2.2: Common Symptoms

Chest Pain

Chest pain has a broad range of causes ranging from non-serious to serious to life threatening (Table 2.2.1). Chest pain is one of the important symptoms of ischemic heart disease. Furthermore, it is also associated with several other forms of heart disease. The most commonly used classification of stable angina is the CSS score (Table 2.2.2), and the Braunwald classification of unstable angina (Table 2.2.3).

Table 2.2.1: Cause of Chest Pain

Cardiovascular	Pulmonary	Gastrointestinal	Musculoskeletal	Psychological	Other
Acute coronary syndrome Stable angina pectoris Aortic dissection (Acute) Pericarditis Cardiac tamponade Arrhythmia	Pulmonary embolism Pneumonia (Spontaneous) pneumothorax and tension pneumothorax Tuberculosis Pleurisy	Disorders of the esophagus (Acid reflu disease, esophagitis, esophageal spasm) Hiatus hernia Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus Functional dyspepsia	Costochondritis Radiculopathy Bornholm disease	Panic attack Anxiety Clinical depression Somatization disorder Hypochondria	Hyperventilation syndrome Carbon monoxide poisoning Sarcoidosis Lead poisoning Precordial catch syndrome High abdominal pain Breast conditions Herpes zoster commonly known as shingles

Table 2.2.2: Canadian Cardiovascular Society Functional Classification of Angina Pectoris

Class	Definition	Specific Activity Scale
I	Ordinary physical activity (e.g., walking and climbing stairs) does not cause angina; angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.	Ability to ski, play basketball, jog at 5 mph, or shovel snow without angina.
II	Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or under emotional stress, or only during the few hours after awakening, when walking more than two blocks on level ground, or when climbing more than one flight of stairs at a normal pace and in normal conditions.	Ability to garden, rake, roller skate, walk at 4 mph on level ground, have sexual intercourse without stopping.
III	Marked limitation of ordinary physical activity. Angina occurs on walking one to two blocks on level ground or climbing one flight of stairs at a normal pace in normal conditions.	Ability to shower or dress without stopping, walk 2.5 mph, bowl, make a bed, play golf.
IV	Inability to perform any physical activity without discomfort.	Anginal symptoms may be present at rest. Inability to perform activities requiring 2 or fewer metabolic equivalents without angina.

Table 2.2.3: Braunwald Classification of Unstable Angina (UA)

Severity		Clinical Circumstances
Note: hr = hours; IAM = myocardial infarction; UA = unstable angina.		A	B	C
		Develops in presence of extracardiac condition that intensifies myocardial ischemia (secondary UA)	Develops in the absence of extracardiac condition (primary UA)	Develops within 2 weeks after acute myocardial infarction (postinfarction UA)
I	New onset of severe angina or accelerated angina; no rest pain	IA	IB	IC
II	Angina at rest within past month but not within preceding 48 hr (angina at rest, subacute)	IIA	IIB	IIC
II	Angina at rest within 48 hr (angina at rest, acute)	IIIA	IIIB Troponin negative IIIB Troponin positive	IIIC

The five most common characteristics of ischemic chest pain are:

• The pain is classically deep, visceral, and intense. Patient often describe this pain as “pressing”, “tearing”, “constricting”, “burning”. Another common presentation is described as chest heaviness such as“a band across the chest”, or “weight in the centre of the chest”.
• The anginal pain is usually substernal located, but may extend to the left or right chest. Furthermore radiation of the pain is common, typically to the left shoulder and arm. Other locations are possible such as the neck, jaw, epigastrium, and, occasionally, the upper back.
• The duration of the pain is minutes, not seconds.
• The pain tends to be precipitated by exercise. The pain can also be provoked by heavy meals or emotional stress.
• The pain ablates promptly by resting (within minutes) or taking sublingual nitroglycerin.

