Many patients describe angina as a tightness or heaviness and it is usually not severe, a 'discomfort' rather than a "pain". Sometimes the nearest experience patients can relate to the symptom is to describe it as 'breathlessness' or "like indigestion". The possibility thai symptoms arc gastrointestinal may also arise from patients relating the discomfort to meals, or more commonly to exercising after meals (postprandial angina). The patients' body language may be helpful -anginal discomfort is poorly localised and usually indicated using the open hand or a fist (Fig. 3.1).

Severity of angina relates to ¡lie degree of functional limitation not the intensity of the pain. Changes in the severity of a patient's angina is the principal means of assessing the response to therapy and will influence management decisions. The Canadian Cardiovascular Classification can be used (Table 3.6). It is necessary to establish:

• the degree of functional limitation

• the pattern of symptoms

• the presence of symptoms at night or al rest

• (he stability of symptoms.

TABLE 3.6 Canadian Cardiovascular Society: functional classification of stable angina

Grade 1 Ordinary physical activity, such as walking and climbing stairs, does not cause angina, Angina with strenuous or rapid or prolonged exertion at work or recreation

Grade 2 Slight limitation of ordinary activity, Walking or climbing stairs rapidly or after meals, in cold, in wind, or when under emotional stress, or only during the few hours after awakening.

Grade 3 Marked limitation ol ordinary physical activity. Walking one to two blocks on the level and climbing less than one flight in normal conditions.

Grade 4 Inability to carry on any physical activity without discomfort -anginal syndrome may be present at rest,

QUESTIONS -To assess the severity of angina

How far can you walk on the flat before experiencing discomfort? Do you get discomfort climbing stairs or hills? Do you experience discomfort gardening, making the bed or during other household chores?

Does sexual intercourse produce discomfort? Is the discomfort Influenced by meals? Is it influenced by cold weather?

The extent of effort limitation is best assessed by identifying those activities that precipitate symptoms. This involves asking specific questions (see Question box).

A palienl's activities may appear to be unrestricted because activities that provoke symptoms have been progressively curtailed. It is therefore important to identify activities that have been abandoned, e.g. dancing or playing golf.

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