Your GP will probably start by asking you about the pattern of your symptoms, such as whether you have noticed any particular triggers.
Your GP will then carry out a general assessment to assess whether you have any signs and symptoms that could suggest that you are at increased risk of developing atherosclerosis, which in turn could lead to the symptoms of angina.
As part of the assessment you will have:
- blood pressure tests
- your weight and waist size measured
- blood tests to measure the amount of cholesterol and glucose (if you are diabetic) in your blood and also to determine how well your liver is working
- a urine test to determine how well your kidneys are working
(Some angina medications are not suitable for people with liver or kidney disease.)
You are also likely to discuss whether you smoke, how much you drink, whether you you have a high fat diet and any family history of heart disease.
If angina is suspected, it is likely that you will be referred to a cardiology department or clinic for further assessment to:
- confirm or disprove a suspected diagnosis of angina, and
- assess your risk of having a heart attack or stroke in the future
The assessment involves a series of tests that are explained below.
An electrocardiogram (ECG) records the rhythms and electrical activity of your heart. A number of electrodes (small metallic discs) are placed on your arms, legs and chest. The electrodes are connected to a machine that records the electrical signals of each heartbeat.
An abnormal ECG reading may indicate that the muscles of your heart are not receiving enough blood.
Exercise tolerance test (ETT)
An exercise tolerance test (ETT) is similar to an ECG but it is carried out when you are exercising, usually on a treadmill or an exercise bike.
An ETT can be used to measure how much exercise your heart is able to tolerate before the symptoms of angina are triggered. This information is useful for assessing how severe your angina is likely to be.
Myocardial perfusion scintigraphy (MPS)
A myocardial perfusion scintigraphy (MPS) is an alternative test to an ETT that can be used if a person is unable to exercise or when the results of an ETT are unclear.
MPS involves injecting a small amount of a radioactive substance into your blood. A special camera, known as a gamma camera, is used to track the substance as it moves through your blood vessels and into your heart. This allows healthcare professionals to determine how well blood is reaching your heart.
MPS is usually carried out both at rest and when you are exercising. If you are unable to exercise, medication can be used to replicate the effects of exercise on your heart.
A coronary angiography is a test that can be used to identify whether your coronary arteries are narrowed and determine how severe any blockages are.
During an angiography, a catheter (a thin, flexible tube) is passed into a vein or artery in your groin or arm, and X-rays are used to guide it into your coronary arteries. A dye is injected into the catheter to highlight the arteries supplying blood to your heart. A number of X-ray images (angiograms) are taken that will highlight any blockages.
Coronary angiographies carry a small risk of serious complications, such as a stroke or a heart attack, which is estimated to be around 1 in 500. Although this risk is small, healthcare professionals are usually unwilling to perform an angiogram unless the benefits of the procedure outweigh the potential risks.
Therefore, it is likely that you will only be referred for a coronary angiogram if:
- the diagnosis of angina remains unclear
- your angina symptoms persist despite treatment and/or you are thought to be at significant risk of having a heart attack or stroke and surgery is being considered
If unstable angina is suspected, you will be admitted to hospital. Depending on the severity of your symptoms, you may be placed in a general ward or in the intensive care unit (ICU).
You will be given an ECG as soon as you arrive at hospital to quickly assess whether your heart has been significantly damaged.
Blood tests will also be carried out to help identify increased enzyme levels that are known to be released when the heart is damaged. A coronary angiography may also be performed to assess the size and location of the blockage in your coronary artery.
Due to the urgent need to prevent serious complications arising from unstable angina, treatment may be started before all of the test results are known.
Global Registry of Acute Cardiac Events (GRACE)
After receiving suitable treatment for symptoms of unstable angina, it will be necessary to assess your likelihood of developing recurring symptoms, or possibly the symptoms of a heart attack, in the next six months. The outcome will have an important bearing on your recommended treatment plan.
The Global Registry of Acute Cardiac Events (GRACE) is a widely used method of assessing the risk of further heart problems occurring. GRACE is essentially a scoring system that is based on factors such as:
- your age
- the number of times that your heart beats every minute
- your blood pressure
- how much of a substance called creatinine is present in your blood - higher than expected levels can be a sign of heart damage
- whether you have any signs and symptoms of heart failure, such as excess fluid inside your lungs - heart failure is where your heart is unable to meet your body’s need for oxygen-rich blood
Your GRACE score will provide a relatively accurate predictor of your risk of developing further heart problems. The score can range from very low (less than 1 in 65) to the highest (more than 1 in 10).
Surgery is usually recommended as a precaution for people who have a GRACE risk score of 1 in 33 or above.
Read more about treating unstable angina.