Ischemic Pain (Angina Pectoris)
Ischemic pain is based on a mismatch between myocardial oxygen demand and delivery. This occurs either due to atherosclerotic narrowing of the coronary arteries or pronounced myocardial hypertrophy (relative insufficiency).
A typical effort angina attack is characterized by:
- Localization: strictly retrosternal (retrosternally).
- Character: pressing, squeezing, burning (not stabbing or aching).
- Triggering factors: physical exertion (e.g., walking against the wind), stress, exposure to cold, heavy meals.
- Duration: from 3 to 15 minutes, with intensity increasing gradually.
- Relief: pain quickly disappears at rest or after sublingual nitroglycerin.
- Radiation: to the left arm and shoulder (along the inner surface), neck, lower jaw, left scapula, less commonly to the epigastrium.
The attack is often accompanied by sympathetic nervous system activation: pallor, sweating, nausea, and a vital dread of death.
Cardialgia: Non-Ischemic Pain
Cardialgia is pain in the precordial region not associated with coronary insufficiency.
Its clinical profile is cardinally different from angina. Patients usually point to pain in the apex of the heart (near the left nipple). The sensation is sharp (stabbing, shooting) or neuropathic (aching, itching). There is no clear relation to physical exertion; the pain may last for seconds (like a shock) or persist monotonously for hours. Nitroglycerin is ineffective for cardialgia.
Diagnostic Complexity: due to innervation features, cardialgia can radiate to the left arm or scapula just like true ischemic pain.
Extracardiac Causes of Pain
Chest pain can be caused by dozens of diseases of other systems. Key differential signs:
- Respiratory system pathology (pleurisy): pain is clearly linked to breathing, worsens on inspiration and coughing, and pleural friction rub may be auscultated.
- Musculoskeletal system: in cervical osteochondrosis or inflammation of costal junctions, pain is provoked by movements (turns, bends) and palpation.
- Digestive system: esophageal spasm or reflux esophagitis causes retrosternal burning occurring in the recumbent position (often at night). Important: this pain subsides after eating and may be relieved by nitroglycerin, strongly mimicking angina.
- Psychogenic factors: in neuroses, pain is often localized at the heart apex and is associated with emotional stress.
Urgent Conditions (High-Risk Group)
There is a category of life-threatening conditions requiring emergency intervention. A physician should be alert if a patient describes intense, prolonged paroxysmal pain behind the sternum or on the left, accompanied by a drop in blood pressure (hypotension).
Such a clinical picture is typical for:
- Myocardial infarction.
- Pulmonary embolism (PE).
- Aortic dissection.
Unstable angina—a condition where the usual character, frequency, or intensity of pain has sharply changed (increased risk of infarction)—also requires immediate hospitalization.
History-Taking Algorithm
For accurate differential diagnosis, it is necessary to consistently clarify 7 characteristics of the pain syndrome:
- Localization and radiation zones.
- Qualitative character of sensations (pressing, burning, or stabbing).
- Factors provoking pain (exertion, food, posture).
- Duration of a single attack.
- Frequency of occurrence.
- Dynamics of the course (whether there is worsening over recent days).
- Effect of nitroglycerin (onset speed and number of doses per day).
Briefly: answers to topical questions
What extracardiac diseases cause chest pain?
Extracardiac causes of chest pain mimicking cardiac pain include:
- Lung and pleural diseases: pneumonia with secondary pleurisy, pneumothorax, pleurisy.
- Esophageal disorders: reflux esophagitis, esophageal spasm.
- Nervous system disorders: intercostal neuralgia.
- Musculoskeletal and chest wall disorders: costosternal inflammation, cervical osteochondrosis, muscular and osteoarticular chest conditions.
- Psychogenic causes: neurosis with a depressive component.
What ECG changes are registered during an angina attack?
During an angina attack, the ECG is most informative: ischemic changes appear or intensify precisely at the moment of pain. The main criterion for ischemia is horizontal or downward ST-segment depression of more than 1 mm. ST-segment changes, including depression or elevation, have diagnostic significance for a preliminary diagnosis of angina or myocardial infarction. Vasospastic angina is characterized by significant ST-segment elevation.
By what signs can esophageal pathology pain be distinguished from angina?
Pain from esophageal pathology can mimic angina, so the effect of nitroglycerin cannot be used as the sole differentiating criterion: it can relieve pain in both esophageal spasm and angina.
| Sign | Esophageal pathology | Angina Pectoris |
|---|---|---|
| Conditions of occurrence | Often at night, in a supine position; in GERD, pain is not related to physical exertion | Triggered by physical exertion, emotional stress, cold, heavy meals, smoking |
| Relieving factors | May subside after eating; in esophageal spasm, may be relieved by nitroglycerin | Quickly subsides after cessation of exertion or administration of nitroglycerin |
| Associated manifestations | Heartburn, regurgitation, eructation, dysphagia, odynophagia | Pallor, diaphoresis, feeling of doom, nausea |
What laboratory markers of myocardial necrosis should be assessed in prolonged substernal chest pain?
If myocardial infarction is suspected—including cases of prolonged substernal pain and an equivocal ECG—serial testing of biochemical markers of myocardial necrosis should be performed.
- CK-MB is a key marker; activity rises within the first hours, peaks around 24 hours, and returns to normal by day 3.
- Troponins T and I are key markers of myocardial necrosis.
- Myoglobin is the earliest marker: it increases sharply within the first hours, peaks up to 12 hours, and quickly normalizes during the first day.
- CK rises within the first hours, peaks around 24 hours, and returns to normal by day 3.
- AST follows the dynamics of CK, but with a smaller amplitude.
- LDH is a late marker, peaking on days 2–4, with activity declining by day 8.
- Troponin I rises within the first hours and can remain elevated for more than a week.
The rule of 7 pain characteristics: Where? What does it feel like? Following what? How long does it last? How often? What has changed? Did nitroglycerin help?
What else to study on this topic
- Pathogenesis and triggers of vasospastic angina
- Relative coronary insufficiency in myocardial hypertrophy
- Anatomic mechanisms of cardiac pain radiation
- Non-coronary chest pain in myocarditis and pericarditis
- Signs of transition from stable to unstable angina
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