Angina Lifestyle changes that may be helpful:

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Candace Gilbert
5 years ago
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1 Angina Chest pain due to reduced blood flow to the heart is known as angina or angina pectoris. Hardening of the coronary arteries (atherosclerosis) that feed the heart is usually the underlying problem. Therefore it is very important that anyone with angina read the section on atherosclerosis; the information there is important for treatment and prevention of angina. The only items covered here are those that specifically relate to angina. Coronary artery spasms may also cause angina. There are three main types of angina. The first is called stable angina. This type of chest pain comes on during exercise and is both common and predictable. Stable angina is most associated with atherosclerosis. A second type, called variant angina, can occur at rest or during exercise. This type is primarily due to sudden coronary artery spasm, though atherosclerosis may also be a component. The third, most severe type is called unstable angina. It occurs with no predictability and can quickly lead to a heart attack. Anyone with significant, new chest pain or a worsening of previously mild angina must seek medical care immediately. Lifestyle changes that may be helpful: Cigarette smoking causes damage to the coronary arteries and, in this way, can contribute to angina. Stopping smoking is critical for anyone with angina who smokes. Smoking has also been

2 shown to reduce the effectiveness of treatment of angina.1 Secondhand smoke should be avoided as well.2 Increasing physical exercise has been clearly demonstrated to reduce symptoms of angina as well as to relieve the underlying causes. One study found that intense exercise daily for ten minutes was as effective as beta-blocker drugs in one group of patients with angina.3 Anyone with a heart condition including angina or anyone over the age of forty should consult a doctor before beginning an exercise plan. Dietary changes that may be helpful: Coffee should probably be avoided. Drinking five cups or more a day has been shown to increase the risk of angina, although specifics about the relationship between different forms of coffee and angina remain unclear.4 (See also the section on atherosclerosis.) Nutritional supplements that may be helpful: Carnitine is an amino acid important for transporting fats that can be turned into energy in the heart. Several studies using 1 gram of carnitine two to three times per day show improvement in heart function and reduced symptoms in patients with angina Coenzyme Q10 also contributes to the energy-making mechanisms of the heart. Angina patients given 150 mg of coenzyme Q10 each day have experienced greater ability to exercise without problems.8 This has been confirmed in independent investigations.9 Low levels of antioxidant vitamins in the blood, particularly vitamin E, are associated with greater rates of

3 angina.10 This is true even when smoking and other risk factors for angina are taken into account. Early, short-term studies using 300 IU per day of vitamin E could not find a beneficial action on angina.11 A later study supplementing small doses of vitamin E (50 IU per day) for longer periods of time showed a minor benefit in people suffering angina.12 Those affected by variant angina have been found to have the greatest deficiency of vitamin E compared with other angina patients.13 Fish oil, which contains the beneficial fatty acids known as EPA and DHA, has been studied in the treatment of angina. In some studies, 3 grams or more of fish oil three times per day (providing a total of about 3 grams of EPA and 2 grams of DHA) have reduced chest pain as well as the need for nitroglycerin, a common medication used to treat angina;14 other investigators could not confirm these findings.15 If fish oil is supplemented, vitamin E should be taken with it, as vitamin E may protect the fragile oil against free radical damage.16 Magnesium deficiency may be responsible for spasms that occur in coronary arteries, particularly in variant angina While studies have used injected magnesium to stop such attacks effectively,19 20 it is unclear if oral magnesium would be effective. Nitroglycerin and similar drugs cause dilation of arteries by interacting with nitric oxide, a potent stimulus for dilation. Nitric oxide is made from arginine, a common amino acid. Blood cells in people with angina are known to make

4 insufficient nitric oxide,21 which may in part be due to abnormalities of arginine metabolism. Taking 2 grams of arginine three times per day for as little as three days has improved the ability of angina sufferers to exercise.22 Detailed studies have investigated the mechanism of arginine and have proven that it operates by stimulating blood vessel dilation.23 Bromelain is a natural blood thinner because it prevents excessive blood platelet stickiness.24 This may explain, in part, the positive reports in a few clinical trials of bromelain to decrease thrombophlebitis (inflammation of veins) and pain from angina and thrombophlebitis Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions. Herbs that may be helpful: The fruits, leaves, and flowers of the hawthorn tree contain anthocyanidins, which protect blood vessels from damage. A 60 mg hawthorn extract containing 18.75% proanthocyanidins taken three times per day improved heart function and exercise tolerance in angina patients.27 Kudzu is used in modern Chinese medicine as a treatment for angina. Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

