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.

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

Low levels of antioxidant vitamins in the blood, particularly vitamin E, are associated with greater rates of 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 amounts 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

Magnesium deficiency may be responsible for spasms that occur in coronary arteries, particularly in variant angina.^{18 19} While studies have used injected magnesium to stop such attacks effectively,^{20 21} 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 insufficient nitric oxide,²² 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.²³ Seven of ten people with severe angina improved dramatically after taking 9 g of arginine per day for three months in an uncontrolled study.²⁴ Detailed studies have investigated the mechanism of arginine and have proven it operates by stimulating blood vessel dilation.²⁵

N-acetyl cysteine (NAC) may improve the effects of nitroglycerin in people with angina.²⁶ People with unstable angina who took 600 mg of NAC three times daily in combination with a nitroglycerin transdermal (skin) patch for four months had significantly lower rates of future heart attacks than people who used either therapy alone or placebo.²⁷

Bromelain has been reported in a preliminary study to relieve angina. In that study, 600 individuals with cancer were receiving bromelain (400 to 1,000 mg per day). Fourteen of those individuals had been suffering from angina. In all fourteen cases, the angina disappeared within four to ninety days after starting bromelain.²⁸ However, as there was no control group in the study, the possibility of a placebo effect cannot be ruled out. Bromelain is known to prevent excessive stickiness of blood platelets,²⁹ which is believed to be one of the triggering factors for angina.

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.³⁰

Kudzu is used in modern Chinese medicine as a treatment for angina.

Other Integrative approaches that may be helpful: Individuals suffering from angina may find that acupuncture can reduce medication use, symptoms, and even the need for invasive surgery. While some studies of acupuncture treatment for angina found no benefit,³¹ others have demonstrated positive results. An uncontrolled study of 49 angina patients found that acupuncture resulted in 58% less nitroglycerin use and a 38% decrease in the number of angina attacks.³² In another study, sixty-nine patients suffering with severe angina were treated with a combination of acupuncture, shiatsu (acupressure), and lifestyle changes. The results were compared to patients with severe angina treated with coronary artery bypass grafting (CABG). The incidence of heart attack and death was 21% among those treated with CABG and 7% in those treated with the combined therapy including acupuncture. In addition, 61% of those treated with the combination therapy, because of their improved health, postponed any further invasive treatment.³³ In a single-blind study of 26 patients, a reduction in angina attack rate and nitroglycerin use, as well as an improvement in exercise performance, occurred in the treatment group compared to a sham (fake) acupuncture group.³⁴ A controlled trial comparing acupuncture treatment (3 treatments per week for 4 weeks) to placebo tablets supports these results, demonstrating a reduction in the number of angina attacks, improved exercise performance, and corresponding improvements in ECG (electrocardiogram) readings.³⁵

Information about the effects of a particular supplement or herb on a particular condition has been qualified in terms of the methodology or source of supporting data (for example: clinical, double blind, meta-analysis, or traditional use). For the convenience of the reader, the information in the table listing the supplements for particular conditions is also categorized. The criteria for the categorizations are: "Primary" indicates there are reliable and relatively consistent scientific data showing a health benefit. "Secondary" indicates there are conflicting, insufficient, or only preliminary studies suggesting a health benefit or that the health benefit is minimal. "Other" indicates that an herb is primarily supported by traditional use or that the herb or supplement has little scientific support and/or minimal proven health benefit.

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;310:951–4.

2. Glantz SA, Parmley WW. Passive smoking and heart disease. JAMA 1995;273:1047–53 [review].

3. Todd IC, Ballantyne D. Antianginal efficacy of exercise training: A comparison with beta blockade. Br Heart J 1990;64:14–9.

4. LaCroix AZ, Mead LA, Liang KY, et al. Coffee consumption and the incidence of coronary heart disease. N Engl J Med 1986;315:977–82.

5. Cherchi A, Lai C, Angelino F, et al. Effects of L-carnitine on exercise tolerance in chronic stable angina: A multicenter, double-blind, randomized, placebo-controlled crossover study. Int J Clin Pharmacol Ther Toxicol 1985;23:569–72.

6. 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;26:221–4.

