What Heart Angina Pains Feel Like
Angina typically feels like substernal pressure, squeezing, tightness, or heaviness in the chest—not sharp or stabbing pain—and is often described as "grip-like," "suffocating," or a sensation of constriction. 1
Classic Characteristics of Anginal Pain
Quality and Description
- Pressure, tightness, heaviness, or squeezing are the most common descriptors 1
- Patients may describe it as "strangling," "constricting," "crushing," or "burning" 1
- Rarely sharp or stabbing—these characteristics make angina less likely 1
- Many patients demonstrate Levine's sign: placing a clenched fist over the precordium to describe the sensation 1
- Some patients describe it as "discomfort" rather than frank "pain" 1
Location and Radiation
- Primary location: Substernal (behind the breastbone) or central chest 1
- Common radiation patterns: 1
- Neck and jaw
- Left arm (most common) or both arms, occasionally right arm alone
- Shoulders and back (between shoulder blades)
- Epigastrium (upper abdomen)
- Can extend to wrists and fingers
- Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely angina 1
Duration and Timing
- Typically lasts minutes—usually less than 10 minutes, commonly even briefer 1
- Fleeting pain lasting only seconds is unlikely to be angina 1
- Gradually builds in intensity over a few minutes rather than sudden onset 1
Triggering and Relieving Factors
- Precipitated by: 1
- Physical exertion (walking uphill, climbing stairs, walking against wind or cold weather)
- Emotional stress
- Heavy meals
- First thing in the morning
- Relieved by: 1, 2
- Rest (within minutes of stopping activity)
- Sublingual nitroglycerin (within 30 seconds to several minutes)
- Does not typically vary with position or respiration 1
Associated Symptoms
Angina may be accompanied by: 1
- Shortness of breath (dyspnea)
- Sweating (diaphoresis)
- Nausea and/or vomiting
- Fatigue or weakness
- Faintness or lightheadedness
- Sense of impending doom
- Restlessness
Atypical Presentations
High-Risk Groups for Atypical Symptoms
Women, elderly patients, and those with diabetes or dementia frequently present atypically 1, 3
Atypical Manifestations Include:
- Epigastric pain or "indigestion-like" symptoms 1
- Isolated dyspnea without chest discomfort 1
- Sharp (atypical) chest pain 1
- Nausea and vomiting as primary symptoms 1
- Midepigastric discomfort 1
- Pain in arms, shoulder, or neck without chest pain 3
- Syncope or near-syncope 1, 3
- In the WISE study, 65% of women with ischemia presented with atypical symptoms 1
Important Clinical Distinctions
What Angina Is NOT:
- Sharp, stabbing pain 1
- Pain that varies with position or breathing 1
- Pain lasting only seconds 1
- Sudden onset of "ripping" pain (suggests aortic dissection) 1
- Pain reproduced by chest wall palpation (suggests musculoskeletal cause) 1
- Positional chest pain 1
Critical Warning Signs Requiring Emergency Evaluation:
- Prolonged pain lasting >20 minutes at rest 1
- New onset severe angina 1
- Rapidly worsening (crescendo) pattern 1
- Pain persisting after 3 nitroglycerin tablets over 15 minutes 2
- Pain different from typical pattern 2
Common Pitfalls
Relief with nitroglycerin is NOT diagnostic of angina alone—esophageal spasm and other conditions may also respond to nitrates 1. The diagnosis requires the complete clinical picture including characteristic quality, location, duration, and relationship to exertion 1.
Do not dismiss atypical presentations in women, elderly, or diabetic patients—over half of Medicare patients with confirmed unstable angina had atypical presentations 3, and these patients may receive less aggressive treatment if their symptoms are not recognized 3.