The explanations for angina pectoris given on healthcare websites are often very old, vague, and even in some cases unsubstantiated. In light of what we now know about how angina occurs and the role glycocalyx plays, the information should be updated. Here follows a review of two sites with my comments on the quotes:

”Angina pectoris (chest pain) is most often due to it becoming too narrow in one or more of the heart’s coronary arteries. The heart then does not get enough oxygen and you get chest pain, especially when you exert yourself.”

I agree that angina can be due to it becoming too narrow in one or more of the heart’s coronary arteries. Below it is shown that plaque has reduced the artery’s (or is it perhaps an arteriole?) inner diameter and made it ”narrow.”

But there is another explanation for the artery becoming narrow. All arteries can stiffen if they do not receive sufficient deliveries of nitric oxide NO ①. Without NO to the smooth muscle layer of the arteries, the tunica media, the arteries lose their elasticity and resilience and become stiff. The reason why NO deliveries to the tunica media decrease and perhaps cease, I will return to. But terminal arterioles (inner diameter 2-10 µm), which like arteries have a tunica media that can stiffen, must not lose their elasticity and resilience, especially if they have an inner diameter as small as 2-5 µm because a red blood cell full of oxygen is about 7-8 µm in outer diameter. Then it becomes tough for the heart to pump red blood cells forward and the number reaching the capillaries decreases. The result is that the cells do not get as much oxygen delivered via tissue diffusion from the capillaries (which do not have a tunica media) as they need to be able to produce optimal energy.

”When there is a narrowing in one or more coronary arteries, it can cause angina.”

No narrowing is needed. It is sufficient that a terminal arteriole, due to a lack of nitric oxide NO, has lost its elasticity and resilience and stiffened – see above.

”Angina is caused by atherosclerosis, which is also called arteriosclerosis”

This old and incomplete explanation must be clarified. Furchgott, Ignarro, and Murad, who received the Nobel Prize in Physiology and Medicine in 1998, showed that endothelial cells deliver nitric oxide NO to the smooth muscle layer, the tunica media, and that if NO deliveries decrease, the tunica media loses its elasticity and resilience and eventually, the tunica media completely stiffens.

In order for fat to be able to adhere to endothelial cells, the glycocalyx, the hairy exterior of the endothelial cells (= the hairy interior of the arteries), must be damaged, i.e., having lost its height and density. As long as the glycocalyx is healthy, i.e., tall and dense, it forms a physical barrier preventing, for example, blood lipids from reaching the membrane of the endothelial cells.

”High levels of the blood lipid cholesterol can increase the risk of angina.”

Certainly, it can, but this assumes that the glycocalyx is damaged, i.e., low and sparse instead of high and dense, so that it no longer provides adequate physical protection against, for example, cholesterol approaching the endothelium’s membrane.

”A less common cause of angina is a temporary contraction of the coronary artery. This means that too little blood can pass through the vessel and into the heart muscle. This is called spasm angina or spasm angina. You can have symptoms similar to those of angina without having any narrowing in the vessels.”

Temporary contraction is an example of an unsubstantiated claim. Probably, this explanation was constructed before the understanding of the consequences of terminal arterioles’ tunica media not receiving enough NO, losing its elasticity and resilience, and becoming stiff. It becomes difficult for red blood cells, normally 7-8 µm in outer diameter, to pass through a stiffened terminal arteriole with an inner diameter of 2-5 µm.


Under the heading ”Symptoms of Angina,” it is written:

”The most important cause of angina is atherosclerosis.”

Yes, if the glycocalyx is damaged, i.e., low and sparse instead of high and dense as when the glycocalyx is healthy. But I wonder how many people from middle age and upwards have a fully healthy endothelial glycocalyx after having eaten 60% carbohydrates and drunk sweet beverages throughout their life? Unfortunately, there are no studies to rely on, but it is likely that a very large proportion walk around with damaged glycocalyx, which is the underlying cause of many different disease symptoms such as angina, heart attack, and stroke. Thus, they expose themselves to the risk that blood fats can reach the endothelial cells and pass through the openings between them. There, the construction of plaque on the backside of the endothelial cells begins. When such plaques have grown large enough, the protective covering of endothelial cells can burst and the plaque can travel towards the heart and brain.

”With atherosclerosis, fat, cells, and connective tissue are stored in the vessel walls, which become stiff and thickened.”

Indeed, this is how hjä expresses itself without solid evidence that this is the case. But as said, as long as your glycocalyx on the inside of the arteries is healthy, no fat can come near the vessel walls. It is not fat that makes the vessel walls stiff – it is a lack of nitric oxide NO ① in the smooth muscle layer of the vessel walls, the tunica media, which thereby loses its elasticity and resilience and becomes stiff.

