The following symptoms and complaints may indicate coronary artery disease (CAD):
Angina pectoris (AP; chest tightness, heart tightness).
- Sudden onset of retrosternal (“located behind the sternum“) pain* (of short duration; see below), left > right; usually radiating to the left shoulder-arm region or neck–lower jaw region as well as to the upper abdomen, back; pain may be dull, pressing, cramping, or drillingCaution! In some cases, the pain is localized in other regions and radiates to the thorax (chest); sometimes the thorax is not affected at all.Furthermore, the following characteristics are met:
- Triggered by physical or psychological stress* (trigger mechanism: see below).
- Decline at rest and/or within a few minutes after nitrate application* .
- Feeling of tightness or annihilation
- Shortness of breath, suffocation
- Sweating
- Anxiety up to fear of death
The duration of an AP is minutes in the context of the trigger mechanism and usually lasts no longer than 20 minutes.Trigger mechanisms can be: physical and emotional stress, opulent meal, cold, etc..
* Note: If only two of these three characteristics are met, it is called “atypical angina“. If only one or none of these three points apply, one speaks of non-anginal thoracic symptoms. A distinction is made between stable angina pectoris and unstable angina pectoris (UA). Unstable angina is characterized by an increase in the intensity or duration of the symptoms compared with previous attacks of angina pectoris. In stable angina pectoris, the thoracic pain improves within 1-2 minutes after glycerol nitrate (GTN; nitrogycerin). In contrast, unstable angina or myocardial infarction (heart attack) is usually nitrorefractory, ie, cannot be influenced by glycerol nitrate.
Acute coronary syndrome (ACS)
The term acute coronary syndrome (ACS; acute coronary syndrome) refers to those phases of coronary artery disease (CAD) that are immediately life-threatening. These include:
- Unstable angina (UA) – unstable angina is when the symptoms have increased in intensity or duration compared with previous attacks of angina.
- Acute myocardial infarction (heart attack):
- Non-ST-segment-elevation myocardial infarction (NSTEMI).
- ST-elevation myocardial infarction (STEMI; ST-segment-elevation myocardial infarction).
- Sudden cardiac death (PHT)
Difficult to distinguish between unstable angina/NSTEMI and STEMI, because their transitions are fluid.For ST-segment elevation myocardial infarction is characterized by prolonged (> 20 min) and nitrorefractory pain symptoms (no response to nitroglycerin)! Prodromal symptoms (precursor symptoms) for acute coronary syndrome (ACS) (median age of study participants was 49 years).
- 85% of women and 72% of men, reported prodromal symptoms in terms of nonspecific complaints:
- Unusual fatigue (60% of women, 42% of men).
- Sleep disturbances
- Anxiety
- Arm weakness or pain
- Thoracic pain (chest pain; = leading symptom of ACS) occurred in only 24% of patients in both sexes before ACS.
Leading symptom of ACS
- Thoracic pain: acute onset retrosternal feeling of pressure or heaviness (“stone on the chest“); pain radiates to the left arm the neck or jaws or to the lower abdomen. Man: chest pain (chest pain) and sweating are more common in men.Woman: pain between the shoulder blades (occur twice as often in female patients)Note: pain radiating to the right arm or both arms is possible but rare.Duration of thoracic pain: intermittent for several minutes or persistent.
Possible accompanying symptoms
- Dyspnea* (shortness of breath)
- Nausea* (nausea)/vomiting
- Palpitations (heart palpitations)
- Sweating
- Syncope – brief loss of consciousness caused by reduced blood flow to the brain, usually accompanied by a loss of muscle tone.
* Nausea and shortness of breath is more common in women. Notice:
- In one study, the so-called typical chest pain for the diagnosis of acute coronary syndrome was shown to have only a 0.54 area under the curve in terms of its discriminatory ability: experienced physicians were 65.8% and novices were 55.4%. After completion of treatment, only 15-20% of patients with chest pain were diagnosed with acute coronary syndrome.
- Good exercise capacity without angina never excludes acute coronary syndrome (STEMI, NSTEMI, and unstable angina).
