Cardiac symptoms

CLINICAL ASSESSMENT

Cardiac symptoms

Differential diagnosis of acute chest pain/discomfort

Neil R Grubb

Cardiovascular • Unstable angina • Myocardial infarction • Variant angina • Syndrome X (microvascular angina) • Aortic dissection • Rupture of thoracic aortic aneurysm • Myopericarditis, pericarditis

Despite the large range of investigations that are now available for the diagnosis of cardiovascular disease, a good clinical history remains the clinician’s most valuable diagnostic tool. In many cases, the diagnosis may be made from the history alone, and examination and investigations are confirmatory. In other cases, a useful differential diagnosis list can be made and used to direct investigations towards the most likely diagnoses. A key objective of history-taking is to establish a clear description of the presenting symptom, and to detect any pattern to episodes of the symptom. This involves asking about precipitating and relieving factors (e.g. exercise, emotional stress, meals), and identifying any diurnal or other temporal pattern. When the history is unclear, it can be helpful to ask patients or their partner to keep a diary of their symptoms. Although this contribution focuses on cardiac symptoms, helpful supportive information is often found by paying attention to the previous medical history, medication and the social history.

Pulmonary • Pulmonary embolism • Pneumonia (usually lobar) Gastrointestinal • Oesophagitis • Oesophageal spasm • Hiatus hernia • Peptic ulcer disease • Biliary colic • Pancreatitis • Pneumothorax • Acute asthma • Pneumomediastinum Others • Chest wall muscle pain • Psychogenic chest pain • Costochondritis • Cervical spondylosis

Common cardiac symptoms Chest pain Chest pain or discomfort is one of the most common symptoms encountered in clinical practice, and is a major cause of admission to hospital. It can be difficult to assess because there are so many different causes (Figure 1). Acute or severe chest pain should always be taken seriously – there are several potentially life-threatening causes, including myocardial ischaemia or infarction, aortic dissection and pulmonary embolism. For patients with new symptoms of chest discomfort, the need to promptly diagnose or exclude myocardial ischaemia has led to the development of rapid-access chest pain assessment clinics in many hospitals throughout the UK.

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arm pain. The Canadian Cardiovascular Society functional classification (Figure 2) may be used to assess the severity of angina. Stable angina is a predictable symptom pattern in which episodes are usually triggered by exertion or emotional stress, and are relieved by rest. It is caused by a stable, fixed obstruction to coronary blood flow through coronary atherosclerosis. Breathlessness may accompany the chest discomfort. Use of glyceryl trinitrate tablets or spray usually achieves complete resolution of the episode. Less common triggers of angina include meals (postprandial angina) and supine posture (decubitus angina). Unstable angina is a more serious condition because of its propensity to lead to myocardial infarction (MI) and death. It can be defined in both clinical and pathophysiological terms. Clinically, unstable angina is defined as onset of chest discomfort at rest, development of abrupt onset of effort-induced angina with marked limitation of exercise capacity, or rapid and marked acceleration of previously stable chronic angina. Patients with unstable angina often experience repeated episodes of discomfort provoked by minimal exertion, emotion or meals. Sometimes, there is a history of ‘crescendo’ angina, characterized by decreasing effort tolerance and increasing frequency and duration of chest discomfort over

Myocardial ischaemia usually presents with chest pain or discomfort termed ‘angina pectoris’. The typical description of angina is a tight, heavy or constricting discomfort in the centre of the chest. This sometimes radiates to the neck or jaw, and to one or both shoulders or arms. Presentation can vary, however, and some patients complain of back pain, epigastric pain, or isolated jaw or

Neil R Grubb is Consultant Cardiologist at the Royal Infirmary, Edinburgh, UK. He qualified from the University of Edinburgh. His clinical interest is cardiac electrophysiology, and his research interests include cardiac arrest in the community and resuscitation. Conflicts of interest: none declared.

