Figure 1.  The classic symptoms and signs of heart disease

The above symptoms and signs may warrant a visit to your doctor or a heart specialist for further cardiac evaluation.

CHEST PAIN

Pain in the chest is by far the most common symptom of coronary heart disease.  It is the commonest presenting symptoms of a heart attack.  Chest pain can also be due to other heart conditions :

• Dissection (tear) of the large main trunk coming out of the heart (called the aorta)
• Inflammation of the lining or covering of the heart called pericarditis.

But not all chest pain is due to heart problems.  Pain in the chest may originate from a variety of other structures in the chest cavity including the pulmonary arteries (blood vessels that supply the lungs), the pleura (lining of the lungs), the oesophagus (gullet) or even the stomach.

Other superficial causes of chest pain may be

• A pulled muscle in the chest wall
• Strained or inflamed cartilage (ribs)
• Irritated joints
• Pinched nerve in the thoracic spine

Chest pain can also originate from organs below the chest cavity due to irritation and inflammation of the diaphragm – the muscle layer separating the chest cavity from the abdomen, e.g.

• Gallbladder with gall stones
• Ulcerated stomach
• Inflamed pancreas
• Heart burn from stomach and refluxing into the oesophagus

Although chest pains may have so many different causes, if you experience chest pain, you should always let your doctor know and let your doctor decide whether it is related to heart disease.

Classical Heart Attack Chest Pain

Description

Chest pain that warrants an emergency visit to the hospital

• Sudden onset central or left-sided chest pain described as “squeezing”, heaviness of chest (as though being sit on by an elephant), vice-like grip (like a bear hug), lasting for more than 2 minutes,
• Radiation of the pain to the neck, jaw or arms (especially left arm)
• Associated cold sweats
• Feeling of “impending doom”
• Giddiness or light-headedness or faintness
• Associated breathlessness
• Appears pale or “ashen” look
• Most of the time the pain will continue beyond 2 minutes and will not go away.

If you have any of the above combination of chest pain description, you should not ignore it.  Rush to the nearest hospital and seek emergency advice, diagnosis and treatment.  Many people have died from heart attacks that might have been saved had they not delayed seeking treatment because they misinterpreted the pain or believed it would go away.

Your cardiologist will

• Evaluate the chest pain
• The characteristics of the chest pain as described above
• The quality, its duration, precipitating factors

Angina Chest Pain

The term “angina pectoris” – (a chest pain arising from the heart) was first described by the British physician William Heberden more than 200 year ago.  This is a chest pain that relates to the lack or insufficient oxygen and blood supply to the muscles of the heart due to a significant narrowing (not amounting to a total blockage) of the coronary arteries usually due to cholesterol plaque formation). When the heart muscle’s demand for oxygen becomes greater than supply, (usually during exertion or moments of great stress, anxiety, anger or upset), pain fibres in the heart muscles are stimulated and angina (chest pain) occurs.

Common activities that increase the demand for oxygen and therefore cause angina includes jogging, carrying heavy objects over a distance, walking briskly up the stairs, emotional engagements (such as family feud or dispute at work). This cause the heart to beat faster and blood pressure to elevate.  Oxygen demand may also exceed supply after a big meal, when the blood and oxygen are diverted from the heart to the stomach and intestinal tract.

Description of Angina Chest Pain

• Chest pain precipitated by three Es – exercise, emotion and eating
• Chest pain is confined to the centre of the chest or left-sided and may also radiate from the centre of the chest to the shoulders and down the side of the left arm. It can also radiate to the jaw and mimic a toothache.
• Generally lasts for 2 to 3 minutes and usually subsides when you stop the activity and rest.
• If the arteries are severely narrowed, angina may occur at rest or after only minimal activity – a term called “rest angina”
• Depending on the degree of the narrowing in the coronary arteries, the onset of angina after exertion may be rapid or delayed. The greater the narrowing, the more rapid the onset of angina and the longer it may persist.

BREATHLESSNESS/SHORTNESS OF BREATH (DYSPNOEA)

Dyspnoea, a medical term for shortness of breath may be the earliest symptoms of heart disease. Everybody experiences some shortness of breath occasionally and therefore it is important to differentiate when it is a concern and when it is not.

It is normal for you to feel short of breath after heavy exertion like running or walking up a flight of stairs, or rushing to catch a bus, taxi or planes, or after sexual intercourse.  However it is abnormal to experience shortness of breath after routine casual walking, walking for only a few steps or while at rest.

Therefore when breathlessness is inappropriate to the activity, it may be a symptom of heart disease.

The onset of breathlessness is another confusing aspect.  Breathlessness that occur abruptly especially at rest may be due to heart failure whereas chronic shortness of breath is more likely due to symptoms of coronary artery disease or heart valve disease or lung conditions like chronic airway disease (often from smoking).

Breathlessness is not easy to recognise because it is a very subjective symptom – some individuals can experience inappropriate shortness of breath yet be unaware of it or deny it, while others may appear to be breathing normally yet feel short of breath.

