Chronic stable angina history and symptoms
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Overview
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina. Angina is considered to be stable when it remains reasonably constant and predictable in terms of severity, presentation, character, precipitants, and response to therapy. Symptoms as progressively worsening angina (accelerated angina), one or more episodes of angina at rest, or a new-onset angina classified as unstable angina.
Type and quality of the pain
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders.Pain or discomfort often described as tight, dull or heaviness at chest. Some patients have difficulty to describing the discomfort or deny that their discomfort is a true pain at all.
Location of the pain
The pain is often retrosternal or left side of chest and can radiate to left arm, neck, jaw and back. The most frequent initial location of angina is in the central chest and the retrosternal area, but the left pectoral region, arms and hands, root of the neck, epigastrium, and even the right side of the chest may be initial sites. Quite frequently, the pain starts in one of the other areas and later on spreads to the central chest. Occasionally, patients may complain of only interscapular or left infrascapular back pain. Discomfort that is located below the umbilicus or above the mandible is unlikely to be angina.
Radiation of the pain
Typical locations for radiation of the pain are the arms (often inner left arm), shoulders, and neck into the jaw.
Severity of the pain
During the initial evaluation of patients with suspected or established angina, it is desirable to assess its severity as a guide to therapy. A number of methods have been proposed to assess function impairment by history, based on the degree of physical activity that precipitates angina. The New York Heart Association (NYHA) functional classification has largely been replaced by the Canadian Cardiovascular Society (CCS) functional classifications or by classification systems based on the activity levels that can be related to the metabolic equivalents during treadmill exercise tests (A Specific Activity Scale developed by Goldman and colleagues and the angina score by Califf and colleagues). It should be noted that any functional classification is subject to variability in activity tolerance as perceived by patients and hence its reproducibility is variable.
After an episode of severe, transient ischemia, the myocardium may be temporarily stunned, which means that it remains transiently dysfunctional after the ischemia has resolved. When a part of the myocardium is chronically hypoperfused, it may not show evidence of ischemia on the electrocardiogram but may still be dysfunctional or even akinetic. It is important to distinguish this reversible clinical entity (so called hibernating myocardium) from myocardium that is dysfunctional secondary to irreversible infarction, because hibernating myocardium may regain normal function when perfusion is restored.
Relation to exertion
Angina is often brought on with exertion or emotional stress and in majority of cases eased with rest. Exertion induced angina (exertional angina), which is the most common clinical presentation of patients with stable angina, is precipitated by an increase in myocardial oxygen demand above myocardial oxygen supply. In some patients, however, myocardial ischemia is partially or totally secondary to a spontaneous reduction in coronary blood flow.
Duration of the pain
Typically angina pectoris symptoms last up to several minutes after exertion or emotional stress has stopped. The duration of angina pectoris is variable but it usually lasts 2 to 5 minutes. It is uncommon for the episodes of stable angina pectoris to be either very brief (<60 sec), or prolonged (>30 min). Anginal pain provoked by emotion may be relieved more slowly than that provoked by physical exercise.
Precipitating factors
Precipitating factors include emotions (anger, excitation, fear and frustration), cold weather, a heavy meal and cocaine use. Exertional angina or classic angina is characteristically induced by physical activity and is often precipitated more easily in cold weather or after eating a heavy meal (fatty and/or spicy meal).
Some patients, experience angina pectoris more frequently in the early morning than during the remainder of the day despite less or no physical activity at this time. Exercising the upper extremities above the head precipitates angina more readily than exercising the lower extremities.
In some patients dyspnea may reflect myocardial ischemia and left ventricular dysfunction and may be termed an "anginal equivalent". Both ischemic cardiac discomfort and cardiac dyspnea are worse during physical activity than at rest, and if activity releives the symptoms, then it is unlikely that the symptoms are related to myocardial ischemia.
Relieving factors
The impact of rest, discontinuation of the activity and nitroglycerin administration should be evaluated. The relief of angina usually occurs within several minutes after cessation of exertion (it may last up to 10 minutes or even longer after very strenuous exercise). Prompt relief is also achieved with administration of sublingual nitroglycerin. The hemodynamic effects of sublingual nitroglycerin usually begin within a minute, and the stable angina is generally relieved within 2 or 3 minutes. Chest discomfort that is instantaneously relieved by nitroglycerin is less likely to be angina pectoris.