Angina is chest pain or pressure caused by reduced blood flow to the heart, and what you do about it depends on whether you’re in the middle of an episode or managing it long-term. During an acute episode, the priority is rest, medication if prescribed, and recognizing when the pain signals something more dangerous. For ongoing management, the approach combines daily medications, exercise within safe limits, and in some cases, surgical procedures to restore blood flow.
Stable vs. Unstable Angina
The single most important thing to understand is the difference between stable and unstable angina, because they require completely different responses.
Stable angina follows a predictable pattern. It shows up during physical exertion or stress, lasts a few minutes, and goes away with rest or medication. You learn its triggers over time, and it behaves consistently. This is the type most people are managing day to day.
Unstable angina is a medical emergency. It doesn’t follow a pattern. The pain may be stronger or last longer than what you’re used to, it can strike without physical activity, and rest or medication may not relieve it. Unstable angina falls on the same spectrum as a heart attack, and it requires immediate emergency care. If your chest pain changes character, happens at rest, or doesn’t respond to your usual treatment, call 911.
What to Do During an Angina Episode
If you’ve been prescribed nitroglycerin, place one tablet under your tongue at the first sign of chest pain. You may feel a burning or tingling sensation in your mouth, which is normal. If the pain doesn’t ease, you can take another tablet about every 5 minutes, up to three tablets total over 15 minutes. If the pain persists after three tablets, or feels different from your typical angina, call 911 immediately.
While waiting for relief, stop what you’re doing and rest. Sit or lie down in a comfortable position. Loosen any tight clothing. If you suspect the episode could be a heart attack rather than your usual angina, chew an aspirin if a healthcare professional has previously told you it’s appropriate, but call for emergency help first before doing anything else.
One practical detail many people overlook: nitroglycerin loses potency if stored improperly. Keep it in its original glass container, tightly capped after each use, at room temperature (68 to 77°F). Don’t transfer tablets to a pill organizer or leave the bottle open.
Daily Medications for Prevention
Long-term angina management typically starts with medications designed to reduce how hard your heart has to work and improve blood flow. The standard approach, recommended by cardiology guidelines, includes several drug classes working together.
Nitrates are the cornerstone for angina-specific relief. Short-acting nitroglycerin handles acute episodes, while long-acting nitrate formulations are taken daily to prevent episodes and improve exercise tolerance. These drugs work by relaxing blood vessel walls, which reduces the workload on your heart and lowers its oxygen demand. They’re available as daily tablets or skin patches (which are typically worn during the day and removed at night for about 12 hours).
The most common side effect of nitrates is headache, reported by up to 82% of patients in clinical trials. For most people, these headaches are mild to moderate and fade as the body adjusts to the medication. About 10% of patients, though, find the headaches or dizziness severe enough that they can’t continue the medication. If you’re in that group, your doctor can adjust the dose or switch your approach.
Beyond nitrates, beta-blockers slow the heart rate and lower blood pressure, reducing the heart’s demand for oxygen during activity. Statins lower cholesterol to slow the buildup of plaque in coronary arteries. ACE inhibitors help relax blood vessels and protect heart function over time. The 2025 ACC/AHA guidelines also recommend high-intensity statin therapy for anyone who has had an acute coronary event, often combined with additional cholesterol-lowering medication.
Exercise and Physical Activity
Exercise is one of the most effective long-term strategies for angina, but it needs to be done within specific limits. The goal is to stay below your “ischemic threshold,” the point at which your heart’s demand for oxygen outstrips supply and triggers pain.
In a supervised cardiac rehabilitation setting, exercise intensity is typically set between 40% and 80% of your heart rate reserve. Heart rate reserve is the difference between your resting heart rate and your maximum heart rate during a stress test. For a typical patient, that might translate to a target exercise heart rate somewhere between 86 and 108 beats per minute, though your numbers will be specific to your test results.
A useful self-monitoring tool is the rate of perceived exertion scale, where you rate how hard the exercise feels on a scale of 6 to 20. Aiming for a 12 to 15, which corresponds roughly to “somewhat hard,” keeps most people in a productive but safe zone. If you start to feel your typical angina symptoms during activity, stop and rest. You can also take a nitroglycerin tablet 5 to 10 minutes before activities you know tend to trigger chest pain.
Cardiac rehabilitation programs produce measurable results. In published case studies, patients who completed structured rehab programs raised their angina threshold significantly, meaning they could exercise harder and longer before symptoms appeared. The key is consistency and gradual progression under guidance, not pushing through pain.
When Medication Isn’t Enough
If your symptoms persist despite taking the maximum tolerated doses of your medications, the next step is typically a coronary angiogram, an imaging test that maps the blockages in your heart’s arteries. What happens after that depends on the number and location of blocked vessels.
For one or two blocked arteries, a stent procedure (percutaneous coronary intervention, or PCI) is the usual recommendation. This involves threading a thin tube through a blood vessel to the blockage, inflating a tiny balloon to open it, and placing a small mesh tube to keep the artery open. Recovery is relatively quick, often a day or two in the hospital.
For three or more blocked arteries, or blockages in the main artery supplying the left side of the heart, bypass surgery is generally more effective. This is a major operation where surgeons use blood vessels from elsewhere in your body to reroute blood flow around the blockages. Recovery takes several weeks, but the long-term outcomes for complex disease are better with bypass than with stenting, particularly for people who also have diabetes or weakened heart function.
Options for Refractory Angina
Some people continue to have angina despite medications and aren’t candidates for stenting or bypass surgery, often because their anatomy is too complex or they’ve already had previous procedures. For this group, enhanced external counterpulsation (EECP) is a noninvasive option worth knowing about.
EECP involves lying on a treatment table while inflatable cuffs wrapped around your legs squeeze in rhythm with your heartbeat, pushing blood back toward the heart between beats. A full course is typically 35 one-hour sessions over seven weeks. The treatment appears to improve blood vessel function, encourage the development of new small blood vessels around blockages, and produce effects similar to regular exercise training.
The results are meaningful: a meta-analysis found that 85% of patients who completed EECP experienced at least one level of improvement in their angina severity, with low rates of side effects. The benefit was consistent even among patients with the most severe symptoms who had no other treatment options available.