an image of your blood vessels. They may do this procedure during cardiac catheterization.

Angina questions for your doctor

  • Do I need any more tests?
  • What type of angina do I have?
  • Do I have heart damage?
  • What treatment do you recommend?
  • How will it make me feel?
  • What can I do to try to prevent a heart attack?
  • Are there activities I shouldn't do?
  • Will changing my diet help?

Your treatment depends on how much damage there is to your heart. For people with mild angina, medicine and lifestyle changes can often help their blood flow better and control their symptoms.


Your doctor might prescribe medicines including:

  • Nitrates or calcium channel blockers to relax and widen blood vessels, letting more blood flow to your heart
  • Beta-blockers to slow your heart down so it doesn't have to work as hard
  • Blood thinners or antiplatelet medications to prevent blood clots
  • Statins to lower your cholesterol levels and stabilize plaque

Cardiac procedures

If meds aren't enough, you may need to have blocked arteries opened with a medical procedure or surgery. This could be:

Angioplasty/stenting. The doctor threads a tiny tube, with a balloon inside, through a blood vessel and up to your heart. Then, they inflate the balloon inside the narrowed artery to widen it and restore blood flow.

They may insert a small tube called a stent inside your artery to help keep it open. The stent is permanent and usually made of metal. It can also be made of a material that your body absorbs over time.

Some stents also have medicine that helps keep your artery from getting blocked again.

The procedure usually takes less than 2 hours. You’ll probably stay overnight at the hospital.

Coronary artery bypass grafting (CABG), or bypass surgery. Your surgeon takes healthy arteries or veins from another part of your body and uses them to go around the blocked or narrowed blood vessels.

You can expect to stay in the hospital about a week after you have this. You'll be in the intensive care unit for a day or two while nurses and doctors keep a close eye on your heart rate, blood pressure, and oxygen levels. You'll then move to a regular room to recover.

Lifestyle changes

You can still be active, but it's important to listen to your body. If you feel pain, stop what you’re doing and rest. Know what triggers your angina, stress or intense exercise. Try to avoid things that tend to set it off.

For example, if large meals cause problems, eat smaller ones and eat more often. If you still feel pain, talk to your doctor about having more tests or changing your medications.

Because angina can be a sign of something dangerous, it’s important to get checked out.

These lifestyle tips may help protect your heart:

If you smoke, stop. It can damage your blood vessels and increase your heart disease risk.

Eat a heart-healthy diet to lower your blood pressure and cholesterol levels. When those are normal range, your chance for heart disease can rise. Eat mainly fruits and vegetables, whole grains, fish, lean meat, and fat-free or low-fat dairy. Limit salt, fat, and sugar.

Use stress-relieving measures meditation, deep breathing, or yoga to relax.

Exercise most days of the week.

See your doctor regularly.

If you have chest pain that is new or unusual for you, and you think you may be having a heart attack, call 911 right away. Quick treatment is very important. It can protect you from more damage.

Angina raises your risk of having a heart attack. But it’s treatable. Consider it a warning sign and make healthy choices.

Talk with others who have it. That may help you learn how to feel better.

Your family, too, may need support to help them understand your angina. They'll want to know what they can do to help.


American Heart Association: “Angina (Chest Pain),” “Angina in Women Can Be Different Than Men,” “Cardiac Catheterization and Angiogram.”

JAMA Internal Medicine: “Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men.”

National Heart, Lung, and Blood Institute: “Angina,” “What is Angina?” “What Is an Electrocardiogram?”

Stanford Health Care: “Angina.”

American Heart Association: “Microvascular Angina,” “Unstable Angina,” Angina in Women Can Be Different Than Men.”

Mayo Clinic: “Angina.”

American Association for Clinical Chemistry: “Angina,” “Troponin.”

Johns Hopkins Medicine: “Microvascular Angina: Why Women Shouldn’t Ignore Chest Pain and Fatigue.”

UpToDate: “Patient education: Chest pain (Beyond the Basics).”

© 2019 WebMD, LLC. All rights reserved.


Angina Pectoris: Epidemiology Forecast to 2028

Angina Pectoris | Johns Hopkins Medicine

Summary Angina pectoris is a chest pain or discomfort often described as squeezing, pressure, heaviness, or tightness in the chest and is caused by reduced blood flow to the heart (Mayo Clinic, 2020).

New York, May 08, 2020 (GLOBE NEWSWIRE) — announces the release of the report “Angina Pectoris: Epidemiology Forecast to 2028” – https://www.reportlinker.

com/p05892808/?utm_source=GNW The reduced blood flow occurs when arteries that carry blood to the heart become narrowed and blocked because of a blood clot or atherosclerosis (Johns Hopkins Medicine, 2020).

