Common symptoms of coronary artery disease (CAD) include angina, shortness of breath (particularly during physical exertion), and rapid heartbeat. Sometimes patients with CAD have few or no symptoms until they have heart attack or heart failure.
Angina is a symptom, not a disease. It is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically felt as chest pain and occurs as a consequence of a condition called myocardial ischemia. Ischemia results when the heart muscle does not get as much blood (and, as a result, as much oxygen) as it needs for a given level of work. Angina is usually referred to as one of two states:Click the icon to see an image about angina.
- Stable Angina (which is predictable)
- Unstable Angina (which is less predictable and a sign of a more serious situation)
Angina may be experienced in different ways and can be mild, moderate, or severe. The intensity of the pain does not always relate to the severity of the medical problem. Some people may feel a crushing pain from mild ischemia, while others might feel only mild discomfort from severe ischemia.Click the icon to see an image of angina.
Stable Angina and Chest Pain
Stable Angina. Stable angina is predictable chest pain. Although less serious than unstable angina, it can be extremely painful or uncomfortable. It is usually relieved by rest and responds well to medical treatment (typically nitroglycerin). Any event that increases oxygen demand can cause an angina attack. Some typical triggers include:
- Cold weather
- Emotional tension
- Large meals
Angina attacks can happen at any time during the day, but most occur between 6 a.m. and noon.
Specific symptoms that are more likely to indicate angina include:
- Angina pain or discomfort is typically described by patients as fullness or tingling, squeezing, pressure, heavy, suffocating, or griplike. It is rarely described as stabbing or burning. Changing one's position or breathing in and out does not affect the pain.
- A typical angina attack lasts minutes. If it is more fleeting or lasts for hours, it is probably not angina.
- Pain is usually in the chest under the breast bone. It often radiates to the neck, jaw, or left shoulder and arm. Less commonly, patients report symptoms that radiate to the right arm or back, or even to the upper abdomen.
- Women are particularly likely to experience atypical symptoms that often involve discomfort in the abdomen instead of the chest.
- Stable angina is usually relieved by rest or by taking nitroglycerin under the tongue.
Other symptoms that may indicate angina or accompany the pain or pressure in the chest include:
- Shortness of breath
- Nausea, vomiting, and cold sweats
- A feeling of indigestion or heartburn
- Unexplained fatigue after activity (more common in women)
- Dizziness or lightheadedness
Unstable Angina and Acute Coronary Syndrome
Unstable angina is a much more serious situation and is often an intermediate stage between stable angina and a heart attack, in which an artery leading to the heart (a coronary artery) becomes completely blocked. A patient is usually diagnosed with unstable angina under one or more of the following conditions:
- Pain awakens a patient or occurs during rest.
- A patient who has never experienced angina has severe or moderate pain during mild exertion (walking two level blocks or climbing one flight of stairs).
- Stable angina has progressed in severity and frequency within a 2-month period, and medications are less effective in relieving its pain.
- Fainting episode.
Unstable angina is usually discussed as part of a condition called acute coronary syndrome (ACS). ACS also includes people with a condition called NSTEMI (non ST-segment elevation myocardial infarction) -- also referred to as non-Q wave heart attack. With NSTEMI, blood tests suggest a developing heart attack. These conditions are less severe than heart attacks but may develop into full-blown attacks without aggressive treatment. [For more information, see In-Depth Report #12: Heart attack and acute coronary syndrome.]
Other Types of Angina
Prinzmetal's Angina. A third type of angina, called variant or Prinzmetal's angina, is caused by a spasm of a coronary artery. It almost always occurs when the patient is at rest. Irregular heartbeats are common, but the pain is generally relieved promptly with standard treatment.
Silent Ischemia. Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia, which may occur when the brain abnormally processes heart pain. This is a dangerous condition because patients have no warning signs of heart disease. Some studies suggest that people with silent ischemia have higher complication and mortality rates than those with angina pain. (Angina pain may actually protect the heart by conditioning it before a heart attack.)
Other Causes of Chest Pain or Discomfort
Chest pain is a very common symptom in the emergency room, but heart problems account for only 10 - 33% of all episodes. There are many other causes of chest pain or discomfort including injured muscles, arthritis, heartburn, and asthma.