This can happen when there is increased demand for oxygen such as during exercise, or decreased supply such as hypotension or anemia. Variant angina occurs due to coronary artery spasm alone. Anginal pain is not typically affected by respiration or by position, although most patients with angina prefer to sit up. Patients with stable angina will have pain after a predictable amount of exertion, and have identical symptoms with each attack. Occasionally, symptoms other than pain may occur with transient myocardial ischemia.
Atypical symptoms are more likely to occur in the elderly and in diabetics.
The physical exam is usually normal. A new S4 may be heard, suggesting a stiff ventricle due to ischemia. The patient may appear pale and diaphoretic during the attack. About half of patients with angina will have ECG changes during an attack. Most commonly ST segment depression is seen, but ST elevation is also possible with angina.