Angina (Angina Pectoris): Types, Symptoms, Diagnosis, Treatment and Nursing Care

Add a suitable educational image showing coronary narrowing and angina pain here.

Learning objectives

• Define angina pectoris and explain how an oxygen supply–demand mismatch produces symptoms.
• Differentiate stable, unstable, vasospastic (Prinzmetal), microvascular and refractory angina.
• Describe typical, atypical and anginal-equivalent presentations, including symptoms in women, older adults and people with diabetes.
• Assess a patient with chest discomfort using a structured history, examination and urgent triage.
• Explain the investigations used to diagnose myocardial ischaemia and exclude myocardial infarction or other life-threatening causes.
• Outline immediate care, long-term medicines, risk-factor control, revascularisation principles and nursing interventions.
• Teach patients how to use their prescribed rescue plan and when to seek emergency help.

1. Definition and core concept

Angina pectoris is a clinical syndrome of discomfort or an equivalent symptom caused by temporary myocardial ischaemia—when the heart muscle needs more oxygen than the coronary circulation can supply. The commonest cause is coronary artery disease (CAD), in which atherosclerotic plaque narrows or destabilises a coronary artery. Angina is a symptom of an underlying cardiovascular problem; it is not itself the same as myocardial infarction.

During increased workload, the myocardium needs more oxygen. If a narrowed artery cannot increase blood flow sufficiently, ischaemic metabolites stimulate cardiac nerves and produce pressure, tightness, heaviness, burning or breathlessness. The episode may settle when the workload falls, but the underlying risk remains.

2. Types of angina

3. Causes and risk factors

3.1 Coronary causes

• Atherosclerotic plaque causing fixed narrowing of a coronary artery.
• Acute plaque rupture with platelet aggregation and partial coronary obstruction, producing unstable angina or myocardial infarction.
• Coronary vasospasm, endothelial dysfunction or microvascular disease.
• Prior coronary intervention, graft disease or congenital coronary abnormality.

3.2 Conditions that increase myocardial oxygen demand or reduce supply

• Uncontrolled hypertension, tachyarrhythmia, fever, thyrotoxicosis or severe emotional stress.
• Anaemia, hypoxaemia, respiratory disease, hypotension or severe infection.
• Aortic stenosis, hypertrophic cardiomyopathy, heart failure or severe valve disease.
• Severe dehydration or blood loss reducing coronary perfusion.

3.3 Modifiable and non-modifiable risks

4. Pathophysiology

1. Endothelial injury allows lipids and inflammatory cells to accumulate in the arterial wall.
2. Atherosclerotic plaque enlarges and narrows the coronary lumen; blood flow becomes inadequate during exertion.
3. Exercise, stress or cold increases heart rate, contractility and blood pressure, raising oxygen demand.
4. The supply–demand mismatch produces transient myocardial ischaemia and anginal symptoms.
5. If a plaque ruptures and thrombosis abruptly reduces flow, pain becomes prolonged or occurs at rest and ACS may develop.
6. Repeated or severe ischaemia can impair ventricular function, provoke arrhythmias and progress to infarction or heart failure.

5. Clinical features

5.1 Typical anginal discomfort

• Pressure, squeezing, heaviness, tightness, burning or an uncomfortable fullness behind the sternum.
• May radiate to one or both arms, shoulders, neck, jaw, back or upper abdomen.
• Triggered by exertion, emotional stress, cold air or a heavy meal in stable angina.
• Usually improves with stopping the trigger, rest or prescribed short-acting medicine in stable disease.
• May be accompanied by breathlessness, sweating, nausea, dizziness, palpitations or a feeling of impending danger.

5.2 Atypical and anginal-equivalent symptoms

Women, older adults and people with diabetes may present without classic chest pressure. Ask about exertional shortness of breath, unexplained fatigue, reduced exercise tolerance, nausea, indigestion-like discomfort, jaw or back pain, dizziness, faintness and sweating. “Atypical” does not mean unimportant; it means the presentation may not match the textbook pattern.

5.3 Features suggesting instability or infarction

• New angina, a rapidly increasing frequency or severity, or pain with less exertion than before.
• Pain at rest, during sleep or lasting longer than the patient’s usual episodes.
• Failure of the usual prescribed rescue plan or recurrence soon after relief.
• Marked dyspnoea, pallor, sweating, vomiting, syncope, hypotension, confusion or a new irregular pulse.
• Persistent symptoms with new ECG changes or elevated cardiac biomarkers.

