Dr Sukhjinder Nijjer
Expert in Angina and Chest Pain
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Angina is a medical term used to refer to a tightness in the chest. If this occurs on exertion (for example, when running) and subsides when resting, and if the discomfort can be felt in either arm or neck, then it is referred to as ‘Classical Angina’. Angina is usually relieved by resting or by giving a medication called Glyceryl Trinitrate (GTN) – in the form a spray under the tongue or small tablets.
In most cases, not all patients will have all of these features and it may be referred to as ‘Atypical Angina’. Cardiologists, like Dr Nijjer will determine if your chest tightness is angina or an another cause of chest tightness.
Angina is usually caused by coronary artery disease. This is a narrowing of the heart’s arteries caused by a process of atherosclerosis – also known as a build up of ‘plaque’. There are a number of patients who have angina due to abnormalities of their micro-vessels – these are the blood vessels that cannot be easily seen using standard tests.
Patients with angina are typically referred to Cardiologists for important investigations including an ECG and Echocardiography. In many cases, some form of stress testing may be performed. In the UK, we have moved to assess the heart arteries through non-invasive means – such as CT Coronary Angiography. This allows us to visualise the plaque in the heart arteries and assess the patient’s risk.
What Causes Angina?
Angina is a symptom that reflects an underlying heart problem. Not all chest pains are angina, but if the story is highly suggestive, then Cardiologists like Dr Sukhjinder Nijjer will assess for coronary artery disease (CAD).
Coronary artery disease is the narrowing of the heart’s arteries by a build up of plaque – this is made up of cholesterol, inflammatory cells and calcium, and occurs through a process of atherosclerosis. This can start off as a minor issue and can be triggered by any injury to the blood vessels – it is most commonly caused by smoking, high blood pressure or high cholesterol. Having a combination of these risks, and if you have a family history, means you are more likely to develop atherosclerosis of the heart arteries. This problem can also occur in the brain arteries (cerebrovascular disease – causing strokes) and the leg arteries (peripheral artery disease – causing leg pain on walking).
A build up of plaque will reduce the blood flow to the heart muscle and so reduce the amount of oxygen and nutrients available to the heart muscle. This is not noticeable when the individual is resting or undertaking light activities – the heart arteries adapt in response to the narrowing. However, when the individual undertakes more activity, such as running or other forms of exercise, the heart has to beat harder to supply the body’s muscles. In this situation, the reduced blood flow through the narrowed heart arteries will be insufficient.
A reduced blood supply to the heart muscle will cause a change in how the heart functions – and this can be detected by certain heart tests before the patient develops symptoms. Once the narrowing is very meaningful, the patient will develop a characteristic set of symptoms on exertion – a feeling of chest tightness across the chest. Many describe it as a band-like sensation, a feeling of pressure or as if there is a weight on the chest. When the increased activity stops, the demand on the heart does down and so the heart goes back to a resting state. As this occurs, the chest tightness will quickly subside and the symptoms will go away.
Symptoms of chest pain or tightness on exertion should not be ignored and repeated symptoms should be assessed by a Cardiologist. Dr Sukhjinder Nijjeris a specialist who runs clinics dedicated to treating patients with angina and is an expert in the appropriate testing, the use of medications to help reduce or resolve the symptoms, and if necessary, the use of invasive procedures to treat the heart artery narrowings causing the problem. Dr Sukhjinder Nijjer has performed major research studies, published in high-impact factor peer-reviewed journals, which have changed international guidelines on the treatment of angina.
What symptoms does angina cause?
Angina is typically a tightness in the chest that occurs when the individual undertakes exertion. It may occur when you are running for the bus, out for a jog or walking up the escalator during your commute. You may notice that you adapt your exertion to walk more slowly to avoid the symptom coming on. The symptoms will be worse on inclines such as hills or stairs.
Those with angina will often comment that the feeling is not really a pain, but an odd sensation of pressure or tightness. Many patients describe the feeling as if they are wearing an overly tight belt or bra around the chest. Others say it feels like a hand being placed on their chest – holding them back. When they stop the activity, the feeling quickly subsides. In some cases, after the initial activity that triggers the symptom, they are able to get back to exercise without major limitation. In others, restarting activity at the same level recreates the symptoms each time.
The symptom of tightness can extend into the left or right arm. In some patients it moves into their throat or neck. Others feel it in their back.
Some patients do not get a chest tightness, but a feeling of breathlessness when they undertake their activities. This can be difficult to diagnose but those with the problem will feel that there has been a distinct change in what they can do compared to previously.
The symptom can be worse at times of stress – either mental or emotional. This is because stress alters your perception of symptoms but also because stress can elevate your blood pressure and raise your heart rate, which can make the symptom of angina worse. Angina can also be worse if the weather is cold or if there has been a change in your medication.
If the symptoms of chest tightness are recurrent, patients will be prescribed a GTN spray that can help alleviate the symptoms. Those with true angina will find their symptoms resolve very quickly with a GTN spray, often within 1-2 minutes.
If the symptoms of chest tightness comes on at rest, without warning, this can be a dangerous symptom and can reflect either “unstable angina” or a true heart attack. In this situation, you should call for emergency medical attention by ringing 999.
How is Angina Diagnosed?
A diagnosis of angina can often be made based on the symptoms a patient reports – but not all angina is caused by heart artery narrowings and Cardiologists, such as Dr Sukhjinder Nijjer, will undertake a number of investigations to assess the individual’s risk.
Commonly, Dr Nijjer will undertake an ECG at rest and an echocardiogram to assess the structure and function of the heart. Following this, further testing will be according to the risk profile of the patient. Some require exercise test, stress echocardiogram, a CT Coronary Angiogram or Cardiac MRI with stress perfusion.
Those patients with severe angina or severe coronary artery disease with specific changes on the tests performed, will be recommended to have an invasive coronary angiogram. This is a day-case procedure performed by passing a tube through the wrist artery into the heart. This enables direct assessment of the heart arteries. In some cases, if the blood flow is reduced beyond certain parameters, coronary stents may be required to improve the blood flow. In some patients, with very severe heart artery narrowings, coronary artery bypass surgery may be needed.
How is Angina Treated?
Angina and coronary artery disease requires a combination of different approaches to reduce the symptoms, enable full activity and reduce the risk of cardiac events such as heart attack. Patients with confirmed coronary artery disease often need blood thinning medication such as Aspirin or super-Aspirins such as Clopidogrel. Patients with confirmed coronary plaque also benefit from taking medications that improve cholesterol levels – these statin medications can stabilise coronary plaque and prevent it from expanding. Patients with recurrent angina are often treated with a number of medication to have reduce their symptoms and improve the blood supply. In many patients, several different tablets will be needed. In those patients requiring many medications, and if their heart arteries are suitable, Dr Sukhjinder Nijjer may need to perform coronary angioplasty or ‘stenting’ to improve the blood flow. In those patients with very severe heart artery disease, we may need to discuss bypass surgery.
Help Your Heart
If you have any concerns regarding your heart health, then please seek a referral to Dr Nijjer.
Call the Team: Monika, Amy, Charlotte, Erin or Grace:
0203 9838 001
Dr Nijjer can be seen at :
68 Harley Street, London, W1G 7HE
He also practices at Cromwell Hospital, Wellington Hospital, BUPA Clinics, BMI Syon Clinic as well as Imperial Private Healthcare.