Symptoms of Heart Disease Cheyne-Stokes Respira6on
Dyspnoea = abnormal awareness of breathlessness; cardiac/resp causes. Occurs on exer:on/ can occur at rest. CSR = alternate hyperven:la:on and apnoea; occurs in v sev
Clinically valuable to grade dyspnoea by amount of physical exer:on possible before SOB occurs. without obvious HF. Related to depression of resp centre, as
Grading of dyspnoea and cardiac status: output and cerebrovascular disease. Also seen following mor
NYHA func6onal and therapeu6c classifica6on applied to dyspnoea: Grade 1) no SOB; Grade 2) SOB on severe
exer:on; Grade 3) SOB on mild exer:on; Grade 4) SOB at rest.
NYHA grading of ‘cardiac status’: Grade 1) uncompromised; 2) slightly compromised; grade 3) moderately Palpita6ons
compromised. Grade 4) severely compromised. Palpita6on = inc awareness of normal heartbeat/sensa:on o
Le@ Ventricular Failure: causes dyspnoea due to rise in pressure in LA and pulmonary capillaries, leading to rhythm. Normal HR is sensed: anxious, excited, exercising, lyi
inters::al and alveolar oedema: makes the lungs s:ff (less compliant), inc the amount of resp effort req to arrhythmias felt as palpita:ons = premature ectopic beats an
breathe. Usually, fast breathing rate (tachypnoea) also present due to s:mula:on of pulmonary stretch Premature beats: Usually felt as ‘missed beats’; premature b
receptors. Dyspnoea on effort usually precedes other forms of SOB, e.g. orthopnoea, or nocturnal dyspnoea. normal beat, which is rather forceful due to longer diastolic fi
Orthopnoea = form of breathlessness when lying flat: lying down results in redistribu:on of blood, leading to inc occur in clusters; may cause pa:ent anxiety
central and pulm blood vol. Lying down also causes abdo contents to rise and press against diaphragm. Paroxysmal tachycardia: Start abruptly; may terminate equa
Redistribu:on of blood and pressure of abdo contents on diaphragm increase difficulty in breathing. Cope with before termina:ng, seems to fade away. Paroxysmal AF no:c
orthopnoea; prop up on cushions. paroxysmal supra ventricular or ventricular tachycardia = reg
Paroxysmal nocturnal dyspnoea: accumula:on of fluid in lungs (pulm oedema) at night. Sensory awareness is esp when prolonged, may be associated with syncope, presyn
reduced during sleepà severe inters::al and alveolar oedema may accumulate. Pt wakes in night figh:ng for Palpita:ons can be graded similarly to grading of dyspnoea/a
breath. Relieve SOB by siVng on side of bed/geVng up. Wheezing, due to bronchial endothelial oedema = Supraventricular tachcardias e.g. AF or junc:onal tachycardia
common (“cardiac asthma”) and cough (o[en frothy/blood-:nged sputum) usually occurs. Ini:ally, episodes POTS: postural orthosta6c tachycardia syndrome: Some pt e
terminate spontaneously. PND episodes o[en occur with coughing; can occur in asthma. assoc with mild drop in BP and dizziness or near syncope. PO
Bradycardias: Unduly slow HR can be felt as slow, regular, ‘he
bradycardias not felt as palpita:ons.
Syncope Palpita6ons: inc awareness of normal heart beat/ sensa:on
Many causes: most common = situa:onal/vasovagal syncope: alacks may be provoked by fright, anxiety, Most commonly felt: premature ectopic beats and paroxysm
phobias or other situa:ons e.g. mictura:on/coughing. Premature beats (ectopics): felt as pause followed by forcefu
Basic mechanism = vasodila:onà venous pooling, followed by emptying of heart. Vigorous contrac:on of near- by pause prior to next normal beat, as heart resets itself. Nex
empty heart s:mulates mechano-Rs in inferoposterior wall of LV. Consequent reflexes via CNS à further longer diastolic period and is thus filled with more blood. Par
vasodila:on and some:mes profound bradycardia = neurocardiogenic syncope (empty heart syndrome): usually heart beat. Bradycardias: slow, regular, heavy or forceful bea
assoc with dizziness, nausea, swea:ng, ringing in ears, sinking feeling and yawning. Recovery: within a few
seconds; par:cularly if pa:ent lies down.
