Chest Pain

Examine yourself while reading about chest pain

Know whether you are suffering from cardiac chest pain or non cardiac chest
Chest pain or discomfort suggestive of myocardial ischaemia is deemed typical. Other chest
pain is called atypical. Certain features will help the clinician to decide whether chest, jaw or
arm pain may be ischaemic and how threatening it is.
Typical angina Meets all three of the following criteria:
1 Characteristic retrosternal chest discomfort—typical (see
below) quality and duration
2 Provoked by exertion or emotion
3 Relieved rapidly by rest or glyceryl nitrate (GTN), or both
Atypical angina Meets two of the above criteria
Non-cardiac chest pain Meets one or none of the above criteria
Location
The pain of angina or myocardial infarction is usually felt in the centre of the chest; embryo-
logically the heart is a mid-line structure. It may be felt primarily in the throat or jaw, ulnar
aspect of the left arm, or one or both arms or wrists. It may also radiate to some or all of these
sites from the chest.
Character
Patients often describe a quality of tightness or heaviness in the chest or throat and may deny
there is any pain. For this reason it may be best to ask about discomfort rather than pain when
questioning the patient. The feeling in the throat may be described as choking, which is what the
word ‘angina’ means in Latin. The feeling in the jaw or arm is often called an ache. Some
patients with angina describe only dyspnoea (shortness of breath) and deny tightness or pain.
This is sometimes called an anginal equivalent. In all cases the symptoms are continuous, with-
out sudden fluctuations or throbbing. A patient who develops recurrent angina after previously
successful treatment, for example angioplasty, will usually say the quality of the discomfort is
similar to what was experienced before.
Women with angina are much more likely than men to have atypical symptoms (at least
atypical compared with those of men). The diagnosis of angina is often more difficult in women3
and non-invasive investigations are less reliable.
Aggravating and relieving factors
Angina typically occurs with exertion or stress,4 and is rapidly relieved by rest. It tends to be
worse in cold weather and when the patient exercises after meals. Angina is said to be stable
when a predictable amount of exertion will usually reproduce the symptoms. The predictable
association with exertion is one of the most reliable features in the history suggesting that
chest pain is due to angina. Rapid relief of pain may occur if the patient has tried sublingual
nitrates. This usually means relief within one or two minutes or by the time the tablet has
dissolved. The use of sublingual nitrates can have a pronounced placebo effect and can also
relieve the pain of oesophageal spasm. Response to nitrates is therefore suggestive of angina
but not diagnostic.
Duration
Episodes of stable angina are rarely prolonged for more than 5–10 minutes. It often feels longer
to the patient. Pain present for longer than this may be due to an acute coronary syndrome
(myocardial infarction or unstable angina) or may not be ischaemic at all.
If you are suffering from any of the above immediately consult the cardiologist in our hospita