When you think of coronary heart disease, you think of angina! As the name implies, in the public’s opinion, angina should be painful; the painful part of angina must be in the area of the heart; and the pain that is effective with nitroglycerin must be angina. Is this really the case?
What is angina pectoris?
Angina is the most common symptom of coronary artery disease, a discomfort in the chest and nearby areas caused by myocardial ischemia. Typical angina is mainly manifested as episodic chest pain. When the pain strikes, patients are often forced to stop the activity they are doing until the symptoms are relieved.
Triggers: labor, exercise, emotional stress, full meals, and cold.
Location: posterior sternum and precordial area are common, and may radiate to other areas.
Nature of pain: pressure, tightness, burning sensation.
Time of onset: Mostly during activity, rarely after activity.
Duration: short duration, only 2-10 minutes.
Frequency of attacks: Once in a few days or weeks, or several times in a day.
Relief: Attacks are relieved by being forced to stop or by nitroglycerin.
Does angina always hurt?
One patient felt chest tightness after walking more than 200 meters or climbing one floor, like a stone pressed on his chest, which was relieved after resting for about 2-3 minutes. I told him that it was typical angina and needed coronary angiography. The patient was puzzled and asked, “I’m not in pain, how can it be angina?” Obviously, he was misled by the word “pain” in angina! A significant number of patients do not experience significant pain during an episode of myocardial ischemia. The discomfort in the chest is often described by terms such as “a burning sensation”, “a stone on the chest” or “a bandage on the chest”, a feeling of pressure, tightness and tightness. Be careful not to be confused by the name angina, as angina is not necessarily a cramping sensation in the heart.
Is angina always located in the precordial region?
No! A typical angina attack is located after the upper middle part of the sternum and can also be located in the left precordial area, which is about the size of the palm of your hand and often has no clear boundaries. It would be a mistake to assume that angina only occurs in the area where the heart is located. When angina attacks, it can radiate through the visceral nervous system to other parts of the body, but not usually to the lower extremities.
Radiation to the shoulders, arms and hands on both sides, misdiagnosed as frozen shoulder, cervical spondylosis, etc.
radiation backward to the back, misdiagnosis as thoracic spine, muscular disorders of the spine, etc.
upward emission to the neck, pharynx, lower jaw, cheeks and teeth, misdiagnosed as pharyngitis, trigeminal neuralgia, dental disease and jaw joint disease
downward emission to the upper abdomen, misdiagnosed as gastric, hepatobiliary diseases.
In our clinical work, we have encountered a patient who visited the stomatology department for recurrent toothache and another patient who visited the gastroenterology department for recurrent epigastric pain, which was finally diagnosed as coronary heart disease and angina pectoris by coronary angiography. Both of these patients had the characteristic that the pain came on during activity and could be relieved with a little rest. It is important not to confine the pain of angina to the heart, but to keep in mind that angina is more important because it likes to be still but not to move.
Does the effectiveness of nitroglycerin necessarily mean angina pectoris?
We often encounter patients who ask, “If I put nitroglycerin on my chest, it will stop hurting after a while. This is not coronary heart disease, right?” When asked carefully, how long does it take for the pain to stop? The answer varies, from 2 to 3 minutes, to more than 10 minutes, to half an hour ……. True angina containing nitroglycerin to relieve pain is generally between 1 and 5 minutes. If it takes more than 10 minutes to relieve, there are two possibilities, either it is unstable angina or myocardial infarction, or it is not myocardial ischemia at all. For example, some esophageal diseases such as esophageal spasm also show chest pain, and taking nitroglycerin can relieve chest pain, but esophageal pain radiates to the back more often than angina, so it is important to consult a cardiologist as well as a doctor with relevant expertise to guide the diagnosis and treatment.
Is chest pain always angina?
Chest pain can be caused not only by the heart, but also by other tissue lesions. Because of the high prevalence of cardiovascular diseases, many friends suspect angina when they have chest pain, which is also an incorrect understanding. The organs of the chest and the digestive organs of the upper abdomen can cause chest pain, and there is a thick clinical monograph devoted to the differential diagnosis of chest pain, and the more common ones are the following causes.
Diseases of the chest wall muscles, ribs or intercostal nerves, and bones and joints: herpes zoster, intercostal neuralgia, rib fractures, cervical spondylosis, thoracic spondylosis, frozen shoulder, etc.
Respiratory system diseases: hyperventilation syndrome, chronic obstructive pulmonary disease, spontaneous pneumothorax, pleurisy, bronchitis, pneumonia and pulmonary embolism
diseases of the digestive system: reflux esophagitis, esophageal spasm, esophageal hiatal hernia, gastric and duodenal diseases, cholecystitis, cholelithiasis, acute pancreatitis, etc.
other circulatory system pathologies: aortic diseases such as acute myocardial infarction, pericarditis, cardiomyopathy, valvular heart disease, aortic coarctation or aortic aneurysm
Neurological or psychological disorders: depression, anxiety, cardiac neurosis.
The causes of chest pain are complex and varied, and can be extremely challenging for clinicians. If chest pain similar to an angina attack occurs, early consultation with a specialist is recommended. The clinician needs to make a differential diagnosis by taking into account the medical history, as well as the location, direction of radiation, nature, triggering factors, duration, relieving factors, frequency of occurrence and concomitant symptoms of the pain, in order to avoid misdiagnosis and mistreatment.
Can a normal ECG rule out angina?
Some patients who have typical angina symptoms but have normal ECG results think they can rule out coronary heart disease. More than half of the patients with angina pectoris have normal ECG when they do not have angina pectoris. If you do not have angina pectoris when you have an ECG, the ECG is likely to be normal; some patients with coronary artery disease have normal ECG even when they have angina pectoris. Therefore, even if your ECG results are normal, if you have typical symptoms of angina attack, you should take further tests such as coronary angiography to clarify the diagnosis to avoid delaying the disease.
The manifestations of angina pectoris are complex and varied and can be easily confused with other diseases. If you have symptoms such as chest tightness and chest pain, you should consult a cardiologist as soon as possible and have the appropriate tests done to clarify the diagnosis. The possibility of angina pectoris should also be considered for atypical angina attack sites such as toothache, jaw pain, sore throat and shoulder and back pain, which affect the possibility of angina pectoris after excluding the corresponding diseases.