Angina Pectoris: A Nutrition and Natural Health Reference
1. Definition and Overview
Ischaemic heart disease (IHD) remains the leading global cause of death and lost life years in adults, notably in younger (<55 years) women. Angina pectoris β derived from the Latin verb angere, meaning "to strangle" β is chest discomfort of cardiac origin. It is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina pectoris is a clinical syndrome occurring in patients with or without obstructive epicardial coronary artery disease.
Angina pectoris is a clinical condition of ischaemic heart disease arising from transient myocardial ischemia. Generally, it develops due to atherosclerosis occurring in the coronary arteries, followed by an imbalance between myocardial demand and coronary blood supply. It is characterized by paroxysmal pain in the substernal or precordial region of the chest, which is provoked by an increase in the demand of the heart. Angina is a pre-indicator symptomatic state for a variety of major cardiovascular events that propagate in a cyclic manner.
It is a common clinical manifestation of IHD with an estimated prevalence of 3%β4% in UK adults. Stable angina is usually caused by coronary atherosclerosis, and affects up to 16% of men and 10% of women aged 65β74 years in the UK. People with angina are at increased risk of other cardiovascular events and mortality compared with people without angina. Among people not thought to need coronary artery revascularisation, annual mortality is 1β2% and the annual non-fatal myocardial infarction (MI) rate is 2β3%.
2. Clinical Presentation
Angina clinically presents as substernal pressure or tightness, often radiating and exacerbated by exertion or stress. Symptoms are transient and typically provoked by exertion, and alleviated by rest or nitroglycerin.
3. Types of Angina
The recognized types of angina are stable, unstable, microvascular, vasospastic, and refractory, with types varying based on severity and cause.
Stable Angina
Stable angina pectoris is induced by exercise and relieved by rest. It occurs when the demand for blood by the heart exceeds the supply provided by the coronary arteries. It is caused by fixed atherosclerotic plaques leading to more than 70% stenosis in the coronary artery, resulting in predictable episodes of chest pain and pressure that typically worsen with exertion, and involves transient subendocardial ischemia.
Unstable Angina
Unstable angina pectoris, also known as "crescendo angina," is a form of acute coronary syndrome. It is defined as angina pectoris that changes or worsens, occurring unpredictably at rest and potentially indicating an impending heart attack. The pathophysiology of unstable angina involves reduction of coronary flow due to transient platelet aggregation. In stable angina, the developing atheroma is protected with a fibrous cap, but this cap may rupture in unstable angina, allowing blood clots to form and further decrease the lumen of the coronary vessel.
Vasospastic (Prinzmetal or Variant) Angina
Vasospastic angina, also known as Prinzmetal angina or variant angina, is not very common. It occurs when a spasm β a sudden tightening of the muscles within the arteries of the heart β causes the arteries to narrow temporarily. A spasm of the coronary arteries can block blood flow to the heart and cause serious pain. This type of angina usually happens while at rest, between midnight and early morning, and in a pattern.
Mechanisms proposed to underlie susceptibility to vasospastic angina include vascular smooth muscle cell hyperreactivity, endothelial dysfunction, magnesium deficiency, low-grade inflammation, altered autonomic nervous system response, hypothyroidism, and oxidative stress.
Microvascular Angina
Microvascular angina can be a sign of coronary microvascular disease, affecting the tiny arteries of the heart. Events can be stable or unstable, and they can be more painful and last longer than other types of angina. Symptoms can occur during exercise or rest, and medicine may not relieve the pain.
4. Body Systems Involved
Angina involves a closely interconnected set of body systems:
- Cardiovascular system: Coronary artery disease involves accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the heart muscle). Coronary arteries are lined by endothelial cells that regulate muscle tone and prevent thrombosis; any injury to this lining triggers the immune system, resulting in development of fibrous tissue and stenosis.
- Autonomic nervous system: Alterations in autonomic nervous system response have been implicated in vasospastic angina, and emotional stress or cold exposure can precipitate episodes via autonomic activation.
