Angina pectoris may not be felt in the heart! Don’t take these types of pain lightly

Author: Zhang Haicheng, Chief Physician, Peking University People's Hospital

Reviewer: Wang Fang, Chief Physician, Beijing Hospital

Angina pectoris, as the name suggests, is the pain in the heart. It is the most common manifestation of coronary atherosclerotic heart disease.

Angina pectoris is a type of chest pain or discomfort caused by insufficient blood flow to the heart, usually manifested as a feeling of pressure, tightness, heaviness or pain in the chest, which may radiate to the left shoulder, arm, neck, jaw or back. The pain usually lasts for several minutes and is often triggered by physical activity or emotional excitement. It can be relieved by resting or taking nitroglycerin.

The word "角" in "angina pectoris" is used to describe the nature of this pain, which is similar to the feeling of being tightly wrapped or tightened by a rope, emphasizing the intensity and oppression of the pain. This description vividly conveys the discomfort in the patient's chest, which is unbearable and terrifying pain. When describing pain caused by other diseases, we usually use dull pain, dull pain, tearing, burning pain, etc. Only when describing pain caused by diseases such as angina pectoris, or spasms and obstructions related to strong contraction of smooth muscles (such as the intestines, bile ducts, ureters, etc.), we use the word "角痛" to describe it.

When typical angina pectoris occurs, the patient often holds his hands in front of his chest, about the size of a fist, and dares not move. If the skin or bone pain in a certain part is relieved by pressing, but the pain in the heart area is not dared to be pressed or released, and the whole body and mind are instantly concentrated in this area. This is typical angina pectoris.

Figure 1 Original copyright image, no permission to reprint

Generally speaking, angina pectoris is a severe pain in the heart, but some people may experience headaches, toothaches, jaw pains, neck pains, stomach pains, abdominal distension, etc.

People may ask, angina pectoris is heart pain, how can other parts of the body hurt? In fact, these symptoms are called equivalent symptoms of angina pectoris, also called referred pain, because the conduction pathways of nerve signals from the heart and other parts of the body overlap in the spinal cord and brain. For example, the sensory nerves of the heart are mainly transmitted to the spinal cord through the sympathetic nerves, and these nerves and sensory nerves from other parts (such as the left shoulder, arm, neck, mandible, etc.) converge in the spinal cord and are uploaded to the brain. Therefore, when angina pectoris occurs, the brain may misjudge the source of the signal, causing heart pain to be mistakenly perceived as pain in other parts of the body. Therefore, the manifestations of angina pectoris may be different for each person.

We often find that patients who visit the dental department have their heartbeat suddenly stop, and emergency treatment is started, because they are not really having toothache, but heartache that is mistaken by the brain as toothache. Some people visit the gastroenterology department and say they have stomachache, and it is also possible that their heartbeat suddenly stops during a gastroscopy, which is often caused by the brain misjudging angina pectoris as stomachache.

Therefore, medical staff in the dental and gastroenterology departments are now more cautious. When they encounter patients with similar symptoms, they will be more vigilant, especially worried about atypical angina pectoris. They recommend that patients be transferred to the cardiology department for examination first. After excluding heart disease, if they still have toothache or stomach pain, they can come back for corresponding examination and treatment.

Figure 2 Original copyright image, no permission to reprint

Some patients with angina pectoris will experience pain in the precordial area that radiates to the entire shoulder, with pain in the arm and shoulder, but usually on the left side.

Some patients feel that the pain is not obvious, but they feel stuffy, suffocated and blocked. For example, the elderly and diabetic patients do not feel obvious pain. They do not feel pain when they are pinched. Therefore, they cannot feel it when their heart hurts, but they may feel weak, a little breathless, a little stuffy and a little blocked.

Some patients feel like there is something blocking or stuck in their throat and they keep wanting to drink water. In fact, this may also be a symptom of atypical angina pectoris.

Some people also say that the esophagus feels like drinking chili water and is very uncomfortable. This symptom may also be angina pectoris.

Therefore, experienced doctors will be particularly vigilant after hearing these descriptions and will first rule out angina pectoris.

In the past, there was only one way to check for angina pectoris, which was to record an electrocardiogram when it occurred. However, angina pectoris does not occur in most cases, and when it does not occur, the electrocardiogram is often normal. When angina pectoris occurs, the patient is often outside the hospital, and the symptoms are quickly relieved after stopping activities or taking nitroglycerin sublingually. Even if you rush to the hospital quickly, register, get a bill, pay the fee, and then do an electrocardiogram, everything is often normal, and the doctor will let you go home for further observation.

For patients with stable angina pectoris, even if they do not have an angina attack when they come to the hospital for treatment, they can undergo an exercise test in the hospital to see if it can induce an angina attack or produce electrocardiogram changes of myocardial ischemia. However, it is too dangerous to do so for patients with unstable angina pectoris, or they cannot undergo exercise tests if they are elderly or have difficulty walking. Therefore, there are certain limitations.

For patients with unstable angina, it is generally recommended to be hospitalized directly for coronary angiography to see if the blood vessels are obviously narrowed or blocked, and then to carry out corresponding treatment. Although direct angiography can confirm the diagnosis, angiography is traumatic after all, and it cannot be performed on everyone. Therefore, for patients who do not show symptoms of acute myocardial infarction or unstable angina, an enhanced CT can be performed in the outpatient clinic for preliminary screening of the coronary arteries. This is the coronary artery CTA examination.

Coronary CTA is a high-speed scanning CT. After contrast agent is injected into the upper arm vein, the heart's blood vessels are scanned to show the course of the coronary arteries and to preliminarily determine whether there is stenosis or occlusion. Of course, this is only a preliminary screening. If the coronary CTA is normal or the stenosis is less than 50%, coronary atherosclerotic heart disease can be ruled out. If the stenosis is obvious, hospitalization for coronary angiography is required to confirm the diagnosis.

Figure 3 Original copyright image, no permission to reprint

Although coronary CTA is good, it does require X-ray exposure and carries the risk of contrast agent allergy. Therefore, it is necessary to grasp the indications and contraindications, and especially be careful not to abuse it.

People who are allergic to iodine contrast agents cannot undergo coronary CTA. Contrast agents may increase the burden on the kidneys, so people with poor kidney function should use them with caution. Unless absolutely necessary, it is generally not recommended for pregnant or breastfeeding women. Severe arrhythmias, especially obvious irregular heartbeats, may affect the test results. Severely obese people may also have a negative impact on image quality due to their excessive weight.

The diagnosis and treatment of heart disease is very professional and individualized. Everyone must undergo diagnosis and treatment under the guidance of a doctor. Do not make decisions on your own or believe in rumors to avoid serious consequences.