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CLINICAL ASSESSMENT

New York Heart Association functional classification Applies to fatigue, dyspnoea and angina Class I • No limitations during ordinary activity Class II • Slight limitation during ordinary activity (e.g. mild or occasional angina/dyspnoea) Class III • Marked limitation of normal activities without symptoms at rest Class IV • Unable to undertake physical activity without symptoms • Symptoms may be present at rest

Canadian Cardiovascular Society functional classification Applies to angina only Class I • No angina on ordinary activity • Angina on strenuous, rapid, or prolonged exertion Class II • Slight limitation of ordinary activity • Angina when walking up stairs briskly, or walking on a cold or windy day Class III • Marked limitation – angina when walking at normal pace up a flight of stairs, or walking one or two blocks Class IV • Angina on minimal exertion or at rest 2

for typical precipitants (effort, emotion), relieving factors (rest, sublingual nitrate) and associated symptoms (breathlessness, autonomic features – sweating, nausea, vomiting, pallor). Most importantly, keep an open mind; do not forget that ‘heartburn’ is one of the most common symptoms of MI.

a few days or weeks. Sublingual glyceryl trinitrate achieves only temporary or incomplete resolution of the chest discomfort. Unstable angina is usually caused by rupture of an atheromatous plaque, with a sudden reduction in coronary blood flow caused by a combination of platelet aggregation, thrombus formation and vasoconstriction. Unstable angina is clinically indistinguishable from non Q-wave MI, in which this process leads to some limited myocardial injury. Unstable angina and acute MI can also be difficult to distinguish clinically because of the similarities in their presentation. Chest discomfort is usually more severe in acute MI than in unstable angina, and autonomic symptoms such as sweating, nausea and vomiting are common. Acute MI is caused by the same process as unstable angina, except that the coronary artery is usually completely occluded by thrombus. Other symptom patterns – although many patients with ischaemia have the above typical symptoms, some patients present with an unusual symptom pattern. In patients with chronic angina, it helps to ask whether the current symptom resembles their normal angina. In patients with atypical symptoms, look

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Other cardiovascular causes of chest pain Aortic dissection – chest pain is a cardinal feature of acute aortic dissection or aortic rupture. It is usually very sudden in onset, is severe, and is often described as ‘tearing’ in nature. The pain often radiates to the interscapular region of the back and may be accompanied by autonomic symptoms. Depending on the extent of the dissection, other symptoms may also occur. Acute limb ischaemia, characterized by pain, pallor, paraesthesia and loss of pulse, may occur. If the dissection extends into the carotid circulation, neurological symptoms may accompany the chest pain. Mesenteric or renal ischaemia may lead to abdominal or loin pain. The coronary circulation can also be affected by proximal (‘type A’) aortic dissection, leading to MI. 120

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Pulmonary embolism – about 60% of patients with acute pulmonary embolism present with chest pain, which is usually pleuritic in nature. This is usually associated with breathlessness, and is often accompanied by sweating and a feeling of apprehension. Haemoptysis may occur. Symptoms of deep vein thrombosis (leg pain or swelling) are present in only one-quarter of patients with pulmonary embolism. Other associated symptoms include palpitation (caused by sinus tachycardia or atrial fibrillation), angina-type chest pain (sometimes termed ‘right-heart’ angina, caused by increased resistance to right ventricular output) and syncope (caused by a transient decrease in cardiac output, associated with hypoxia). Acute pericarditis is a common and usually benign cause of chest pain. The pain is sharp, retrosternal or left-sided, and sometimes radiates to the trapezius ridge or to the neck. It is worse on inspiration, particularly in the supine position, and may be relieved by sitting forwards. However, this symptom pattern is not invariable, and the relationship to posture varies between patients. Coughing or swallowing may also aggravate the pain. Breathlessness is not usual, but can occur as a result of restriction of respiratory movement from pain or, less commonly, cardiac compromise from associated pericardial effusion. The diagnosis is supported by a recent history of influenza-like illness, suggesting an acute viral cause.

may occur only on lying flat (orthopnoea), and patients may prop themselves up with pillows at night to prevent this. Patients may also wake during the night with episodes of breathlessness, which is relieved by getting up (and classically by opening a window to take fresh air). This is termed ‘paroxysmal nocturnal dyspnoea’. Reduced cardiac output is a cause of breathlessness in many patients with chronic cardiac failure. It results in exertional breathlessness and fatigue as the result of a mismatch between oxygen demand and oxygen delivery in peripheral tissues. The resulting tissue hypoxia and systemic acidosis produces the symptoms. In some cases, cardiac output is compromised during exertion by obstruction to cardiac output rather than by impairment of myocardial function. Examples include severe aortic stenosis, hypertrophic obstructive cardiomyopathy (in which hypertrophy of the intraventricular septum causes dynamic obstruction to LV ejection) and left atrial myxoma (with mitral valve obstruction). When assessing the severity of symptoms in heart failure, it is helpful to use the New York Heart Association functional classification. This provides a quick and easy method of documenting changes in symptom severity over time (Figure 2). Arrhythmias can cause breathlessness for several reasons. Tachycardia may compromise cardiac output if it is extremely rapid, or if it occurs in a patient with impaired baseline cardiac function. Atrial fibrillation and atrial flutter are associated with loss of effective atrial contribution to cardiac output. Inappropriate bradycardia (caused by conducting system disease or by drugs) can result in exertional breathlessness and fatigue caused by an inability to raise heart rate and cardiac output to meet the demands of exercise.

Breathlessness Almost all types of cardiac illness can cause breathlessness. It is most helpful to consider the following broad categories: • pulmonary oedema • reduced cardiac output • obstruction to cardiac output • arrhythmia.

Other causes: do not forget that patients with cardiac disease are also prone to pulmonary embolism, hospital-acquired chest infections and anxiety. All of these can manifest as breathlessness. Some cardiac medications can cause breathlessness (e.g. β-blockers cause bronchospasm, amiodarone causes pulmonary fibrosis).

Pulmonary oedema: breathlessness in acute left ventricular (LV) failure results from accumulation of fluid in the alveolar spaces (pulmonary oedema), resulting in impaired gas exchange. The most common cause is acute MI. Episodes of acute LV failure are also common in patients with chronic ischaemic heart disease (impaired LV function caused by previous MI, or sometimes by acute myocardial ischaemia) and valvular heart disease. Pulmonary oedema results from an increase in left atrial pressure that is transmitted into the pulmonary veins and capillaries. Left atrial pressure increases because of resistance to emptying in diastole (resulting from incomplete ventricular ejection and impairment of LV diastolic function). This increased pulmonary capillary hydraulic pressure normally results in pulmonary oedema when the pressure exceeds 20 mm Hg. For similar reasons, patients with cardiomyopathy or significant aortic or mitral valve disease can also be prone to pulmonary oedema. The typical symptom pattern in acute pulmonary oedema is a sudden episode of severe breathlessness that is aggravated by lying flat and relieved by sitting or standing up. There may be associated wheeze, caused by bronchospasm triggered by the pulmonary oedema itself. Patients often appear extremely anxious or agitated. In severe pulmonary oedema, oxygen delivery can be so severely compromised that depression of consciousness level or death results. Pulmonary oedema may present less dramatically in some patients with chronic cardiac failure. In these cases, breathlessness

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Palpitation The term ‘palpitation’ is used by patients to describe various sensations, some of which are related to cardiac rhythm. Some patients are unusually aware of their normal rhythm; in other cases, a ‘flutter’ may signify anxiety. A good description of the symptom and the situation in which it occurs helps in diagnosing the underlying problem. It is worth asking whether the onset of palpitation is sudden (gradual onset and resolution suggest sinus tachycardia), and whether the sensation is fast, slow, forceful, regular or irregular. Pauses and thumps often indicate extrasystoles. It helps to ask patients to tap out the rhythm with their hand, to gain an impression of rate and regularity. In some patients, there are definite precipitants; for example, palpitation triggered by effort or occurring in the context of an anginal episode may signify ventricular arrhythmia, particularly if it is associated with dizziness or syncope. Atrial arrhythmias do not commonly cause presyncope or syncope unless the ventricular response is very fast, or in the context of severe myocardial or valvular disease. Alcohol is an occasional trigger of palpitation; sinus tachycardia is a common association, but alcohol can also trigger episodes of atrial flutter or fibrillation. 121