Cardiovascular syncope = sudden and brief. Classical variety = Stokes-Adams aYack: disturbance of cardiac Chest Pain DD
rhythm (profound bradycardia related to complete heart block): without warning, pt drops to ground, pale and Chest pain = most common symptom associated with ischaem
unconscious. Pulse usually v. slow or absent. A[er few secs, person flushes brightly and regains consciousness as Angina Pectoris: Gripping/crushing central chest pain; may b
pulse quickens. If prolonged period of unconsciousness, pt may suffer a generalised convulsion (rare). chest. Pain may radiate to neck, jaw, back, teeth or abdo. Ass
Caro6d sinus syncope = uncommon cause; occurs when exaggerated vagal resonse to s:mula:on of caro:d pain in one/both arms. Pain that lasts >few mins, typically pro
sinus; resul:ng vasodila:on and bradycardia cause syncope and dizziness rest. Angina of inc frequency/ coming on at rest = unstable (c
Cardiac Causes of Syncope: = myocardial hypoxia secondary to inadequate coronary bloo
- Arrhythmias: Ventricular tachycardia; rapid SVT; sinus arrest; AV block; ar:ficial PM failure Acute MI: CP radiates to both arms; 3rd heart sound on ausc
- Obstruc6on: Aor:c/pulmonary stenosis; hypertrophic obstruc:ve cardiomyopathy; Fallot’s tetralogy; searing pain radia:ng to back, neck, jaw, shoulders and arms
Pulmonary HTN/ embolism; atrial myxoma; atrial thrombus; defec:ve prosthe:c valve weakness
- Situa6onal: Neurocardiogenic (vasovagal); postural hypotension Myocardi6s: Heart muscle inflamma:on: may cause fever, fa
Syncope = transient loss of consciousness due to inadequate cerebral blood flow. Pericardi6s: Inflamma:on of sac around heart. Clinical triad:
Vascular Causes (neurocardiogenic [vasovagal]; postural HTN; postprandial HTN; micturi:on syncope, caro:d reclining; lessened leaning forwards (sharp, steady pain, alon
sinus syncope) worsens with breathing, swallowing or lying on back); 2) Peri
Vasovagal aYack: simple faint; most common cause of syncope; peripheral vasodila:on and venous pooling of diffuse ST eleva:on and PR interval depression without T wav
blood à reduced blood returned to heart; near empty heart responds by contrac:ng vigorously, which in turn chest, aggravated by movement, posture, respira:on and cou
s:mulates mechanoreceptors in inferoposterior wall of LV; these trigger reflexes via CNS, which act to reduce forwards. Sharp and severe CP
ventricular stretch (further vasodila:on and some:mes profound bradycardia) à drop in BP and thus syncope. Hypertrophic Cardiomyopathy: (HCM) = gene:c disease caus
Episodes are o[en associated with prodrome of dizziness, nausea and swea:ng, :nnitus, yawning and a sinking thick. CP and SOB with exercise. Over :me, HF may occur wh
feeling. Recovery occurs within a few seconds, esp if pt lies down. Associated with dizziness, light-headedness, fain:ng.
Postural (orthosta6c hypotension): drop in sBP of >20mmHg on standing from lying posi:on; usually, reflex Mitral valve prolapse: CP, palpita:ons, dizziness (may be asy
vasoconstric:on prevents drop in BP, but if this is absent or if pt is fluid-depleted or on vasodila(ng/ diure(c Coronary artery dissec6on: Sudden severe pain with tearing/
drugs, hypotension occurs. Common in elderly; inadequate reflex vasoconstric:on on standing from lying/siVng back or abdomen.
