Living With Angina

WHAT IS ANGINA? Who Has Coronary Artery Disease?

If you have symptomatic coronary artery disease (CAD), you are not alone. More than 3 million Americans either have had a heart attack or have angina pectoris. Two-thirds of all American men die of the complications of CAD. In some other countries, such as Finland, the percentage is even higher. The dollar costs are staggering. Over $1 billion is spent yearly on worker disability, and almost ten times that amount on medical treatment. A parade of Americans went to coronary artery bypass surgery each year at a cost in excess of $100,000 per operation, including catheterization. This number peaked at 190,000 operations in 1996 but has been gradually falling ever since, as non-operative therapies have so greatly improved.

CAD is often thought of as a disease of old age. Not so. Most people with angina or previous myocardial infarction, or heart attack, are in the 45- to 65-year-old group, and many are even younger. The famous autopsy studies of Korean War soldiers proved that coronary atherosclerosis starts in the late teenage years. Two hundred and ten (77 percent) of 300 soldiers tested, with an average age of 22 years, showed some evidence of coronary disease and 10 percent showed high-grade blockage of at least one major coronary artery. Review of late 19th- and early 20th-century hospital records seems to confirm that angina was an uncommon diagnosis. Also, the symptoms of hospital patients did not fit the clinical syndrome of angina pectoris as we know it. It is highly unlikely that the dramatic complaints of angina or heart attack we hear today could have gone unnoticed and unrecorded, especially if the frequency had been anywhere near that seen today. Symptomatic coronary artery disease is indeed a condition of modern society.

How Does Angina Feel?

Angina is usually not painful. This is often obvious to the patient and suspected by the doctor. Why, then, did the term "chest pain" become the nickname for angina?

I cannot count the number of visits to my office that have started off with the same stupid little conversation:

"Well, John, has your chest pain troubled you much since I saw you last?"

"I don't have any chest pain, Doc."

"You know what I mean—have you been bothered by that ..."

At this point my head goes into a whirl as I try to remember how John refers to his angina. I glance at my notes, hoping for a quick cue, as I usually write down the patient's own words as he describes his symptoms. Seeing nothing, I flash through my catalog of words and phrases that other patients have used to describe what they are feeling when angina strikes. Mixed in with this ever-expanding list are the terms I teach medical students so they may also avoid that confusing word "pain." Shall I say "chest pressure," "chest distress" or "chest heaviness"? How about "that burning feeling," "that squeezing," "constriction" or "tightness"? One lady called it her "elephant," and one man even called it his "little friend."

Even though this well-practiced mental exercise has taken but a fraction of a second, my brains are left scrambled. I am exhausted and only 20 seconds into the office visit. ". . that stuff," I finally say, and John gets my meaning. We then get down to the business of the day.

Not only is angina infrequently painful, sometimes it does not even occur in the chest. True, most angina has at least some component localized in the front of the chest, but you can't depend on it. I have had many patients referred by dentists after the patient had consulted them regarding jaw pain during exercise. Orthopedists will come upon patients complaining of arm, elbow or wrist pain with no muscular or skeletal basis. A chiropractor once referred a patient who complained of pain between the shoulder blades when he walked uphill. Angina can be very sneaky.

Your heart is not located on the left side of the chest, as is generally thought. It is positioned almost squarely in the center, except for some of the left ventricle projecting slightly toward the left. You can come very close to perfectly covering your heart if you make a fist with your left hand and place your flexed little finger in the indentation where the ribs bend up to meet the bottom of the breastbone. You will see that the right border of the heart is at the junction of the right side of the breastbone, or sternum, and ribs. The top of the heart is at the level of the midsternum and the bottom is at the lower end of the sternum. The left border of the heart arcs down to a point just below and slightly to the right of the left nipple. The location of the heart has almost nothing to do with where angina is perceived.

Textbooks usually indicate that angina occurs under the central sternum (a little higher than where you placed your fist) and radiates into the left arm. This textbook angina may fit only a third of angina sufferers, but it does serve to make the point that angina usually radiates upward and outward. In patients with arm discomfort associated with angina, about 50 percent feel it only in the left arm, 40 percent feel it in both arms simultaneously and 10 percent are only aware of right arm discomfort. The arm sensation is likely to follow the onset of the chest sensation by 10 to 60 seconds and may not occur at all if only a mild episode is experienced. Some individuals gauge the severity of an attack by how much heaviness or numbness they feel in their arm or arms after first having noticed chest distress. By the time the full arm radiation occurs, many individuals know they have walked too long or too fast after the onset of chest distress, or that they were a bit slow reaching for the nitroglycerin bottle.

Any imaginable combination of chest and arm symptoms is possible. Simultaneous appearance in chest and arm is distinctly less common than the radiation from chest to arm. Aching in the arm without chest awareness of any kind is unusual but by no means rare. Isolated heaviness or numbness in both wrists or lower arms with exertion is more likely due to coronary artery disease than not.

Angina very frequently radiates from the central chest up to the base of the throat and may continue into the jaw. Again, there may be discomfort only in the jaw, making the diagnosis sometimes very tricky.

The sneakiest angina of all occurs in the upper back without any awareness in the front part of the chest. Patients may accept this symptom as a minor arthritic problem and not consult a physician. This puts them at risk of a heart attack because they will not gain access to the protective measures modern medicine has to offer after a diagnosis is made. Even those who present themselves to a cardiologist, usually having been referred by a suspicious primary-care physician, may have to go through elaborate testing to determine if the back pain is a pulled muscle, arthritis of the lower neck or upper spine, or angina. Treadmill testing, discussed in detail later, is not always conclusive because arthritis is often made worse by exercise. Even proving the presence of coronary artery disease by cardiac catheterization does not prove that the back pain is angina. The worst situation of all is that of a patient who goes on to coronary bypass surgery to relieve back pain presumed to be angina, based on sophisticated testing, who continues to complain of some sort of backache after surgery. Did the chest surgery injure his back? Did the angina return? Did he ever have angina in the first place? I have gone around this circle several times, and I can assure you it is nerve-racking, not only to me and the patient, but to the patient's family, the referring physician and the heart surgeon.