Tension angina: symptoms

Angina may present as vague discomfort, pain, or intense, rapidly increasing, "tearing" sensations in the heart area. This sensation is rarely described as pain. The discomfort is most often felt behind the breastbone, although the location may vary. These sensations may radiate to the left shoulder and down the inside of the left arm, all the way to the fingers; through the chest to the back; to the neck, jaws, and teeth; and sometimes down the inside of the right arm. Discomfort may also be felt in the upper abdomen.

Some patients develop atypical angina (presenting with flatulence, belching, and abdominal discomfort), often attributed to indigestion based on the symptoms; the patient may feel that belching relieves the symptoms. Other patients develop dyspnea due to an acute, reversible increase in left ventricular filling pressure that often accompanies ischemia. Often the patient's descriptions are so imprecise that determining the cause of the sensations (angina, dyspnea, or both) is very difficult. Because ischemic episodes resolve within a minute or more, brief episodes rarely represent angina.

Between attacks of angina (and even during them), the physical condition may be normal. However, during an attack, the heart rate may increase slightly, blood pressure often increases, heart sounds become duller, and the apical impulse becomes more diffuse. Palpation of the precordial region may reveal a limited systolic impulse or paradoxical movement as a reflection of segmental myocardial ischemia and limited dyskinesia. The second heart sound may become paradoxical, since the ejection period from the LV is prolonged during an episode of ischemia. The fourth heart sound is often detected. A murmur at the apex in mid- or late systole (rough, but very loud) occurs if ischemia leads to the development of papillary muscle dysfunction, which in turn leads to mitral regurgitation.

With angina pectoris, an attack usually occurs during physical exertion or strong emotions, lasts no more than a few minutes, and passes at rest. The reaction to exertion is quite predictable, but in some patients, physical exertion, previously tolerated normally, at a certain point in time can provoke the development of an attack of angina, which is associated with changes in arterial tone. Manifestations of angina increase if physical exertion follows a meal or occurs in cold weather; walking in windy weather or the first contact with cold air after leaving a warm room can also cause an attack. The severity of angina is classified according to the degree of exertion that causes the attack.

The frequency of attacks may vary from a few episodes per day to long periods without them (weeks, months or years). The frequency of attacks may increase (so-called progressive angina) until fatal or gradually decrease (even disappearance of attacks is possible) if sufficient collateral coronary blood flow develops, and also if myocardial infarction occurs, circulatory failure or intermittent claudication develops, limiting the patient's activity.

Nocturnal angina attacks may occur if sleep causes sudden changes in respiratory rate, pulse rate, and blood pressure. Nocturnal angina attacks may also occur as a result of repeated episodes of left ventricular failure as the equivalent of nocturnal dyspnea.

Canadian Cardiovascular Society Classification of Angina

Class	Physical activity that leads to the development of an attack of chest pain
1	Strenuous, rapid or prolonged physical activity, unusual physical activity (eg, fast walking, climbing stairs)
2	Fast walking. Walking on an incline surface. Fast climb up the stairs. Walking or climbing stairs after eating. Cold. Wind. Emotional stress
3	Walking short distances on a horizontal surface even at a normal pace, climbing the stairs to the first floor
4	Any physical activity, sometimes attacks occur at rest

Angina may occur spontaneously at rest (the so-called rest angina). It is usually accompanied by a slight increase in heart rate and a significantly greater increase in blood pressure, which increases the myocardium's need for oxygen. An increase in these indicators may be both the cause of rest angina and the consequence of ischemia caused by the rupture of an atherosclerotic plaque and the formation of a thrombus. If the attack is not stopped and the myocardium's need for oxygen continues to increase, the likelihood of myocardial infarction increases.

Since the manifestations of angina are quite characteristic for each patient, any changes in its manifestations (for example, the appearance of angina at rest, new symptoms of the onset of an attack, increasing angina) must be considered serious symptoms. Such changes are called unstable angina.

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