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
Shaded areas show where you may have 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.
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 full-blown 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. 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.
- Does not cause permanent damage to the heart.
- 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.
- 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.
- 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 blocked coronary artery).
- Could result in permanent damage to the heart muscle.
- Symptoms usually last more than a few minutes and include chest pain or discomfort that lasts for more than a few minutes and does not completely resolve with nitroglycerin; 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.
- Requires emergency medical attention if symptoms last longer than 5 minutes.
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 perfect in picking up reduced 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
Gastrointestinal causes of chest pain include:
- Reflux (acid from the stomach washing back into the esophagus)
- 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:
- Pulmonary embolus
- Chronic obstructive pulmonary disease (COPD)
- 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
- 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.
Care and Treatment
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: "Time is muscle"
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.
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. If chest discomfort or pain is unimproved or is worsening 5 min after one dose, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely.
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.
When to Call the Doctor
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.
Doctors Who Treat
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, Vascular & Thoracic Institute Outcomes.
Cleveland Clinic Heart, Vascular & Thoracic Institute Cardiologists and Surgeons
Choosing a doctor to treat your coronary artery disease depends on where you are in your diagnosis and treatment.
Click on the following links to learn more about Sections and Departments that treat patients with Coronary Artery Disease:
- Cardiovascular Medicine
- Cardiothoracic Surgery Department
The Miller Family Heart, Vascular & Thoracic Institute offers specialty centers and clinics for patients whose treatment requires the expertise of a group of doctors and surgeons who focus on a specific condition.
- Advanced Ischemic Heart Disease Center
- Preventive Cardiology Programs and Clinics
- Women’s Cardiovascular Center
See: About Us to learn more about the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute.
If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
Becoming a Patient
Diagnostic tests are used to diagnose coronary artery disease and the most effective treatment method.
Our webchats and video chats give patients and visitors another opportunity to ask questions and interact with our physicians.
- Coronary Artery Disease webchats and video chats
- All Miller Family Heart, Vascular & Thoracic Institute webchats
- Coronary Artery Disease and Treatments Videos
- All Miller Family Heart, Vascular & Thoracic Institute Videos
Additional information and resources
- Recovery at Home
- Support Groups and Information
- Visit Health Essentials - Read articles on coronary artery disease and healthy living on Health Essentials
- Follow Heart, Vascular & Thoracic Institute webchats and news stories on Twitter*
- Subscribe to Heart, Vascular & Thoracic eNews
- American Heart Association*
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