The severity of anginal pain, dyspnoea, palpitations or fatigue may be classified according to the New York Heart Association (NYHA) grading of ‘cardiac status’.
The New York Heart Association grading of ‘cardiac status’ (modified):
- Grade 1 – Uncompromised (no breathlessness).
- Grade 2 – Slightly compromised (on severe exertion).
- Grade 3 – Moderately compromised (on mild exertion).
- Grade 4 – Severely compromised (breathless at rest).
Chest pain or discomfort is a common presenting symptom of cardiovascular disease and must be differentiated from non-cardiac causes. The site of pain, its character, radiation and associated symptoms will often point to the cause.
Common causes of chest pain
- Angina pectoris – Crushing pain on exercise, relieved by rest. May radiate to jaw or arms.
- ACS – Similar in character to angina but more severe occurs at rest, lasts longer.
- Pericarditis – Sharp pain aggravated by movement, respiration, and changes in posture.
- Aortic dissection – Severe tearing chest pain radiating through to the back.
- Massive PE – With dyspnoea, tachycardia, and hypotension.
- Musculoskeletal – Tender to palpate over the affected area.
- GORD – May be exacerbated by bending or lying down (at night). Pain may radiate into the neck.
- Pulmonary infarct, Pneumonia, Pneumothorax – Pleuritic pain, i.e. sharp, well-localized, aggravated by inspiration, coughing, and movement.
- Musculoskeletal – Sharp, well-localized pain with a tender area on palpation.
- Lung carcinoma – Constant dull pain.
- Herpes zoster – Burning unilateral pain corresponding to a dermatome that appears 2 to 3 days before the typical rash.
Left heart failure is the most common cardiac cause of exertional dyspnoea and may also cause orthopnoea and paroxysmal nocturnal dyspnoea.
Palpitations are an awareness of the heartbeat. The normal heartbeat is sensed when the patient is anxious, excited, exercising or lying on the left side. In other circumstances, it usually indicates a cardiac arrhythmia, commonly ectopic beats or paroxysmal tachycardia.
This is a temporary impairment of consciousness due to inadequate cerebral blood flow. There are many causes and the most common is a simple faint or vasovagal attack.
The cardiac causes of syncope are the result of either very fast (e.g. ventricular tachycardia) or very slow heart rates (e.g. complete heart block) which are unable to maintain an adequate cardiac output. Attacks occur suddenly and without warning. They last only 1 or 2 minutes, with complete recovery in seconds (compare with epilepsy, where complete recovery may be delayed for some hours).
Obstruction to ventricular outflow also causes syncope (e.g. aortic stenosis, hypertrophic cardiomyopathy), which typically occurs on exercise when the requirements for increased cardiac output cannot be met. Postural hypotension is a drop in systolic blood pressure (BP) of 20 mmHg or more on standing from a sitting or lying position.
Tiredness and lethargy occur with heart failure and result from poor perfusion of the brain and skeletal muscle, poor sleep, side effects of medication, particularly β-blockers, and electrolyte imbalance due to diuretic therapy. Heart failure also causes salt and water retention, leading to edema, which in ambulant patients is most prominent over the ankles. In severe cases, it may involve the genitalia and thighs.
Source: Essentials of Kumar & Clark’s Clinical Medicine 6th ed.
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