5 References: 1. Deanfield J, Wright C, Krikler S, et al. Cigarette smoking and the treatment of angina with propranolol, atenolol, and nifedipine. N Engl J Med 1984;310: Glantz SA, Parmley WW. Passive smoking and heart disease. JAMA 1995;273: [review]. 3. Todd IC, Ballantyne D. Antianginal efficacy of exercise training: A comparison with beta blockade. Br Heart J 1990;64: LaCroix AZ, Mead LA, Liang KY, et al. Coffee consumption and the incidence of coronary heart disease. N Engl J Med 1986;315: Cherchi A, Lai C, Angelino F, et al. Effects of L-carnitine on exercise tolerance in chronic stable angina: A multicenter, double-blind, randomized, placebocontrolled crossover study. Int J Clin Pharm Ther Toxicol 1985;23: Canale C, Terrachini V, Biagini A, et al. Bicycle ergometer and echocardiographic study in healthy subjects and patients with angina pectoris after administration of L-carnitine: Semiautomatic computerized analysis of M-mode tracing. Int J Clin Pharmacol Ther Toxicol 1988;26: Cacciatore L, Cerio R, et al. The therapeutic effect of L-carnitine in patients with exercise-induced stable angina: A controlled study. Drugs Exp Clin Res 1991;17: Kamikawa T, Kobayashi A, Yamashita T, et al. Effects of coenzyme Q10 on exercise tolerance in chronic stable angina pectoris. Am J Cardiol 1985;56: Mortensen SA. Perspectives on therapy of cardiovascular diseases with coenzyme Q10 (ubiquinone). Clin Invest 1993;71:s [review]. 10. Riemersma RA, Wood DA, Macintyre CC, et al. Risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene. Lancet 1991;337: Rinzler SH, Bakst H, Benjamin ZH, et al. Failure of alpha-tocopherol to influence chest pain in patients with heart disease. Circulation 1950;1: Rapola RM, Virtamo J, Haukka JK, et al. Effect of vitamin E and beta carotene on the incidence of angina pectoris. A randomized, double-blind, controlled trial. JAMA 1996;275: Miwa K, Miyagi Y, Igawa A, et al. Vitamin E deficiency in variant angina. Circulation 1996;94: Saynor R, Verel D, Gillott T. The long-term effect of dietary supplementation with fish lipid concentrate on serum lipids, bleeding time, platelets and angina. Atheroscl 1984;50: Mehta JL, Lopez LM, Lawson D, et al. Dietary supplementation with omega-3 polyunsaturated fatty acids in patients with stable coronary heart disease. Effects on indices of platelet and neutrophil function and exercise performance. Am J Med 1988;84:45 52.

6 16. Wander RC, Du SH, Ketchum SO, Rowe KE. Alpha-tocopherol influences in vivo indices of lipid peroxidation in postmenopausal women given fish oil. J Nutr 1996;126: Turlapaty P, Altura B. Magnesium deficiency produces spasms of coronary arteries: Relationship to etiology of sudden death ischemic heart disease. Science 1980;208: Goto K, Yasue H, Okumura K, et al. Magnesium deficiency detected by intravenous loading test in variant angina pectoris. Am J Cardiol 1990;65: Cohen L, Kitzes R. Magnesium sulfate in the treatment of variant angina. Magnesium 1984;3: Cohen L, Kitzes R. Prompt termination and/or prevention of cold-pressorstimulus-induced vasoconstriction of different vascular beds by magnesium sulfate in patients with Prinzmetal s angina. Magnesium 1986;5: Mollace V, Romeo F, Martuscelli E, et al. Low formation of nitric oxide in polymorphonuclear cells in unstable angina pectoris. Am J Cardiol 1994;74: Ceremuzynski L, Chamiec T, Herbaczynska-Cedro K. Effect of supplemental oral L-arginine on exercise capacity in patients with stable angina pectoris. Am J Cardiol 1997;80: Egashira K, Hirooka Y, Kuga T, et al. Effects of L-arginine supplementation on endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary arteriograms. Circulation 1996;94: Heinicke R, van der Wal L, Yokoyama M. Effect of bromelain (Ananase) on human platelet aggregation. Experientia 1972;28: Nieper HA. Effect of bromelain on coronary heart disease and angina pectoris. Acta Med Empirica 1978;5: Seligman B. Oral bromelains as adjuncts in the treatment of acute thrombophlebitis. Angiology 1969;20: Hanack T, Bruckel MH. The treatment of mild stable forms of angina pectoris using Crataegutt novo. Therapiewoche 1983;33: [in German]

Angina Pectoris. Edward JN Ishac, Ph.D. Smith Building, Room

Angina Pectoris. Edward JN Ishac, Ph.D. Smith Building, Room Angina Pectoris Edward JN Ishac, Ph.D. Smith Building, Room 742 eishac@vcu.edu 828-2127 Department of Pharmacology and Toxicology Medical College of Virginia Campus of Virginia Commonwealth University