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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
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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 *
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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
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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
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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
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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?