The “Marburg Heart Score” supports the differential diagnostic clarification of chest pain in a family practice (see below). Possible comorbidities (concomitant diseases)
Left heart failure
- Dyspnea (shortness of breath)
- Impaired performance, fatigue
- Orthopnea – maximum shortness of breath, compensated only by upright posture.
- Cyanosis – violet-bluish discoloration of the oral mucosa, tongue, lips and conjunctiva as a result of decreased oxygen saturation (SpO2) of the blood.
- Congestive bronchitis with irritable cough
- Possibly rusty brown sputum
- Nocturnal asthma cardiale
- Pulmonary edema – fluid in the lungs
- Leg edema – fluid accumulation in the legs.
- Tachycardia – heartbeat too fast: > 100 beats per minute.
Cardiac arrhythmias
- Palpitations (heart palpitations)
- Tachycardia (heartbeat too fast: > 100 beats per minute).
- Increased extrasystoles – heart stumbles with “extra beats”.
- Atrial fibrillation (VHF)
- Atrial flutter
Further notes on CHD
- The dangerous thing about CHD is that even without symptoms, there may already be high-grade atherosclerosis and coronary stenosis (narrowing of the coronary arteries). Only a restriction of the vessel lumen by at least 60% leads to a detectable reduction in blood flow.
- Approximately 50% of all patients with suspected stenosing CHD show no relevant stenoses (narrowing) in a coronary angiography (radiological procedure that uses contrast agents to visualize the lumen (interior) of the coronary arteries (arteries that surround the heart in a wreath shape and supply the heart muscle with blood).
- There is also stable angina pectoris (AP), which is not explained by stenoses (narrowings) of the coronary vessels (coronary arteries). In such cases, there is usually a microvascular, or possibly vasospastic, cause:
- Microvascular angina (coronary microvascular dysfunction, MVD) usually presents with typical retrosternally localized and exercise-induced angina in association with signs of ischemia on an exercise test. An obstructive CHD is thereby angiographically not white detectable.
- Vasospastic angina typically presents with localized pectanginal symptoms that occur predominantly at rest rather than on exertion, often at night or in the early morning hours.
- Coronary microvascular dysfunction (MVD): mismatch between myocardial oxygen demand and supply; likely caused by chronic inflammation (inflammation); risk factors: Hypertension (high blood pressure), diabetes mellitus, hypercholesterolemia (high blood cholesterol); diagnostic: CT coronary angiography and PET measurement of myocardial flow reserve [MVD: lack of vasodilation (dilation of blood vessels) and/or increased vasoconstriction (vasoconstriction)/spasm tendency].
- With the help of the acetylcholine test (ACh test), however, functional disturbances of the coronary vessels (coronary microvascular dysfunction) can now be detected. In patients with stable angina pectoris without higher grade coronary obstruction, acetylcholine (ACh) test was performed to detect epicardial and microvascular spasm. This showed that 70% of women but only 43% of men had a pathological ACh test. CONCLUSION: Coronary microvascular dysfunction is more common in women.
- A 33-year follow-up study of 12,745 subjects showed that xanthelasmata (yellowish plaques formed by deposition of cholesterol in the tissues of the upper and lower eyelids) are an important skin marker of atherosclerosis (arteriosclerosis, hardening of the arteries), independent of lipid levels. Individuals with this skin marker have an additional risk factor for myocardial infarction (heart attack) and ischemic heart disease (coronary artery disease, CAD).
Marburg Heart Score
| Feature | Score |
| Gender and age(men ≥ 55 years; women ≥ 65 years). | 1 |
| Known vascular disease (vascular disease) | 1 |
| Complaints load-dependent | 1 |
| Pain is not reproducible by palpation (palpation) | 1 |
| Patient suspects heart disease as the cause | 1 |
| Points | Probability CHD | |
| 0-1 | < 1 % | very low |
| 2 | 5 % | Low |
| 3 | 25 % | Medium |
| 4-5 | 65 % | high |
