Difficulty with breathing

• Similar mechanism as orthopnoea - woken up by dyspnoea, frightened and struggles for air. Improve within a few minutes
• Orthopnoea: less specific [Pt lies down and immediately gets SOB and has to sit up]
• Caused: (1) Heart (2) Lung (3) Diaphragm: eg. Pushed up by ascites
• May progress to acute pulmonary oedema - noisy breathing, cough + frothy sputum, blood stained.

"New York Heart Association Classification" of dyspnoea due to heart disease

• Class I: Heart disease but asymptomatic
• Class II: Dyspnoea on moderate - severe exertion
• Class III: Dyspnoea on mild exertion (eg. ADL)
• Class IV: Dyspnoea at rest

Prognostic indicator: decreased survival with a higher functional class

Eg. Class IV: mortality 1 yr 50%

Features

• Rapid and shallow breathing
• Exertional and progressive (resting)
• Orthopnoea: increased VR, high diaphragm, may need to lie on several pillows
• (Other causes: ascites, severe pulmonary disease)
• Paroxysmal nocturnal dyspnoea

1. Hyperventilation from acidosis: Pt does not feel hyperventilation so much
2. General causes: anaemia
3. Respiratory
4. Cardiac

Location

• Middle or upper 1/3 of sternum, sometimes the neck and lower jaw
• Radiate to the arm
• Pain localised to the left nipple (inframammary pain) is virtually not angina (which is diffuse pain)

Character

• Frequently not pain, but a pressing feeling (pressure) or a tight band across the chest
• Neck: choking
• Jaw: dull ache, "tooth ache"
• Arm: numbness, heaviness or tingling sensation

Provoking factors

• Exertion e.g. walking uphill, climbing stairs, sexual intercourse
• Worse after a heavy meal or in cold weather (and Pt is exerting)
• Nocturnal: bad dreams, increase coronary tone
• Emotionally triggered (often with an exertional component)

Duration

• Relieved with rest or sublingual nitrate in 5 minutes
• Seldom < 30 sec or > 15 minutes
• Consider MI if > 30 minutes

• Imbalance between blood supply and demand
• Eg. Coronary artery stenosis (> 70% stenosis), coronary spasm, anaemia, thyrotoxicosis, aortic stenosis, hypertension
• Anaemia, thyrotoxicosis: increase demand on body and heart

• Cardiac: Pericarditis, aortic dissection Aortic dissection: very severe, radiate to back, Pt Hx of HT, unequal pulses, dilated mediastinum, ECG normal (no evidence of MI)
• Chest wall: Costochondritis (Trietz's disease)
• Lungs: Pneumonia, embolism, effusion, pleuritis
• Pleura: pleuritis
• GI tract: Reflux oesophagitis, Gall stone, Ulcer syndrome, Pancreatitis

Awareness of the heart beat

• Thumping sensation
• Throbbing in the neck
• Missed beats - ectopic beats
• Rapid heart action

Features suggestive of an underlying abnormal rhythm (versus sinus tachycardia)

• Missed beats
• Sudden onset, sudden termination (palpitations more common during PA, emotional agitation - eg. PA: HR increases and decreases gradually - eg. Pathological: onset and termination very sudden)
• Irregular: Pt documents
• Associated features: syncope (lots of Pt with vasovagal syncope are preceded by sinus tachycardia - therefore not 100%), pre-syncope

Significance of arrhythmia

1. Frequency and severity: determines Tx
2. Haemodynamic consequence
3. Hobbies and occupation: eg. Pt has SVT and airline pilot, will lose license [supraventricular tachycardia]

• Right heart failure occurs in dependent parts and preceded by weight gain
• Ascites: constrictive pericarditis, cardiac cirrhosis, late cases of CHF (decreased albumin)

• Central cyanosis (cyanotic congenital heart disease, severe heart failure)
• Squatting: eg. Tetralogy of Fallot, Pt squats to improve oxygen circulation to lungs

• Relatively uncommon in CV disease
• Frank haemoptysis: rupture of pulmonary and bronchial veins, pulmonary infarction.
• Frothy blood streaked sputum: pulmonary oedema

• Transient loss of consciousness due to inadequate central blood flow with spontaneous recovery (if not -> coma)
• Cardiac causes: Vasovagal syncope, Micturition syncope
• Arrhythmia: supraventricular or ventricular tachycardia;
• Adams-Stokes attack - asystole or ventricular arrhythmia (complete heart block) (Pt falls down suddenly, becomes white, when spine: Pt's face turns red)
• Exertional syncope - severe aortic stenosis (increased work cannot be done by heart during PA therefore cerebral insufficiency of blood flow), hypertrophic cardiomyopathy
• Carotid sinus syncope - reflex bradycardia or hypotension (nurses with high collars - nod and then get syncope; common in elderly)

Postural syncope (esp. in Pt with diuretics for HT, autonomic neuropathy in DM)

Epilepsy: neurological prodrome: flashing lights, abn smell, abn weakness

Cardiac syncope

1. No neurological prodrome
2. No convulsion
3. Fully aroused afterwards