- Metabolic and endocrine system: Older age, male sex, smoking, hypertension, diabetes mellitus, and hyperlipidemia are among the strongest risk factors; obesity, limited physical activity, psychosocial factors such as stress and depression, as well as co-existing chronic kidney disease are also associated with ischaemic heart disease.
- Haematological system: Plaque rupture exposes thrombogenic substances, activating the platelet and coagulation pathways leading to luminal thrombus formation.
5. Contributing and Associated Factors
Major Modifiable Risk Factors
Major risk factors for atherosclerosis β the predominant underlying cause of angina β include a family history of premature coronary artery disease, cigarette smoking, diabetes mellitus, hypercholesterolaemia, and systemic hypertension. Other risk factors include left ventricular hypertrophy, obesity, and elevated serum levels of homocysteine, lipoprotein (a), plasminogen activator inhibitor, fibrinogen, serum triglycerides, or low high-density lipoprotein (HDL).
Modifiable risk factors account for 90% of acute myocardial infarction (AMI) cases in men and 94% in women. These modifiable risk factors include cigarette smoking, physical inactivity, hypertension, obesity, elevated cholesterol levels (particularly LDL), and high triglyceride levels.
Smoking
Smoking is a significant modifiable risk factor. Smokers over the age of 60 have a doubled risk of atherosclerosis and subsequent cardiovascular disease compared to non-smokers. Patients who continue to smoke after an MI have a 22β47% increased risk of reinfarction and death.
Hypertension
Among the modifiable risk factors, arterial hypertension is recognized as the key driver of ischemic diseases and disorders of cerebral circulation.
Obesity and Physical Inactivity
Angina was significantly associated with greater age, a higher BMI, former smoking, and drinking alcohol. Coronary heart disease was associated with age, male gender, unhealthy diet, being obese and overweight, former smoking, and lower education.
Psychosocial Factors
Psychosocial factors such as stress and depression are also associated with ischaemic heart disease.
Homocysteine
Elevated serum levels of homocysteine are recognized among the risk factors associated with atherosclerosis and angina.
6. Dietary Factors
Mediterranean Dietary Pattern
Since the 1950s, when Ancel Keys popularized the traditional Mediterranean diet, an immense accrual of large and valid studies β including prospective cohort studies, randomized controlled trials (RCT), and systematic reviews β have been conducted to investigate its potential health benefits. Its protective effects on cardiovascular disease have been supported by several consistent large RCTs, namely the Lyon Diet-Heart Study, PREDIMED, PREDIMED-Plus, and CORDIOPREV.
The traditional Mediterranean diet is not a vegetarian diet, but it emphasizes the preferential consumption of minimally processed plant-based foods: fruits, vegetables, whole-grain cereals, legumes, and tree nuts. It also involves consuming a lot of olive oil and plant-based foods, varying amounts of fish, moderate amounts of alcohol (red wine in particular), dairy products, and relatively little meat, especially red meat.
Findings from systematic reviews consistently demonstrate that higher adherence to the Mediterranean diet is associated with a reduced risk of overall mortality, both in the general population and in patients with previous CVDs. Evidence suggests that following this dietary pattern likely decreases the risk of cardiovascular events including heart attacks, various types of coronary artery disease, stroke, and cardiovascular mortality.
In the context of angina specifically, one study reported a significant reduction (HR 0.6; 95% CI 0.47β0.77) in the composite outcome of myocardial infarction (fatal and non-fatal) and angina requiring revascularization. A study in unstable angina patients found that adherence to a Mediterranean dietary pattern may protect against coronary artery wall production of inflammatory mediators, providing a mechanistic basis for the diet's cardioprotective effect.
Regarding vasospastic angina specifically, while many studies report on the Mediterranean diet in heart disease prevention, the investigation of this dietary pattern in relation to serum markers (prostacyclin, nitric oxide, thromboxane B2) in Prinzmetal angina patients is an emerging area of research.
