CARDIOVASCULAR SYMPTOMS BY DR KAUSAR MALIK Assistant professor medicine CHEST PAIN CHARACTERISTICS OF ISCHAEMIC CARDIAC PAIN Site of origin of pain. Cardiac pain is typically located in the centre of the chest Radiation. Radiate to the neck, jaw, and upper or even lower arms. Occasionally, cardiac pain may be experienced only at the sites of radiation or in the back. Pain situated over the left anterior chest and radiating laterally may have many causes, including pleural or lung disorders, musculoskeletal problems and anxiety. Character of the pain • Dull, constricting, choking or 'heavy', and is usually described as squeezing, crushing, burning or aching but not sharp, stabbing, pricking or knife-like. • The sensation can be described as breathlessness. • Patients often emphasise that it is a discomfort rather than a pain. • They typically use characteristic hand gestures (e.G. Open hand or clenched fist) when describing ischaemic pain Provocation. • Anginal pain occurs during (not after) exertion and is promptly relieved (in less than 5 minutes) by resting. • Brought on or exacerbated by emotion and tends to occur more readily during exertion, after a large meal or in a cold wind. • Unstable angina, similar pain may be precipitated by minimal exertion and may occur at rest. • Decubitus angina. • The pain of myocardial infarction may be preceded by a period of stable or unstable angina but may occur de novo. pleural or pericardial a 'sharp' or 'catching' sensation that is exacerbated by breathing, coughing or movement. Pain associated with a specific movement (bending, stretching, turning) is likely to be musculoskeletal in origin. Pattern of onset • The pain of myocardial infarction typically takes several minutes or even longer to develop • similarly, angina builds up gradually in proportion to the intensity of exertion. • Pain that occurs after rather than during exertion is usually musculoskeletal or psychological in origin. • The pain of aortic dissection, massive pulmonary embolism or pneumothorax is usually very sudden or instantaneous in onset. Associated features Autonomic disturbance including sweating, nausea and vomiting. Breathlessness Breathlessness may also accompany any of the respiratory causes of chest pain and may be associated with cough, wheeze or other respiratory symptoms. Effort-related 'indigestion' is usually due to heart disease. COMMON CAUSES OF CHEST PAIN Cardiac Myocardial ischaemia (angina) Myocardial infarction Myocarditis Pericarditis Mitral valve prolapse Aortic Aortic dissection Aortic aneurysm Oesophageal Oesophagitis Oesophageal spasm Mallory-Weiss syndrome • Lungs/pleura – Bronchospasm – Pulmonary infarct – Pneumonia – Tracheitis – Pneumothorax – Pulmonary embolism – Malignancy – Tuberculosis – Connective tissue disorders (rare) • Musculoskeletal – Osteoarthritis – Rib fracture/injury – Intercostal muscle injury – Costochondritis (Tietze's syndrome) – Epidemic myalgia (Bornholm disease) • Neurological – Prolapsed intervertebral disc – Herpes zoster – Thoracic outlet syndrome Myocarditis and pericarditis Retrosternally, to the left of the sternum, or in the left or right shoulder Varies in intensity with movement and the phase of respiration Described as 'sharp' and may 'catch' the patient during inspiration or coughing; there is occasionally a history of a prodromal viral illness. Mitral valve prolapse Sharp left-sided chest pain that is suggestive of a musculoskeletal problem may be a feature of mitral valve prolapse. Aortic dissection Severe sharp tearing, often felt in or penetrating through to the back, and very abrupt in onset . Oesophageal pain Oesophageal pain can mimic that of angina very closely Sometimes precipitated by exercise and may be relieved by nitrates However, it is usually possible to elicit a history relating chest pain to supine posture or eating, drinking or oesophageal reflux It often radiates to the back. Bronchospasm Patients with reversible airways obstruction, such as asthma, may describe exertional chest tightness that is relieved by rest. Bronchospasm may be associated with wheeze, atopy and cough Musculoskeletal chest pain Variable in site and intensity Does not usually fall into any of the patterns