The reduced blood flow can also occur because of unstable plaques, poor blood flow through a narrowed heart valve, a decreased pumping function of the heart muscle, as well as a coronary artery spasm (Johns Hopkins Medicine, 2020; Mayo Clinic, 2020).

Angina can be classified as stable angina, unstable angina, Prinzmetal angina, and microvascular angina the above-mentioned causes (The Society for Cardiovascular Angiography and Interventions, 2014; Mayo Clinic, 2020). In 2018, there were 1,128,150 diagnosed incident cases of angina pectoris in men and women combined, age 18 years and older, in the 7MM.

The US accounted for the majority of these cases with 801,516 diagnosed incident cases, while Spain accounted for the fewest cases with 36,820 cases in 2018. Epidemiologists forecast an increase in the diagnosed incident cases of angina pectoris to 1,292,695 cases in 2028 in the 7MM at an Annual Growth Rate (AGR) of 1.46% during the forecast period.

In 2018, there were 19,584,590 diagnosed prevalent cases of angina pectoris in men and women combined, age 18 years and older, in the 7MM.The US accounted for the majority of these cases with 5,527,282 cases, while Japan accounted for the fewest cases with 465,983 cases in 2018.

The diagnosed prevalent cases of angina pectoris will increase to 22,797,390 cases in 2028 at an AGR of 1.64% during the forecast period.

Scope – The Angina Pectoris Report provides an overview of the risk factors, comorbidities, and the global and historical trends for angina pectoris in the seven major markets (7MM: US, France, Germany, Italy, Spain, UK, and Japan).

– The report includes a 10-year epidemiological forecast for the diagnosed incident cases and the diagnosed prevalent cases of angina pectoris, each segmented into stable angina, unstable angina, Prinzmetal angina, and microvascular angina in those ages 18 years and older.

– The forecast for the diagnosed incident cases and diagnosed prevalent cases of angina pectoris, Prinzmetal angina, and microvascular angina are segmented by age, and stable angina and unstable angina are segmented by both sex and age.

– The comorbidities-diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and chronic renal disease-among the diagnosed incident cases and diagnosed prevalent cases of angina pectoris are also provided. Lastly, the report includes diagnosed prevalent cases of refractory angina among diagnosed prevalent cases of angina pectoris. – The angina pectoris epidemiology report is written and developed by Masters- and PhD-level epidemiologists. – The Epidemiology Report is in-depth, high quality, transparent and market-driven, providing expert analysis of disease trends in the 7MM. Reasons to Buy The Angina Pectoris Epidemiology series will allow you to – – Develop business strategies by understanding the trends shaping and driving the global angina pectoris market. – Quantify patient populations in the global angina pectoris market to improve product design, pricing, and launch plans. – Organize sales and marketing efforts by identifying the age groups that present the best opportunities for angina pectoris therapeutics in each of the markets covered. – Understand magnitude of refractory angina and angina pectoris by types.

Read the full report:

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ReportLinker is an award-winning market research solution. Reportlinker finds and organizes the latest industry data so you get all the market research you need – instantly, in one place.


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Johns Hopkins Develops Criteria for Diagnostic Imaging

Angina Pectoris | Johns Hopkins Medicine

Newswise — On June 30, the Centers for Medicare & Medicaid Services (CMS) announced that the Johns Hopkins University School of Medicine has been designated a so-called “qualified provider-led entity.

” This allows Johns Hopkins to develop criteria that meet the requirements of the federal Protecting Access to Medicare Act of 2014 when ordering diagnostic imaging tests such as computed tomography (CT) scans, MRI scans and nuclear imaging in the emergency department and ambulatory settings.

Johns Hopkins joins 21 other institutions across the nation that CMS has formally approved to design these criteria.

“We are honored by this approval, as it dovetails nicely with our effort to improve the value of medical care in our health system and across the nation,” says Pamela Johnson, M.D.

, vice chair of quality and safety in the Department of Radiology, professor of radiology and radiological science at the Johns Hopkins University School of Medicine and director of the High Value Practice Academic Alliance.

“Our goal is to deliver health care of the highest quality, safety, efficiency and effectiveness for our patients.

By helping doctors and advanced practice providers use evidence in the literature at the point of care to know which tests to order, which treatments to prescribe and when patients can safely be discharged from the emergency department, we aim to avoid unwarranted variation in care and avoid unnecessary use of medical resources that does not add value, while delivering the best outcomes for our patients.”

