Speaking up to ease chest pain Health Article

In spite of clear guidelines for treating angina, many people don’t get the treatments they need for chronic chest pain.

As conditions go, chest pain that predictably appears with exercise or stress — angina pectoris — lends itself to effective control. Lifestyle changes and drug therapy form the bedrock for controlling chest pain as well as for preventing a heart attack or stroke.

Sometimes this combination is all that’s needed to do the job. Yet a new nationwide study indicates that many people aren’t getting the most rudimentary medications they need to keep angina in check.

A pain in the heart In the process known as atherosclerosis, cholesterol-filled plaque builds up inside one or more coronary arteries. This limits the space available for blood flow. If the artery can’t deliver enough blood, and thus enough oxygen and nutrients, to part of the heart muscle, the heart sends distress signals the body interprets as pain, discomfort, or tightness. These sensations are called angina.

Not measuring up

In an effort to gauge the adequacy of angina treatment, researchers asked more than 7,000 veterans with angina if they could look at their medical records and prescription lists. The men and women, all of whom were being treated at Veterans Affairs medical centers from California to Vermont, also filled out standardized angina questionnaires.

According to the surveys, one-third of the veterans did not have their angina under control. Uncontrolled angina was defined as having temporary chest pain — or taking a drug to stop or prevent its onset — three or more times a week. Almost half of those with uncontrolled angina hadn’t been prescribed any anti-angina medications or weren’t given adequate dosages of them.

The results of this study are troubling. Angina pectoris is a well-defined disease. Doctors can turn to detailed guidelines for help managing it. And a variety of drugs and procedures have been proven to halt or control chest pain. Yet even in the VA system where doctor visits and drugs cost little to nothing, a substantial fraction of people didn’t get the basic medications for controlling angina.

Why not? Doctors are partly to blame, say the Veterans Affairs researchers who conducted the study. Busy physicians may not ask questions to determine whether the treatment strategy they’ve concocted is working, or may not listen closely to patients’ stories about their chest pain. They may also be overly cautious about prescribing beta blockers and other standard anti-angina drugs.

People with angina must shoulder some of the responsibility as well. One of the biggest problems with drug therapy is adherence — taking the right drug(s), in the right amount(s), at the right times, and with the correct foods. Poor communication is also an issue. Some people are reluctant to tell their doctor they are still suffering from something that was supposed to be “fixed.”

The main message from this study for anyone with angina, or any other condition, is this: You may need to be a squeaky wheel to get the treatments you need.

ABCs of angina therapy

There are two basic parts to managing angina. One focuses on stopping or pre-empting chest pain. The other aims to halt or reverse atherosclerosis, the artery-narrowing process that contributes to angina and that also leads to more dire consequences, such as heart attack, stroke, or sudden cardiac arrest.

The American College of Cardiology and American Heart Association have devised a simple mnemonic device — ABCDE — that sums up the basic elements of therapy for almost everyone with angina.

A. Anti-anginal medications include short- or long-acting nitrates such as nitroglycerin or isosorbide mononitrate (Imdur, others) that can be used to stop chest pain or prevent it. Aspirin helps prevent blood clots that can block an artery and cause a heart attack or stroke.

B. Beta blockers slow the heart and reduce the amount of oxygen it needs. Blood pressure control may ease angina by preventing further artery narrowing. It also helps prevent heart attack and stroke.

C. Cholesterol control offers much the same benefits as blood pressure control. Cigarette cessation halts a process that damages arteries and reduces the heart’s oxygen supply.

D. Diabetes wreaks havoc on arteries. Controlling it can help the heart, kidneys, and general health. A healthy diet also offers all-around health benefits.

E. Exercise is essential for controlling chest pain and preventing it from getting worse. The better educated you are about angina, the better your chances of beating it.

Since everyone is different, it often takes some tinkering to quell angina. The more you can do with the ABCDE approach, the better for your chest pain and overall health.

When the ABCDEs aren’t enough

When chest pain persists despite lifestyle changes — especially exercise — and drug therapy, more drastic options are available. The most common next step is either angioplasty to open a narrowed artery or surgery to bypass it.

Sometimes a procedure doesn’t work, or isn’t an option. What then? A few approaches exist for so-called refractory angina. Most of these are still experimental, or their benefits have yet to be completely defined. Options include changes in the types or timing of medications, methods to interrupt pain signals from the chest by blocking or stimulating nerves, the use of inflatable pants to push blood through the heart’s arteries, a procedure to create tiny channels for extra blood flow to the heart muscle, and gene therapy.

Finding relief for refractory angina may take an even squeakier wheel. Get involved in your care, and don’t hesitate to speak up if you think your doctor is letting it slide.