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Angina: Chest Pain During Exercise

If you have pain in your chest, jaw, arm, or neck when you exercise, you could have angina, which is pain caused by reduced blood flow through narrowed arteries leading to your heart. You should check with a doctor as soon as possible. Symptoms of angina can also include feeling lightheaded, over-tired, short of breath or nauseated.

Other conditions that can cause chest pain with exercise include eating too quickly, acid reflux, muscle spasms or breathing problems. A simple test is to place your finger where you feel the pain. If it hurts to touch that area, the odds are that the pain is not coming from your heart. For example, if it hurts to touch anywhere on the side of your sternum, the large bone in the center of your chest, you probably have a benign condition called costochondritis, swelling of the ends of your ribs where they enter your chest bone.

What Causes Angina?
The heart is a muscle that must receive oxygen all the time. Angina means that the heart muscle starts to hurt from not receiving all of the oxygen that it needs. The most common type of angina is called stable angina. Stable angina means that you develop chest pain when you exercise and the pain goes away soon after you stop. While at rest, narrowed arteries leading to the heart can supply enough blood flow to the heart, but during exercise, the heart muscle does not get all of the extra oxygen it needs. When the blood flow through the narrowed arteries does not supply enough oxygen to the heart muscle, it hurts.

Exercising in cold weather can cause chest pain in some people who have no problems when they exercise in warm weather. When cold wind blows on your face, your heart rate slows down. This decreases the blood flow to the heart and can cause pain in people with blocked coronary arteries. See my report on cold weather exercise (below).

Unstable angina means that you get heart pain even when you are not exercising or excited. Unstable angina is far more serious than stable angina, and puts you at greater risk for a heart attack.

What Causes Narrowing of Arteries Leading to the Heart?
When you are born the inner linings of your arteries are completely clean. Gradually over time, plaques develop and narrow the channels through which blood flows. The most common cause of plaques is inflammation, where your own immunity punches holes in the inner linings of arteries. The holes bleed, clot and then start to heal. With healing, a plaque forms and covers the inner lining of the artery. Anything that turns on your immunity and keeps it on can cause plaques. This includes chronic infections and diseases of inflammation, an unhealthful diet, being overweight, not exercising or vitamin D deficiency.

What Causes a Heart Attack?
Heart attacks are not caused by narrowed arteries. They are caused by a sudden breaking off of a plaque from the inner lining of an artery leading to the heart. After the plaque breaks off, the area bleeds and clots. Then the clot extends to block the flow of blood to the heart muscle. If the blood flow is completely blocked the heart muscle will die.

If You Have Chest Pain
If your doctor thinks that you have unstable angina (chest pain when you are not exercising), a heart attack or heart pain other than stable angina, he may hospitalize you. If he thinks that you have stable angina, he may order the following tests:
• EKG (Electrocardiogram that measures the electrical activity of your heart)
• Stress Test (an EKG in which you exercise to make your heart work hard and beat fast)
• Chest X Ray (pictures of your heart, lungs, and blood vessels)
• Coronary Angiography (injecting dyes into your bloodstream to see if the arteries leading to your heart are narrowed or blocked)
• Cardiac Catheterization (a thin, flexible catheter is put into a blood vessel in your arm, groin, or neck and is threaded into your coronary arteries)
• Blood Tests (cholesterol, triglycerides, sugar, CRP, proteins in your blood and so forth)

If You Have Stable Angina
If your diagnosis is stable angina, your doctor may prescribe many different medications. You may be given nitrates (nitroglycerine) to temporarily open your arteries to prevent or treat chest pain. Your doctor may also prescribe drugs to lower blood pressure, lower cholesterol, slow your heart rate, relax blood vessels, reduce heart strain and prevent blood clots. These drugs include statins, beta blockers, calcium channel blockers, ACE inhibitors, oral antiplatelet medicines and anticoagulants (blood thinners). However, no drugs will cure angina. At this time, the only way to reverse plaques in arteries is to change the lifestyle that caused the plaques to form in the first place.

Lifestyle Changes to Cure Stable Angina
We have known since 1974 that plaques are reversible with changes in lifestyle. You can get rid of plaques by:
• Eating lots of vegetables and fruits
• Avoiding sugar-added foods and drinks, red meats, processed meats and fried foods
• Losing weight if overweight
• Exercising
• Keeping hydroxy vitamin D levels above 50 nmol/L
• Avoiding alcohol, smoking and recreational drugs
• Limiting exposure to air pollution

Why Your Doctor will Prescribe Exercise
Regular exercise can reduce inflammation, lower high blood pressure and cholesterol, treat diabetes and obesity, and increase blood flow to the heart. However, people with angina have reduced blood flow to their hearts and are at increased risk for suffering heart attacks when they exercise. So whatever exercise plan your doctor prescribes:
• Start each session slowly with an adequate warm up.
• Stop exercising immediately if you have chest pain, difficulty breathing or extreme fatigue.
• Probably you should not exercise outdoors in temperatures below 50 degrees Fahrenheit.

The group of bicyclists I ride with includes some men over seventy who previously had angina and even a few who have had heart attacks. They now ride at least three days a week and most ride every day. They can average faster than 18 miles per hour and some can finish a ride at much faster than that. They have changed their lifestyles and have found that angina can be cured.

Caution: Exercise can cause heart attacks in people who have blocked arteries.

Checked 3/12/17

February 21st, 2016
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About the Author: Gabe Mirkin, MD

Sports medicine doctor, fitness guru and long-time radio host Gabe Mirkin, M.D., brings you news and tips for your healthful lifestyle. A practicing physician for more than 50 years and a radio talk show host for 25 years, Dr. Mirkin is a graduate of Harvard University and Baylor University College of Medicine. He is board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology. The Dr. Mirkin Show, his call-in show on fitness and health, was syndicated in more than 120 cities. Read More
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