A Sticky Wicket: How to recognize the symptoms of coronary artery disease.
Reed Humphrey, Ph.D., P.T., FACSM, is professor of physical therapy at Idaho State University. He recently completed a four-year term as head of the World Council for Cardiovascular and Pulmonary Rehabilitation and is a past president of the American Association of Cardiovascular & Pulmonary Rehabilitation. He is associate editor of ACSM's Resources for Clinical Exercise Physiology and past associate editor of ACSM's Guidelines for Exercise Testing and Prescription. Humphrey currently serves as an Associate Editor for ACSM's Health & Fitness Journal®.
They say you never forget the first time. In my case, it was the first two times. Of course, I'm referring to my inaugural independent supervision of exercise testing. What were you thinking? My very first patient had ventricular arrhythmias only an electrophysiologist could love. The second was a bricklayer, referred for evaluation of vague but troubling symptoms. He explained that after some time at work, both of his hands would become "heavy" and he would have to stop what he was doing to alleviate the discomfort. Trained to focus upon differentiating symptoms that might be more likely related to underlying coronary artery disease (CAD), I followed the drill: was there any chest or retrosternal discomfort, radiating to the left arm, neck, or jaw? He had none. My pre-test assessment was of course that he had symptoms consistent with say, bricklaying, but probably not CAD. However, the exercise test revealed early onset of bilateral hand heaviness associated with an abnormal electrocardiogram (ECG); his symptoms subsided as the ECG resolved to normal. He had triple vessel bypass surgery within the week.
I have often thought, what would my interpretation have been on the floor of the gym if my client reported similar symptoms?
The heart, of course, in contrast to skeletal muscle, has no direct neural pathway to provide clear symptoms of hypoxia. Because the C3-T4 spinal segments supply the heart, symptoms are referred to the corresponding somatic area, so symptoms vary accordingly. In addition, chest discomfort can be noncardiac in origin and associated with a wide variety of causes, from anxiety to even pulmonary or cervical disk disease. Although the symptoms of an impending heart attack-unrelenting chest pain and classic radiation to the left arm or jaw-is fairly obvious, recent evidence suggests that there is a gender variation as well and that women may have a very different presentation of symptoms. It should be increasingly apparent that assessing the significance of chest discomfort is a skill that requires both experience and ongoing continuing education.
The American Heart Association estimates the prevalence of angina is more 6.4 million individuals in the United States-nearly 4% of the population-with an incidence of nearly 400,000 (1). Classification methods have been developed to help classify angina. Typical angina (definite) is described as 1) substernal chest discomfort with a characteristic quality and duration that is 2) provoked by exertion or emotional stress and 3) relieved by rest or drugs designed to relieve angina, such as nitroglycerin. Atypical angina (probable) meets two of those characteristics, and noncardiac chest pain meets one or none of the typical anginal characteristics (2). Use of the term discomfort over "pain" is important in the investigation of suspicious symptoms because the quality of the anginal discomfort is often described as "squeezing," "pressure," "suffocating," or "heavy."
Tables have been developed to help determine the probability of CAD based upon gender, age, and symptoms. If my bricklayer had typical angina, based upon his age of 50, he would have had a 93% probability of CAD. With his atypical symptoms, the probability drops to 65%. This probability falls farther with younger age groups and with women (3). As noted, women may have a different symptom presentation than men, so probability estimates may be skewed. Although assessing probability based upon gender, age, and classification of discomfort has obvious diagnostic relevance, given the variability of predicting CAD based upon age and gender in the presence of even atypical symptoms, exercise leaders should consider atypical discomfort as significant to advise cessation of exercise and medical referral.
As mentioned, there is evidence that women and minorities have different symptoms from white men in the presence of CAD, which is particularly important considering that the training most exercise staff receive about the warning signals for underlying CAD is based largely upon men. In particular, shortness of breath, as opposed to chest pain, is very significant in women (4, 5). Because shortness of breath can be confused with being "winded" during exercise, it is important for exercise staff to appreciate the difference between unusual shortness of breath and also query the client about his or her personal health history and any other signs or symptoms that might be revealing about the possibility of an underlying cardiac source.
For those clients with established CAD and exercise-induced symptoms, clear guidelines about the upper safe limit of exercise should be established in cooperation with the client's physician and, as relevant, the hospital's cardiac rehabilitation staff. Moreover, exercise personnel should be cognizant of the client's symptom description so as to appreciate any clinical change in the characterization of the discomfort while he or she is participating in the exercise facility. Clients should be educated to appreciate and report any change or new symptoms in their home exercise programs, as well.
Exercise leaders rely upon their academic training combined with increasing experience to make decisions based upon their assessment of client complaints. The foregoing discussion should improve the exercise leader's grasp of symptoms that are more likely to be associated with a more serious underlying problem. Similarly, the bricklayer experience provides emphasis that exercise leaders must err on the side of caution with any exercise-induced symptom. The benefit of early recognition and investigation of even atypical signs and symptoms always exceeds the risk of dismissing symptoms as unimportant.
1. American Heart Association. Heart Disease and Stroke Statistics-2005 Update. Dallas, Texas: American Heart Association; 2005.
2. Gibbons, R.J., J. Abrams, K. Chatterjee, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with ChronicStable Angina). 2002.
3. Snow, V., P. Barry, S.D. Fihn, et al., and the ACP; ACC Chronic Stable Angina Panel. Evaluation of primary care patients with chronic stable angina: Guidelines from the American College of Physicians. Annals of Internal Medicine
4. Pope, J.H., T.P. Aufderheide, R. Ruthazer, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. New England Journal of Medicine
5. Nicholson, A., I. White, P. Macfarlane, et al. Rose questionnaire angina in younger men and women: Gender differences in the relationship to cardiovascular risk factors and other reported symptoms. Journal of Clinical Epidemiology