Where is anginal pain felt and where may it radiate?

Anginal chest pain may occur anywhere between the diaphragm and mandible, but it is most often substernal or on the left side of the chest. It tends to be diffuse and not localized to a small discrete area. It may radiate to the neck, throat, mandible, shoulder, or arm (usually the inner aspect of the arm and more commonly the left arm).

Pain patterns with myocardial ischemia. (From Horwitz LD: Chest pain. In Horwitz LD, Groves BM, (eds): Signs and Symptoms in Cardiology, Philadelphia, J.B. Lippincott, 1985, p 9; with permission.)

What are the classic associated symptoms for myocardial ischemia?

In addition to typical anginal chest pain, one or more of the following may be observed:

Shortness of breath


Nausea and emesis

What findings on the physical examination may be seen with myocardial ischemia?

The physical findings may be normal. An S4gallop (4th heart sound) is due to atrial contraction against a stiff or noncompliant ventricle. If an S4gallop is heard with symptoms and disappears as the symptoms resolve, this suggests transient ventricular noncompliance (from ischemia) and is strong evidence for myocardial ischemia. An S4gallop may be present before symptoms develop (and then will likely be present after symptoms resolve) due to other causes of ventricular noncompliance (left ventricular hypertrophy, hypertension, aortic stenosis, previous myocardial infarction, etc.). Evidence of congestive heart failure may exist (elevated jugular venous pressure, pulmonary rales, S3gallop). There may be a visible and/or palpable dyskinetic bulge of the chest wall during active ischemia or infarction. Murmurs, especially if new, may suggest ischemic-related processes. Papillary muscle ischemia may lead to mitral regurgitation. Rupture of the interventricular septum will produce a ventricular septal defect and its associated murmur. Aortic stenosis and hypertrophic obstructive cardiomyopathy have characteristic murmurs and can cause myocardial ischemia and symptoms of angina.

What changes on the 12-lead electrocardiogram (ECG) may be seen with myocardial ischemia?

The classic ECG changes of myocardial ischemia are horizontal ST-segment depression in leads corresponding to the anatomic regions of the heart. ST depression is neither 100% sensitive (there can be myocardial ischemia and angina without ST depression) nor 100% specific (not all ST depression represents myocardial ischemia). ECG changes associated with symptoms that resolve as the symptoms resolve more strongly suggest myocardial ischemia.

How do you differentiate between angina and myocardial infarction?

The symptoms of an acute myocardial infarction are usually more intense, longer in duration (1-8 hours), and more often associated with shortness of breath, diaphoresis, nausea, and emesis. In addition, the 12-lead ECG shows ST-segment elevation rather than depression and may show T-wave inversion and/or pathologic Q waves.

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