Symptoms arising from the heart are not specific and itoften requires a careful history to differentiate them fromsimilar complaints arising from chest disease, dyspepsia oranxiety. Chest pain, breathlessness, oedema, palpitations,dizziness, syncope and fatigue can all be caused by heartdisease. Exercise capacity is limited in most forms of heartdisease, and the limiting symptom may be obvious, suchas pain and breathlessness, or much more subtle, such asexcessive exhaustion. The degree to which symptoms havebegun to limit normal activities requires careful definition,as patients may not always volunteer the information,wrongly thinking that age alone is enough to accountfor their increasing inability to exert themselves withoutdyspnoea or dizziness. Others may prevent angina or breathlessness by greatly restricting their lives. In assessingthe effectiveness of treatment it is useful to have anidea of the activities that can and cannot be performed,using relevant examples from the patients’ own lives, theease with which they can walk and talk, or how theymanage household chores. Improvements in patients’ performancemay then be judged by their own yardstick.Patients sometimes need considerable encouragement tore-establish more normal patterns of activity after beingtreated.
Chest pain Chest pain arising from the heart and great vessels maybe caused by cardiac ischaemia, pericardial inflammation,aortic dissection or massive pulmonary embolism.The history may allow differentiation between the variouspossibilities, but the severity of the symptom has virtuallyno relationship to the potential severity of the underlyingcause. Many patients suffer pains in the chest which areprobably cardiac in origin but for which no adequate explanation is possible; for example, some patients maydescribe abnormal sensations produced by ectopic beats aspain.
Cardiac ischaemic pain In a typical case the discomfort associated with myocardial ischaemia is described as a pressure or tightness in thechest, which may also be felt in the throat, producing thechoking feeling that led to the symptom being called angina pectoris. The characteristics of angina include common patterns of radiation to the arms, more commonly the left, the jaw and teeth and, less commonly, through tothe back. The pain, and its sites of radiation, are often reproducible, but incomplete or mild attacks may not havethe same full distribution of the more severe episodes. Inangina, which represents episodes of reversible ischaemia,the precipitating causes are typically those that will increase myocardial oxygen demand beyond the coronary supply. The patient may report discomfort only whenhaving to run, or when they try to walk in the face of a coldwind or after a heavy meal. Emotional upsets are powerful precipitants of angina in some patients, even withoutphysical exertion.The discomfort may be very severe and be associatedwith frightening feelings of impending death. It can alsobe a mild discomfort or ache in the chest, which may bethought trivial and ignored. Many patients do not experiencetheir angina as a pain, and feel it as a faint constrictionin the chest. Some attacks of myocardial ischaemia areunaccompanied by any discomfort (silent ischaemia}.Angina usually disappears fairly rapidly if the patientrests, or takes glyceryl trinitrate (GTN). Angina buildsup over several seconds and is usually not greatly influencedby posture, unlike musculoskeletal chest pain(which may also occur with exertion). Although similar innature and radiation, the pain of myocardial infaraction lasts much longer than angina. It is more intense and doesnot pass off with rest or GTN. In an attack, a patient withcardiac ischaemia usually looks pale and sweaty, unlikesomeone with an attack of indigestion, who often appearsflushed.Other causes of chest pain
Pericardial pain can be easily confused with thepain of myocardial infarction or angina, but is often influencedby posture, sometimes being relieved or worsenedby leaning forwards, and aggravated by swallowing. It ismore often described as a burning or dull pain, and is lesslikely to be associated with breathlessness than is myocardialischaemia.The pain of dissection of the ascending aorta isa severe, tearing pain, often starting suddenly, usually felt retrosternally at first, and sometimes radiating through tothe back or to the left shoulder.Massive pulmonary embolism can also produce aretrosternal constricting discomfort indistinguishable from myocardial ischaemia; smaller peripheral emboli may beresponsible for more pleuritic-type pains .Oesophageal spasm due to reflux can produce a severeretrosternal pain which may be confused with that ofmyocardial ischaemia, and may be relieved by GTN. Thepain of oesophageal rupture can be confused with myocardial infarction.Sharp, stabbing precordial pains are common in highlystrung patients. They may have a muscular origin, but occasionally coincide with the accentuated post ectopic contraction of the heart, which is perceived by the patientas a knife-like pain.