Physicians learn best practices during their training. However, as health care and technology evolve and improve, medical best practices also must change. And while professional societies publish clinical practice guidelines annually, adopting change can be slow.

“Studies estimate that it takes an average of 17 years for new evidence in the literature to translate into changes in practice by the greater medical community,” says Johnson.

“We wanted to skip that 17 year delay and improve health care quality as quickly as possible so our patients start benefiting right away.”

Even before the Johns Hopkins University School of Medicine was designated a qualified provider-led entity, Johnson and colleagues had established teams of physicians from multiple specialties to review primary medical literature and identify the best data to use to design the criteria.

After mining the data and writing the criteria, the Johns Hopkins teams integrated them directly into diagnostic decision-making guidelines in the electronic medical record system used by the hospitals and ambulatory practices in the Johns Hopkins Health System.

From the electronic medical record system, clinicians can access calculators, forms, consultation guides, videos and other resources to make it easier to locate the latest knowledge and best practices when they diagnose and treat patients.

To optimize care delivery for each patient, decision trees guide selection of tests and treatments according to clinical symptoms.

This effort resulted in more than 70 guidelines addressing both diagnosis and management for a range of clinical scenarios, such as chest pain and syncope, which have already been built into The Johns Hopkins Hospitals’ emergency department electronic medical record system.

Preliminary analyses confirm improvements in care delivery — for example, adhering to the chest pain guideline reduced the number of patients with noncardiac chest pain who were admitted to the hospital unnecessarily.

All Johns Hopkins Health System adult emergency departments are now implementing these guidelines.  

Johns Hopkins’ new qualified provider-led entity status will allow its experts to write criteria that can be used to guide physicians’ use of diagnostic imaging tests as required by the CMS Appropriate Use Criteria Program, beginning with eight clinical priority areas: chest pain, pulmonary embolism, neck pain, low back pain, shoulder pain, hip pain, headache and lung cancer. Johns Hopkins plans to make the criteria available to other care providers across the nation by January of next year, when CMS will require all health care professionals to consult clinical decision support tools when ordering advanced diagnostic imaging tests for Medicare patients.

“While CMS is focused on advanced diagnostic imaging tests, we at Johns Hopkins are keen to ensure best practice across all aspects of medicine and surgery both within our institution and nationally,” says Johnson.

“Our rigorous evidentiary literature review coupled with the clinical expertise of the multidisciplinary teams will hopefully refine the practice of medicine so that patients get tests and treatments that add value to their care and benefit from advances in practice more efficiently than they have traditionally.”


About Johns Hopkins’ high value care efforts:

In 2018, the health system’s High Value Care Committee implemented targeted appropriate use interventions for lab and imaging tests. The avoidance of unnecessary testing at The Johns Hopkins Hospital alone resulted in more than $4 million in reduced hospital charges for payers and patients.

In 2016, Johns Hopkins experts organized academic medical centers from across the nation and Canada to form the High Value Practice Academic Alliance. Today, the consortium consists of more than 90 academic medical centers working together to advance high-value medical practice nationally through research, innovation, collaboration and education.

The group’s national high-value health care conference, co-directed with the American Hospital Association, is scheduled for Nov. 15–17 at the Baltimore Convention Center. High-value care experts from 80 medical centers across the country will present more than 200 value-based performance improvement initiatives.

There will also be many other skill-building opportunities in value-based care.


Angina Pectoris

Angina Pectoris | Johns Hopkins Medicine

Linkedin Pinterest Heart and Vascular

Angina pectoris—or simply angina—is chest pain or discomfort that keeps coming back. It happens when some part of your heart doesn't get enough blood and oxygen. Angina can be a symptom of coronary artery disease (CAD).

This occurs when arteries that carry blood to your heart become narrowed and blocked because of atherosclerosis or a blood clot.

It can also occur because of unstable plaques, poor blood flow through a narrowed heart valve, a decreased pumping function of the heart muscle, as well as a coronary artery spasm.

There are 2 other forms of angina pectoris. They are:

Variant angina pectoris(or Prinzmetal's angina) Microvascular angina
  • Is rare
  • Occurs almost only when you are at rest
  • Often doesn't follow a period of physical exertion or emotional stress
  • Can be very painful and usually occurs between midnight and 8 a.m.
  • Is related to spasm of the artery
  • Is more common in women
  • Can be helped by medicines such as calcium channel blockers. These medicines help dilate the coronary arteries and prevent spasm.
  • A recently discovered type of angina
  • People with this condition have chest pain but have no apparent coronary artery blockages
  • Doctors have found that the pain results from poor function of tiny blood vessels nourishing the heart, as well as the arms and legs
  • Can be treated with some of the same medicines used for angina pectoris
  • Was once called Syndrome X
  • Is more common in women

What causes angina pectoris?