Table 4: Typical features in various types of chest pain

Cause of Pain	Type of Pain	Referred Pain	Response to Posture/Movement	Response to food/fluid	Tenderness	Response to nitroglycerin
Cardiovascular
Ischemic cardiac pain	Visceral	Yes	No	No	No	Yes
Aortic dissection	Visceral	Yes	No	No	No	No
Pericarditis	Visceral	Yes	Yes	No	No	No
Arrhythmia	Visceral	No	No	No	No	No
Pulmonary disease	Visceral/cutaneous	Usually no	No	No	No	No
Pneumothorax	Visceral/cutaneous	No	Yes	No	Usually no	No
Musculoskeletal	Cutaneous	No	Yes	No	Yes	No
Gastrointestinal	Visceral	Sometimes	No	Yes	No	Sometimes
Psychiatric	Visceral/cutaneous	No	No	No	No	No

Dyspnoea

Dyspnoea is a frequent complaint of patients with a variety of cardiac diseases. Generally four types of dyspnoea can be distinguished:

• Exertional dyspnoea. Dyspnoea provoked by exercise, usually caused by a mild underlying condition because an increased demand of exertion is needed to precipitate symptoms.
• Dyspnoea at rest. Dyspnoea is suggestive for severe cardiac disease.
• Paroxysmal nocturnal dyspnoea. Dyspnoea characterized by the patient awakening after being asleep or recumbent for an hour or more. This type of dyspnoea is commonly caused by the redistribution of body fluids from the lower extremities into the vascular space and back to the heart, resulting in volume overload. Because of this pathophysiological background it suggests a more severe condition.
• Orthopnoea. Dyspnoea that occurs immediately on assuming the recumbent position. The mild increase in venous return (caused by lying down), before any fluid is mobilized from interstitial spaces in the lower extremities, is responsible for the symptom.

The cause of dyspnoea is certainly not limited to cardiac disease. Exertional dyspnoea, for example, can be due to pulmonary disease or anaemia. Orthopnoea is also a frequent complaint in patients with chronic obstructive pulmonary disease and postnasal drip. Resting dyspnoea is also a common sign of pulmonary disease such as pneumonia or bronchial infection. However, paroxysmal nocturnal dyspnoea is the most specific symptom for an underlying cardiac cause because alternative diagnoses are limited.

Syncope and Pre-syncope

Light-headedness, dizziness, pre-syncope, and syncope are important symptoms, often caused by a reduction in cerebral blood flow. The mentioned symptoms are nonspecific and can be due to a broad caused by a broad range of underlying pathophysiology such as metabolic conditions, dehydration, primary central nervous system disease, or inner-ear problems. Because bradyarrhythmias and tachyarrhythmias are important cardiac causes of these symptoms, they are of importance in the cardiovascular examination. A careful history taking, including preceding symptoms such as palpitations or chest pain, are of great importance. Further information on this topic can be found here.

Transient Central Nervous System Deficits

Transient central nerves system deficits such as transient ischemic attacks (TIAs) suggest the existence of (micro) emboli originating form greater vessels, the carotid arteries or the heart. Rarely a TIA can also be caused by emboli from the venous circulation through an intracardiac shunt. As a result, a TIA should prompt the search for underlying cardiovascular disease. Any sudden loss of blood flow to (parts of) the limbs are also suggestive for an underlying cardioembolic event.

Fluid Retention

Fluid retention is not a very specific symptom for heart disease but may be caused due to reduced cardiac function. Symptoms associated with fluid retention are peripheral oedema, weight gain, bloating, and/or abdominal pain from an enlarged liver or spleen. Decreased appetite, jaundice, nausea and vomiting can also occur from gut and hepatic dysfunction due to a build up of fluids.

Palpitation

Cardiac activity usually cannot be experienced by individuals in normal resting condition. If a patient is aware of its heart activity it is usually referred to as palpitation. Among cultures and patients there is no standard definition for the type of sensation represented by palpitation. It is often very illustrative to ask the patients to tap with their hand the perceived heartbeat. Most commonly palpitations are caused by an unusually forceful heart beat at a normal rate (60–100 bpm). When a patient senses more forceful contractions as usual without a significant increased heart rate, the palpitations are most commonly the result of endogenous catecholamine excretion. A customary cause of this phenomenon is anxiety. Another common experienced feeling is that of the heart stopping transiently and/or the occurrence of isolated forceful beats. The nature of this sensation is usually premature ventricular contractions. The rapid regular or irregular heart rates most linked to the term “palpitations” are the least common sensation reported by individual patients and is usually supraventricular of origin. More information on palpitations caused by arrhythmias can be found in chapter 4.

Cough

Although cough is usually associated with disease of pulmonary origin, there are also several cardiac conditions that lead to pulmonary abnormalities which causes subsequent pulmonary disease and subsequent cough. A cough from cardiac origin is usually dry and non-productive. Pleural fluid retention from conditions such as heart failure or pulmonary hypertension from any cause may present as cough. Finally, it should be mentioned that angiotensin-converting enzyme inhibitors, which are frequently used in cardiac conditions, can cause a typical dry cough.