Certain nutrients play key roles at different stages of atherosclerosis and cardiovascular disease, and the combined nutrients of a Mediterranean-style diet offer a significant source of primary and secondary disease prevention. Although current evidence does not support recommendations for or against single-nutrient supplementation, a Mediterranean-style diet should be recommended to reduce the risk of cardiovascular disease.
General Dietary Recommendations from Authoritative Sources
With respect to dietary patterns and cardiovascular health, the available evidence supports the adoption of overall healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), the Alternative Healthy Eating Index (AHEI), or the traditional Mediterranean diet for the primary and secondary prevention of CVD.
Behavioral and lifestyle interventions, such as regular exercise, quitting smoking, and reducing alcohol consumption, can help prevent and manage patients with coronary heart disease and angina. Similarly, nutritional interventions play a significant role in lowering the risk of CVD.
7. Nutrients, Herbs, and Natural Ingredients
7.1 Omega-3 Fatty Acids (EPA and DHA)
Traditional Use
Omega-3-rich fish oils have a long history of use in traditional diets, particularly among coastal and Nordic populations, where consumption of fatty fish was closely associated with observed differences in cardiovascular mortality. The mechanistic basis for this association was explored extensively from the mid-twentieth century onward.
Scientific Evidence
Omega-3 fatty acids (FAs) are polyunsaturated fatty acids commonly found in marine fish and closely linked to cardiovascular health. Omega-3 FA mainly contains Ξ±-linolenic acid (ALA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA).
A meta-analysis of RCTs published in PMC (Omega-3 Fatty Acid Supplementation and Coronary Heart Disease Risks) found that 0.8β1.2 g omega-3 FA supplementation reduced the risk of major adverse cardiovascular events (MACE), cardiovascular death, and MI. Gender and diabetes had no significant association with the MACE risk benefit. Omega-3 FA supplementation had a positive effect in reducing the incidence of MACE, cardiovascular death, and MI. Regardless of the stage of CHD, omega-3 FA supplementation can prevent the occurrence of MI, with the 0.8β1.2 g dose range proving more effective than lower or higher doses.
The Japan EPA Lipid Intervention Study (JELIS) in a large cohort (N = 18,645) of Japanese men and women suggested significant benefits in the reduction of unstable angina and nonfatal coronary events. The totality of evidence supports a strong role for omega-3 fatty acids derived from fish oil in secondary prevention through a presumptive role as an antiarrhythmic agent and through an ability to promote plaque stabilization.
One randomized, double-blind, placebo-controlled trial of 223 patients with angiographically proven coronary artery disease used fish oil concentrate (55% EPA and DHA) at 6 g/day for 3 months and then 3 g/day for 21 months, with outcomes evaluated by standardized coronary angiography before and after 2 years.
A notable complexity: a meta-analysis published in PubMed (PMID 19148838) of eight RCTs comprising 20,997 patients found that in patients with prior MI, omega-3 fatty acids reduced the relative risk of sudden cardiac death (RR = 0.43; 95% CI: 0.20β0.91); however, in patients with angina (without prior MI), omega-3 fatty acids were associated with an increased relative risk of sudden cardiac death (RR = 1.39; 95% CI: 1.01β1.92). This finding underscores the complexity of the evidence and the importance of patient population when interpreting results.
A coronary computed tomography angiography study found that high-risk plaque prevalence was lower in the omega-3 group (3.8% vs. 32%, p < 0.001); CT density of plaque was higher in the omega-3 group, indicating more fibrous-dense plaque rather than lipid-rich atheroma.
Regarding EPA specifically, EPA has shown cardiovascular benefit in addition to statins in large outcome trials, and multiple serial-imaging studies have demonstrated benefits on plaque progression and stabilization. Due to its pleiotropic properties, icosapent ethyl (pure EPA) outperforms other omega-3 FAs in decreasing cardiovascular disease risk and is currently recommended as an adjunct to statins.
Evidence strength: Moderate to strong for secondary prevention of MI and reduction of cardiovascular events in post-MI patients. Evidence for angina-specific endpoints is mixed, with at least one meta-analysis finding potential harm for patients with angina who have not had a prior MI. Large, long-term RCTs remain the primary basis for recommendations.
