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Angina Pectoris in Emergency Medicine Clinical Presentation

  • Author: Marc D Haber, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Feb 18, 2015


Classically, angina presents as substernal chest discomfort that occurs with exertion, but it also may occur at rest. The discomfort is frequently described as a pressure or heaviness. Other commonly used adjectives for anginal pain include dull, aching, or squeezing. Pain may radiate to one or both arms, to one or both shoulders, or to the neck or jaw. Symptoms are highly variable. The entity cannot be expected to present with the classic triad of chest pressure with exertion radiating to the left arm. The diversity of disease expression is likely related to a patient's age, sex, race, and culture.

The caveat is to have a high index of suspicion for the disease. Many factors influence the expression of anginal symptoms. Familiar terms such as anginal equivalent and atypical chest pain are frequently used in these cases. In addition, systemic diseases, such as diabetes mellitus or chronic pain syndromes, may alter presenting anginal symptoms; while other diseases, such as prior cerebral vascular accident or dementia, may limit the patient's reporting of symptoms. A pain-free variant of angina—sometimes referred to as silent chest pain—also exists. These patients can present with complaints of shortness of breath, nausea, altered mentation, or abdominal pain.[10]

Chest discomfort quality

Which of the following describes the patient's chest discomfort?

  • Pain
  • Pressure
  • Squeezing
  • Dullness
  • Burning
  • Heaviness
  • Absent chest discomfort (eg, dyspnea, vomiting, altered sensorium)

Location (often diffuse to any location of C7-T4 dermatomes)

Which of the following is the site of the patient's chest pain?

  • Retrosternal or substernal
  • Inframammary
  • Left sided
  • Right sided
  • Upper abdominal
  • Shoulder, neck, arm
  • Teeth, jaw, lower face (above C7 unclear etiology)
  • Back, scapular region


Which of the following areas does the patient's chest pain radiate to?

  • Unilateral or bilateral arms
  • Unilateral or bilateral shoulders
  • Back
  • Neck
  • Jaw, ear, or lower face


Which of the following describes the temporal relationship of the chest pain?

  • Onset to maximum discomfort is progressive: With exertion (with or without increasing frequency) or at rest
  • Alleviation to relief is progressive.
  • Alleviation mediators may include oxygen, nitroglycerin, reduction of stressful activity, pain medication, and the placebo effect (eg, "GI cocktail")


Which of the following describes the patient's pain severity?

  • Mild to severe (1/10 to >10/10)
  • "Like my heart pain" - Patients in the emergency department (ED) may refer to the pain as being consistent with prior heart pains.


The physical examination may reveal signs of a hyperadrenergic state. One might observe tachycardia, tachypnea, hypertension, and/or diaphoresis. In addition, ischemia may lead to the presence of crackles due to the loss in contractility with subsequent pulmonary edema or a reduction in the S1 intensity.[11]

That said, no definitive examination findings suggest angina. Much of the information obtained from the physical examination may suggest other comorbidities that place the patient at higher risk for anginal symptoms (eg, chronic obstructive pulmonary disease [COPD], tachycardia, pale conjunctiva). Therefore, the physical examination is necessary to qualify the patient's current physical state and comorbidities. In this manner, the emergency physician obtains a baseline physical examination. Also, as mentioned, comorbid illnesses that affect the patient's level of cardiac, pulmonary, and circulatory function can be assessed.

As with many presentations to the emergency department, the physical examination in angina pectoris also serves as a marker for response to therapy. Important comorbidities that can be identified on physical examination include aortic stenosis, gastrointestinal bleeding, and airway obstruction. Unfortunately, no examination findings are pathognomonic for angina pectoris. In addition, no physical examination findings rule out the disease state.

Of note, while the reproducibility of chest wall pain with palpation may lower the likelihood of angina, this alone cannot rule out angina or myocardial infarction.[12, 13]



See Pathophysiology.

