A. Sudden onset substernal chest pressure radiating to the left arm
B. Chest pain associated with shortness of breath and diaphoresis
C. A “tightness”, “discomfort, not pain”, “squeezing,” “indigestion,” “heaviness,” or an “elephant sitting on my chest”
D. Chest pain worse with emotional upset
E. All of the above are typical descriptions of angina
Pain from myocardial ischemia is gradual onset and gradual offset and not sudden. When sudden, severe substernal chest pain could indicate an acute aortic dissection (especially if the pain radiates to the mid-upper thoracic region).
Typical angina is substernal chest pressure upon physical exertion with radiation to the medial portion of the left arm or left jaw. Emotional upset/stress or other hemodynamic stresses (i.e. hypertensive emergency) as described above are well known to cause anginal symptoms as well.
There are many descriptions of angina which include a “tightness”, “discomfort, not pain”, “squeezing,” “indigestion,” “heaviness,” or an “elephant sitting on my chest”. Levine sign is typical during angina and occurs when a patient places their fist in the center of their chest to describe the squeezing/tightness feeling of angina. Pain from angina is gradual in onset and must last for at least 5 minutes. Also, the pain is diffuse and difficult to localize to one part of the chest (large area of pain, not small which can help distinguish from musculoskeletal pain).
Less common presentations include only shoulder pain, pain down both arms, left wrist pain, right-sided chest or jaw pain, radiation to the right arm, mid-thoracic pain and only dyspnea without chest pains. Rarely the pain of angina is described as sharp.
Frequently dyspnea, diaphoresis (cold sweats), fatigue/weakness, nausea and dizziness occur simultaneously with angina. Women, elderly patients and diabetics tend to have more atypical presentations of angina (see Women and Heart Disease).