Page 28 - Medicine and Surgery

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24 Chapter 2: Cardiovascular system

back. Its onset is abrupt and of greatest intensity at the and may hang their legs over the side of the bed or go
time of onset. to the window to relieve the dyspnoea.
Chest pain associated with tenderness is suggestive of Cheyne–Stokes respiration is alternate cyclical hy-
musculoskeletal pain. Pleuritic pain (e.g. pneumonia, perventilation and hypoventilation (or even apnoea).
pulmonary embolism) is usually sharp and made worse This occurs in patients with very severe left ventricular
by inspiration and coughing. Oesophageal pain is a ret- failure, in some normal individuals (often elderly), in
rosternal sensation often related to eating and may be patients with cerebrovascular disease and patients re-
associated with dysphagia. Oesophageal reflux causes a ceiving opiate analgesia. It is thought that this pattern
retrosternal burning pain, often exacerbated by bending of breathing results from depression of the respiratory
forwards.Painfromthegallbladderorstomachcanoften drive centre within the brain.
mimiccardiacpain.Equally,painarisingfromstructures Patients with severe acute left ventricular failure often
in the chest may present as abdominal pain, e.g. myocar- have a cough productive of frothy sputum, which may
dial infarction, pneumonia. be blood stained. Frank haemoptysis may occur in
mitral stenosis or following a pulmonary embolus.
Dyspnoea However, the major causes of frank haemoptysis are
from the respiratory system.
Dyspnoea is defined as difficulty in breathing. In general
dyspnoea arises from either the respiratory or cardio-
vascular system and it is often difficult to distinguish Palpitations
between them. A palpitation is an increased awareness of the heartbeat.
Cardiac dyspnoea is generally the result of left ventric- It may be a fluttering, rapid sensation or a slow, some-

ular failure when fluid accumulates in the interstitium times heavy thumping sensation. The patient may feel
of the lungs. The patient may notice it on strenuous ‘a missed beat’, or their heart beating irregularly.
exertioninitially,withgraduallyreducing‘exercisetol- It is important to try to elicit from the patient when
erance’ (the distance a patient can walk before having the palpitations occur, precipitating factors, duration,
to stop for a rest). In severe failure, patients are breath- rate and rhythm (ask the patient to tap out the beat with
less at rest. In any acute exacerbation of cardiac dys- their hand). Associated symptoms may include breath-
pnoea an underlying cause should be sought, such as lessness, dizziness, syncope and/or chest pain.
ischaemia, arrhythmias or a worsening heart valve le- Palpitations during or just after exercise, or caused by
sion. anxiety are often simply awareness of a normal heart
Orthopnoea is defined as breathlessness on lying flat. rate.

This symptom normally arises when a patient’s exer- Palpitations lasting just a few seconds are often due
cise tolerance is already reduced. It is thought that two to premature beats. The patient becomes aware of the
mechanisms are responsible for this phenomenon: a pause that occurs in the normal rhythm after a prema-
redistribution of fluid through gravity in the lungs ture beat and may sense the following stronger beat.
and a pressing of the abdominal contents on the di- Post-palpitation polyuria is a feature of supraventric-
aphragm,whichreducesthevitalcapacityofthelungs. ular tachycardia due to the release of atrial natriuretic
Many patients avoid the sensation of breathlessness by peptide. Some patients may know how to terminate
propping themselves up on pillows at night, or, in se- their rapid palpitations with manoeuvres such as
vere cases, sleeping in a chair. Orthopnoea is highly squatting, straining or splashing ice-cold water on the
suggestive of a cardiac cause of dyspnoea, although it face. These features are very suggestive of a distinct
may also occur in severe respiratory disease due to the tachyarrhythmia rather than general anxiety or pre-
second mechanism. mature beats.
Paroxysmal nocturnal dyspnoea is waking from sleep

suddenly breathless. It is thought to occur by a simi- Syncope
lar mechanism to orthopnoea coupled to a decreased
sensory response whilst asleep. Patients awake breath- Syncope is defined as a transient loss of conscious-
less and anxious, they often describe having to sit up ness due to inadequate cerebral blood flow. Cerebral