Angina treatment: Stents, drugs, lifestyle changes — What's best?
Medically reviewed on April 6, 2018.
Your doctor says your chest pain (angina) is caused by blockages in your heart arteries and that you need to get those blockages taken care of. What are your options?
First, it's important to determine what type of angina you have. Different types of angina may need different treatments. Common types of angina are chronic stable angina — a type of angina that occurs when your heart is working hard — and unstable angina, which is new chest pain or chest pain that is getting worse.
Other types of angina include variant angina — a rare type of angina caused by a spasm in the coronary arteries — and microvascular angina, which can be a symptom of disease in the small coronary artery blood vessels.
Unstable angina is a serious situation and requires emergency treatment. Treatment for unstable angina involves hospitalization with medications to stabilize your condition. Some people with unstable angina may require a procedure called angioplasty (also known as percutaneous coronary intervention), usually combined with the placement of a small metal tube called a stent. In some cases of unstable angina, heart surgery (coronary bypass surgery) may be needed.
Generally, if you have mild stable angina that is controlled by medications, you may not need further treatments. If you're experiencing symptoms of chronic stable angina even after taking medications and making lifestyle changes, or if you're at higher risk of serious heart disease, your doctor may recommend angioplasty or coronary bypass surgery.
Making a decision on how to treat your angina can be difficult, but knowing the benefits and risks of stents and medications may help you decide.
Why are there different treatments for each type of angina?
Angina is pain, discomfort or pressure in the chest, and doctors usually describe it as chronic stable angina or unstable angina.
Chronic stable angina. Chronic stable angina is a form of chest pain that happens when your heart is working hard and needs more oxygen, such as during exercise. The pain goes away when you rest. In chronic stable angina, the pattern of chest pain is consistent, or stable, as far as how much physical exertion will trigger it. Your narrowed arteries can be the cause of this form of angina.
If you have chronic stable angina, you may need angioplasty with stenting or medications as treatment. If the blockage causing chronic stable angina is severe, it's possible your doctor may recommend coronary bypass surgery. In this procedure, the blocked arteries are replaced with blood vessels grafted from another part of your body.
Unstable angina. Unstable angina is either new chest pain or a change in your usual pattern of chest pain or discomfort — such as chest pain that is getting worse, lasting longer, or not being relieved with rest or use of medications.
Unstable angina is dangerous and a warning sign of a heart attack. If your angina is unstable, seek urgent medical care. You may need hospitalization, adjustment of medications, angioplasty with stents or coronary bypass surgery.
What are the treatment options for chronic stable angina?
Angioplasty and stenting
During an angioplasty (AN-jee-o-plas-tee), your doctor inserts a tiny balloon in your narrowed artery through a catheter that's placed in an artery, generally in your groin. Your doctor inflates the balloon to widen the artery, and then he or she may insert a small metal tube (stent) to keep the artery open. Some stents are bare metal, some are covered with a synthetic fabric, and others are coated with medications to help keep your artery open (drug-eluting stents).
Angioplasty and stenting involve some risks. These include a risk of blockages re-forming after a stent is implanted, a risk of a blood clot forming in the stent, as well as small risks of having a heart attack, stroke, or life-threatening bleeding during or after the procedure.
You should consider that even if you have a stent placed, you'll likely need to take aspirin for the rest of your life. You may also need to take additional medications to prevent blood clots.
You'll probably remain hospitalized for at least a day while your heart is monitored and your vital signs are checked frequently. You can generally return to work or your normal routine soon after angioplasty.
Many doctors consider angioplasty with stent placement to be a good angina treatment option for blocked arteries and chronic stable angina. Some reasons that it may be considered a good treatment option are that it's less invasive than open-heart surgery and generally has good results.
If you have stable angina, you may be able to treat it with medications and lifestyle changes alone, and you may not need angioplasty with stenting. Several medications can improve angina symptoms, including:
- Aspirin. Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clotting may reduce your risk of a heart attack.
Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle.
