The most common symptom of coronary artery disease is angina (also called angina pectoris). Angina is often referred to as chest pain. It is also described as chest discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back or jaw.
If you have angina or any of the symptoms listed below that last for more than 5 minutes, SEEK EMERGENCY TREATMENT (CALL 9-1-1) WITHOUT DELAY. These symptoms could be the signs of a heart attack (also called myocardial infarction or MI) and immediate treatment is essential.
- Pain or discomfort in other areas of the upper body including the arms, left shoulder, back, neck, jaw, or stomach
- Difficulty breathing or shortness of breath
- Sweating or “cold sweat”
- Fullness, indigestion, or choking feeling (may feel like “heartburn”)
- Nausea or vomiting
- Light-headedness, dizziness, extreme weakness or anxiety
- Rapid or irregular heart beats
Are there other causes for chest pain other than cardiac causes?
There are many causes of chest pain. The one that doctors worry about the most is cardiac because it has the potential to be life-threatening. Non-invasive tests to diagnose coronary artery disease are not all sensitive to picking up blood flow to the heart in all people; especially in those with increased body mass index or special populations. Therefore, if you have symptoms of coronary disease but have been told they are not cardiac in nature, you may want to get a second opinion at a Center with experience in diagnostic testing. Once coronary disease is truly ruled out the work-up can proceed at a more leisurely pace.
Please note: If you have chest pain that lasts longer than 5 minutes and is not relieved by rest or medication, please seek emergency assistance (call 911).
Cardiac causes of chest pain are: ischemia (due to blockages - including both stable and unstable angina and acute heart attack and coronary artery spasm), pericarditis (inflammation of the sack around the heart), myocarditis (inflammation of the heart), cardiomyopathy (heart failure) and rarer causes such as coronary artery dissection, acute rupture of the heart and valves and infections of the pericardium.
Gastrointestinal causes of chest pain include: reflux (acid from the stomach washing back into the esophagus), gallstones, esophageal spasm, esophageal rupture, varicose veins of the esophagus, strictures of the esophagus, tumors of the esophagus and other less common GI problems.
Pulmonary (lung) causes include: pneumonia, pulmonary embolus, pneumothorax, pleuritis and bleb rupture.
Other potential causes are: aortic dissection, back and spine problems and musculoskeletal (muscle strain, rib fracture, etc.).
Psychological causes of chest pain are: common and include panic attacks, anxiety, stress and mental duress.
As you can see the list of potential causes in long and may take a little bit of time to determine the precise cause. A good internal medicine doctor or cardiologist can work through the potential causes of your symptoms.
Symptoms of coronary artery disease in women:
Studies show that women's symptoms are less likely identified as heart disease related. The symptoms of coronary artery disease and heart attack can be different for women than they are in men. Women are also less likely to recognize the symptoms of a heart attack and seek treatment. By learning and recognizing the symptoms, women can become assertive in their treatment. The most common symptoms of heart disease in women are:
- Pain or pressure over the chest that travels to the arm or jaw
- A burning sensation in the chest or upper abdomen
- Shortness of breath, irregular heartbeat, dizziness, sweating, fatigue and nausea.
On average, symptoms of heart disease appear 10 years later in women than men. Women tend to have heart attacks 10 years later than men do.
In addition, women often report their symptoms before having a heart attack, although the symptoms are not typical “heart” symptoms. In a multi-center study of 515 women who had an acute myocardial infarction (MI), the most frequently reported symptoms were unusual fatigue, sleep disturbances, shortness of breath, indigestion and anxiety. The majority of women (78%) reported at least one symptom for more than one month before their heart attack. Only 30% reported chest discomfort, which was described as an aching, tightness, pressure, sharpness, burning, fullness or tingling.