Dyspnoea or shortness of breath This symptom is a feeling of laboured, or unnaturallydifficult, breathing. In heart failure it is due to the lungsbecoming stiff and difficult to ventilate, owing to the risein pulmonary venous pressure. The reduced cardiac outputlimits the oxygen-carrying capacity of the circulation, precipitatinganaerobic metabolism. The acidosis producedcauses increased ventilation, which persists for longer thannormal after exertion. Thus, even minor exertion producesdisproportionate and prolonged dyspnoea. Finally, insevere left heart failure with pulmonary oedema, arterialoxygen desaturation adds to the distress.
Palpitations A careful interpretation of what the patient means by theword ‘palpitations’ is essential. It may be simply an awarenessof the normal heart beat, which may be more forcefulor faster than usual because of anxiety. It may, however,be indicative of a serious cardiac arrhythmia. It may beuseful to ask the patient to tap on the table to indicate therate and rhythm during the attack. It is helpful to determinethe following:• Onset and cessation of the attacks. Is it sudden, with athump (ectopic), or gradual?• Are there any symptoms to suggest cardiac decompensation(failure) during the attacks?• Was there irregular thumping (ectopics or atrialfibrillation)?• Was there chest pain (the occurrence of angina impliesa very fast and potentially dangerous heart rate)?• Has there been any fainting or near fainting with theattacks?True syncope indicates an urgent need for investigation, asthe arrhythmia is potentially fatal. Polyuria sometimesoccurs on cessation of supraventricular tachycardias, but isnot usually described by the patient unless a leading questionis asked.
Syncope and presyncope (dizziness) Sudden collapse with loss of consciousness during exertionalmost always has a cardiac cause. It is due either to anobstruction to outflow from the left or right ventricle,which prevents an adequate increase in cardiac outputon exertion, or to a cardiac arrhythmia induced by the exertion. Both may result in a sudden fall in blood pressureand cerebral perfusion. Some mental confusion dueto cerebral anoxia is common.Syncope after exertion is not uncommon and may simplybe due to blood pooling in the legs and a poor venousreturn. However, syncope under other circumstancesmay be cardiac, and an eyewitness account is invaluable.Cardiogenic syncope usually occurs without warning; thecollapsed patient is vasoconstricted and grey, and the pulseis either absent or very slow.
Other forms of syncope ‘Vasovagal’ syncope. The common faint, often triggeredby pain or an unpleasant sight, gastrointestinal upset,haemorrhage or pyrexial illness, is a vagal phenomenon,and the syncopal episode is followed by profuse cold sweat,a feeling of sickness or actual vomiting, and bradycardia.Micturition syncope and cough syncope are rarely cardiogenic,but are probably triggered by a Valsalva manoeuvre,the first when initiating micturition with a full bladderand the latter after repeated bouts of coughing, whichinhibit venous return.Presyncope or dizziness is a common and much less welldefined symptom, and has a variety of causes as well asheart disease. It may result from a cardiac arrhythmia, buteven then is much more common in elderly patients withassociated cerebrovascular disease.
Oedema Right heart failure causes pitting oedema of the feet andlegs, worse at the end of the day and relieved by rest andelevating the legs. Unlike other causes of oedema it maybe associated with other symptoms of heart failure, such asdyspnoea and fatigue. The oedema may spread to thethighs, abdominal wall, sacrum and back. There may beascites and hepatic congestion, with abdominal distension.The hepatic congestion may be worse on exertion, withpain over the liver (usually epigastric) during exercise andfor several minutes afterwards – hepatic angina.The differential diagnosis of cardiac oedema includesfluid retention from other causes, such as nephrotic syndromeand cirrhosis of the liver, oedema of one or bothlegs from venous insufficiency, or lymphatic insufficiency.
Fatigue Fatigue is a non-specific and often neglected symptom. Itis, however, a very real feature of heart disease, a result ofthe reduced effort tolerance and lactic acidosis producedby anaerobic muscle metabolism and changes in the skeletal muscle. It is a prominent symptom in low cardiac outputstates, e.g. severe left ventricular failure.