1. Systolic murmurs: occur between S1 and S2, when the ventricles contract.
   • Ejection systolic, crescendo-decrescendo: aortic stenosis, pulmonary stenosis, innocent flow murmur.
   • Pansystolic / holosystolic: same intensity throughout systole; mitral regurgitation, tricuspid regurgitation, ventricular septal defect.
   • Late systolic: mitral valve prolapse, often with a midsystolic click.
2. Diastolic murmurs: occur between S2 and the next S1, while ventricles relax and fill. These generally need clinical evaluation.
   • Early diastolic, decrescendo blowing murmur: aortic regurgitation or pulmonary regurgitation.
   • Mid-diastolic, low-pitched rumble: mitral stenosis or tricuspid stenosis.
   • Presystolic accentuation: louder just before S1 in mitral stenosis when sinus rhythm is present.
3. Continuous murmurs: heard in both systole and diastole, continuing through S2.
   • Classic example: patent ductus arteriosus, often described as a “machinery” murmur.
4. To-and-fro murmurs: separate systolic and diastolic murmurs with a gap around S2, often from combined stenosis and regurgitation of the same valve.

Typical symptoms

• Pressure, tightness, heaviness, squeezing, burning, or “indigestion” in the chest
• May spread to the left arm, shoulder, neck, jaw, back, or upper abdomen
• Can include breathlessness, sweating, nausea, or unusual fatigue
• In women, older adults, and people with diabetes, symptoms may be less typical.

Main types

1. Stable angina
   Predictable discomfort with exertion, emotional stress, cold exposure, or heavy meals. It usually settles within a few minutes with rest or prescribed nitroglycerin.
   Lippincott Illustrated Reviews: Pharmacology, p. 413.
2. Unstable angina
   New chest pain, pain at rest, pain that is increasing in frequency/severity, lasts longer, or fails to improve with rest or prescribed medication. This is part of acute coronary syndrome and needs emergency assessment.
3. Vasospastic (Prinzmetal or variant) angina
   Usually occurs at rest, often at night or early morning, due to temporary spasm of a coronary artery.
4. Microvascular angina
   Related to dysfunction of the heart’s small vessels. It may occur with exertion or at rest and is more commonly recognized in women.

Important

Initial evaluation

• Clinical history and physical examination: character of pain, relation to exertion, duration, associated breathlessness/sweating, and cardiac risk factors.
• 12-lead ECG: looks for ischemic ST-T changes, prior myocardial infarction, arrhythmia, or left ventricular hypertrophy.
• Blood tests:
  • High-sensitivity cardiac troponin, repeated over time if acute or recent prolonged pain is possible. Raised troponin suggests myocardial injury such as NSTEMI rather than unstable angina.
  • Full blood count, glucose/HbA1c, lipid profile, kidney function, and sometimes thyroid testing to identify risk factors or contributors such as anemia.

Tests to confirm coronary disease or inducible ischemia

• Exercise ECG stress test (treadmill test): assesses symptoms, ECG changes, exercise capacity, and blood-pressure response during exertion.
• Stress echocardiography: uses exercise or medication-induced stress to detect new regional wall-motion abnormalities.
• Nuclear myocardial perfusion imaging: SPECT or PET assesses blood flow to the heart muscle during stress and rest.
• Stress cardiac MRI: evaluates myocardial perfusion and scar without ionizing radiation.
• Coronary CT angiography (CCTA): a non-invasive scan showing coronary plaques and narrowing. It is often used when obstructive coronary disease is suspected.
• Invasive coronary angiography: catheter-based imaging, usually for high-risk patients, persistent symptoms despite treatment, strongly abnormal non-invasive tests, or when revascularization may be needed. Pressure-wire measures such as FFR/iFR can determine whether a narrowing is actually limiting blood flow.

Additional tests in selected cases

• Echocardiography at rest: assesses heart pumping function, wall-motion abnormalities, valve disease, and alternative causes of symptoms.
• Ambulatory ECG monitoring: if symptoms could be due to intermittent arrhythmia or vasospastic angina.
• Coronary vasoreactivity and microvascular testing: may be considered when symptoms persist but CCTA/angiography shows no major blockage, to assess vasospastic or microvascular angina.

Myocardial ischemia

• Angina is the common symptom of myocardial ischemia.
• Ischemia may also be silent, with no chest pain, especially in some people with diabetes or older adults.
• If ischemia is severe or prolonged, heart muscle injury can occur, producing a myocardial infarction (heart attack).

Common features

• Central chest pressure, tightness, heaviness, or burning
• Discomfort spreading to an arm, shoulder, neck, jaw, back, or upper abdomen
• Shortness of breath, sweating, nausea, dizziness, or fatigue
• Often triggered by exertion or stress in stable coronary disease, but may occur at rest in acute coronary syndrome.

How it is detected

• ECG, including possible ST-segment or T-wave changes
• Serial high-sensitivity troponin tests if acute injury is suspected
• Exercise ECG or stress imaging
• Coronary CT angiography or invasive coronary angiography when indicated