Angina pectoris occurs when your heart muscle (myocardium) does not get enough blood and oxygen for a given level of work. Insufficient blood supply is called ischemia.

Who is at risk for angina pectoris?

Anything that causes your heart muscle to need more blood or oxygen supply can result in angina. Risk factors include physical activity, emotional stress, extreme cold and heat, heavy meals, drinking excessive alcohol, and cigarette smoking.

What are the symptoms of angina pectoris?

These are the most common symptoms of angina:

  • A pressing, squeezing, or crushing pain, usually in the chest under your breastbone
  • Pain may also occur in your upper back, both arms, neck, or ear lobes
  • Pain radiating in your arms, shoulders, jaw, neck, or back
  • Shortness of breath
  • Weakness and fatigue
  • Feeling faint

Angina chest pain is usually relieved within a few minutes by resting or by taking prescribed cardiac medicine, such as nitroglycerin.

An episode of angina means some part of the heart is not getting enough blood supply. If you have angina, you have an increased risk for a heart attack.

Note the pattern of your symptoms—what causes the chest pain, what it feels , how long it lasts, and whether medicine relieves the pain.

If angina symptoms change sharply, or if they happen when you are resting or they start to occur unpredictably, call 911. You may be having a heart attack. Do not drive yourself to the emergency department.

The symptoms of angina pectoris may look other medical conditions or problems. Always see your healthcare provider for a diagnosis.

How is angina pectoris diagnosed?

In addition to a complete medical history and medical exam, your healthcare provider can often diagnose angina from your symptoms and how and when they occur. Other tests may include:

  • Electrocardiogram (ECG). Records the electrical activity of the heart, shows abnormal rhythms (arrhythmias), and detects heart muscle damage.
  • Stress test (usually with ECG; also called treadmill or exercise ECG). Given while you walk on a treadmill or pedal a stationary bike, to monitor your heart's ability to function when placed under stress such as during exercise. Breathing and blood pressure rates are also monitored. A stress test may be used to detect coronary artery disease, or to determine safe levels of exercise after a heart attack or heart surgery. A special type of stress test uses medicine to stimulate the heart as if you were exercising.
  • Cardiac catheterization. With this procedure, a wire is passed into the coronary arteries. Next a contrast agent is injected into your artery. X-ray images are taken to locate the narrowing, blockages, and other abnormalities of specific arteries.
  • Cardiac MRI. This test can find the amount of blood flow to the heart muscle. It may not be available at all medical centers.
  • Coronary CT scan. This test looks at the amount of calcium and plaque inside of the blood vessels of the heart.

How is angina pectoris treated?

Your healthcare provider will determine specific treatment, :

  • How old you are
  • Your overall health and past health
  • How sick you are
  • How well you can handle specific medicines, procedures, or therapies
  • How long the condition is expected to last
  • Your opinion or preference

Your healthcare provider may prescribe medicines if you have angina. The most common is nitroglycerin, which helps to relieve pain by widening your blood vessels.

This allows more blood flow to your heart muscle and decreases the workload of your heart. Nitroglycerin may be taken as a long-acting form daily to prevent angina.

Or, it may be taken as a nose spray, or under the tongue when angina occurs.

Don't take sildenafil (for erectile dysfunction) with nitroglycerin. This can cause a dangerous drop in blood pressure. Talk to your healthcare provider if you are taking erectile dysfunction medicines before taking nitroglycerin.

Beta-blockers and calcium channel blockers are also used to treat angina.

Your healthcare provider may recommend other medicines to help treat or prevent angina.

What are the complications of angina pectoris?

Angina means that you have coronary artery disease and that some part of your heart is not getting enough blood supply. If you have angina, you have an increased risk for a heart attack.

Can angina pectoris be prevented?

Maintaining a healthy lifestyle can help to delay or prevent angina pectoris. A healthy lifestyle includes:

  • A healthy diet
  • Physical activity and exercise
  • Stress management
  • Not smoking or quitting smoking if you do smoke
  • Keeping or working toward a healthy weight
  • Taking medicines as prescribed
  • Treating any related conditions such as high blood pressure, high cholesterol, diabetes, and overweight

Living with angina pectoris

If you have angina, note the patterns of your symptoms. For example, pay attention to what causes your chest pain, what it feels , how long episodes usually last, and whether medicine relieves your pain. Call 911 if your angina episode symptoms change sharply. This is called unstable angina.

