What are the symptoms of Coronary Artery Disease (CAD)?

Symptoms of Coronary Artery Disease (CAD)

The primary symptoms of coronary artery disease include chest discomfort described as pressure, tightness, or heaviness that is typically located in the substernal area, provoked by exertion or emotional stress, and relieved by rest or nitroglycerin within minutes. 1

Chest Pain Characteristics

• Location: Typically substernal, but may radiate to the epigastrium, lower jaw, teeth, between shoulder blades, or either arm (extending to wrist and fingers) 1
• Quality: Often described as pressure, tightness, heaviness, squeezing, constricting, or strangling; burning sensation may also occur 1
• Duration: Brief episodes lasting up to 10 minutes, most commonly just a few minutes; chest pain lasting only seconds is unlikely to be angina 1
• Precipitating factors: Typically occurs with increased levels of exertion (walking up inclines, against cold wind), emotional stress, after heavy meals, or upon waking in the morning 1
• Relieving factors: Rapidly subsides within minutes when exertion stops; quickly relieved by sublingual or buccal nitrates 1

Classification of Angina

Typical Angina (Definite)

• Meets all three characteristics: substernal chest discomfort of characteristic quality and duration, provoked by exertion or emotional stress, and relieved by rest/nitrates within minutes 1
• Associated with higher prevalence of obstructive CAD (odds ratio 3.47) 2

Atypical Angina (Probable)

• Meets two of the three characteristics of typical angina 1
• May be associated with lower prevalence of obstructive CAD compared to typical angina 2

Non-Anginal Chest Pain

• Meets only one or none of the characteristics 1

Associated Symptoms

• Shortness of breath: May accompany angina or be the sole symptom of CAD 1
• Less-specific symptoms: Fatigue, faintness, nausea, burning, restlessness, or sense of impending doom 1
• Exertional dyspnea: Important symptom that may indicate CAD, especially in patients who don't present with classic angina 1

Severity Classification (Canadian Cardiovascular Society)

• Class I: Ordinary activity doesn't cause angina; symptoms occur with strenuous, rapid, or prolonged exertion 1
• Class II: Slight limitation of ordinary activity; angina occurs when walking/climbing stairs rapidly, after meals, in cold/wind, under emotional stress, or climbing more than one flight of stairs 1
• Class III: Marked limitation of ordinary activity; angina occurs when walking 1-2 blocks (100-200m) or climbing stairs under normal conditions at normal pace 1
• Class IV: Inability to perform any physical activity without discomfort; angina may be present at rest 1

Special Considerations

• Atypical presentations: Women may experience different symptom patterns than men, including more frequent angina despite less extensive epicardial CAD 1, 3
• Silent ischemia: Some patients, particularly those with diabetes with autonomic neuropathy or elderly individuals with sedentary lifestyles, may have CAD without anginal symptoms 1
• Variant angina: Characterized by pain starting at rest from low intensity, slowly intensifying, remaining at maximum for up to 15 minutes, then slowly decreasing; suggests coronary vasospasm 1
• Microvascular angina: May present with exertional pain that occurs some time after exertion and responds poorly to nitrates 1

Physical Examination Findings

• Physical examination during angina episodes may reveal a third or fourth heart sound 1
• Mitral insufficiency may be apparent during ischemic episodes 1
• These signs are elusive and non-specific 1
• Reproducing chest pain with palpation makes CAD less likely 1

Clinical Pitfalls

• Chest pain lasting only seconds is unlikely to be angina 1
• Pain that is pleuritic (sharp, provoked by respiration), localized to a single point, reproduced by movement/palpation, or radiating to lower extremities is not characteristic of myocardial ischemia 1
• Careful evaluation is needed before classifying chest pain as non-cardiac, including objective exclusion of myocardial ischemia caused by obstructive CAD, microvascular disease, and/or coronary vasospasm 1
• The absence of typical symptoms does not exclude severe CAD, particularly in patients with diabetes or elderly individuals with sedentary lifestyles 1