Criteria for Typical Angina
Typical angina is defined by three specific characteristics: 1) substernal chest discomfort with a characteristic quality and duration, 2) provoked by exertion or emotional stress, and 3) relieved by rest or nitroglycerin. 1
Diagnostic Criteria for Angina Classification
Typical (definite) angina must meet all three of the following criteria 1:
- Substernal chest discomfort with a characteristic quality and duration
- Provoked by exertion or emotional stress
- Relieved by rest and/or nitroglycerin within minutes
Atypical (probable) angina meets two of the three characteristics of typical angina 1
Noncardiac chest pain meets one or none of the typical anginal characteristics 1
Detailed Characteristics of Typical Angina
Location and Quality
- Typically substernal chest discomfort, but may radiate to the epigastrium, lower jaw, teeth, between shoulder blades, or either arm 1
- Quality is often described as pressure, tightness, heaviness, squeezing, constricting, or strangling 1, 2
Duration and Timing
- Brief episodes lasting up to 10 minutes, most commonly just a few minutes 1
- Chest pain lasting only seconds is unlikely to be angina 2
- May be exacerbated after a heavy meal or upon waking in the morning 1
Precipitating Factors
- Increased levels of exertion (such as walking up an incline, against a breeze, or in cold weather) 1
- Emotional stress 1, 3
- May show "warm-up" phenomenon (reduced with continued exertion) or "walk-through" angina 1
Relieving Factors
- Rapid subsidence within minutes when exertion stops 1, 4
- Quick relief by sublingual or buccal nitrates 1, 5
Severity Classification
The Canadian Cardiovascular Society Classification system grades angina severity 1:
- Class I: Ordinary activity does not cause angina; symptoms occur only 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 weather, under emotional stress, or climbing more than one flight of stairs 1
- Class III: Marked limitation of ordinary physical activity; angina occurs when walking one to two blocks on level ground or climbing one flight of stairs at normal pace 1
- Class IV: Inability to carry on any physical activity without discomfort; angina may be present at rest 1
Clinical Pearls and Pitfalls
- Pain that is pleuritic, localized to a single point, reproduced by movement/palpation, or radiating to lower extremities is not characteristic of myocardial ischemia 2
- Women may experience different symptom patterns than men, including more frequent angina despite less extensive epicardial coronary artery disease 2
- Silent ischemia may occur in patients with diabetes or elderly individuals with sedentary lifestyles 2
- Physical examination during angina episodes may reveal a third or fourth heart sound, and mitral insufficiency may be apparent during ischemic episodes 1
- Chest pain reproduced by palpation makes coronary artery disease less likely 1, 2
Differential Considerations
- Microvascular dysfunction can cause typical angina symptoms even in the absence of significant epicardial coronary stenosis 6, 7
- Atypical angina may present as chest pain resembling typical angina in location and character, responsive to nitrates but without precipitating factors (suggesting possible coronary vasospasm) 1
- Shortness of breath may accompany angina or be the sole symptom of coronary artery disease 2
Understanding these criteria for typical angina is essential for accurate diagnosis and appropriate management of patients with suspected coronary artery disease.