described above. The pain may vary with posture or movement of the upper body and local tenderness over a rib or costal cartilage. •BREATHLESSNESS (DYSPNOEA) Dyspnoea of cardiac origin may vary in severity from an uncomfortable awareness of breathing to a frightening sensation of 'fighting for breath'. There are several causes of cardiac dyspnoea acute left heart failure, chronic heart failure, arrhythmia and angina equivalent. SOME CAUSES OF DYSPNOEA Cardiovascular system Acute pulmonary oedema Chronic congestive cardiac failure Myocardial ischaemia • Respiratory system * • • • • • • • • • Acute severe asthma * Acute exacerbation of chronic obstructive pulmonary disease * Pneumothorax * Pneumonia * Pulmonary embolus Acute respiratory distress syndrome Inhaled foreign body (especially in the child) Lobar collapse Laryngeal oedema (e.g. anaphylaxis) * • *Chronic – obstructive pulmonary disease – Chronic asthma – Chronic pulmonary thromboembolism – Bronchial carcinoma – Interstitial lung diseases: sarcoidosis, fibrosing alveolitis, extrinsic allergic alveolitis, pneumoconiosis – Lymphatic carcinomatosis (may cause intolerable dyspnoea) – Large pleural effusion(s) Acute left heart failure triggered by myocardial infarction in a previously healthy heart, or onset of atrial fibrillation in a diseased heart. ACUTE LEFT VENTRICULAR FAILURE Terrifying experience sensation of 'fighting for breath'. Sitting upright or standing may provide some relief by helping to reduce congestion at the apices of the lungs. The patient may be unable to speak and is typically distressed, agitated, cyanosed, sweaty and pale. Respiration is rapid with recruitment of accessory muscles, coughing and wheezing. Sputum may be profuse, frothy and blood-streaked or pink. Extensive crepitations and rhonchi are usually audible in the chest and there may also be signs of right heart failure. CHRONIC HEART FAILURE most common cardiac cause of chronic dyspnoea. Symptoms may first present on moderately severe exertion, such as walking up a steep hill, and may be described as a difficulty in 'catching my breath'. As heart failure progresses, the dyspnoea is provoked by lesser exertion and ultimately the patient may be breathless walking from room to room, washing, dressing or trying to hold a conversation. Orthopnoea. Lying down increases the venous return to the heart and may provoke breathlessness in patients with heart failure. The patient may use more pillows to prevent this. Paroxysmal nocturnal dyspnoea In patients with severe heart failure, fluid shifts from the interstitial tissues in the peripheries to the circulation within 12 hours of lying down in bed. Pulmonary oedema may supervene, causing the patient to wake and sit upright, profoundly breathless. ARRHYTHMIA Any arrhythmia may cause breathlessness, but usually only does so if the heart is structurally abnormal, such as with the onset of atrial fibrillation in a patient with mitral stenosis. ANGINA EQUIVALENT The sensation of breathlessness is a common feature of angina. Patients will sometimes describe chest tightness as 'breathlessness'. However, myocardial ischaemia may also induce true breathlessness by provoking transient left ventricular dysfunction or heart failure. When breathlessness is the dominant or sole feature of myocardial ischaemia it is known as 'angina equivalent'. A history of chest tightness, the close correlation with exercise, and objective evidence of myocardial ischaemia from stress testing may all help to establish the diagnosis. .SYNCOPE AND PRESYNCOPE A wide variety of cardiovascular disorders can cause an abrupt fall in cerebral perfusion that may manifest as recurrent or isolated episodes of syncope (sudden loss of consciousness) and presyncope (lightheadedness and near-collapse). FUNNY TURN OR BLACK OUT SENSATION OF MOVEMENT LABRYNTHINE DYSFUNCTION CENTRAL VESTIBULAR DYSFUNCTION LOSS OF BALANCE ATAXIA WEAKNESS LOSS OF SENSATION IN FEET JOINT DISEASE VISUAL DISTURBANCE FEAR OF FALLING FUNNY TURN OR BLACK OUT LIGHTHEADEDNESS PRESYNCOPE CARDIAC DISEASE ARRYTHMIAS LV DYSFUNTION AORTIC STENOSIS HOCM VASOVAGAL SYNCOPE POSTMICTURATION SYNCOPE COUGH SYNCOPE HYPOGLYCEMIA AnXIETY HYPERVENTILATION POST CONCUSSIVE SYNDROME PANIC ATTACK