6. Focused history: OPQRST and cardiovascular detail

7. Physical examination and immediate triage

1. Assess airway, breathing and circulation; note work of breathing, skin colour, sweating and level of consciousness.
2. Measure pulse, blood pressure in the appropriate arm, respiratory rate, oxygen saturation, temperature and pain score.
3. Check pulse rhythm, capillary refill, peripheral temperature and signs of shock.
4. Auscultate heart and lungs for murmurs, gallop rhythm, crackles, wheeze or reduced air entry.
5. Look for raised JVP, oedema, hepatomegaly, calf swelling, unequal pulses or neurological deficit.
6. Obtain a 12-lead ECG promptly when current chest pain or suspected ACS is present, according to local protocol.
7. Place the patient at rest in a safe position, keep the environment calm, and ensure emergency equipment is available.

8. Important differential diagnoses

Chest discomfort has many causes. A cardiac cause must be considered before a non-cardiac explanation is accepted.

• Acute coronary syndrome: unstable angina, NSTEMI or STEMI.
• Pulmonary embolism: sudden dyspnoea, pleuritic pain, tachycardia, hypoxaemia or risk factors for venous thrombosis.
• Aortic dissection: abrupt tearing pain to the back, pulse/BP difference or neurological signs.
• Pneumothorax or pneumonia: pleuritic pain, breathlessness and abnormal chest signs.
• Pericarditis or myocarditis: positional pain, viral prodrome or inflammatory findings.
• Gastro-oesophageal reflux or oesophageal spasm: burning or post-meal symptoms, but cardiac disease must be excluded first.
• Musculoskeletal chest pain: localised tenderness or movement-related pain; do not rely on tenderness alone to exclude ACS.
• Panic or anxiety: may coexist with or mimic cardiac disease; never label a first severe episode as anxiety without assessment.

9. Diagnostic investigations

10. Immediate management of an angina episode

Follow the patient’s written action plan and the current facility protocol. The steps below describe safe principles, not a substitute for clinical assessment or prescription.

1. Stop exertion and sit the patient in a comfortable supported position; do not allow the patient to walk unassisted.
2. Stay with the patient, assess ABCDE and obtain vital signs and a focused history.
3. Ask whether this is the patient’s usual pattern and what prescribed rescue medicine is available.
4. Administer the prescribed short-acting anti-anginal medicine using the ordered route and safety checks; reassess pain, BP, pulse and symptoms.
5. Obtain an ECG and activate the ACS pathway when pain is new, severe, prolonged, occurs at rest, differs from usual or is accompanied by red flags.
6. Provide oxygen only when clinically indicated by hypoxaemia or significant respiratory distress, according to local protocol.
7. Prepare prescribed antiplatelet, anticoagulant, analgesic or reperfusion-related treatment when ACS is suspected; do not give unprescribed medicines or delay referral.
8. Escalate if the patient becomes hypotensive, develops pulmonary oedema, arrhythmia, persistent pain, syncope or altered consciousness.
9. Document onset, ECG time, medicines, response, observations, escalation and handover information.

11. Medical management of stable angina

11.1 Goals

• Relieve symptoms and improve activity tolerance and quality of life.
• Prevent myocardial infarction, heart failure and cardiovascular death.
• Control the disease processes causing coronary narrowing and thrombosis.
• Support informed shared decisions about medication, rehabilitation and revascularisation.

11.2 Medicine groups

11.3 Revascularisation

When symptoms remain limiting despite appropriate medical therapy, or when anatomy places the patient at high risk, the cardiology team may consider percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The decision depends on coronary anatomy, ventricular function, diabetes, kidney function, surgical risk, local resources and the patient’s informed preferences.

12. Nursing management

12.1 Nursing assessment

• Assess current pain with OPQRST, severity and functional effect; compare with the patient’s known pattern.
• Record pulse, rhythm, BP, respirations, oxygen saturation, temperature, mental state and skin signs.
• Monitor ECG, cardiac biomarkers and trends as ordered; report new abnormalities immediately.
• Assess breathlessness, orthopnoea, oedema, fatigue, exercise tolerance and sleep disturbance.
• Review smoking, diet, activity, alcohol, diabetes, BP, lipids, kidney disease and previous cardiovascular events.
• Check all prescribed medicines, last doses, allergies, use of non-prescription drugs and access barriers.

