REVIEW OF SPECIFIC SYMPTOMS
The important symptoms of cardiac disease are the following:
- Chest pain
- Palpitations
- Dyspnea
- Syncope
- Fatigue
- Dependent edema
- Hemoptysis
- Cyanosis
CHEST PAIN
Chest pain is probably the most important symptom of cardiac disease. It is not, however, pathognomonic for heart disease. It is well known that chest pain may result from pulmonary, intestinal, gallbladder, and musculoskeletal disorders. Ask the following questions of any patients complaining of chest pain:
- “Where is the pain?”
- “How long have you had the pain?”
- “Do you have recurrent episodes of pain?”
- “What is the duration of the pain?”
- “How often do you get the pain?”
- “What do you do to make it better?”
- “What makes the pain worse? Breathing? Lying flat? Moving your arms or neck?”
- “How would you describe the pain?1 Burning? Pressing? Crushing? Dull? Aching? Throbbing? Knifelike? Sharp? Constricting? Sticking?”
- “Does the pain occur at rest? With exertion? After eating? When moving your arms? With emotional
- “Is the pain associated with shortness of breath? Palpitations? Nausea or vomiting? Coughing?
strain? While sleeping? During sexual intercourse?”
Fever? Coughing up blood? Leg pain?”
PALPITATIONS
Palpitations are the uncomfortable sensations in the chest associated with a range of arrhythmias. Patients may describe palpitations as “fluttering,” “skipped beats,” “pounding,” “jumping,” “stopping,” or “irregularity.” Determine whether the patient has had similar episodes and what was done to extinguish them. Palpitations are common and do not necessarily indicate serious heart disease. Any condition in which there is an increased stroke volume, as in aortic regurgitation, may be associated with a sensation of “forceful contraction.” When a patient complains of palpitations, ask the following questions:
- “How long have you had palpitations?”
- “Do you have recurrent attacks?” If so, “How frequently do they occur?”
- “When did the current attack begin?”
- “How long did it last?”
- “What did it feel like?”
- “Did any maneuvers or positions stop it?”
- “Did it stop abruptly?”
- “Could you count your pulse during the attack?”
- “Can you tap out on the table what the rhythm was like?”
- “Have you noticed palpitations after strenuous exercise? On exertion? While lying on your left side? After a meal? When tired?”
- “During the palpitations, have you ever fainted? Had chest pain?”
- “Was there an associated flush, headache, or sweating associated with the palpitations?”2
- “Have you noticed an intolerance to heat? Cold?”
- “What kind of medications are you taking?”
- “Do you take any medications for your lungs?”
- “Are you taking any thyroid medications?”
- “Have you ever been told that you had a problem with your thyroid?”
- “How much tea, coffee, chocolate, or cola sodas do you consume a day?”
- “Do you smoke?” If yes, “What do you smoke?”
- “Do you drink alcoholic beverages?”
- “Did you notice that after the palpitations you had to urinate?”
- The complaint of dyspnea is important. Patients report that they have “shortness of breath” or that they “can’t get enough air.” Dyspnea is commonly related to cardiac or pulmonary condition.
- Paroxysmal nocturnal dyspnea (PND) occurs at night or when the patient is supine. This position increases the intrathoracic blood volume, and a weakened heart may be unable to handle this increased load; congestive heart failure may result. The patient is awakened about 2 hours after having fallen asleep, is markedly dyspneic, is often coughing, and may seek relief by running to a window to “get more air.” Episodes of PND are relatively specific for congestive heart failure.
- The symptom of PND is often associated with the symptom of orthopnea, the need for using more pillows on which to sleep. Inquire of all patients, “How many pillows do you need to sleep?” To help quantify the orthopnea, you can state, for example, “Three-pillow orthopnea for the past 4 months.”
- Dyspnea on exertion (DOE) is usually caused by chronic congestive heart failure or severe pulmonary disease.
- Trepopnea is a rare form of positional dyspnea in which the dyspneic patient has less dyspnea while lying on the left or right side. The pathophysiologic process of trepopnea is not well understood.