Reference: McSweeney J, Cody M, O’Sullivan P, Elberson K, Moser D, Garvin B. Women’s Early Warning Symptoms of Acute Myocardial Infarction. Circulation. 2003; 108(21):2619-2623
Types of Angina
A type of angina brought on by an imbalance between the heart’s need for oxygen-rich blood and the amount available. It is "stable," which means the same activities bring it on; it feels the same way each time; and is relieved by rest and/or oral medications. Stable angina is a warning sign of heart disease and should be evaluated by a doctor. If the pattern of angina changes, it may progress to unstable angina.
This type of angina is considered an acute coronary syndrome. It may be a new symptom or a change from stable angina. The angina may occur more frequently, occur more easily at rest, feel more severe, or last longer. Although this angina can often be relieved with oral medications, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure is required. Unstable angina is an acute coronary syndrome and should be treated as an emergency.
Variant angina (also called Prinzmetal's angina or coronary spasm):
A coronary artery can go into spasm, disrupting blood flow to the heart muscle (ischemia). It can occur in people without significant coronary artery disease. However, two thirds of people with variant angina have severe disease in at least one vessel, and the spasm occurs at the site of blockage. This type of angina is not common and almost always occurs when a person is at rest - during sleep. You are at increased risk for coronary spasm if you have: underlying coronary artery disease, smoke, or use stimulants or illicit drugs (such as cocaine). If a coronary artery spasm is severe and occurs for a long period of time, a heart attack can occur.
What’s the difference between angina and a heart attack?
Angina is a warning symptom of heart disease – but it is not a heart attack. The symptoms of a heart attack (also called myocardial infarction or “MI”) are similar to angina.
|Is brought on by a brief period of poor blood supply to the heart muscle
||Occurs when the blood supply to the heart muscle is blocked for an extended period of time (often due to a clot forming in a partially blocked coronary artery)
|Does not cause permanent damage to the heart
||Results in permanent damage to the heart muscle
|Symptoms last just a few minutes and are usually relieved by rest and/or medications. Symptoms include chest pain or discomfort, shortness of breath, palpitations, faster heart rate, dizziness, nausea, extreme weakness and sweating.
||Symptoms usually last more than a few minutes and include chest pain or discomfort that lasts for more than a few minutes or goes away and comes back; pain or discomfort in other areas of the upper body; difficulty breathing or shortness of breath; sweating or “cold” sweat; fullness, indigestion or choking feeling; nausea or vomiting; light-headedness; extreme weakness; anxiety; rapid or irregular heartbeats
|Symptoms are relieved by rest and/or medications within a few minutes
||Symptoms are not relieved by rest or oral medications
|Does not require emergency medical attention; however, it is important to call your doctor if this is the first time you’ve experienced angina, if you have new symptoms or if they become more frequent or severe
||Requires emergency medical attention if symptoms last longer than 5 minutes
Don’t Be Embarrassed to Death!
The good news about heart attacks:
Advances in technology over the past decade or so have dramatically lowered the death rate from acute heart attacks (myocardial infarction, or MI).
The bad news:
Many people never get to the hospital in time to take advantage of these life-saving advances. In fact, about 40% of the 1.1 million heart attacks that occur annually in the U.S. are fatal. That’s about 460,000 deaths from heart attack. Many more patients who survive their heart attacks do so with chronically damaged hearts.
Why timing is everything
When an acute MI occurs, there is a limited amount of time before significant and long-lasting damage is done to the muscle of your heart. If a large area of the heart is injured during the heart attack, full recovery becomes much more difficult. To obtain the greatest benefits of emergency care, anyone who thinks they are having a heart attack should get to the hospital within one hour of the onset of symptoms. The sooner you get to the emergency room, the sooner the appropriate treatment can begin, meaning the lesser the chances of permanent damage.
Sadly, only one in five patients actually gets to the hospital within this time frame. Therefore, many people who survive the MI are unnecessarily left with large portions of the heart scarred by the heart attack. This decreases the heart’s ability to pump blood effectively. Such patients may experience lifelong problems such as shortness of breath and angina (chest discomfort). Patients are also at an increased risk of developing heart failure, in which the heart weakens progressively over time.
