Signs and Symptoms of CAD with Obstructive Lesions
The cardinal symptom of obstructive CAD is substernal chest discomfort described as pressure, tightness, or heaviness that is provoked by exertion or emotional stress and relieved by rest or nitroglycerin within minutes. 1
Primary Symptom: Anginal Chest Pain
Typical angina is the hallmark presentation and meets all three characteristics: 1
- Substernal chest discomfort of characteristic quality (pressure, tightness, heaviness, squeezing, constricting, or strangling sensation) 1
- Provoked by exertion or emotional stress (increased levels of exertion, emotional stress, after heavy meals, or upon waking) 1
- Relieved by rest or nitrates within minutes (rapid subsidence when exertion stops, quick relief with sublingual/buccal nitrates) 1
Typical angina is the strongest independent predictor of obstructive CAD, with greater predictive accuracy than other clinical risk factors. 2
Pain Characteristics and Radiation Patterns
The chest discomfort typically: 1
- Lasts brief episodes up to 10 minutes, most commonly just a few minutes 1
- Radiates to the epigastrium, lower jaw, teeth, between shoulder blades, or either arm 1
- Is NOT pleuritic, localized to a single point, reproduced by movement/palpation, or radiating to lower extremities 1
- Does NOT last only seconds (pain lasting seconds is unlikely to be angina) 1
Atypical Presentations
Atypical angina meets only two of the three typical characteristics and is associated with lower prevalence of obstructive CAD compared to typical angina. 1, 2
Anginal Equivalents and Associated Symptoms
Beyond chest pain, obstructive CAD may present with: 1
- Dyspnea on exertion (may accompany angina or be the sole symptom) 1
- Fatigue, faintness, nausea 1
- Burning sensation, restlessness, or sense of impending doom 1
Physical Examination Findings During Ischemic Episodes
During active angina episodes, physical examination may reveal: 1
- Third or fourth heart sound (S3 or S4 gallop) 1
- Mitral regurgitation murmur (may be apparent during ischemic episodes) 1
Important caveat: Reproducing chest pain with palpation makes CAD less likely. 1
Severity Classification (Canadian Cardiovascular Society)
The functional severity of angina is classified as: 1
- Class I: Ordinary physical activity doesn't cause angina 1
- Class II: Slight limitation of ordinary activity 1
- Class III: Marked limitation of ordinary activity 1
- Class IV: Inability to perform any physical activity without discomfort 1
Special Population Considerations
Women with Obstructive CAD
Women may experience: 1
- Different symptom patterns than men 1
- More frequent angina despite less extensive epicardial CAD 1
- Contemporary data shows anginal chest pain is equally prevalent in both sexes, though with slightly different characteristics 3
Silent Ischemia
Absence of anginal symptoms does not preclude severe obstructive CAD in: 3
Common Pitfalls to Avoid
Critical warning: Only 10% to 25% of patients with suspected CAD present with classic angina with typical aggravating and relieving factors, while 57% to 78% have less characteristic symptoms. 3 This means:
- Do not dismiss the diagnosis based on absence of "textbook" typical angina 3
- Careful evaluation is needed before classifying chest pain as non-cardiac 1
- Even patients with normal coronary arteries or diffuse non-obstructive CAD can have elevated risks of major adverse cardiovascular events compared to reference populations 4
Diagnostic Approach for Suspected Obstructive CAD
When obstructive CAD is suspected based on symptoms: 3
- 12-lead resting ECG should be obtained 3
- Echocardiography at rest to assess LV function and valvular disease 3
- Stress testing (exercise treadmill, stress imaging with PET/SPECT MPI, or stress CMR) to assess for ischemia in patients with obstructive CAD 3
- Coronary angiography remains the gold standard for diagnosis and treatment of obstructive lesions causing medically refractory stable angina 5