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The diagnosis of angina pectoris often requires consider-able clinical skill because there is no totally specific symptom, physical finding, or laboratory examination to confirm its pres-ence. The history is probably the most powerful tool for diag-nosing angina and provides the skilled interviewer an assess-ment of both the stability (or instability) of the syndrome as well as its severity. The patient should be instructed to de-scribe the chest discomfort according to its character, location, radiation, duration, precipitating and alleviating factors, ac-companying symptoms, and change in pattern over the past few weeks or days.
As indicated above, the typical history is that of exertion-al chest discomfort of several minutes duration alleviated by rest. The discomfort typically involves the region of the ster-num (substernal or, more properly, retrosternat location) but may instead manifest itself in any region between the jaw and epigastrium. Commonly the discomfort radiates to the shoul-ders or arms, especially the left, to the neck or jaw, and less commonly to the back or epigastrium. Most patients perceive angina as a deep or visceral (rather than superficial) sensation and describe it as a "tightness heaviness", or "choking sen-sation" rather than as a definite pain. The discomfort is usually of several minutes duration; discomfort of less than 1 minutes' s duration is rarely angina, and discomfort at full intensity ex-ceeding 20 minutes in duration should arouse suspicion of my-ocardial infarction or discomfort unrelated to myocardial is-chemia. The pain of unstable angina, however, may wax and wane repeatedly over several hours.
Typically angina is provoked by exertion, especially walk-ing uphill, climbing stairs, vigorous arm work, coitus, or ex-ercising in cold weather (when peripheral vascular resistance is great). Discomfort may also be provoked by emotion (fear, anger, anxiety), may follow a meal, or may occur on lying down (angina decubitus) owing to increased ventricular filling pressure, or may occur during sleep (nocturnal angina), per-haps owing to increased adrenergic output related to dreams. Typically, exertional angina is relieved promptly (within 5 minutes) by rest; emotionally triggered angina may last longer; both usually are alleviated within 3 to 5 minutes with sublingual nitroglycerin. For patients with exertional angina, quantitation of the severity of the discomfort by a scale such as that of the Canadian Cardiovascular Society can be useful (Table 10).
TABLE 10 CANANIAN CARDIOVASCULAR
CLASSIFICATION OF ANGINA SEVERITY
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I Ordinary physical activity does not cause.., angina, such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion ff work or recreation Ⅱ Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in wind, or under emotional stress, or only during the few hours after awak-ening. Walking more than two blocks on the level and climbing more than I one flight of ordinary stairs at a normal pace and in normal conditions Ⅲ Marked limitation of ordinary physical activity. Walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace IV Inability to carry on any physical activity without discomfort--anginal syn. drome may be present at rest |
Other conditions that should be considered in the differen-tial diagnosis of angina include the following: gastrointestinal disease-especially disordered esophageal motility, gastroe-sophageal reflux, peptic ulcer disease, and cholecystitis; exer-tional bronchospasm related to asthmatic bronchitis; chest wall discomfort related to costochondritis, muscle spasm, herpes zoster, or anxiety states, the last often presenting as submam-mary sharp pain of a few seconds' duration; and other cardiac and vascular diseases such as pericarditis, myocardial infarc-tion, aortic dissection, or pulmonary embolism. These should be readily distinguished from angina in mast cases by a detailed histo-ry, physical examination, and appropriate laboratory tests.