Contributor Information and Disclosures

Marc D Haber, MD Assistant Professor, Department of Emergency Medicine, Tufts University School of Medicine; Clinical Associate of Radiology, Baystate Medical Center; Past President of Young Physician Section, AAEM

Marc D Haber, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Radiology, Radiological Society of North America, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Thomas A Brunell, MD, MA, FACEP, FAAEM Director, Emergency Medicine Education, St Francis Hospital and Medical Center; Assistant Professor of Traumatology and Emergency Medicine, University of Connecticut Medical Center

Thomas A Brunell, MD, MA, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

  1. Clarendon E. The Life of Edward, Earl of Clarendon. Oxford at the Clarendon Press; 1827. 18.

  2. Jay V. The legacy of William Heberden. Arch Pathol Lab Med. 2000 Dec. 124(12):1750-1. [Medline].

  3. Kelemen MD. Angina pectoris: evaluation in the office. Med Clin North Am. 2006 May. 90(3):391-416. [Medline].

  4. Maseri A, Crea F, Kaski JC, Davies G. Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis. 1992 Jul-Aug. 35(1):1-18. [Medline].

  5. Servoss SJ, Januzzi JL, Muller JE. Triggers of acute coronary syndromes. Prog Cardiovasc Dis. 2002 Mar-Apr. 44(5):369-80. [Medline].

  6. Yang EH, Lerman A. Management of the patient with chest pain and a normal coronary angiogram. Cardiol Clin. 2005 Nov. 23(4):559-68, viii. [Medline].

  7. Mozaffarian D, Benjamin EJ, Go AS, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2015 update: a report from the american heart association. Circulation. 2015 Jan 27. 131(4):e29-e322. [Medline].

  8. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009 Jan 27. 119(3):e21-181. [Medline]. [Full Text].

  9. Centers for Disease Control and Prevention. Prevalence of heart disease--United States, 2005. MMWR Morb Mortal Wkly Rep. 2007 Feb 16. 56(6):113-8. [Medline]. [Full Text].

  10. Almeda FQ, Kason TT, Nathan S, Kavinsky CJ. Silent myocardial ischemia: concepts and controversies. Am J Med. 2004 Jan 15. 116(2):112-8. [Medline].

  11. Clarke WB, Austin SM, Shah PM, Griffin PM, Dove JT, McCullough J, et al. Spectral energy of the first heart sound in acute myocardial ischemia. A correlation with electrocardiographic, hemodynamic, and wall motion abnormalities. Circulation. 1978 Mar. 57(3):593-8. [Medline].

  12. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. 2002 Mar. 9(3):203-8. [Medline].

  13. Tierney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med. 1985 Jul. 13(7):526-31. [Medline].

  14. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989 Nov 15. 64(18):1087-92. [Medline].

  15. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996 Jul. 14(4):341-5. [Medline].

  16. Rogers JT. Risk Management in Emergency Medicine. 1985. 4-6.

  17. Bamberg F, Truong QA, Blankstein R, Nasir K, Lee H, Rogers IS, et al. Usefulness of age and gender in the early triage of patients with acute chest pain having cardiac computed tomographic angiography. Am J Cardiol. 2009 Nov 1. 104(9):1165-70. [Medline]. [Full Text].

  18. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002 Dec 4. 288(21):2693-700. [Medline].

  19. Miller CD, Hwang W, Hoekstra JW, Case D, Lefebvre C, Blumstein H, et al. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med. 2010 Sep. 56(3):209-219.e2. [Medline].

  20. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26. 367(4):299-308. [Medline].

  21. Chen EH, Mills AM. Is it necessary to admit low-risk patients with suspected acute coronary syndrome to inpatient telemetry beds?. Ann Emerg Med. 2005 Nov. 46(5):440-4. [Medline].

  22. Kou V, Nassisi D. Unstable angina and non-ST-segment myocardial infarction: an evidence-based approach to management. Mt Sinai J Med. 2006 Jan. 73(1):449-68. [Medline].

  23. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation. 1994 Apr. 89(4):1545-56. [Medline].

  24. Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet. 2004 Sep 4-10. 364(9437):849-57. [Medline].

  25. American Heart Association, American Stroke Association. Heart Disease and Stroke Statistics --2006 Update. Available at

  26. [Guideline] Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4. 44(3):671-719. [Medline].

  27. [Guideline] Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002 Oct 2. 40(7):1366-74. [Medline]. [Full Text].

  28. Kaski JC, Rosano GM, Collins P, Nihoyannopoulos P, Maseri A, Poole-Wilson PA. Cardiac syndrome X: clinical characteristics and left ventricular function. Long-term follow-up study. J Am Coll Cardiol. 1995 Mar 15. 25(4):807-14. [Medline].

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