So, What is angina and what does it feel like?

Angina is chest discomfort caused by the heart muscle not receiving enough blood, almost always because one or more of the coronary arteries has narrowed. It usually feels like a pressure, heaviness or tightness across the centre of the chest rather than a sharp pain, and it typically comes on with exertion and eases within a few minutes of stopping. Patients describe it as a band around the chest, a weight sitting on them, or a dull ache spreading into the arm, neck or jaw. It is often accompanied by breathlessness, sweating or nausea.

The most important thing to understand is that angina is a symptom, not a disease in its own right. It is the heart signalling that its blood supply cannot keep up with demand, and it is almost always a warning that coronary artery disease is present. Over more than 20 years as a Consultant Cardiologist at Kingston Hospital, much of that time as Clinical Lead of the department, and across my private clinics at Parkside, The New Victoria, Cleveland Clinic London and Heartsure, I would estimate that roughly half the patients referred to me with suspected angina turn out to have a non-cardiac cause for their chest discomfort. The other half genuinely have narrowed arteries, and for them, recognising the pattern early changes everything.

What angina actually feels like

The word “pain” is misleading, and it is the single biggest reason angina gets missed. Most of my patients do not describe pain at all. They describe discomfort, tightness, heaviness, an ache, a band, a weight, or simply a strange awareness that something is wrong in the chest. Some say it feels like indigestion. Some say it feels like a strap being pulled tight. Very few say it hurts in the way a cut or a broken bone hurts.

The discomfort is usually central or slightly to the left, and it tends to be diffuse rather than pinpoint. It can radiate to the left arm, though it also travels to the right arm, the neck, the jaw, the shoulders, or between the shoulder blades. The pattern of heart-related chest discomfort is worth understanding in detail, because the character and the triggers matter far more than the severity.

One pattern I have come to rely on heavily is the gesture patients use when describing it. Someone who places a flat palm or a clenched fist over the middle of their chest is describing something very different from someone who points to a single spot with one fingertip. The flat hand strongly suggests a cardiac cause. The pointing finger almost never does. It sounds trivial, but it is one of the most useful things I watch for in the first thirty seconds of a consultation.

The triggers that give angina away

What separates angina from most other causes of chest pain is its predictability. It comes on with effort and settles with rest, usually within two to five minutes. Patients often find they can walk on the flat without trouble but have to stop halfway up a hill, or that they manage fine in summer but struggle on a cold morning. Cold air, a heavy meal, emotional stress and walking uphill into wind are the classic provokers, and many patients notice the first hill of the day is worse than the third.

Across the many patients I have assessed for chest discomfort, asking what stops them works better than asking them to describe the pain, because people are poor at putting sensations into words but excellent at telling you exactly what they can no longer do. When a patient tells me they used to walk to the station in twelve minutes and now it takes twenty because they pause twice, that tells me more than any adjective they could offer.

Angina is not a heart attack, but the two are related

This distinction causes a great deal of anxiety, so it is worth being clear. In stable angina, the artery is narrowed but blood is still flowing. The discomfort appears when the heart works harder, and it disappears when the demand drops. No permanent damage occurs. In a heart attack, the artery becomes suddenly blocked, blood flow stops, and heart muscle begins to die within minutes. The discomfort does not settle with rest, and it is a medical emergency.

Between these sits unstable angina, which is the one that concerns me most. This is angina that is new, that comes on at rest, that is getting worse rapidly, or that no longer responds to the usual measures. It represents an unstable plaque in the artery and it carries a real risk of progressing to a heart attack. Anyone whose angina changes character or frequency needs to be assessed urgently rather than at the next available appointment.

There is also the quieter end of the spectrum, where reduced blood flow produces little or no discomfort at all. This is more common than people expect, particularly in patients with type 2 diabetes and in older women, and it is why silent heart attacks are sometimes only found on an ECG performed for an unrelated reason.

What causes angina

The underlying process is atherosclerosis, the gradual build-up of fatty plaque in the walls of the coronary arteries. This narrows the vessel and limits how much blood can flow through when the heart demands more. The risk factors that drive it are well established and largely modifiable. Smoking, high cholesterol, high blood pressure, diabetes, obesity, physical inactivity and a family history of early heart disease all contribute.

Not all angina comes from large-vessel narrowing, though. Microvascular angina, where the small vessels of the heart function poorly despite normal-looking main arteries, is increasingly recognised and disproportionately affects women. Coronary spasm, sometimes called variant angina, causes discomfort at rest and often at night, and it can occur in arteries that look almost normal on imaging. Both are real, both are treatable, and both are frequently dismissed as anxiety before the right diagnosis is reached.