posi:on, with resultant pronounced reduced BP and reduced cerebral profusion: may cause pt to collapse. No Acute thoracic aor6c dissec6on: Acute chest/back pain and p
specific treatment, but avoid vasodila:ng drugs (e.g. for hypertension or angina) Central CP radia:ng to back = dissec:ng/enlarging aor:c ane
Postprandial hypotension: drop in sBP >20mmHg or sBP drops from above 100mmHg to under 90mmHg within Dissec:on MUST be excluded - admission of thromboly:c age
2h of ea:ng; unknown mechanism, but may inv pooling of blood in splanchnic vessels. In normal subjects, this Heart failure: Pulmonary oedema on CXR; clinical impression
elicits homeosta:c response via ac:va:on of baro-Rs and sympathe:c system, peripheral vasoconstric:on and Muscle and bone: Chest Wall Pain: 2+ of following: localised
increased cardiac output. reproducible by palpa:on; absence of cough
Micturi6on syncope: loss of consciousness whilst urina:ng Costochondri6s: rib cage car:lage becomes inflamed and pai
Caro6d sinus syncope: exaggerated vagal response to caro:d sinus s:mula:on, provoked by wearing a :ght Sore muscles: chronic pain syndromes; fibromyalgia; muscle-
collar, looking upwards or turning the head. worsens with ac:vity
Obstruc6ve Causes: (aor:c stenosis, HCM, pulm stenosis, tetralog of fallot, pulm HTN/ embolism, atrial Injured ribs: bruised/broken rib can à CP; worsens with dee
myxoma/ thrombus, defec:ve prosthe:c valve) GI causes: GORD: Burning retrosternal pain; acid regurgita:o
Restric:on of BP from heart to rest of circula:on, or b/w different chambers of heart à LOC down/ a[er ea:ng; PPI 1-week high dose trial relieves sympt
Arrhythmias (Rapid tachy, profound bradycardias (Stokes-Adams), significant pauses (in rhythm), ar:ficial PM) Swallowing disorders: Central CP similar to angina may occur
Stokes-Adams aYacks: sudden LOC unrelated to posture, and due to intermilent high-grade AV block, profound Eosophageal contrac6on disorders: uncoordinated/ high-pre
bradycardia or ventricular stands:ll. Pt falls to ground w/o warning, is pale and deeply unconscious. Pulse Eosophageal hypersensi6vity: sensi:ve to small change in pr
usually v. slow/absent. A[er few secs, pt flushes brightly and recovers consciousness as pulse quickens. O[en, Eosophageal rupture/perfora6on: sudden, severe CP a[er vo
no sequelae, but pt may injure themselves during falls. Occasionally, generalised Pep6c ulcers: vague recurring discomfort; RF - smokers, alcoh
convulsion may occur if period of cerebral hypoxia is prolonged, leading to misdiagnosis of epilepsy. when eat/ take antacids
Hiatus hernia: stomach pushes into lower chest a[er ea:ng;
symptoms
Systemic Symptoms GB/Pancreas problems: abdominal pain may radiate to chest
Fa6gue = non-specific symptom of HF, persistent cardiac arrhythmias and cyano:c heart disease: due to poor Pancrea66s: pain in lower chest; worse when lie flat and bel
cerebral and peripheral perfusion and poor oxygena:on. Fa:gue may be caused by infec:ve endocardi:s or Gallbladder problems: a[er ea:ng faly meals, sensa:on of f
disorders of most systems. Drugs for angina/HTN (esp beta-blockers) can cause fa:gue. right upper side of abdomen
Weight loss and anorexia: features of chronic cardiac condi:ons e.g. HF give rise to cardiac cachexia. Conges:ve Pulmonary causes: Pneumonia: Egophony, dullness to percu
HF can also cause abdominal symptoms: N&V, dyspepsia (due to engorgement of visceral organs). cough, cough up pus from respiratory tract.