Under the heading ”Risk Factors,” it is written:

”Both angina and heart attack are caused by atherosclerosis in the heart’s coronary arteries.”

Only if the glycocalyx is damaged, i.e., low and sparse instead of high and dense as when the glycocalyx is healthy, is my comment.

”Overweight and diabetes”:

When one becomes overweight and is diagnosed with diabetes, the breakdown of the endothelial glycocalyx has been ongoing for a long time. What damages the glycocalyx is that it is exposed to a blood content that it is not accustomed to, which slowly but surely breaks down the glycocalyx’s molecular balance (homeostasis). During the hundreds of thousands of years or perhaps even millions of years, during which we evolved into the Homo sapiens we are now, our diet probably consisted of 1/3 fat (likely mostly animal), 1/3 protein, 1/3 carbohydrates, and water – all directly from nature.

During those years, the glycocalyx achieved its molecular balance (homeostasis). Since about 200 years ago, we have slowly but surely changed our diet to today typically consist of about 20% fat, 20% protein, and 60% carbohydrates (sugar, flour, and starch) and sweet drinks in addition. It’s not surprising that the glycocalyx, which over hundreds of thousands or perhaps even millions of years built up a stable molecular balance (homeostasis), has now become imbalanced and in many people lost both its protective function against, for example, cholesterol, and its signaling function to the endothelial cells to deliver NO to the tunica media.

What hjä points out as a risk factor for diabetes is correct, but mentioned far too late. When you are diagnosed with diabetes, you have been ill for a long time without noticing it, and the breakdown of glycocalyx that started much earlier, without being detected by either you or healthcare, just continues if you do not return to the diet and eating habits that built up your glycocalyx to be a stable protective and signaling mechanism for you, for your body, and for your brain.

It’s not the diagnosis of diabetes that can lead to secondary diseases. It is the breakdown of glycocalyx, whose development due to an imbalance in diet began long before you receive your diabetes diagnosis, that causes secondary diseases without you noticing it – at least initially.

”Metabolic Syndrome”:

”…the cause is primarily an unhealthy, calorie-rich diet with a lot of fat and sugar.”

What does ”unhealthy calorie-rich” mean? How is anyone supposed to understand what that means? Such a statement needs to be explained – it can’t just be left there as if it’s obvious what it means. It’s not!

The same goes for ”a lot of fat and sugar” – do they mean that this information is sufficient for one to know how to approach fat and sugar in food?

When will hjä provide explanations that help those who want to improve their diet not give up before they even start to eat and drink better because the instructions are too vague, i.e., impossible to understand?

”High Blood Pressure”

It is explained as follows: ”The causes behind high blood pressure can be many and are influenced by both genetics and environment.” ”…it often pays off to have healthy habits.” plus, ”In younger women, birth control pills can be a cause of high blood pressure.”

This is hjä’s advice to those who have or want to avoid high blood pressure. Which genetics or environment causes what? How is the reader supposed to know what healthy habits are?

My advice is to ensure that the glycocalyx is healthy or recovers by switching to a diet consisting of 1/3 each of fat, protein, and carbohydrates and to drink water – not sweet beverages. Make sure not to eat between 1800 – 1000 the next day ②. You can drink water, coffee, and tea without sugar. Then the critical blood vessels, the terminal arterioles, will regain their elasticity so that enough red blood cells reach the capillaries from where oxygen can diffuse through the tissues to the cells in such an extent that they can produce optimal energy for you to feel good.

”High Cholesterol Levels”

”Too high proportions of saturated fat in the diet lead to higher cholesterol levels.”

High cholesterol levels are not dangerous in themselves. It’s only when the glycocalyx loses its molecular balance (homeostasis) and goes from being high and dense to low and sparse that cholesterol starts to become dangerous.

”Everyone who has or has had coronary artery disease should strive to lower their cholesterol levels.”

Why so? Clearly, the advice is good for those who do not intend to try to recover their glycocalyx. A much better piece of advice is to ensure that the glycocalyx is allowed to grow healthy, i.e., high and dense, so that cholesterol cannot come near the membranes of the endothelial cells.

”Cholesterol-lowering Medication”

For those who have ensured that their glycocalyx has grown healthy, i.e., high and dense, there is no reason to take cholesterol-lowering medications.

Glycocalyx and Angina Pectoris

① Furchgott, Ignarro, Murad Nobel Prize in Physiology or Medicine 1998

② Karl Arfors, professor of microcirculation – laboratory studies


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