7.2 Coenzyme Q10 (CoQ10)
Traditional Use
CoQ10 is not an herb with a traditional herbal medicine history in the classical sense. Its use in cardiovascular contexts stems from biochemical research beginning in the 1960s and 1970s, with interest in its role in mitochondrial energy production growing substantially from the 1980s onward.
Scientific Evidence
Coenzyme Q10 (CoQ10) is a vitamin-like organic compound widely expressed in humans as ubiquinol (reduced form) and ubiquinone (oxidized form). CoQ10 plays a key role in electron transport in oxidative phosphorylation of mitochondria. It acts as a potent antioxidant, membrane stabilizer, and cofactor in the production of adenosine triphosphate, inhibiting the oxidation of proteins and DNA.
CoQ10 is an essential compound of the human body, and there is growing evidence that CoQ10 is tightly linked to cardiometabolic disorders. Its supplementation can be useful in a variety of chronic and acute disorders. A major review analyses the role of CoQ10 in hypertension, ischaemic heart disease, myocardial infarction, heart failure, viral myocarditis, cardiomyopathies, cardiac toxicity, dyslipidaemia, obesity, type 2 diabetes mellitus, metabolic syndrome, cardiac procedures, and resuscitation.
One clinical study found that CoQ10 at 60 mg/day for 8 weeks, added to basic treatment of patients with stable class IIβIII angina, significantly improved clinical status without clinically significant side effects.
Evidence strength: Preliminary to moderate for angina specifically. Small studies and the mechanistic rationale are supportive, but large-scale, placebo-controlled RCTs specific to angina endpoints are limited. Most robust evidence is for CoQ10 in heart failure, not angina per se.
7.3 L-Carnitine
Traditional Use
L-carnitine is a naturally occurring compound synthesized in the body from amino acids lysine and methionine. Dietary sources include red meat and dairy. Its use as a nutritional supplement for cardiovascular conditions originated from biochemical observations that cardiac ischaemia depletes myocardial carnitine levels.
Scientific Evidence
Cardiac muscle normally contains very high levels of L-carnitine. In the setting of myocardial ischaemia, L-carnitine levels are reduced, leading to impairment of the electrical and contractile activities of the heart.
A multicenter, double-blind, randomized, placebo-controlled crossover study involving 44 men with stable chronic angina administered L-carnitine (1 g twice daily) or placebo for 4 weeks. The results showed that treatment with L-carnitine increases exercise tolerance and reduces ECG indices of ischaemia in stable effort-induced angina. The mean exercise workload showed an increase after L-carnitine compared to placebo, as did watts to onset of angina. ST segment depression was reduced by L-carnitine both at maximum workload and at the common maximum workload. 22.7% of patients became free of angina with L-carnitine and 9.1% with placebo.
A second controlled study of 200 patients aged 40β65 years with exercise-induced stable angina, randomized to oral L-carnitine (2 g/day) for 6 months, found that patients showed a significant reduction in the number of premature ventricular contractions at rest, as well as increased tolerance during ergometric cycle exercise, including increased maximal cardiac frequency, increased maximal systolic arterial blood pressure, and reduced ST-segment depression during maximal effort, accompanied by improvement in cardiac function.
A further randomized study (47 patients; 2 g/day for 3 months) reported that in the L-carnitine group there was a statistically significant improvement in exercise duration from 7.8 Β± 2.2 min to 8.6 Β± 1.8 min (p = 0.006).
Evidence strength: Ten trials have reported carnitine to benefit patients with angina pectoris, but all have severe limitations. Sample sizes ranged from 12 to 44 in all but one trial. A placebo arm was used in six, subjects were randomized in six, and only three were double-blind, randomized, controlled trials. There are no definitive large-scale trials, and the best available evidence did not examine a clinical endpoint such as mortality or MI. Overall evidence is preliminary to moderate.