OTHER DISORDER EPILEPTIC FITS TYPICAL FEATURES OF CARDIAC SYNCOPE, VASOVAGAL SYNCOPE AND SEIZURES CARDIC SYNCOPE • • • • • • Often none Lightheadedness Palpitation Chest pain Breathlessness Nausea VASOVAGAL SYNCOPE • Lightheadedness • Sweating SEIZURES • Confusion • Hyperexcitability • Olfactory hallucinations • 'Aura' Unconscious period CARDIAC SYNCOPE Extreme 'death-like' pallor VASOVAGAL SYNCOPE Pallor Prolonged (> 1 min) unconsciousness SEIZURES Motor seizure activity* Tongue-biting Urinary incontinence RECOVERY CARDIC SYNCOPE Rapid recovery (< 1 min) VASOVAGAL SYNCOPE Slow Lightheadednes Nausea SEIZURE Flushing Prolonged confusion (> 5 mins) Headache Focal neurological signs LightheadednesS due to profound bradycardia or malignant ventricular tachyarrhythmias. Ambulatory ECG recorDING In patients with presyncope or syncope in whom these investigations fail to establish a cause, an implantable 'loop recorder' can be placed beneath the skin of the upper chest under local anaesthetia. This device continuously records an ECG and will store arrhythmic events in its digital memory, which can be later accessed using a telemetry device. Structural heart disease Severe aortic stenosis, hypertrophic obstructive cardiomyopathy and severe coronary artery disease can cause lightheadedness or syncope on exertion. This is usually mediated by profound hypotension due to the combination of a reduction in cardiac output and a drop in peripheral vascular resistance, but may also be the consequence of an arrhythmia. Carotid sinus syndrome Hypersensitivity of the carotid baroreceptors can cause recurrent episodes of altered consciousness by promoting inappropriate bradycardia and vasodilatation. The diagnosis can be established by monitoring the ECG and blood pressure during carotid sinus massage; However, this should not be attempted in patients with suspected or proven carotid vascular disease as it may cause TIA. They are reproduced by carotid sinus massage. A positive cardio-inhibitory response is defined as a sinus pause of 3 seconds or more; a positive vasodepressor response is defined as a fall in systolic blood pressure of more than 50 mmHg. Vasovagal syncope This is usually triggered by a reduction in venous return due to prolonged standing, excessive heat or a large meal. It is mediated by the Bezold-Jarisch reflex, which is characterised by initial sympathetic activation that then leads to vigorous contraction of the relatively underfilled ventricles. This stimulates ventricular mechanoreceptors and in turn produces parasympathetic (vagal) activation and sympathetic withdrawal causing bradycardia, vasodilatation or both. Head-up tilt testing, which involves lying the patient on a table that is then tilted to an angle of 70° for up to 45 minutes while the ECG and blood pressure are monitored, can be used to confirm the diagnosis. A positive test is characterised by profound bradycardia (cardio-inhibitory response) and/or hypotension (vasodepressor response) that is associated with typical symptoms. Postural hypotension Symptomatic postural hypotension is caused by a failure of the normal compensatory mechanisms. Relative hypovolaemia (often due to excessive diuretic therapy Sympathetic degeneration (diabetes mellitus, parkinson's disease, ageing) and Drug therapy (vasodilators, antidepressants) can all cause or aggravate the problem. PALPITATION Patients may use the term to describe a wide variety of sensations including an unusually erratic, fast, slow or forceful heart beat and even chest pain or breathlessness. Initial evaluation should concentrate on determining the likely mechanism of the symptom and whether or not there is significant underlying heart disease. THE EVALUATION OF PALPITATION Is the palpitation continuous or intermittent? Is the heart beat regular or irregular? What is the approximate heart rate? Do symptoms occur in discrete attacks? Is the onset abrupt? How do attacks terminate? Are there any associated symptoms? e.g. Chest pain Lightheadedness Polyuria (a feature of supraventricular tachycardia Are there any precipitating factors, e.g. exercise, alcohol? Is there a history of structural heart disease, e.g. coronary artery disease, valvular heart disease?