Cardiac Symptom
Angina
Chest tightness triggered by exertion — the hallmark symptom of narrowed coronary arteries. Expert assessment identifies the cause and relieves the symptoms.
Overview
What Is Angina?
Angina is a medical term for chest tightness that occurs on exertion and subsides at rest. When the discomfort also radiates into an arm or the neck, it is called Classical Angina. It is typically relieved within minutes by rest or by a GTN (glyceryl trinitrate) spray under the tongue.
Not every patient presents in a textbook way — many experience what is termed Atypical Angina, where one or more of the classic features are absent. Dr Nijjer will determine whether chest tightness is angina or another cause, and will not assume a diagnosis until the appropriate investigations have been completed.
Angina is most commonly caused by coronary artery disease — a narrowing of the heart arteries due to atherosclerosis (plaque build-up). In a smaller group of patients, angina arises from abnormalities of the tiny micro-vessels deep in the heart muscle — vessels too small to be visible on standard tests.
Patients with angina are referred to a cardiologist for investigation. Dr Nijjer will assess and interpret the results of ECG, echocardiography, stress testing, and CT coronary angiography, and will guide you through the findings and treatment options at each step.
The Mechanism
What Causes Angina?
Angina reflects an underlying mismatch between the heart's demand for blood and the supply available through narrowed coronary arteries.
Coronary artery disease (CAD) is the narrowing of the heart's arteries by a build-up of plaque — a mixture of cholesterol, inflammatory cells, and calcium that accumulates through a process of atherosclerosis. This process can be triggered by injury to the vessel wall, most commonly caused by smoking, high blood pressure, or raised cholesterol. A family history and combination of risk factors accelerates its progression.
At rest, the heart adapts to the reduced blood flow through a narrowed artery — the demand is low enough that supply remains adequate. But during exertion, the heart must beat harder and faster to supply the working muscles of the body. In that moment, the restricted flow through a narrowed artery is no longer sufficient, and the heart muscle is starved of oxygen.
This imbalance — increased demand, insufficient supply — is what produces the characteristic sensation of angina. When exertion stops and the heart slows, the symptom subsides within minutes.
The same process of atherosclerosis can affect arteries elsewhere in the body: the brain arteries (causing stroke) and the leg arteries (causing pain on walking). Managing the underlying risk factors therefore benefits the entire cardiovascular system, not only the heart.
In some patients, changes consistent with reduced blood flow can be detected on heart tests before any symptoms develop — which is why risk assessment and screening can be valuable even in people who feel well.
Plaque narrows the coronary artery, restricting blood flow to the heart muscle during exertion
Internationally Recognised Research Dr Nijjer has conducted major clinical research studies — published in high-impact peer-reviewed journals — that have changed international guidelines on the assessment and treatment of angina.
How It Feels
Symptoms of Angina
Angina typically presents as a tightness in the chest that comes on with exertion — running for a bus, climbing stairs, walking uphill — and passes within minutes of stopping. Patients often describe it in distinctive ways:
Like wearing an overly tight belt or bra around the chest
A feeling of pressure, as if a hand is placed on the chest holding you back
A band-like sensation across the front of the chest
Many patients instinctively slow their pace or avoid inclines to prevent the symptom coming on — this subconscious adaptation is itself a telling clinical sign. Some notice that after the first episode of exertion, they can continue at the same level without the tightness returning — a phenomenon known as warm-up angina.
The discomfort can radiate beyond the chest:
Some patients feel breathlessness rather than chest tightness — a distinct change from their previous exercise tolerance that warrants investigation. Symptoms are also worsened by cold weather, mental stress, emotional strain, and changes in medication.
Those with confirmed angina are prescribed a GTN spray (glyceryl trinitrate) to use under the tongue at the onset of symptoms. True angina typically resolves within 1–2 minutes of using GTN.
Emergency WarningChest tightness that comes on at rest, without any warning or trigger, may represent unstable angina or a heart attack. Call 999 immediately — do not drive to hospital.
Assessment
How Is Angina Diagnosed?
A diagnosis of angina can often be suspected from the symptoms alone — but Dr Nijjer will always undertake investigations to confirm the cause, assess risk, and guide treatment decisions accurately.
The test pathway is tailored to each patient. Those with low risk may only need non-invasive imaging; those with severe symptoms or high-risk features may be recommended for an invasive angiogram. Dr Nijjer will explain the rationale at each step.
- ECG at rest Baseline snapshot of the heart's electrical activity. A normal ECG does not exclude significant coronary artery disease.
- Echocardiogram Ultrasound assessment of the heart muscle, pump function, and valve structure.
- Exercise stress test ECG recorded during exercise on a treadmill or bike. Looks for electrical changes consistent with reduced blood flow under demand.
- Stress echocardiogram Ultrasound images taken at rest and during pharmacological or exercise stress — detects wall motion abnormalities caused by reduced blood supply.
- CT Coronary Angiogram Non-invasive scan that visualises plaque in the coronary arteries, measures calcium score, and identifies narrowings — all without requiring a catheter.
- Cardiac MRI Stress perfusion MRI identifies areas of the heart muscle with reduced blood flow — particularly useful for detecting microvascular disease.
- Invasive angiogram Gold standard for patients with severe angina or high-risk test findings. Performed through the wrist artery as a day-case procedure, with simultaneous iFR pressure-wire measurement to guide whether stenting is needed.
Tests are selected according to each patient's symptoms, risk factors, and prior investigations
Dr Nijjer is one of the world's leading experts in iFR pressure-wire physiology — a technique he helped develop that measures blood flow within coronary arteries to identify which narrowings are actually causing angina and which can be safely managed with medication alone.
Management
Treating Angina
Effective angina management combines risk factor control, medications to reduce symptoms and stabilise disease, and in appropriate cases, a procedure to restore blood flow.
- Anti-platelet Therapy Aspirin 75mg reduces platelet activity and lowers the risk of a clot forming on a vulnerable plaque. Patients with confirmed coronary artery disease are typically started on aspirin. In some cases, a more potent anti-platelet such as Clopidogrel is used alongside or instead.
- Statins — Cholesterol Management Statin medications lower LDL cholesterol, stabilise existing coronary plaques, and reduce inflammation within the artery wall. In patients with confirmed coronary disease, statins are a cornerstone of treatment and can slow or halt disease progression.
- Anti-anginal Medications Several drug classes reduce the frequency and severity of anginal symptoms by lowering the heart's oxygen demand or improving blood flow: beta-blockers slow the heart rate; long-acting nitrates dilate coronary arteries; calcium channel blockers reduce arterial spasm and heart rate; and newer agents such as ivabradine or ranolazine offer additional options.
- Coronary Angioplasty (PCI) When a narrowing is proven by pressure-wire measurement to be genuinely restricting blood flow, coronary angioplasty and stenting can open the artery and restore normal flow — relieving symptoms that have not responded adequately to medications. Dr Nijjer is one of the UK's leading complex angioplasty operators.
- Coronary Artery Bypass Surgery Patients with very severe or widespread coronary artery disease — particularly where multiple vessels are involved — may be best served by bypass surgery. Dr Nijjer works closely with cardiac surgeons to ensure the right patients are referred to the most appropriate treatment.
Further Information
Additional Resources
The British Heart Foundation provides patient information on angina, including downloadable PDF guides on symptoms, medications, and what to expect at a cardiology appointment.
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Experiencing Chest Tightness
on Exertion?
Do not ignore recurring angina symptoms. Dr Nijjer offers same-week appointments at Harley Street and across London — prompt assessment and a clear diagnosis.