Symptoms of heart disease

Chest pain

Chest pain is a common symptom of cardiac disease. Cardiac ischaemia causes angina, a tight and crushing retrosternal pain that may radiate to the jaw and down into the arm. Angina may be precipitated by effort, emotion, food or cold weather. It is usually relieved by rest or glyceryl trinitrate (GTN). If angina occurs at rest for more than 20 minutes, a diagnosis of myocardial infarction should be presumed until proven otherwise.

Other cardiovascular causes of chest pains include pericarditis, often described as a sharp pleuritic chest pain that may radiate to the back (trapezius ridge pain) and is relieved by sitting forwards. The pain of aortic dissection has a tearing quality and is usually described as the most severe pain to be experienced by the patient. It originates in the chest and may radiate to the back or abdomen.



Shortness of breath

Cardiac failure is an important cause of dyspnoea. Its severity is often measured in relation to the New York Heart Association (NYHA) functional class. Symptoms of left ventricular failure are dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea. Orthopnoea refers to shortness of breath when lying flat, and is thought to be due to the redistribution of the interstitial oedema of the lungs. It is relieved by sitting upright, presumably facilitating gravitational redistribution to the lung bases. Paroxysmal nocturnal dyspnoea is sudden onset of dyspnoea whilst sleeping that wakes the patient suddenly and is also relieved by sitting upright. Concomitant symptoms of right ventricular failure are peripheral oedema and abdominal distension (hepatomegaly, ascites).

Palpitations

Palpitation is an awareness of the heartbeat. Arrhythmia is the usual underlying cardiac cause . A variety of complaints are used to describe palpitations, including 'fluttering', 'pounding' and 'skipping a beat'. Symptoms may also be experienced in the neck. Important aspects are the frequency, regularity of palpitation (e.g. fast and irregular) and precipitating factors.

Knowledge of precipitating factors is important. Palpitations can be a normal manifestation of anxiety or panic reactions. However, it is vitally important that an organic cause is excluded as it is common for anxiety disorders to coexist in a patient with supraventricular tachycardia. Exercise is associated with excess catecholamines and also a precipitator of arrhythmia (supraventricular tachycardia, atrial fibrillation and ventricular tachycardia usually originating from the right ventricle). Excessive caffeine, smoking and alcohol intake are also thought to be precipitators of arrhythmia.

A history of any underlying heart disorder is important, as arrhythmia is associated with ischaemic heart disease (ventricular arrhythmia), hypertensive heart disease (atrial fibrillation), heart failure (ventricular arrhythmia) and heart valve disease.
Early age of onset of arrhythmia (childhood or teenage years) suggests the presence of a congenital abnormality such as a bypass tract that can lead to supraventricular tachycardia.

Syncope

Syncope is often due to vasovagal reaction (simple faint) but can also be a symptom of serious underlying disease. Cardiac outflow obstruction, which occurs with aortic stenosis and hypertrophic obstructive cardiomyopathy, can result in syncope on effort as the cardiac output is not increased on demand. Orthostatic hypotension causes a transient decrease in cerebral perfusion and if sufficiently severe can lead to loss of consciousness. This may result from the use of antihypertensive medications, and especially diuretics, in the elderly. In carotid sinus syndrome, the receptors of the carotid sinus are more sensitive than normal; thus minor stimulation, such as turning the head or pressure from a tight collar, may elicit the carotid sinus reflex and precipitate syncope.