Call 911 – not a friend
Calling 911 is almost always the fastest way to get lifesaving treatment. Emergency medical services (EMS) staff can begin treatment when they reach you. And they are trained to revive someone whose heart has stopped. Also, you’re likelier to get treated faster at the hospital if you arrive by ambulance.
If you are having symptoms of a heart attack, do not drive yourself.
What are the warning signs of a heart attack?
- Sudden chest pain or pressure (also called angina) that worsens. This may be felt as discomfort, heaviness, or pain. May also be felt in the back, jaw, throat, arm or below the breastbone.
- Feeling as if a belt is being tightened around your chest
- Pain that spreads from the center of the chest to your arms, shoulders, neck or jaw
- Feeling sick to your stomach, nausea, vomiting
- Shortness of breath
- A fullness, indigestion or choking feeling (may feel like "heartburn")
- Rapid or irregular heartbeats
- Extreme weakness, anxiety
Why do people delay?
Many people don’t recognize the symptoms of a heart attack (see list). The image we get from TV and movies is that a heart attack is a dramatic, chest-clutching event, yet this is rarely the case. Arm pain may signal a heart attack. Or shortness of breath. Or even an awareness of sweating.
Some people mistake heart attack symptoms for heartburn, take an antacid and wait for it to work. Many people will call 911 for someone else, but not for themselves.
Many people feel they will be embarrassed if they call 911 and they are not in fact having a heart attack. But don’t be embarrassed to death – heart attacks are the leading cause of death in both men and women.
Know in advance
- The symptoms of a heart attack.
- If you are at risk for a heart attack. Ask your doctor about your risk and what you should do to reduce your risk. Be sure to ask about aspirin and nitroglycerin.
- Who to call for emergency help. Do not call a friend or family member. Call for an ambulance to take you to the nearest emergency room (Dial 9-1-1 in most areas).
Share this information with your family members and caregivers so they can recognize the symptoms of a heart attack and when to seek emergency treatment.
- Learn to recognize your symptoms and the situations that cause them.
- Call your doctor if you begin to have new symptoms or if they become more frequent or severe.
If angina occurs:
What is Nitroglycerin?
Nitroglycerin is the most common vasodilator used for acute cases of angina. It works to dilate or widen the coronary arteries, increasing blood flow to the heart muscle and to relax the veins, lessening the amount of blood that returns to the heart from the body.
This combination of effects decreases the amount of work for the heart. Nitroglycerin comes in tablet or spray form. If you have angina, it is important that you keep this medication with you at all times.
- Nitroglycerin must be kept in a dark container.
- Keep it away from heat or moisture.
- Check the expiration date on the container.
- Once the container is opened, it must be replaced every 6 months
If you have been prescribed nitroglycerin and experience angina, stop what you are doing and rest. Take one nitroglycerin tablet and let it dissolve under your tongue, or if using the spray form, spray it under your tongue. Wait 5 minutes. If you still have angina after 5 minutes, call 911 to get emergency help.
For patients diagnosed with chronic stable angina: If you experience angina, take one nitroglycerin tablet and let it dissolve under your tongue, repeating every 5 minutes for up to 3 tablets spanning 15 minutes. If you still have angina after taking 3 doses of nitroglycerin, call 911 to get emergency help.
[Reference: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology, 2007. 50(7):1-157.]
Use of Aspirin with unstable chest pain: After you call 9-1-1, if you do not have a history of aspirin allergy or bleeding, emergency personnel may advise that you chew one full (325 mg) aspirin slowly. It's especially effective if taken within 30 minutes of the onset of symptoms.
Do not drive yourself to the hospital. In many cases, the emergency personnel can begin to give you heart-saving care right away.
To prevent damage to your heart muscle, do not delay seeking medical treatment.
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart and Vascular Institute Outcomes.
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