You might take a nitrate when you have angina-related chest discomfort, before doing something that usually triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is sublingual nitroglycerin tablets, which you put under your tongue.
- Beta blockers. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, your heart beats more slowly and with less force, reducing blood pressure and reducing the workload on your heart. Beta blockers also help blood vessels relax and open up to improve blood flow, which reduces or prevents angina.
- Statins. Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in the buildup of fats (plaques) in your artery walls, helping prevent further blockage in your blood vessels.
- Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina. Calcium channel blockers also slow your pulse and reduce the workload on your heart.
- Ranolazine (Ranexa). Ranolazine, an anti-angina medication, may be prescribed with other angina medications, such as beta blockers. It can also be used as a substitute if you can't take beta blockers.
- Angiotensin-converting enzyme (ACE) inhibitors. These drugs help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system in numerous ways, including narrowing your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder. These medications might help people with other conditions such as high blood pressure and diabetes.
If you try drug treatment and lifestyle changes and you still have symptoms that are limiting you, an angioplasty with stenting or coronary bypass surgery may be an option, depending on your condition and the cause of your angina.
Enhanced external counterpulsation therapy (EECP) therapy
EECP therapy may be recommended for some people with angina. During this therapy, a doctor places cuffs on your legs and applies air pressure to your legs in rhythm with your heartbeats. This therapy may help improve blood flow to your heart and may improve angina.
Lifestyle changes: Part of all treatments
Regardless of which angina treatment you choose, your doctor will recommend that you make healthy lifestyle changes.
Because heart disease is often the underlying cause of most forms of angina, you can reduce or prevent angina by working on reducing your heart disease risk factors and making healthy lifestyle changes. These risk factors may include:
- Smoking. If you smoke, stop.
- Poor diet. Eat a healthy diet with limited amounts of saturated fat, trans fat and salt. Include a variety of fruits and vegetables, whole grains, lean meats, and low-fat dairy products in your diet.
- High cholesterol. Know your cholesterol numbers and ask your doctor if you've optimized them to the recommended levels.
- Lack of physical activity. Talk to your doctor about starting a safe exercise plan. Because angina is often brought on by exertion, it's helpful to pace yourself and take rest breaks.
- Excess weight. If you're overweight, talk to your doctor about weight-loss options.
- Underlying conditions. Get treatment for diseases or conditions that can increase your risk of angina, such as diabetes, high blood pressure and high blood cholesterol.
- Stress. Avoiding stress is easier said than done, but try to find ways to relax. Talk with your doctor about stress-reduction techniques.
When placing a coronary artery stent, your doctor will find a blockage in your heart's arteries (A) using cardiac catheterization techniques. A balloon on the tip of the catheter is inflated to widen the blocked artery, and a metal mesh stent is placed (B). After the stent is placed, the artery is held open by the stent, which allows blood to flow through the previously blocked artery (C).
So which angina treatment is better — angioplasty and stenting or medications?
Your medical condition will determine whether having angioplasty and stenting or taking medications will work better for you. Talk to your doctor about which angina treatment is best for your situation. Consider this:
- People who have angioplasty and stenting first may feel better quicker. For example, their chest pain may decrease quicker than those who just take medication.
- People who take only medications for angina may not feel better as quickly, but medications require no recovery time and are less expensive than angioplasty and stenting. If you choose to take medications to treat your angina, it's important that you take them exactly as your doctor says so that you get the most benefit.
What if your angina treatment doesn't work?
If you try medication and lifestyle changes first, but they don't relieve your angina, angioplasty and stenting may be another option. In some cases coronary bypass surgery may be needed. It might be reasonable to try more-conservative steps first — medications and lifestyle therapy — before considering angioplasty and stenting or other treatments.
Research is ongoing in new therapies and medications to treat angina. Discuss with your doctor if other therapies may be appropriate for you.
Talk to your doctor if you're concerned that medications or stents aren't controlling your angina. Remember that with any treatment plan, lifestyle changes are important.