Pulmonary Embolism: blood clot lodged in pulmonary artery
Oedema Pleurisy: inflamma:on of membrane covering lungs; worsens
HF results in salt and water reten:on; retained fluid à swollen ankles and feet of ambulant pt; accumulates Collapsed lung: sudden onset, can last hours; hypotension Pu
Asthma: SOB, wheezing, coughing, CP
Dyspnoea = abnormal awareness of breathlessness; cardiac/resp causes. Occurs on exer:on/ can occur at rest. CSR = alternate hyperven:la:on and apnoea; occurs in v sev
Clinically valuable to grade dyspnoea by amount of physical exer:on possible before SOB occurs. without obvious HF. Related to depression of resp centre, as
Grading of dyspnoea and cardiac status: output and cerebrovascular disease. Also seen following mor
NYHA func6onal and therapeu6c classifica6on applied to dyspnoea: Grade 1) no SOB; Grade 2) SOB on severe
exer:on; Grade 3) SOB on mild exer:on; Grade 4) SOB at rest.
NYHA grading of ‘cardiac status’: Grade 1) uncompromised; 2) slightly compromised; grade 3) moderately Palpita6ons
compromised. Grade 4) severely compromised. Palpita6on = inc awareness of normal heartbeat/sensa:on o
Le@ Ventricular Failure: causes dyspnoea due to rise in pressure in LA and pulmonary capillaries, leading to rhythm. Normal HR is sensed: anxious, excited, exercising, lyi
inters::al and alveolar oedema: makes the lungs s:ff (less compliant), inc the amount of resp effort req to arrhythmias felt as palpita:ons = premature ectopic beats an
breathe. Usually, fast breathing rate (tachypnoea) also present due to s:mula:on of pulmonary stretch Premature beats: Usually felt as ‘missed beats’; premature b
receptors. Dyspnoea on effort usually precedes other forms of SOB, e.g. orthopnoea, or nocturnal dyspnoea. normal beat, which is rather forceful due to longer diastolic fi
Orthopnoea = form of breathlessness when lying flat: lying down results in redistribu:on of blood, leading to inc occur in clusters; may cause pa:ent anxiety
central and pulm blood vol. Lying down also causes abdo contents to rise and press against diaphragm. Paroxysmal tachycardia: Start abruptly; may terminate equa
Redistribu:on of blood and pressure of abdo contents on diaphragm increase difficulty in breathing. Cope with before termina:ng, seems to fade away. Paroxysmal AF no:c
orthopnoea; prop up on cushions. paroxysmal supra ventricular or ventricular tachycardia = reg
Paroxysmal nocturnal dyspnoea: accumula:on of fluid in lungs (pulm oedema) at night. Sensory awareness is esp when prolonged, may be associated with syncope, presyn
reduced during sleepà severe inters::al and alveolar oedema may accumulate. Pt wakes in night figh:ng for Palpita:ons can be graded similarly to grading of dyspnoea/a
breath. Relieve SOB by siVng on side of bed/geVng up. Wheezing, due to bronchial endothelial oedema = Supraventricular tachcardias e.g. AF or junc:onal tachycardia
common (“cardiac asthma”) and cough (o[en frothy/blood-:nged sputum) usually occurs. Ini:ally, episodes POTS: postural orthosta6c tachycardia syndrome: Some pt e
terminate spontaneously. PND episodes o[en occur with coughing; can occur in asthma. assoc with mild drop in BP and dizziness or near syncope. PO
Bradycardias: Unduly slow HR can be felt as slow, regular, ‘he
bradycardias not felt as palpita:ons.
Syncope Palpita6ons: inc awareness of normal heart beat/ sensa:on
Many causes: most common = situa:onal/vasovagal syncope: alacks may be provoked by fright, anxiety, Most commonly felt: premature ectopic beats and paroxysm
phobias or other situa:ons e.g. mictura:on/coughing. Premature beats (ectopics): felt as pause followed by forcefu
Basic mechanism = vasodila:onà venous pooling, followed by emptying of heart. Vigorous contrac:on of near- by pause prior to next normal beat, as heart resets itself. Nex
empty heart s:mulates mechano-Rs in inferoposterior wall of LV. Consequent reflexes via CNS à further longer diastolic period and is thus filled with more blood. Par
vasodila:on and some:mes profound bradycardia = neurocardiogenic syncope (empty heart syndrome): usually heart beat. Bradycardias: slow, regular, heavy or forceful bea
assoc with dizziness, nausea, swea:ng, ringing in ears, sinking feeling and yawning. Recovery: within a few
seconds; par:cularly if pa:ent lies down.