How I diagnose angina in clinic

The history does most of the work. If a patient describes exertional chest tightness that settles with rest, I am already fairly confident before any test is performed. That said, the diagnosis needs confirming and the extent of disease needs mapping, so the assessment is structured.

A resting ECG is performed at the consultation, though it is worth saying plainly that a normal resting ECG does not rule out angina. In fact, most of my patients with significant coronary disease have a completely normal ECG when they are sitting comfortably in my clinic and feeling well. An echocardiogram assesses the heart muscle and valves and looks for evidence of previous damage. Blood tests cover cholesterol, glucose, HbA1c and kidney function.

The decisive test in most cases is a CT coronary angiogram, which produces a detailed picture of the arteries themselves. Drawing on the patients I have investigated for stable chest discomfort in recent years, a CT coronary angiogram works better than an exercise ECG as a first-line test because it shows the arteries directly rather than inferring narrowing from indirect changes, and it identifies both the patients who need intervention and, just as importantly, the substantial group who can be reassured and sent home without further testing. Where the CT shows significant disease, an invasive coronary angiogram follows to plan treatment precisely.

How angina is treated

Treatment runs on two tracks that operate at the same time. The first is symptom relief. A GTN spray used under the tongue opens the arteries within a minute or two and is the fastest way to settle an episode. Beta-blockers reduce how hard the heart works, calcium channel blockers relax the arteries, and long-acting nitrates, ivabradine, nicorandil or ranolazine are added where needed.

The second track is prevention, and this is the one that changes outcomes rather than comfort. Statins stabilise the plaque and reduce the chance of it rupturing. Aspirin or another antiplatelet reduces clot formation. Blood pressure control, diabetes control and stopping smoking all cut future risk substantially.

Where medication is not enough, or where the disease is extensive, revascularisation comes into the picture. Angioplasty and stenting opens the narrowed segment from inside the artery, and I refer these patients to Professor Simon Redwood. Where multiple vessels are involved or the anatomy is unfavourable, bypass surgery gives better long-term results, and those patients go to Mr Chandrasekaran. Alongside either route, structured cardiac rehabilitation through the Heartsure team makes a measurable difference to how confidently patients return to normal activity.

Living with angina

Most patients with stable angina live full, active lives. The condition is manageable, and for many the diagnosis becomes the trigger for changes they had been putting off for years. Knowing your triggers and using GTN before them rather than after them is one of the most practical things I teach in clinic. If a particular hill reliably brings on symptoms, a spray at the bottom is far more sensible than suffering at the top.

Looking back at the patients who have done best over the years, the ones who kept walking within their limits recovered more capacity than those who withdrew from activity out of fear. The heart responds to regular, moderate effort. It does not respond well to being wrapped in cotton wool.

When to seek urgent help

Chest discomfort that lasts more than fifteen minutes, that comes on at rest, that does not settle with GTN, or that is accompanied by sweating, nausea, vomiting or severe breathlessness needs an ambulance. Call 999. Do not drive yourself and do not wait to see whether it passes.

Angina that is new, that is becoming more frequent, or that is now provoked by less effort than it used to be also needs prompt review, ideally within days rather than weeks. This is the pattern that most often precedes something more serious, and it is the one where early assessment has the greatest impact.

When to seek a cardiology opinion

A specialist assessment is worth arranging if you have chest tightness or heaviness brought on by exertion, discomfort that spreads to the arm, neck or jaw, unexplained breathlessness on effort, reduced exercise tolerance over recent months, or a family history of heart disease before the age of 60 alongside any chest symptoms. It is also worth arranging if you have been told your chest discomfort is not cardiac but you remain unconvinced, particularly if you have significant risk factors.

You can read verified feedback from patients I’ve seen if it helps you decide whether a private cardiology opinion is the right step for you.

Conclusion

Angina is the heart asking for more blood than its arteries can currently deliver. It rarely announces itself as dramatic pain. It tends to arrive as a tightness, a heaviness, or a quiet limitation on what you can do, and it is easy to attribute to age, weight or being unfit. The patients who do well are the ones who recognise the pattern, take it seriously, and get assessed while the disease is still stable and highly treatable.

If you have chest discomfort brought on by exertion, or symptoms that have changed recently, you can contact me, Dr Arvind Vasudeva, on 020 8977 4826 to arrange an assessment. I consult at Parkside Hospital in Wimbledon, The New Victoria Hospital in Kingston, Cleveland Clinic London and the Heartsure Clinic, and you can book a convenient appointment here through my secretary Hannah.