Heart: Symptoms and signs

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COMMON SYMPTOMS
The most common symptoms of Heart disease are dyspnea, Chest pain, palpitations, syncope or presyncope, and fatigue. None are specific, and interpretation depends on the entire clinical picture and, in many cases, diagnostic testing.

Dyspnea
Dyspnea due to Heart disease is precipitated or exacerbated by exertion and results from elevated left atrial and pulmonary venous pressures or from hypoxia. The former are most commonly caused by left ventricular systolic dysfunction, left ventricular diastolic dysfunction (due to hypertrophy, fibrosis, or pericardial disease), or valvular obstruction. The acute onset or worsening of left atrial hypertension may result in pulmonary edema. Hypoxia may be due to pulmonary edema or intracardiac shunting.

Dyspnea should be quantified by the amount of activity that precipitates it. Dyspnea is also a common symptom of pulmonary disease, and the etiologic distinction may be difficult. Shortness of breath is also found in sedentary or obese individuals, anxiety states, anemia, and many other illnesses.

Orthopnea is dyspnea that occurs in recumbency and results from an increase in central blood volume. Orthopnea may also result from pulmonary disease and obesity. Paroxysmal nocturnal dyspnea is shortness of breath that occurs abruptly 30 minutes to 2 hours after going to bed and is relieved by sitting up or standing up; this symptom is more specific for cardiac disease. Both are more specific for cardiac diseases than exertional dyspnea, but neither is diagnostic of heart failure.

Chest Pain or Discomfort
Chest pain and other forms of discomfort are common symptoms that can occur as a result of pulmonary, pleural, or musculoskeletal disease, esophageal or other gastrointestinal disorders, cervicothoracic nerve root irritation, or anxiety states, as well as many cardiovascular diseases. Myocardial ischemia is the most frequent cause of cardiac Chest pain, but it is often experienced more as a sensation of discomfort than actual pain, thereby increasing the potential for neglect on the part of the patient and misdiagnosis by the physician. This is usually described as dull, aching, or as a sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than as sharp or spasmodic. Ischemic symptoms usually subside within 5-20 minutes but may last longer. Protracted episodes often represent myocardial infarction. The pain is commonly accompanied by a sense of anxiety or uneasiness. The location is usually retrosternal or left precordial. Though the pain may radiate to or be localized in the throat, lower jaw, shoulders, inner arms, upper abdomen, or back, it nearly always also involves the sternal region. Ischemic pain is often precipitated by exertion, cold temperature, meals, stress, or combinations of these factors and is usually relieved by rest, but many episodes do not conform to these patterns. It is not related to position or respiration and is usually not elicited by chest palpation. In myocardial infarction, a precipitating factor is frequently not apparent.

Hypertrophy of either ventricle and aortic valvular disease may also give rise to ischemic pain or pain with less typical features. Myocarditis, cardiomyopathy, Primary pulmonary hypertension, and mitral valve prolapse are associated with Chest pain atypical for angina pectoris. Pericarditis may produce pain that changes with position or respiration. Aortic dissection produces an instantaneous onset of tearing pain of great intensity that often radiates to the back.

Palpitations, Dizziness, Syncope
Palpitations, or awareness of the heartbeat, may be a normal phenomenon or may reflect increased cardiac or stroke output in patients with many noncardiac conditions (eg, exercise, thyrotoxicosis, anemia, anxiety). It may also be due to cardiac abnormalities that increase stroke volume (regurgitant valvular disease, Bradycardia) or may be a manifestation of cardiac dysrhythmias. Ventricular premature beats may be sensed as extra or “skipped” beats. Supraventricular or ventricular Tachycardia may be felt as rapid, regular or irregular palpitations or “fluttering”; many patients are asymptomatic, however.

If the abnormal rhythm is associated with a sufficient decline in arterial pressure or cardiac output, it may—especially in the upright position—impair cerebral blood flow, causing dizziness, blurring of vision, loss of consciousness (syncope), or other symptoms. However, dizziness in particular is very nonspecific and only infrequently is a symptom of cardiac disease or dysrhythmia.

Cardiogenic syncope most commonly results from sinus node arrest or exit block, atrioventricular conduction block, or ventricular Tachycardia or fibrillation. It is associated with few prodromal symptoms and may thus be an occasion for injuries. The absence of premonitory symptoms helps distinguish cardiogenic syncope from vasovagal faints, postural hypotension, or seizure but is not a reliable screening tool. Although recovery is often immediate, some patients may exhibit seizure-like movements. Aortic valve disease and hypertrophic obstructive cardiomyopathy may also cause syncope, which is usually exertional or postexertional. Another form of syncope is termed neurocardiogenic syncope, commonly known as vasovagal syncope. In this syndrome, there is an inappropriate increase in vagal efferent activity, often resulting from a precedent increase in sympathetic cardiac stimulation. Syncope may follow a brief period of diaphoresis and presyncopal symptoms, or it may be abrupt in onset, mimicking arrhythmia-induced syncope. 

RELATED STORIES:
Cardiovascular Screening of Athletes   The Cardiac Patient & Pregnancy   Cardiovascular Complications of Pregnancy   The Cardiac Patient & Surgery   Traumatic Heart Disease   Pulmonary Heart Disease (Cor Pulmonale)   Cardiac Involvement in Miscellaneous Systemic Diseases   Neoplastic Diseases of the Heart   Constrictive Pericarditis   Primary Pulmonary Hypertension   Pericardial Effusion   Acute Pericarditis

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