Cardiovascular syncope = sudden and brief. Classical variety = Stokes-Adams aYack: disturbance of cardiac Chest Pain DD
rhythm (profound bradycardia related to complete heart block): without warning, pt drops to ground, pale and Chest pain = most common symptom associated with ischaem
unconscious. Pulse usually v. slow or absent. A[er few secs, person flushes brightly and regains consciousness as Angina Pectoris: Gripping/crushing central chest pain; may b
pulse quickens. If prolonged period of unconsciousness, pt may suffer a generalised convulsion (rare). chest. Pain may radiate to neck, jaw, back, teeth or abdo. Ass
Caro6d sinus syncope = uncommon cause; occurs when exaggerated vagal resonse to s:mula:on of caro:d pain in one/both arms. Pain that lasts >few mins, typically pro
sinus; resul:ng vasodila:on and bradycardia cause syncope and dizziness rest. Angina of inc frequency/ coming on at rest = unstable (c
Cardiac Causes of Syncope: = myocardial hypoxia secondary to inadequate coronary bloo
- Arrhythmias: Ventricular tachycardia; rapid SVT; sinus arrest; AV block; ar:ficial PM failure Acute MI: CP radiates to both arms; 3rd heart sound on ausc
- Obstruc6on: Aor:c/pulmonary stenosis; hypertrophic obstruc:ve cardiomyopathy; Fallot’s tetralogy; searing pain radia:ng to back, neck, jaw, shoulders and arms
Pulmonary HTN/ embolism; atrial myxoma; atrial thrombus; defec:ve prosthe:c valve weakness
- Situa6onal: Neurocardiogenic (vasovagal); postural hypotension Myocardi6s: Heart muscle inflamma:on: may cause fever, fa
Syncope = transient loss of consciousness due to inadequate cerebral blood flow. Pericardi6s: Inflamma:on of sac around heart. Clinical triad:
Vascular Causes (neurocardiogenic [vasovagal]; postural HTN; postprandial HTN; micturi:on syncope, caro:d reclining; lessened leaning forwards (sharp, steady pain, alon
sinus syncope) worsens with breathing, swallowing or lying on back); 2) Peri
Vasovagal aYack: simple faint; most common cause of syncope; peripheral vasodila:on and venous pooling of diffuse ST eleva:on and PR interval depression without T wav
blood à reduced blood returned to heart; near empty heart responds by contrac:ng vigorously, which in turn chest, aggravated by movement, posture, respira:on and cou
s:mulates mechanoreceptors in inferoposterior wall of LV; these trigger reflexes via CNS, which act to reduce forwards. Sharp and severe CP
ventricular stretch (further vasodila:on and some:mes profound bradycardia) à drop in BP and thus syncope. Hypertrophic Cardiomyopathy: (HCM) = gene:c disease caus
Episodes are o[en associated with prodrome of dizziness, nausea and swea:ng, :nnitus, yawning and a sinking thick. CP and SOB with exercise. Over :me, HF may occur wh
feeling. Recovery occurs within a few seconds, esp if pt lies down. Associated with dizziness, light-headedness, fain:ng.
Postural (orthosta6c hypotension): drop in sBP of >20mmHg on standing from lying posi:on; usually, reflex Mitral valve prolapse: CP, palpita:ons, dizziness (may be asy
vasoconstric:on prevents drop in BP, but if this is absent or if pt is fluid-depleted or on vasodila(ng/ diure(c Coronary artery dissec6on: Sudden severe pain with tearing/
drugs, hypotension occurs. Common in elderly; inadequate reflex vasoconstric:on on standing from lying/siVng back or abdomen.