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Dizziness and syncope Dizziness is a nonspecific symptom that is common in cardiac patients. It affects about one-third of patients aged over 65 years. The term ‘dizziness’ is used to describe a range of symptoms experienced by patients. It is particularly important to distinguish light-headedness from rotational vertigo; the latter usually reflects a non-cardiac cause. Common causes of dizziness in patients with cardiac disease are vasodilator drugs (most anti-anginal medications can cause dizziness), diuretics (volume depletion) and a low cardiac output state. All of these can cause postural hypotension. Associated symptoms may assist diagnosis (flushing, palpitation or syncope can suggest arrhythmia or vasovagal syndrome). Dizziness can also reflect carotid, vertebrobasilar or cerebrovascular disease. In the elderly, dizziness is often multifactorial, and caused by a combination of heart disease, medication, impaired autoregulatory reflexes and cerebrovascular disease.

Zigmond A S, Snaith R P. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–70. (Validation of one of the most commonly used psychological assessment tools in hospital practice; the Hospital Anxiety and Depression Scale is available on several web sites, including www. clinical-supervision.com/hads.htm and www.sahs.utmb.edu/ Psychology/Adultrehab/hospital_anxiety_and_depression.htm)

Syncope must be assessed meticulously, because it can reflect serious cardiac disease. Types of syncope include: • cardiac syncope caused by arrhythmia or reduced cardiac output from structural disease • inappropriate vasodilatation (including vasovagal syncope) • neurogenic syncope (e.g. epilepsy, cerebrovascular ischaemia) • metabolic syncope (e.g. hypoglycaemia). Cardiac syncope accounts for about 10% of cases. The 5-year mortality is about 50%. Diagnosis or exclusion of structural and conducting system disease is a priority in the assessment of these patients. Psychological problems Anxiety and depression affect up to 50% of patients with chronic cardiac disease. Depression after MI is associated with premature arrhythmic death. Fear of death, illness or becoming dependent on others is common, and many patients feel a lack of control. Patients seldom volunteer these symptoms, so they must be specifically sought during history-taking. Fears often arise from misconceptions about or lack of understanding of the underlying condition. The Hospital Anxiety and Depression questionnaire (see Further Reading) can be used to screen for anxiety and depression, and is easy to administer. 

FURTHER READING Aitken A, Fox K A A. Angina: natural history and risk factors. Trends Cardiol Vasc Dis 1999; 2: 29–33. (A helpful overview of stable angina, symptoms and natural history.) Boon N A, Fox K A A, Bloomfield P. Major manifestations of heart disease. In: Haslett C, Chilvers E R, Hunter J A A, Boon N A. Davidson’s principles and practice of medicine. Edinburgh: Churchill Livingstone, 1999: 204–26. (Useful information on the assessment of patients with chest pain and other cardiac symptoms.) Colledge N R, Barr-Hamilton R M, Lewis S J, Sellar R J, Wilson J. Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study. BMJ 1996; 313: 788–92. (A practical review of the evaluation of elderly patients with dizziness.)

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Practice points • The key to diagnosis is establishing a clear description of the nature and pattern of symptom episodes • New chest pain or discomfort requires prompt assessment – it may reflect serious pathology such as MI, aortic dissection or pulmonary embolism • Dizziness is a common symptom in the elderly and may be multifactorial; drug treatment may be a contributing factor • Syncope of cardiac origin is associated with high mortality; identification of underlying structural and electrical disease is important in the evaluation of syncope

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