COMMON PRESENTING SYMPTOMS OF HEART DISEASE

The common symptoms of heart disease are chest pain, breathlessness, palpitations, syncope, fatigue and peripheral oedema, but none are specific for cardiovascular disease. The severity of anginal pain, dyspnoea, palpita-tions or fatigue may be classified according to the New York Heart Association grading of ‘cardiac status' (Table 10.1).

Chest pain

Chest pain or discomfort is a common presenting symptom of cardiovascular disease and must be differentiated from non-cardiac causes. The site of pain, its character, radiation and associated symptoms will often point to the cause (Table 10.2)

Dyspnoea

Causes are discussed on page 407. Left heart failure is the most common cardiac cause of exertional dyspnoea and may also cause orthopnoea and paroxysmal nocturnal dyspnoea (p. 407).

Palpitations

Palpitations are an awareness of the heartbeat. The normal heartbeat is sensed when the patient is anxious, excited, exercising or lying on the left side. In other circumstances it usually indicates a cardiac arrhythmia, com-monly ectopic beats or a paroxysmal tachycardia (p. 420).

Syncope

This is a temporary impairment of consciousness due to inadequate cerebral blood flow. There are many causes and the most common is a simple faint

Table 10.1 The New York Heart Association grading of ‘cardiac status' (modified)
Grade 1	Uncompromised (no breathlessness)
Grade 2	Slightly compromised (on severe exertion)
Grade 3	Moderately compromised (on mild exertion)
Grade 4	Severely compromised (breathless at rest)

Table 10.2 Common causes of chest pain
Central
Angina pectoris	Crushing pain on exercise, relieved by rest. May radiate to jaw or arms
ACS	Similar in character to angina but more severe, occurs at rest, lasts longer
Pericarditis	Sharp pain aggravated by movement, respiration and changes in posture
Aortic dissection	Severe tearing chest pain radiating through to the back
Massive PE	With dyspnoea, tachycardia and hypotension
Musculoskeletal	Tender to palpate over affected area
GORD	May be exacerbated by bending or lying down (at night). Pain may radiate into the neck
Lateral/peripheral
Pulmonary infarct Pneumonia Pneumothorax	Pleuritic pain, i.e. sharp, well-localized, aggravated by inspiration, coughing and movement
Musculoskeletal	Sharp, well-localized pain with a tender area on palpation
Lung carcinoma	Constant dull pain
Herpes zoster	Burning unilateral pain corresponding to a dermatome that appears 2 to 3 days before the typical rash
ACS, acute coronaiy syndrome; PE, puỉmonaiy emboỉus; GORD, gastro-oesophageaỉ reflux disease.

or vasovagal attack (p. 717). The cardiac causes of syncope are the result of either very fast (e.g. ventricular tachycardia) or very slow heart rates (e.g. complete heart block) which are unable to maintain an adequate cardiac output. Attacks occur suddenly and without warning. They last only 1 or 2 minutes, with complete recovery in seconds (compare with epilepsy, where

complete recovery may be delayed for some hours). Obstruction to ventricular outflow also causes syncope (e.g. aortic stenosis, hypertrophic cardiomyo-pathy), which typically occurs on exercise when the requirements for increased cardiac output cannot be met.

Other symptoms

Tiredness and lethargy occur with heart failure and result from poor perfusion of brain and skeletal muscle, poor sleep, side-effects of medication particu-larly β-blockers, and electrolyte imbalance due to diuretic therapy. Heart failure also causes salt and water retention leading to oedema, which in ambulant patients is most prominent over the ankles. In severe cases it may involve the genitalia and thighs.