There are 3 major causes of breathlessness

1. Cardiac (heart)
2. Pulmonary (lungs) or
3. Functional (psychological)

Breathlessness of cardiac origin is usually due to a weakness in the heart’s pumping action usually due to an obstruction of the blood supply to the heart muscles.  The poor pumping quality of the heart muscles can be due to :

1. Coronary artery disease
2. Narrowing or leaking of the heart valves from one chamber to another resulting in too little forward blood flow or too much backward flow and causing overload of the heart chambers.

If too little blood is pumped forward with each beat, there will be a build-up of pressure in the lungs with resultant fluid being pushed to the lung tissues leading to flooding of the lungs (congestion) – similar to drowning and cause acute breathlessness.  In addition fluid may also back up into the lower legs causing swellings.

Breathlessness associated with swelling of the legs and ankles will require a visit to your doctor as it may be due to heart failure.

Breathlessness due to lung disease

Lung conditions like asthma, chronic obstructive airway disease (due to smoking), infection of the lungs (pneumonia) can also present with shortness of breath.  It may be difficult to distinguish between breathlessness of cardiac origin from a lung origin.  In any case it is best to see your doctor.

Other important causes of breathlessness due to lung conditions include :

• Pneumothorax (collapse of the lung due to a ruptured air sac of the lung leading to air leak into the lung cavity) – It may occur spontaneously or due to a trauma/injury to the chest e.g. road traffic accident or playing extreme sports with physical contact. This can be an emergency and requires medical attention to release the air from the chest cavity.
• Pulmonary embolism – This is a condition where blood clots are showered in the major blood vessels supplying the lung (pulmonary artery) leading to a significant loss of oxygenated blood from returning to the heart from the lungs and causing breathlessness and low blood pressure

Blood clots can be transported to the  lung from several conditions :

• An individual who is bedridden or recovering from major surgery (especially hip and pelvic surgery) because of prolonged immobilisation resulting in a diminished return of blood flow from the legs
• Travellers sitting for long period of time in a car or aircraft
• Inflammation of the deep veins in the legs (termed deep vein thrombosis). Clots from the leg veins can be thrown off into the circulation ultimately being trapped in the blood vessels supplying the lungs.
• Paroxysmal nocturnal dyspnoea

This is a condition which is characterised by waking up suddenly from sleep feeling breathlessness (in fact the breathlessness cause the individual to awake from sleep).  This is invariably due to heart pump failure. Excessive blood volume and fluid that accumulates in the legs during the day is reabsorbed into the blood stream at night when the individual is lying flat in bed.  This results in an added workload on the failing heart and the build-up of pressure in the lungs.

Functional (Psychological) breathlessness

This is usually brought on by feelings of anxiety and panic attack.  The breathing pattern is usually described as short, shallow and rapid – a medical term for hyperventilation.

This type of breathlessness can present dramatically and in its most severe form, is associated with tingling sensation and spasm of the fingers.

If this happens, taking slow, deep, controlled breaths may help.  Functional (psychologically-induced breathlessness) is often also characterised by a sensation of difficulty in getting air in.

Caution :

Even though this may be functional rather than pathological, it should not be ignored.  Breathlessness due to panic disorder can be treated.  Best therefore is to see your doctor.

PALPITATIONS

• Normally people are not aware of their heart beats.
• Palpitation is the awareness of one’s heart beat and is often quite disturbing when it occurs. It is different from the expected strong heart beats sometimes described as “pounding of the chest” when you exercise or during strenuous heavy exertion.

How is palpitations manifested?

1. Feels heart beat faster. Normal heart beat at rest ranges between 60 – 80 beats / min
2. Fluttering sensation in the chest (like a bird beating its wings)
3. Thumping
4. Flip-flopping
5. Extra heart beats
6. Skipped heart beats
7. Pounding in the chest or neck region at rest

Palpitations is usually not a serious condition on its own, but can be an indication of heart disease.

Fortunately most common cause of palpitations is not due to heart disease, but may simply be a heightened awareness of your heart beat because of anxiety, stress or tension.  Palpitation is often experienced during a panic attack along with symptoms of tingling sensation of the fingers and shortness of breath – due to hyperventilation (characterised by short, rapid in- and out- breathing).

Palpitations not related to heart disease can also be due to exercise eating, emotions, smoking, alcohol ingestion, caffeine-containing beverages or taking certain prescription drugs.

Cardiac causes of palpitations

• Atrial premature beats (extra beats arising from the upper chambers of the heart atria)
• Ventricular premature beats (extra beats arising from the lower chambers of the heart [ventricles])
• Supraventricular tachycardia (rapid, continuous fast heart beats arising from a short circuit of the conducting fibres from the upper heart chambers [atria])
• Atrial fibrillation (quivering of the upper heart chambers instead of regular contractions)
• Ventricular tachycardia (most serious condition due to rapid heartbeats originating from the lower pumping chamber called ventricles) – usually life-threatening.

Palpitations are difficult to assess as by the time the patient sees the doctor, the palpitations have already subsided and therefore difficult to evaluate.  24-hour Holter monitoring or trans-telephone monitoring may be required to aid in the diagnosis.