7. 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;17:225–35.

8. Kamikawa T, Kobayashi A, Yamashita T, et al. Effects of coenzyme Q10 on exercise tolerance in chronic stable angina pectoris. Am J Cardiol 1985;56:247.

9. Mortensen SA. Perspectives on therapy of cardiovascular diseases with coenzyme Q10 (ubiquinone). Clin Investig 1993;71:S116–23 [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;337:1–5.

11. Rinzler SH, Bakst H, Benjamin ZH, et al. Failure of alpha-tocopherol to influence chest pain in patients with heart disease. Circulation 1950;1:288–90.

12. 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;275:693–8.

13. Miwa K, Miyagi Y, Igawa A, et al. Vitamin E deficiency in variant angina. Circulation 1996;94:14–8.

14. 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. Atherosclerosis 1984;50:3–10.

17. Oostenbrug GS, Mensink RP, Hornstra G. A moderate in vivo vitamin E supplement counteracts the fish-oil-induced increase in in vitro oxidation of human low-density lipoproteins. Am J Clin Nutr 1993;57:827S.

18. Turlapaty P, Altura B. Magnesium deficiency produces spasms of coronary arteries: Relationship to etiology of sudden death ischemic heart disease. Science 1980;208:199–200.

19. Goto K, Yasue H, Okumura K, et al. Magnesium deficiency detected by intravenous loading test in variant angina pectoris. Am J Cardiol 1990;65:709–12.

20. Cohen L, Kitzes R. Magnesium sulfate in the treatment of variant angina. Magnesium 1984;3:46–9.

21. Cohen L, Kitzes R. Prompt termination and/or prevention of cold-pressor-stimulus-induced vasoconstriction of different vascular beds by magnesium sulfate in patients with Prinzmetal’s angina. Magnesium 1986;5:144–9.

22. Mollace V, Romeo F, Martuscelli E, et al. Low formation of nitric oxide in polymorphonuclear cells in unstable angina pectoris. Am J Cardiol 1994;74:65–8.

23. 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;80:331–3.

24. Blum A, Porat R, Rosen schein U, et al. Clinical and inflammatory effects of dietary L-arginine in patients with intractable angina pectoris. Am J Cardiol 1999;83:1488–90.

25. 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;94:130–4.

26. Marchetti G, Lodola E, Licciardello L, Colombo A. Use of N-acetylcysteine in the management of coronary artery diseases. Cardiologia 1999;44:633–7.

27. Ardissino D, Merlini PA, Savonitto S, et al. Effect of transdermal nitroglycerin or N-acetylcysteine, or both, in the long-term treatment of unstable angina pectoris. J Am Coll Cardiol 1997;29:941–7.

28. Nieper H. Effect of bromelain on coronary heart diseases and angina pectoris. J Int Acad Prev Med 1976;3(2):62–3.

29. Heinicke R, van der Wal L, Yokoyama M. Effect of bromelain (Ananase) on human platelet aggregation. Experientia 1972;28:844–5.

30. Hanack T, Bruckel MH. The treatment of mild stable forms of angina pectoris using Crataegutt® novo. Therapiewoche 1983;33:4331–3 [in German].

31. Ballegaard S, Pedersen F, Pietersen A, Nissen VH, Olsen NVEffects of acupuncture in moderate, stable angina pectoris: a controlled study.J Intern Med 1990;227:25–30.

32. Ballegaard S, Karpatschoff B, Holck JA, Meyer CN, Trojaborg W. Acupuncture in angina pectoris: do psychosocial and neurophysiological factors relate to the effect? Acupunct Electrother Res 1995;20:101–16.

33. Ballegaard S, Norrelund S, Smith DF. Cost-benefit of combined use of acupuncture, Shiatsu and lifestyle adjustment for treatment of patients with severe angina pectoris. Acupunct Electrother Res 1996;21:187–97.

34. Ballegaard S, et al. Acupuncture in severe, stable angina pectoris: a randomized trial. Acta Med Scand. 1986;220:307–13.

35. Richter A, Herlitz J, Hjalmarson A. Effect of acupuncture in patients with angina pectoris. Eur Heart J 1991;12:175–8.