Clinical symptoms of stable ischaemic heart disease

Ischaemic heart disease (IHD) becomes symptomatic when myocardial demand exceeds blood supply. Myocardial ischaemia leads to a wide range of symptoms, including chest pain as well as diffuse, worrisome sensations, all of which can be summarized under the term ‘chest discomfort’. Cardiac chest discomfort may be characterized according to four attributes: character, location, duration, and association with provoking or relieving factors. Typical angina pectoris, with a very high probability of significant epicardial coronary stenosis, can be diagnosed if three pre-specified criteria are met, whereas atypical angina pectoris, with only a moderate probability of IHD, and non-anginal chest pain fulfil fewer of these criteria. Angina pectoris can be quantified according to the Canadian Cardiovascular Society classification, which is based on threshold activities of angina-limited physical exertion. Some patients with IHD do not complain of chest discomfort but report symptoms such as sweating, nausea, or dyspnoea that have been demonstrated to be early indicators of IHD, denoted here as ‘angina equivalents’. Patients who do not experience any symptoms at all although myocardial ischaemia is detected are said to have ‘silent’ ischaemia. Patients with chest pain or discomfort use certain uniform hand gestures to describe the localization and character of the pain; thus, body language may be complementary to diagnostic criteria for IHD. Women are more likely to present with atypical forms of chest discomfort, and IHD is diagnosed roughly 10 years later in women than in men. Careful interpretation of patients’ descriptions of their symptoms is crucial to correctly diagnosing IHD.