Fainting, or syncope, is the transient loss of consciousness that results from inadequate cerebral perfusion. Ask patients what they mean by “fainting” or “dizziness.” Syncope may have cardiac or noncardiac causes. When a patient describes fainting, ask the following questions:
- “What were you doing just before you fainted?”
- “Have you had recurrent fainting spells?” If so, “How often do you have these attacks?”
- “Was the fainting sudden?”
- “Did you lose consciousness?”
- “In what position were you when you fainted?”
- “Was the fainting preceded by any other symptom? Nausea? Chest pain? Palpitations? Confusion? Numbness? Hunger?”
- “Did you have any warning that you were going to faint?”
- “Did you have any black, tarry bowel movements after the faint?”
The activity that preceded the syncope is important because some cardiac causes are associated with syncope during exercise (e.g., valvular aortic stenosis, idiopathic hypertrophic subaortic stenosis, and primary pulmonary hypertension). If a patient describes palpitations before the syncope, an arrhythmogenic cause may be present. Cardiac output may be reduced by arrhythmias or obstructive lesions.
Orthostatic hypotension is a common form of postural syncope and is the result of a peripheral autonomic limitation. There is a sudden fall in systemic blood pressure, resulting from a failure of adaptive reflexes to compensate for an erect posture. Symptoms of orthostatic hypotension include dizziness, blurring of vision, profound weakness, and syncope. Many drugs can cause orthostatic hypotension by leading to changes in intravascular volume or tone. Older patients are most prone to orthostatic hypotension.
Micturition syncope usually occurs in men during straining with nocturnal urination. It may occur after considerable alcohol consumption.
Vasovagal syncope is the most common type of fainting and is one of the most difficult to manage. It has been estimated that 40% of all syncopal events are vasovagal in nature. Vasovagal syncope occurs during periods of sudden, stressful, or painful experiences, such as receiving bad news, surgical manipulation, trauma, the loss of blood, or even the sight of blood. It is often preceded by pallor, nausea, weakness, blurred vision, lightheadedness, perspiring, yawning, diaphoresis, hyperventilation, epigastric discomfort, or a “sinking feeling.” There is a sudden fall in systemic vascular resistance without a compensatory increase in cardiac output as a result of an increased vagotonia. If the patient sits or lies down promptly, frank syncope
can be aborted.
Carotid sinus syncope is associated with a hypersensitive carotid sinus and is most common in the older adult population. Whenever a patient with carotid sinus syncope wears a tight shirt collar or turns the neck in a certain way, there is an increased stimulation of the carotid sinus. This causes a sudden fall in systemic pressure, and syncope results. Two types of carotid sinus hypersensitivity exist: a cardioinhibitory (bradycardia) type and a vasodepressor (hypotension without bradycardia) type.
Posttussive syncope usually occurs in patients with chronic obstructive lung disease. Several mechanisms have been postulated to explain its occurrence. It is generally accepted that coughing produces an increase in intrathoracic pressure, which decreases both venous return and cardiac output. There may also be a rise in cerebrospinal fluid pressure, producing a decreased perfusion to the brain.
FATIGUE
Fatigue is a common symptom of decreased cardiac output. Patients with congestive heart failure and mitral valvular disease frequently complain of fatigue. Fatigue, however, is not specific for cardiac problems. The most common causes of fatigue are anxiety and depression. Other conditions associated with fatigue include anemia and chronic diseases. You must attempt to differentiate organic from psychogenic fatigue. Ask the following questions:
- “How long have you been tired?”
- “Did the fatigue start suddenly?”
- “Do you feel tired all day? In the morning? In the evening?”
- “When do you feel least tired?”
- “Do you feel more tired at home than at work?”
- “Is the fatigue relieved by rest?”
Patients with psychogenic fatigue are tired “all the time.” They are often more tired at home than at work but occasionally describe being more tired in the morning. They may feel their best at the end of the day, which is when most patients with organic causes feel the worst.
DEPENDENT EDEMA
Swelling of the legs, a form of dependent edema, is a frequent complaint of patients. Ask the following questions:
