Living With Stable Angina: Symptoms, GTN, Treatment and Everyday Life

Stable angina is chest discomfort caused by the heart muscle not receiving enough blood and oxygen for its workload. It often occurs during activity or stress and settles with rest or prescribed glyceryl trinitrate, known as GTN.

The word “stable” does not mean unimportant. It means that the symptoms have a reasonably predictable pattern. Treatment can reduce attacks, improve quality of life and lower the risk of heart attack and stroke.

What does stable angina feel like?

People commonly describe:

• pressure, heaviness, squeezing, tightness or burning in the chest
• discomfort spreading to an arm, shoulder, neck, jaw, back or upper abdomen
• shortness of breath or unusual tiredness instead of obvious pain
• symptoms brought on by walking quickly, climbing hills, cold weather, stress or a heavy meal
• improvement after stopping to rest or using prescribed GTN

Not every person has a textbook pattern. Women, older people and people with diabetes can have less typical symptoms. New or unexplained symptoms should be assessed rather than self-diagnosed.

What causes angina?

The most familiar cause is narrowing of the larger coronary arteries by atherosclerosis, the build-up of fatty plaque in artery walls. During exertion, the heart needs more oxygen. A narrowed artery may be unable to increase blood flow enough, producing symptoms.

Angina can also occur without a major obstructive narrowing. Problems affecting the tiny vessels within the heart muscle, or abnormal spasm of a coronary artery, can restrict blood flow. These conditions sit within the broader terms ANOCA and INOCA and may require different tests and treatment.

Anaemia, uncontrolled blood pressure, a very fast heart rhythm and other illnesses can increase the heart's workload or reduce oxygen delivery. Your clinician will consider the whole picture.

How is stable angina diagnosed?

Diagnosis starts with a careful description of the symptoms, medical history, examination and cardiovascular risk factors. Tests may include:

• an ECG, which records the heart's electrical activity
• blood tests for cholesterol, diabetes, anaemia, kidney function and other conditions
• an echocardiogram to assess heart structure and pumping function
• CT coronary angiography to look for plaque and narrowing in the coronary arteries
• stress imaging to assess blood flow when the heart works harder
• invasive coronary angiography in selected patients

A normal resting ECG does not rule out angina. Similarly, an angiogram without a severe narrowing does not prove that symptoms are non-cardiac. Persistent symptoms sometimes require assessment for microvascular dysfunction or coronary spasm.

What should I do during an angina attack?

Follow the personal plan supplied by your clinician. In general:

1. Stop the activity and rest, preferably sitting down.
2. Use your short-acting GTN exactly as prescribed.
3. Follow the instructed timing for a repeat dose if symptoms have not settled.
4. Call 112 or 999 if the pain does not settle according to your plan, or sooner if it is severe or accompanied by breathlessness, sweating, nausea, collapse or other concerning symptoms.

GTN may cause headache, flushing or light-headedness. Sit down before taking it to reduce the risk of falling. Ask your pharmacist or clinician to check that you know how to operate and store your spray or tablets.

GTN can interact dangerously with medicines for erectile dysfunction and certain treatments for pulmonary hypertension. Discuss these medicines openly with your prescriber. Never assume they are safe to combine.

How is stable angina treated?

Treatment has two separate aims.

Reducing angina symptoms

Medicines may reduce the heart's workload, improve blood flow or prevent attacks. Options include beta-blockers, calcium-channel blockers, long-acting nitrates and other anti-anginal medicines. The best choice depends on heart rate, blood pressure, other health conditions, side effects and the likely mechanism of the angina.

Tell your clinician if treatment is not improving your daily life. A medicine that is effective on paper may still need adjustment if it causes troublesome tiredness, dizziness or other adverse effects.

Preventing heart attack and stroke

Separate treatments address the underlying cardiovascular risk. These may include antiplatelet medication, cholesterol-lowering therapy and treatment for high blood pressure or diabetes. Smoking cessation, regular activity and a heart-healthy eating pattern remain important even when medicines are prescribed.

Do not start aspirin or change prescribed medicines without individual advice. The balance between benefit and bleeding risk differs between people.

Do I need a stent or bypass surgery?

Not everyone with stable angina needs a procedure. Many people achieve good symptom control with medicines and risk-factor treatment.

A stent, also called percutaneous coronary intervention, widens a narrowed coronary artery. Coronary artery bypass grafting creates new routes for blood to reach the heart muscle. A procedure may be considered when symptoms remain unacceptable despite suitable medical treatment, when tests show high-risk coronary disease, or when the pattern of disease makes revascularisation beneficial.

The decision should reflect your anatomy, symptoms, other medical conditions and preferences. Ask what the procedure is expected to achieve for you: symptom relief, improvement in prognosis, or both.

Can I exercise with angina?

For most people with stable, assessed angina, appropriately prescribed physical activity is beneficial. It can improve fitness, blood pressure, mood, diabetes control and overall cardiovascular health.

Start at a level agreed with your healthcare team. Warm up gradually, carry your GTN and pay attention to your usual symptom threshold. Your clinician may advise using GTN before a predictable activity.

Stop and follow your angina plan if symptoms occur. Seek review if you are developing symptoms with less activity than before. New rest pain or persistent symptoms need urgent assessment.

What about work, travel and sex?

Many people with well-controlled stable angina continue their usual activities.

• Work: Adjustments may be needed for heavy physical work, extreme temperatures or safety-critical roles.
• Driving: Rules depend on symptom control, licence type and jurisdiction. Check current Irish regulations and follow your clinician's advice.
• Travel: Carry enough medicine in hand luggage, keep GTN accessible and take a current medication list. Discuss unstable symptoms or recent procedures before flying.
• Sex: Sexual activity is usually possible when symptoms are stable and ordinary moderate activity is comfortable. Ask for individual advice if symptoms occur or you are uncertain.

When does stable angina become an emergency?

Call 112 or 999 if chest discomfort:

• occurs at rest or wakes you from sleep
• lasts longer than usual
• becomes more frequent, severe or unpredictable
• begins with much less activity than before
• does not respond to rest and GTN as your plan predicts
• occurs with marked breathlessness, sweating, nausea, faintness or collapse

This change in pattern may indicate unstable angina or a heart attack.

What should I monitor between appointments?

Keep a brief symptom record. Note the trigger, duration, severity, GTN use and whether your exercise capacity is changing. Also take prescribed medicines consistently and attend requested monitoring for blood pressure, cholesterol, kidney function or diabetes.

The goal is not simply to tolerate chest pain. Good management should help you live more confidently while reducing future cardiovascular risk. If angina is limiting your life, ask for a review.

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Medical note: This is general information. Your diagnosis, GTN instructions, medicine choices and safe activity level must be individualised by your healthcare team. Call 112 or 999 for possible heart-attack symptoms.

Sources

• NICE CG126: Stable angina management
• NHS: Angina
• NHS England: Making a decision about stable angina
• ESC 2024 Guidelines for chronic coronary syndromes