It is important to work with your healthcare provider to treat your underlying coronary artery disease, which causes angina.

You need to control your risk factors: high blood pressure, cigarette smoking, high blood cholesterol levels, lack of exercise, excess weight, and a diet high in saturated fat. Taking you medicines as your healthcare provider directs is an important part of living with angina.

If your provider prescribes nitroglycerin, it important that you have it with you at all times and follow his or her directions for using it whenever you have an episode of angina.

When should I call my healthcare provider?

Call 911 if you have any of the following:

  • Angina symptoms change sharply
  • Symptoms happen when you are resting
  • Symptoms continue after using nitroglycerin
  • Symptoms last longer than usual
  • Symptoms start to occur unpredictably

You may be having a heart attack. Do not drive yourself to the emergency department.

Call your healthcare provider right away if:

  • Your angina symptoms become worse or you notice new symptoms
  • You have side effects from your medicines

Key points about angina pectoris

  • Angina is chest pain or discomfort that keeps coming back. It happens when some part of your heart does not get enough blood and oxygen.
  • Angina is a symptom of coronary artery disease. This occurs when arteries that carry blood to your heart become narrowed and blocked because of atherosclerosis or a blood clot.
  • Angina can feel a pressing, squeezing, or crushing pain in the chest under your breastbone or upper back, both arms, neck, or ear lobes. You may also have shortness of breath, weakness, or fatigue
  • Nitroglycerin is the most common medicine prescribe for angina
  • Managing angina includes managing high blood pressure, stopping cigarette smoking, reducing high blood cholesterol levels, eating less saturated fat, exercising, and losing weight


For Patients

Angina Pectoris | Johns Hopkins Medicine

This web site is designed for Cardiologists, Radiologists, and other specialists who want the most detailed and complete training in cardiac CT. However, if you are a patient who would to participate in either our clinical or research program, you are welcome to do so.

Clinical scans can be arranged by calling Susan Orr at 410-550-0849. Note that the scan must be ordered by your physician, who must fax a requisition or a prescription to our imaging department. A very brief summary of the capabilities of 64 slice cardiac CT follows:

There are two types of cardiac exams that can be performed using CT. The first exam is called a “calcium scan”.

This study detects calcium deposits in the walls of the coronary arteries, and is best used in patients at risk for coronary artery disease but without symptoms.

The test supplements the use of conventional risk factors for predicting who is at risk for the development of symptomatic coronary disease.

The second exam is called “cardiac CT angiography”. This test provides images of the coronary arteries, and may detect obstructions of the coronary arteries due to atherosclerotic plaque, and also may detect early atherosclerosis before obstructions develop.

It provides information similar to what would be revealed by cardiac catheterization, but without the need for placing catheters into the heart. CT angiography can “rule out” coronary artery disease, and a normal study is generally considered definitive evidence that coronary disease is not present.

However, if obstructions ARE seen by CT, catheterization is often necessary to confirm their presence and establish a therapeutic plan.

The indications for cardiac CT angiography are rapidly evolving, and some of those listed below may be controversial. This test has only been available for about 4 years. It is covered by Medicare in most states, but private insurors vary greatly in their willingness to cover it. Your doctor may order cardiac CT angiography if:

  1. Cardiac catheterization is indicated to rule out coronary disease but there is a contraindication or hesitancy to order this invasive test.
  2. Stress testing has been performed but has not resulted in a definite diagnosis.
  3. Evaluation of chest pain is necessary in patients with an “intermediate probability” of having disease who cannot perform a definitive stress test.
  4. Evaluation of acute chest pain is needed quickly.
  5. There is weakness of the heart muscle (cardiomyopathy) and the presence or absence of obstructions of the coronary arteries must be determined.
  6. There is an extremely high risk of coronary artery disease and stress testing and calcium scanning are not thought to be adequate for guiding preventative therapy.
  7. Heart rhythm disturbances (particularly atrial fibrillation) are present and catheter ablation is planned.
  8. Bi-ventricular cardiac pacing is planned and knowledge of the course of the cardiac veins is required.
  9. Congenital heart disease is present or suspected.
  10. Disease of the membrane surrounding the heart is suspected.
  11. A cardiac tumor or mass is present or suspected.
  12. Dissection of the aorta is suspected.
  13. A blood clot in the lungs is suspected.
  14. Other indications as determined by your physician are present.