posi:on, with resultant pronounced reduced BP and reduced cerebral profusion: may cause pt to collapse. No Acute thoracic aor6c dissec6on: Acute chest/back pain and p
specific treatment, but avoid vasodila:ng drugs (e.g. for hypertension or angina) Central CP radia:ng to back = dissec:ng/enlarging aor:c ane
Postprandial hypotension: drop in sBP >20mmHg or sBP drops from above 100mmHg to under 90mmHg within Dissec:on MUST be excluded - admission of thromboly:c age
2h of ea:ng; unknown mechanism, but may inv pooling of blood in splanchnic vessels. In normal subjects, this Heart failure: Pulmonary oedema on CXR; clinical impression
elicits homeosta:c response via ac:va:on of baro-Rs and sympathe:c system, peripheral vasoconstric:on and Muscle and bone: Chest Wall Pain: 2+ of following: localised
increased cardiac output. reproducible by palpa:on; absence of cough
Micturi6on syncope: loss of consciousness whilst urina:ng Costochondri6s: rib cage car:lage becomes inflamed and pai
Caro6d sinus syncope: exaggerated vagal response to caro:d sinus s:mula:on, provoked by wearing a :ght Sore muscles: chronic pain syndromes; fibromyalgia; muscle-
collar, looking upwards or turning the head. worsens with ac:vity
Obstruc6ve Causes: (aor:c stenosis, HCM, pulm stenosis, tetralog of fallot, pulm HTN/ embolism, atrial Injured ribs: bruised/broken rib can à CP; worsens with dee
myxoma/ thrombus, defec:ve prosthe:c valve) GI causes: GORD: Burning retrosternal pain; acid regurgita:o
Restric:on of BP from heart to rest of circula:on, or b/w different chambers of heart à LOC down/ a[er ea:ng; PPI 1-week high dose trial relieves sympt
Arrhythmias (Rapid tachy, profound bradycardias (Stokes-Adams), significant pauses (in rhythm), ar:ficial PM) Swallowing disorders: Central CP similar to angina may occur
Stokes-Adams aYacks: sudden LOC unrelated to posture, and due to intermilent high-grade AV block, profound Eosophageal contrac6on disorders: uncoordinated/ high-pre
bradycardia or ventricular stands:ll. Pt falls to ground w/o warning, is pale and deeply unconscious. Pulse Eosophageal hypersensi6vity: sensi:ve to small change in pr
usually v. slow/absent. A[er few secs, pt flushes brightly and recovers consciousness as pulse quickens. O[en, Eosophageal rupture/perfora6on: sudden, severe CP a[er vo
no sequelae, but pt may injure themselves during falls. Occasionally, generalised Pep6c ulcers: vague recurring discomfort; RF - smokers, alcoh
convulsion may occur if period of cerebral hypoxia is prolonged, leading to misdiagnosis of epilepsy. when eat/ take antacids
Hiatus hernia: stomach pushes into lower chest a[er ea:ng;
symptoms
Systemic Symptoms GB/Pancreas problems: abdominal pain may radiate to chest
Fa6gue = non-specific symptom of HF, persistent cardiac arrhythmias and cyano:c heart disease: due to poor Pancrea66s: pain in lower chest; worse when lie flat and bel
cerebral and peripheral perfusion and poor oxygena:on. Fa:gue may be caused by infec:ve endocardi:s or Gallbladder problems: a[er ea:ng faly meals, sensa:on of f
disorders of most systems. Drugs for angina/HTN (esp beta-blockers) can cause fa:gue. right upper side of abdomen
Weight loss and anorexia: features of chronic cardiac condi:ons e.g. HF give rise to cardiac cachexia. Conges:ve Pulmonary causes: Pneumonia: Egophony, dullness to percu
HF can also cause abdominal symptoms: N&V, dyspepsia (due to engorgement of visceral organs). cough, cough up pus from respiratory tract.
Pulmonary Embolism: blood clot lodged in pulmonary artery
Oedema Pleurisy: inflamma:on of membrane covering lungs; worsens
HF results in salt and water reten:on; retained fluid à swollen ankles and feet of ambulant pt; accumulates Collapsed lung: sudden onset, can last hours; hypotension Pu
Asthma: SOB, wheezing, coughing, CP
