Angina Pectoris Symptoms

The pain of true angina pectoris generally starts in the region of

the heart, radiates up around the left chest, into the shoulders,

and often down the left arm. This is typical. It may not follow this

course, however, but may be referred to the right chest, up into the

neck, down toward the stomach, or toward the liver. The attack may

be coincident with acute abdominal pain, almost simulating a gastric

crisis of locomotor ataxia. There may also be coincident pains down

the legs. It has been shown, as mentioned in another part of this

book, that disturbances in different parts of the aorta may cause

pain and the pain be referred to different regions, depending on the

part affected.

Instances occasionally occur in which a patient had an anginal

attack, as denoted by facial anxiety, paleness, holding of the

breath, and a slow, weak pulse, without real pain. This has been

called angina sine dolore. The patient has an appearanece of anxious

expectation, as though he feared something terrible was about to


The position of the patient with true angina pectoris is

characteristic. He stops still wherever he is, stands perfectly

erect or bends his body backward, raises his chin, supports himself

with one hand, leans against anything that is near him, and places

his other hand over his heart, although he exercises very little

pressure with this hand. The position assumed is that which will

give the left chest the greatest unhampered expansion, as though he

would relieve all pressure on the heart.

Besides the feeling of constriction, even to some spasm, perhaps, of

the intercostal muscles, respiration is slowed or very shallow,

because of the reflex desire of the patient not to add to the pain

by breathing. The face is pale, the eyes show fear, and the whole

expression is almost typical of cardiac anxiety. The patient feels

that he is about to die. The pulse is generally slowed, may be

irregular, and may not be felt at the wrist. The blood pressure has

been found at times to be increased. It could of course be taken

only in those cases in which there were more or less continued

anginal pains; the true typical acute angina pectoris attack is

over, or the patient is dead, before any blood pressure

determination could be made. When there is more or less constant

ache or frequent slight attacks of pain, the blood pressure may be

raised by the causative disease, arteriosclerosis. During the acute

attack with inefficient cardiac action and a diminished force and

frequency of the beat, the peripheral blood pressure can only be


The duration of an acute attack, that is, the acute pain, is

generally but a few seconds, sometimes a few minutes, and rarely has

lasted for several hours. In the latter cases some obstruction to an

artery has been found at necropsy, but not sufficient to stop the

circulation at a vital point. Repeated slight attacks, more or less

severe, may occur frequently throughout one or more days, or even

perhaps a series of days, caused by the least exertion, even that of

turning in bed.

While most cases of sudden death with cardiac pain are due to a

local disease in or around the heart, it is quite probable that some

disturbance in the medulla oblongata may cause acute inhibitory

stoppage of the heart through the pneumogastric (vagi) nerves. The

power of the pneumogastric reflex to inhibit the action of the heart

is, of course, easily demonstrated pharmacologically. Clinically

reflexes down these nerves interfering with the heart's action cause

faintness and serious prostration, if not actual shock, and perhaps,

at times, death. The most frequent cause of such a reflex is

abdominal pain, perhaps due to some serious condition in the

stomach, to gastralgia, to an intestinal twist, to intussusception

or other obstruction, or to hepatic or renal colic. A severe nerve

injury anywhere may cause such a heart reflex. Hence serious nerve

pain must always be stopped almost immediately, else cardiac and

vasomotor shock will occur. In serious pain morphin becomes a life


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