Signs and Symptoms of Coronary Artery Disease
The primary signs and symptoms of coronary artery disease include chest discomfort described as pressure, tightness, or heaviness that is typically provoked by exertion or emotional stress and relieved by rest or nitroglycerin within minutes. 1
Chest Discomfort Characteristics
Location and Radiation
- Located in the chest, typically near the sternum (substernal)
- May radiate to:
- Epigastrium
- Lower jaw or teeth
- Between shoulder blades
- Either arm to the wrist and fingers
- Neck 1
Quality
- Often described as:
- Pressure
- Tightness
- Heaviness
- Sometimes strangling, constricting, or burning
- Many patients may not feel "pain" but rather "discomfort" 1
Duration
- Brief—typically less than 10 minutes
- Often only minutes or less
- Pain lasting only seconds is unlikely to be angina 1
Relationship to Exertion and Other Factors
- Appears or worsens with increased exertion levels
- Precipitated by:
- Walking up an incline
- Walking against a breeze
- Cold weather
- Emotional stress
- After heavy meals
- Upon waking in morning 1
- Rapidly disappears within minutes when triggering factors abate
- Promptly relieved by rest and/or sublingual nitrates 1
Classification of Chest Pain
Typical Angina (All Three Characteristics)
- Substernal chest discomfort of characteristic quality and duration
- Provoked by exertion or emotional stress
- Relieved by rest and/or nitrates within minutes 1
Atypical Angina (Two of Three Characteristics)
- May have characteristic location and quality but no precipitating factors
- May start at rest, slowly intensify, remain at maximum for up to 15 minutes, then slowly decrease (suggesting possible coronary vasospasm) 1
Non-Anginal Chest Pain (One or None of the Characteristics) 1
Angina Equivalents
Symptoms that may represent coronary ischemia without classic chest pain:
- Shortness of breath (may be the sole symptom)
- Fatigue or faintness
- Nausea
- Burning sensation
- Restlessness
- Sense of impending doom 1
- Dyspnea or dizziness on exertion
- Pain in arms, jaw, neck, or upper back 1
Severity Classification (Canadian Cardiovascular Society)
| Class | Description |
|---|---|
| I | Ordinary activity doesn't cause angina. Occurs with strenuous/rapid/prolonged exertion |
| II | Slight limitation of ordinary activity. Angina with rapid walking/stairs, after meals, in cold/wind, under stress |
| III | Marked limitation of ordinary activity. Angina after walking 1-2 blocks or climbing one flight of stairs at normal pace |
| IV | Inability to perform any physical activity without discomfort; angina may occur at rest [1] |
Physical Examination Findings
- No specific diagnostic signs for angina pectoris
- During/after ischemic episode:
- Third or fourth heart sound may be heard
- Mitral insufficiency may be apparent
- Signs are often elusive and non-specific 1
- Examination should include:
- Assessment of peripheral pulses
- Auscultation of carotid and femoral arteries
- Evaluation of ankle-brachial index
- Assessment for signs of comorbidities (thyroid disease, renal disease, diabetes) 1
Features Not Characteristic of Myocardial Ischemia
- Pleuritic pain (sharp pain provoked by respiration/cough)
- Primary location in middle/lower abdomen
- Pain localized by fingertip, especially at LV apex or costochondral junction
- Pain reproduced by movement/palpation of chest wall or arms
- Brief episodes lasting seconds
- Pain maximal at onset
- Pain radiating to lower extremities 1
Common Pitfalls in Diagnosis
Misinterpreting Atypical Presentations: Especially in women, elderly, and diabetic patients who may present with atypical symptoms or angina equivalents rather than classic chest pain 1
Overlooking Shortness of Breath: May be the sole manifestation of CAD, easily confused with pulmonary conditions 1
Dismissing Reproducible Pain: While pain reproducible by palpation makes SCAD less likely, it doesn't completely exclude it—7% of patients whose pain was reproduced with palpation had ACS 1
Focusing Only on Typical Symptoms: In the Multicenter Chest Pain Study, acute ischemia was diagnosed in 22% of patients with sharp/stabbing pain and 13% with pleuritic pain 1
Failing to Consider Vasospastic Angina: Characterized by pain starting at rest, slowly intensifying, remaining at maximum for up to 15 minutes, then slowly decreasing 1
By recognizing these characteristic patterns and avoiding common diagnostic pitfalls, clinicians can more accurately identify coronary artery disease and initiate appropriate management to reduce morbidity and mortality.