Symptoms

Chest pain, shortness of breath, and palpitations are the principal manifestations of heart disease. It is the symptoms that provide a measure of functional capacity. However, it is important to appreciate that severe heart disease may be asymptomatic, and may come to light only when a complication or other problem arises.

There is no substitute for an accurate description of the symptoms you experience. Questions which often prove helpful to answer include the following: ‘What do you now find difficult which you used to be able to do easily?’ ‘When you are walking, can you talk at the same time?’ or ‘Can you keep pace with others?’ or, ‘If you wanted to precipitate the problem, what could you do to bring it on?’

The most common cardiac pain is due to myocardial ischemia and is usually caused by coronary artery disease. Less frequently pain may arise from the pericardium or as a result of disease of the aorta, the main artery leaving the heart. Heberden originally used the term Angina Pectoris in 1772 to describe a characteristic chest pain occurring on exertion, which we now know to be the principal symptom of myocardial ischemia. Often the word angina is also used for pain caused by myocardial ischemia under other circumstances, for example during coronary artery spasm, but typically means heart pain on effort.

The classic description of the pain results in the person placing a clenched fist or both hands on the chest over the lower sternum.

A feeling of heaviness or uselessness in one arm, often the left, or both arms frequently accompanies the sensation in the chest. Aching in the wrists or in the jaw or neck, and less often in the back of the chest may be felt. Any of these sites may be involved without necessarily having discomfort in the chest, and the relationship to exertion is usually the indication that the pain is probably coming from the heart.

The pain is typically described as like a tight band round the chest, or a feeling of constriction or heaviness " an elephant on my chest". The pain is often attributed wrongly to indigestion, may be described as a discomfort rather than a pain or may be regarded as a form of breathlessness.

Cardiac pain produced by exertion usually begins at about the same place in the course of regular exercise. It generally demands a rest or a slower pace, so that it is not permitted to become severe. With rest the pain usually disappears in a few minutes. Sometimes a ‘second wind’ effect occurs "variable threshold angina" -for example mild angina during the first hole of a game of golf may not subsequently occur despite encountering steeper hills.

Typical attacks of angina provoked by less and less exertion, and/or attacks of chest pain like angina occurring at rest with increasing frequency, constitute the syndrome of crescendo angina or acute coronary insufficiency. This may precede myocardial infarction and requires urgent medical attention

Pain persisting significantly longer than about five minutes after the end of exercise is not typical of angina pectoris. A sense of time, however, is not always reliable, especially in the presence of pain, and severe pain may seem to last for several minutes when it’s true duration is much shorter. Nitroglycerin relieves or eases angina pain, but is also effective in relieving esophageal spasm, and it cannot be regarded as specific.

A sensation of being short of breath is a frequent accompaniment of angina, belching is common, and may appears to relieve the pain; it may confuse the picture directing attention towards the stomach.

Anemia, obesity or an over active thyroid gland can provoke angina.

The pain of myocardial infarction or heart attack (see coronary artery disease) generally differs from that of angina because it is usually severe, oppressive and occurs or persists at rest. The quality, location and radiation are similar. The pain or discomfort is often accompanied by a sense of anxiety or a fear of dying. One tends to lie still and is generally quiet, pale, and often sweaty. The pain usually reaches a maximum in minutes, or over an hour or so, and then may be persistent for hours until relieved by appropriate painkillers. Occasionally the pain imay come amd go even without treatment. A heart attack is not always painful, and electrocardiograph (ECG) evidence of ‘silent infarction’ may be found in patients who have never had typical symptoms.

Prolonged heart pain at rest similar to that of myocardial infarction may result from attacks of paroxysmal tachycardia, especially in patients with diseased coronary arteries; the patient may be aware of palpitation, or the doctor may find a fast heart rate during an attack.

The pain of pericarditis is often mistaken for that of myocardial ischemia. The features in common are that it is retrosternal and may radiate to shoulders, neck or upper arms. However, it is usually made worse by breathing or minimal movement; this is not usual with myocardial pain. However pericarditis may follow a few days after a myocardial infarction and at this stage there may be pain associated with breathing. The pain of pericarditis may also be provoked by swallowing or by change of position. Relief is often gained by sitting forward.

Pain from dissecting aneurysm of the aorta is usually dramatically sudden in onset and located in the upper chest posteriorly. Typically it then gradually eases. Spread of the dissection to the abdominal aorta may provoke abdominal pain. There is often a sensation of loss of power in the legs.

A momentary jab of pain typically below the left nipple is a common experience in normal subjects and is sometimes called a precordial catch; it never indicates organic heart disease.

Shortness of breath on effort is frequently the first symptom of left heart failure. Exercise leads to increased venous return, and the relatively normal ‘right side of the heart’ transmits this increase through the pulmonary circulation. In the presence of an inefficient left ventricle the result is pulmonary venous congestion. This causes a sensation of breathlessness. When exercise is stopped, venous return diminishes, congestion subsides and shortness of breath is relieved.

Breathlessness that demands a more upright position is called Orthopnea. Usually it is improved at night by using multiple pillows or by sleeping in a recliner. When due to heart disease, it is a symptom of persistent congestion and indicates that heart disease requires medical attention. With current medical therapy it is not seen as frequently as before.

Paroxysmal nocturnal dyspnea is a characteristic symptom of left heart failure. It is traditionally attributed to a rise in venous pressure associated with lying flatter. This results in acute "air hunger" accompanied usually by coughing and, generally, significant anxiety and upset.

Palpitation, or awareness of the heart beat, is a common feature in otherwise normal people. Often it can be produced by anxiety or by sympathomimetic drugs such as caffeine, adrenaline some cough medicines and also by alcohol. Panic attacks are commonly confused with paroxysmal tachycardia.

One can often say whether the heart beat seems to be regular or irregular, and by tapping your finger can sometimes indicate the approximate heart rate to your physician. This is helpful in diagnosing paroxysmal tachycardias because most often normal rhythm has returned at the time you are in the office to be seen.

Continuous ambulatory ECG monitoring is of great value in detecting paroxysmal arrhythmia.

The complaint of dizziness is common, and presents a challenge since the causes range from the trivial to the serious. In the clinical setting it is first essential to understand what you mean by being dizzy.

Although the term dizzy is most frequently used to describe some lightheadedness, it is also sometimes meant to denote attacks of vertigo (the room was turning) or of limb weakness or even to describe a ‘blackout’ or syncope where consciousness is lost.

Most blackouts are due either to a reduction of blood flow to the brain or infrequently to epilepsy.