Although angina may be perceived as an epigastric discomfort, the pain usually does not radiate far below the level of the diaphragm. Some patients describe their angina as shortness of breath, mistaking a sense of constriction for being out of wind. A careful history eliciting the patient's need to take a deep breath rather than to breathe quickly may identify shortness of breath as an anginal equivalent. Physical exertion typically induces angina, and rest usually relieves it promptly. Other precipitating factors include emotional tension, cold weather, and a large meal.
Many patients manifest atypical chest pain, which complicates the differential diagnosis.
Pain that originates in the chest wall is classically fleeting, exacerbated by chest wall movement, and associated with tenderness over the involved area, which is frequently a costochondral joint. Exertion that increases chest wall movement can bring on such pain, which may radiate to the left arm. Unfortunately, chest wall pain is often incorrectly interpreted as angina because of a failure to examine each costochondral junction for tenderness in an effort to reproduce the patient's complaints. Esophageal spasm can produce a severe substernal pressure that often radiates to the back. Radiation to the left arm is unusual.