7.4 Hawthorn (Crataegus spp.)
Traditional Use
Hawthorn (Crataegus oxyacantha) is a widely used Chinese herb for treatment of gastrointestinal ailments and heart problems and is also consumed as food. In North America, its role in the treatment of heart problems dates back to the 1800s. Hawthorn (Crataegus spp.), a member of the Rosaceae family, has been used for medicinal purposes since ancient times. In European herbal tradition, hawthorn leaf and flower preparations have been employed as cardiac tonics. Hawthorn leaf and flower (Crataegi folium cum flore) can be used as a traditional herbal medicinal product to relieve symptoms of temporary nervous cardiac complaints such as palpitations and perceived extra heartbeats due to mild anxiety, after serious conditions have been excluded.
In Traditional Chinese Medicine (TCM), angina pectoris is classified under xiong bi (chest obstruction) and heartache, involving various disharmonies between the heart, liver, kidney, and spleen. The pathogenic factors are qi deficiency, blood stasis and stagnation, and phlegm stasis.
Scientific Evidence
Hawthorn fruit has potent antioxidant and free radical scavenging properties due to the presence of several bioactive compounds, such as flavonoids (hyperoside and quercetin) and oligomeric proanthocyanidins (epicatechin and procyanidin). Its protective effects on the cardiovascular system have been studied in vitro, in animals, and in humans.
Evidence is accumulating from in vivo and in vitro studies that hawthorn extracts exert a wide range of cardiovascular pharmacological properties, including antioxidant activity, positive inotropic effect, anti-inflammatory effect, anticardiac remodelling effect, antiplatelet aggregation effect, vasodilating effect, endothelial protective effect, reduction of smooth muscle cell migration and proliferation, protective effect against ischaemia/reperfusion injury, antiarrhythmic effect, lipid-lowering effect, and decrease of arterial blood pressure.
Reviews of placebo-controlled trials have reported both subjective and objective improvement in patients with mild forms of heart failure (NYHA IβIII), hypertension, and hyperlipidaemia. The German Commission E approved the use of hawthorn leaf with flower extracts in patients suffering from heart failure graded stage II according to the NYHA.
Hawthorn has been suggested as an alternative therapy for several cardiovascular conditions, such as angina pectoris, hypertension, hyperlipidaemia, cardiac dysrhythmias, and NYHA functional class II congestive heart failure.
Regarding direct angina evidence: there is not enough evidence to know whether hawthorn affects heart disease, angina (chest pain or discomfort from a lack of blood flow to the heart), abnormal heartbeat, or the buildup of plaque in arteries, according to NCCIH (NIH). One study indicated that a specific preparation of hawthorn (C. oxycantha) may have caused early risk of heart failure progression in patients.
A 2024 meta-analysis of randomized placebo-controlled trials concluded that hawthorn significantly reduces blood pressure in hypertensive individuals, which is relevant as hypertension is a primary contributor to angina. This meta-analysis evaluated the antihypertensive effects and safety of hawthorn in six studies with a total of 428 participants, with trials focused on systolic and diastolic blood pressure changes over treatment periods of 10 weeks to 6 months.
Evidence strength: For angina specifically, evidence is insufficient per NCCIH. For chronic heart failure (NYHA II), evidence is stronger, with German Commission E approval. Mechanistic data from in vitro and animal studies are promising. Hawthorn should be considered a slow-acting herb. Hawthorn is a slow-acting herb and should be used for at least 4 to 8 weeks for full benefit.
7.5 Magnesium
Traditional and Mechanistic Background
Magnesium has actions in the body that resemble those of drugs in the calcium channel blocker family, although much weaker. Because calcium channel blockers are useful for angina, magnesium has been studied for this condition. Additionally, magnesium deficiency has been proposed as one of the mechanisms underlying susceptibility to vasospastic angina.
Scientific Evidence
The role of magnesium in vasospastic angina has been studied given its calcium-antagonist properties and the proposed link between deficiency and coronary vasospasm. However, robust large-scale RCTs specifically examining magnesium supplementation as a standalone intervention in angina patients are limited. Most of the available evidence relating magnesium to cardiovascular disease pertains to blood pressure reduction and arrhythmia management rather than angina episodes directly. This represents a gap in the literature, and evidence for a direct anti-anginal effect of magnesium supplementation in clinical populations remains preliminary.
