Chest Pain – Oppressive, Retrosternal, Radiating
Angina pectoris is probably the first symptom that comes into a medical student’s mind when thinking of cardiac diseases. A persistent, oppressive, retrosternal pain, that does not respond to nitroglycerin, is concerning for symptoms of impaired cardiac circulation.
Typically, anginal pain radiates to the left shoulder and the left arm, but can also radiate to the jaw, the abdomen or the back. Consider a cardiac cause even for patients with toothache or stomach-ache, especially in women where atypical pain localization and radiation is more common.
In addition, pain with effort or exercise is highly suggestive of angina, whether the effort be physical or emotional. Anginal pain should stop with rest, usually within 5 – 10 minutes. Pain may increase with cold temperature, and can be accompanied by anxiety and panic.
The severity of angina can be classified using the CCS-classification (similar to NYHA-stages) as follows:
|CCS1||Angina during strenuous/prolonged physical activity|
|CCS2||Angina during moderate physical activity|
|CCS3||Angina during low physical activity|
|CCS4||Angina at rest|
Cyanosis – Pale and Blue
A livid discoloration of hands, feet or lips, is a sign for an insufficient oxygen supply of the peripheral circulation. A distinction is made between central and peripheral cyanosis, where central cyanosis also leads to a blue coloration of mucous membranes. In the case of a central cyanosis, consider a right-to-left shunt, where the blood returning to the right heart bypasses the lungs and mixes with oxygenated blood returning from the lungs, ready to enter the aorta.
In these situations, deoxygenated blood mixes with oxygen-rich blood, such that the peripheral oxygen concentration is reduced. Peripheral, generalized cyanosis is evidence for cardiac insufficiency and increased oxygen extraction by the tissues, which may be caused by valvular heart diseases, arrhythmia, a cardiac tamponade or cardiomyopathy. In peripheral cyanosis, the tissues furthest from the heart suffer the most from lack of oxygen.
Dyspnea – The Heart Causes Heavy Breathing
In the case of a left ventricular insufficiency, the left ventricle does not eject adequate blood, thereby causing blood to back up into the pulmonary circulation. This leads to an increase of pressure and pulmonary edema; that’s why dyspnea can have pulmonary, as well as cardiac causes, especially chronic dyspnea.
Left ventricular dysfunction can be due to myocardial or valvular disease: such as myocardial infarction, myocarditis, cardiomyopathy or mitral or aortic valve disease. Other less common reasons include patent ductus arteriosus, or a defect between ventricles or the inter-atrial septum.
Edema – Not Only Swollen Legs
Edema is a pathological accumulation of fluid in the interstitial space. Typically, left ventricular insufficiency causes pulmonary edema and right ventricular insufficiency cause peripheral edema: Usually, the legs are affected first. On inspection, the skin may be taught and with pressure on palpation, there may be pitting of the subcutaneous tissue.
Have a look at both legs! Edema on one leg only is often due to non-cardiac causes, most often phlebothrombosis.
Generalized edema or ascites or a congestive hepatopathy may lead to hepatic dysfunction and splenomegaly. Men may also develop scrotal edema.
Syncope Causes Falls
Syncope is defined as a sudden, brief and self-limited episode of loss of consciousness, which is accompanied by a loss of tone of the skeletal muscles.
There are many causes for syncope, but one cause is cerebral hypo perfusion due to a cardiac arrhythmia.
History Taking: Discerning Cardiac Symptoms
Important questions to ask:
Do you have chest pain? Is this pain rather sharp or rather oppressive and dull? When does it arise? Is it associated with preceding physical activity? Do the symptoms improve when breathing deeply? How long does it last? Does it stop spontaneously? How often do you feel the pain (per month/year?)
Do you have dyspnea at times? Is this associated with physical activity? Do the symptoms improve when you are lying down or sitting?
Did you become unconscious recently? Did you fall more often?
On examination, pay attention to edema and cyanosis.
Furthermore, nocturia can be an evidence for heart insufficiency. Palpitations or tachycardia may suggest cardiac arrhythmia.
Cardiovascular risk factors should be determined, including:
- Arterial hypertension
- Diabetes mellitus
- Consumption of alcohol or nicotine (not only ask whether they smoke and drink, but also how much!)
- Exercise during daily life
- Family history of cardiac risk factors: include all of the above as well as myocardial infarction and stroke.
Additional questions of the autonomic nervous system should be asked:
Did you have a fever, shivering attacks or night sweats? How is your sleep? Do you sleep well through the night? How is stool and urination?
Physical Examination – Looking for Evidence of Cardiac Disease
The following summarizes what to pay attention to when doing a physical examination focused on the cardiac system:
- Cyanosis (central or peripheral)
- Clubbing of the fingers/nails (evidence for chronic hypoxia)
- Engorged neck veins (inducible by the hepatojugular reflux test)- measure Jugular Venous Pressure.
- Apical impulse translocated? (suggests left ventricular hypertrophy)
- Checking pulses (heart defects, dysrhythmia)
- Pleural effusion
- Heart sounds, cardiac murmur
- Heart rate
- Heart rhythm
- Respiratory sounds (decreased in the case of pleural effusion, crackles in the case of pulmonary vascular congestion)
Methods of Medical Imaging – Behind the Scene
Chest x-ray is an important part of the cardiac exam, with attention to cardiomegaly, and evaluate for pulmonary causes of symptoms.
Frequently repeated and recorded measurements of blood pressure and continuous cardiac monitoring (with a Holter monitor) may provide evidence for cardiac disease, such as arterial hypertension as a risk factor for coronary heart disease, cardiac arrhythmias or myocardial infarction.
Doppler ultrasound can be useful to visualize blood flow. Extracardiac diseases like arterial or venous stenosis can be identified as the cause of heart stress, cyanosis or syncope, so that on a primary cardiac disease can be ruled out.
An abdominal sonography may reveal signs of a right ventricular insufficiency, e.g congestive hepatopathy, a splenohepatomegaly or ascites, which may help assess the severity of the disease and help promote therapeutic options.
Echocardiography can be done via transthoracic or a transesophageal approach. This will identify ejection fraction, cardiac wall motion and morphology, as well as valvular function (ability to close, open, rapidity of trans valvular flow). In addition, the pathological causes of blood flow abnormalities (i.e. reflux) and turbulences can be identified. The ejection fraction can be calculated.
For further diagnostics, CT is available, which can help quantify coronary calcification, particularly the newest helical CT’s with 3D reconstructions. A cardio-MRI may allow the detection of malformations of the heart or heart vessels, valvular malformations, tumors and thrombi. Older infarction scars or myocarditis can be made visible by different contrast agents.
Cardiac catheter examination and percardiocentesis are invasive techniques used in cardiac diagnostics: the latter is used for the treatment of pericardial effusion to relieve the heart and possibly perform microbiological diagnostics (inflammatory heart diseases).
During cardiac catheterization (also known as cardiac angiography), the cardiac catheter can be placed as a right or left ventricular catheter. In doing so, this procedure will allow measurement of pressures, visualization of the coronary vessels, myocardial biopsies can be taken and, if necessary, electrophysiological measurements (rhythm diagnostics) can be taken.