What are the symptoms of coronary steal syndrome?

Symptoms of Coronary Steal Syndrome

Coronary steal syndrome presents with classic angina symptoms including chest pain, shortness of breath, and fatigue that typically occur during physical exertion or emotional stress, particularly in patients with prior coronary artery bypass grafting using internal mammary artery grafts.

Clinical Presentation

Coronary steal syndrome (also known as coronary-subclavian steal syndrome) manifests with various symptoms related to myocardial ischemia:

Primary Symptoms

• Chest discomfort described as pressure, heaviness, or tightness 1
• Retrosternal pain that may radiate to the left arm, neck, or jaw 2
• Symptoms typically provoked by physical exertion or emotional stress 2, 1
• Pain that may be relieved by rest or nitroglycerin 2

Common Presentations

• Unstable angina 3, 4
• Acute myocardial infarction 3
• Acute systolic heart failure 3
• Dyspnea (especially during exertion) 2

Angina Equivalents

• Unexplained fatigue 2
• Diaphoresis (excessive sweating) 2
• Nausea or vomiting 2
• Epigastric discomfort 2
• Unexplained shortness of breath 1

Distinguishing Features of Coronary Steal Syndrome

Unlike typical coronary artery disease, coronary steal syndrome has some unique characteristics:

• Symptoms often occur after coronary artery bypass grafting (CABG) using internal mammary artery grafts 3, 5
• Unequal blood pressure measurements between arms 5
• Difference in pulse strength between arms 5
• Symptoms may worsen with arm exercise on the affected side 3
• Symptoms may occur without significant native coronary artery disease progression 4

Clinical Scenarios That Should Raise Suspicion

Be particularly vigilant for coronary steal syndrome in the following situations:

• Post-CABG patients (especially with LIMA to LAD grafts) presenting with new-onset angina 3, 4
• Patients with known atherosclerotic disease in multiple vascular beds 6
• Patients with peripheral arterial disease and coronary artery disease 6
• Patients with a history of subclavian artery stenosis 3, 5

Diagnostic Pitfalls

Several common pitfalls can lead to missed or delayed diagnosis:

• Misinterpreting symptoms as progression of native coronary artery disease 4
• Failing to check bilateral arm blood pressures in post-CABG patients 3
• Overlooking atypical presentations, especially in women, elderly, and diabetic patients 2
• Dismissing chest pain that is reproducible with palpation (7% of such patients may still have acute coronary syndrome) 2
• Focusing only on typical symptoms, as acute ischemia can present with sharp or stabbing pain (22%) or pleuritic pain (13%) 2

Key Takeaways

• Coronary steal syndrome should be suspected in any post-CABG patient presenting with recurrent angina symptoms
• The condition is characterized by reversal of blood flow in an internal mammary artery graft due to proximal subclavian artery stenosis 3, 4
• Bilateral arm blood pressure measurements are essential for screening 3
• Symptoms can range from stable angina to acute myocardial infarction or heart failure 3
• Early recognition is critical as the condition is treatable through percutaneous or surgical revascularization of the subclavian artery 3, 4