7.6 Ginkgo biloba
Traditional Use
Ginkgo biloba is the oldest living tree species in the world, and its extracts are among the most used herbal preparations in the prevention and treatment of cardiovascular diseases. It is sold in over-the-counter herbal preparations, prescribed by TCM doctors, and administered in Chinese hospitals for angina pectoris, acute myocardial infarction, and ischaemic and thrombotic disorders. In traditional East Asian medicine, Ginkgo has been used for thousands of years for its circulatory properties.
Scientific Evidence
In vitro and animal studies suggest it may be vasoactive, scavenge free radicals, and inhibit platelet aggregation. It displays myocardial suppressant and vasorelaxant activities ex vivo, potentiating endothelial-dependent and -independent pathways, and improves perfusion in different vascular beds, including ocular, cochlear, cutaneous, cerebral, and coronary.
However, results from large clinical trials are not supportive of a direct protective effect on angina. The Ginkgo Evaluation of Memory (GEM) Study β a double-blind trial randomizing 3,069 participants over 75 years of age to 120 mg of Ginkgo biloba EGb 761 twice daily or placebo with mean follow-up of 6.1 years β found that there were no differences in coronary heart disease death, incident myocardial infarction (n=164), angina pectoris (n=207), or stroke (n=151) between Ginkgo biloba and placebo.
Evidence strength: Preclinical evidence suggests plausible cardiovascular mechanisms, but large clinical trial evidence does not support a protective effect on angina incidence. Despite less than encouraging clinical results, extracts from its leaves are among the most used herbal preparations in the prevention and treatment of cardiovascular diseases.
7.7 Danshen (Salvia miltiorrhiza)
Traditional Use
Danshen is one of the most important herbs in Traditional Chinese Medicine and has been used for centuries for conditions associated with blood stasis, including chest pain classified under xiong bi. It is prepared as a decoction, tincture, or standardized extract, and is prescribed extensively in Chinese hospitals for ischaemic heart disease and angina.
Scientific Evidence
The active compounds in danshen are tanshinones and phenolic compounds. Danshen has been studied in China for acute MI and ischaemic heart disease. Most studies are neither placebo-controlled nor blinded, and often use danshen combined with other herbs. A double-blind study of 67 subjects with ischaemic heart disease reported symptomatic and electrocardiographic improvement with tanshinone IIA, a compound present in danshen.
Evidence strength: Preliminary; methodological quality of existing studies is generally limited. Most human evidence comes from China, and blinding and placebo controls are often absent. The double-blind study with tanshinone IIA provides limited supportive evidence but replication in larger, well-controlled trials is lacking.
8. Lifestyle Factors
Physical Activity
Risk factors for stable angina include physical inactivity and overweight, alongside hypertension, elevated serum cholesterol levels, and smoking. Regular aerobic exercise is widely discussed in the authoritative cardiovascular literature as a tool for reducing angina burden by improving coronary collateral circulation, lowering myocardial oxygen demand, and improving endothelial function. Behavioral and lifestyle interventions, such as regular exercise, quitting smoking, and reducing alcohol consumption, can help prevent and manage patients with coronary heart disease and angina.
Smoking Cessation
Patients who continue to smoke after an MI have a 22β47% increased risk of reinfarction and death, and smoking cessation is among the most consistently recommended lifestyle modifications in the cardiovascular literature.
Weight Management
Obesity and limited physical activity are associated with ischaemic heart disease. The evidence base for weight reduction as a strategy to improve angina symptoms is primarily mediated through its effects on blood pressure, lipid profiles, and insulin sensitivity.
Psychosocial Stress
Modifiable risk factors for coronary artery disease include hypertension, smoking, obesity, lipid levels, and psychosocial variables. Emotional and psychological stress can acutely precipitate angina episodes through sympathetic activation, increasing myocardial oxygen demand and inducing coronary vasoconstriction.
References
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