12.2 Nursing interventions and rationale

13. Lifestyle and secondary prevention

• Stop smoking and avoid second-hand smoke; refer to cessation support where available.
• Take prescribed medicines consistently even when symptoms improve; never stop antiplatelet, beta-blocker or other long-term medicine without advice.
• Choose a heart-healthy eating pattern with vegetables, fruit, legumes, whole grains and appropriate portions; reduce excess salt, trans fats, saturated fats and highly processed foods.
• Control BP, diabetes, lipids and body weight through an individualised plan.
• Use graded activity or cardiac rehabilitation as advised; avoid sudden strenuous exertion until assessed.
• Manage stress, sleep and harmful alcohol use; address social barriers that make treatment difficult.
• Keep a symptom diary noting triggers, duration, rescue medicine and response.
• Attend follow-up and report a change from the established pattern rather than waiting for the next appointment.

14. Patient education: the rescue and emergency plan

1. Keep prescribed rescue medicine accessible, in its original labelled container and within expiry.
2. Stop and rest as soon as usual symptoms begin; do not continue walking or driving.
3. Use the prescribed rescue medicine exactly as instructed, while monitoring dizziness and blood pressure symptoms.
4. Seek emergency help for pain that is new, severe, prolonged, occurs at rest, feels different, does not settle as expected or is accompanied by breathlessness, sweating, faintness, collapse or neurological symptoms.
5. Do not drive yourself during suspected ACS; arrange emergency transport according to local services.
6. Tell all health workers about angina, stents, bypass surgery, allergies and antiplatelet/anticoagulant treatment.

15. Complications

16. Worked clinical scenarios

Scenario 1: Predictable stable angina

A 58-year-old reports central pressure whenever he walks quickly uphill. It stops after several minutes of rest and has been unchanged for two months. The nurse documents the pattern, checks vital signs and cardiovascular risk factors, confirms the prescribed rescue plan, arranges medical review and teaches him not to exceed his safe activity threshold until assessed.

Scenario 2: Change from baseline

A patient who normally has discomfort after 20 minutes of walking now has pain while sitting and says the episodes are lasting longer. The nurse does not label it “usual angina.” She keeps the patient at rest, starts urgent assessment, obtains an ECG, calls the clinician/emergency team and prepares prescribed ACS treatment.

Scenario 3: Atypical presentation in diabetes

A 67-year-old with diabetes reports unusual fatigue, nausea and breathlessness while doing household work but denies chest pain. Because diabetes may reduce pain perception, the nurse treats the symptoms as possible anginal equivalents, assesses ABCDE, obtains observations and ECG, and escalates according to risk.

Scenario 4: Nitrate-related dizziness

After prescribed short-acting nitrate, a patient becomes dizzy and pale. The nurse keeps the patient seated or lying safely, checks BP and pulse, reassesses pain and follows the medicine and escalation protocol. The patient is taught not to stand suddenly or take extra doses outside the written plan.

17. Examination and revision questions

1. Define angina pectoris and explain the myocardial oxygen supply–demand mismatch.
2. Compare stable, unstable and vasospastic angina in relation to triggers, timing and urgency.
3. List at least eight cardiovascular risk factors for coronary artery disease.
4. Describe typical and atypical presentations of myocardial ischaemia.
5. What changes in a patient’s usual pattern suggest unstable angina or ACS?
6. Outline the focused history and examination for a patient with chest discomfort.
7. Explain the role and limitations of ECG and serial troponin testing.
8. Describe the immediate nursing care of a patient with suspected ACS.
9. Discuss the medicine groups used in stable angina and the monitoring required for each.
10. Prepare a teach-back discharge plan for a patient with newly diagnosed stable angina.
11. Differentiate angina from pulmonary embolism, aortic dissection and musculoskeletal chest pain.
12. Explain why an absence of chest pain does not exclude myocardial ischaemia in diabetes.

Key takeaways

• Angina is temporary myocardial ischaemia and a warning sign of underlying cardiovascular disease.
• Stable angina is predictable; new, worsening, prolonged or rest pain is an emergency until proven otherwise.
• Women, older adults and people with diabetes may present with breathlessness, fatigue, nausea or other equivalents rather than classic pain.
• Rapid ABCDE assessment, ECG, monitoring and escalation prevent avoidable delay in ACS.
• Long-term care combines medicines, risk-factor control, rehabilitation, patient education and reliable follow-up.

Suggested references

1. National Health Service. Angina: symptoms and urgent warning signs.
2. American Heart Association. Stable angina, unstable angina and acute coronary syndrome resources.
3. American Heart Association/American College of Cardiology. Guideline for the management of patients with chronic coronary disease. 2023.
4. Relevant Uganda Ministry of Health and facility protocols for chest pain, ACS, emergency transport, antiplatelet therapy and cardiac rehabilitation.