SWELLING OF THE LEGS AND ANKLE (OEDEMA)

Swelling around the ankles, legs and sometimes the eyes, abdomen (walls) and chest (wall) is due to water retention.  The medical term is called oedema.

Oedema is an observable sign that may suggest a heart disease ( usually heart failure).  But oedema can also be due to kidney disease.

Cardiac oedema

The site of oedema can give an idea for several different problems with the heart.  If the right heart muscle is weakened, the right heart pump is diminished leading to water retention in the abdomen, liver congestion, swelling of the legs and ankles – due to back pressure build up behind the right heart.

Swelling of the ankle that occur at the end of the day but not on awakening may indicate salt and water retention after standing and walking during the day and may also be due to right-sided heart failure.  If the left side of the heart is weakened, pressure build up in the blood vessels of the lungs will lead to water retention in the lung tissues (lung congestion) and the symptoms is breathlessness, not oedema.

Causes of Oedema

1. Cardiac – heart failure
2. Kidney disease – kidney failure
3. Liver disease
4. Varicose veins of the legs
5. Medications – e.g. ACE inhibitors, calcium channel blockers (types of high blood pressure medications)
6. Allergies
   • Food
   • Insect venom
7. Lymphatic system abnormalities secondary to cancer (e.g. breast cancer or spread of cancer)
8. Pregnancy
9. Prolonged travelling

Oedema is nearly always considered a concern and a potential sign of disease. A doctor’s visit is advised.

FAINTING SPELLS (SYNCOPE)

Syncope is a medical terminology used to describe fainting (passed out) or sudden loss of consciousness.  The mechanism of fainting is usually due to a lack of oxygenated blood supply to the brain (usually ≥ 10 seconds).  There are many causes of fainting (see Table 1).

Table 1

Fainting or loss of consciousness is a symptom/sign that should be attended to and assessed by a doctor to determine the causes listed in table 1.

FATIGUE / EASY EXHAUSTION

Fatigue is a very common complaint and can be difficult to find the actual cause.  It is a very subjective and common symptom of many physical diseases as well as depression.  Cardiac-related fatigue however will usually be of recent onset.  It can present in one of several ways :

1. You could begin the day with a relatively normal energy level, then becoming increasingly tired through the day to the point of exhaustion
2. You could suddenly feel fatigue or winded after doing something you had no problems doing in the past – like climbing the stairs or carrying groceries from the car.
3. You feel weakness or heaviness of the legs
4. You have poor or loss of appetite or eat poorly

This is because the heart muscle has become weakened and lost its ability to pump enough blood and oxygen for the body to function normally.

Extreme exhaustion or unexplained weakness sometimes for days at a time can also be a symptom of a heart attack, especially in women.

Fatigue may occur with or without shortness of breath.  The latter should also warrant a visit to a doctor.

Heart disease patient can also experience fatigue because of their medications, e.g. fatigue may be noted in about 10% of people on blood pressure lowering medications.

There are other non-cardiac causes of fatigue:

• Anaemia
• Chronic illness due to infection
• Chronic diseases
• Diabetes mellitus
• Hyperthyroidism
• Lung disease
• Cancer
• Sleep disorders e.g. sleep apnoea
• Depression
• Aging

People who feel tired when they awaken and remain tired throughout the day with little variability are more likely to have a psychological disorder than heart disease.

Fatigue is a major and common symptom of undiagnosed depression.  It may also occur temporarily in people who are under extreme stress or who simply have not been getting enough sleep.

CYANOSIS (BLUISH DISCOLOURATION OF THE SKIN AND MUCUS MEMBRANE – e.g. eyelids, lips, tongue and nail beds)

This is caused by too little oxygen-carrying red blood cells that flow via the capillaries (small blood vessels) in the various vascular beds described above. The bluish discolouration is most obviously seen in the finger nail beds and round the lips.

Cyanosis may be a sign of heart disease.  There are two types of cyanosis :

• Central cyanosis
• peripheral cyanosis

Central Cyanosis

This is a sign of an inherited form of heart disease (i.e. congenital heart disease)

In central cyanosis there is an abnormal mixing of the venous (deoxygenated) blood and arterial (oxygenated) blood.

Venous blood is usually bluish and darker in colour because it is carrying little oxygen, having given up its oxygen to the tissues).

Arterial blood is bright red because it has been enriched with oxygen after it has passed through the lungs.

Central cyanosis occurs when the venous and arterial blood are mixed together in the heart either because of a congenital defect (opening, hole) between the left and right sides of the heart or because of a genetically defective heart in which there is a common mixing chambers.  It can also occur in advanced lung disease.

Peripheral Cyanosis

Peripheral cyanosis is usually due to exposure to cold temperatures – due to the body’s  attempts to conserve heart for vital organs by constricting the small blood vessels of the skin and slowing blood flow.  Peripheral cyanosis can also occur in peripheral arterial disease.  Peripheral cyanosis is manifested as bluish discolouration on the skin surfaces primarily in the fingers and toes and can be assessed using the ankle-brachial index to look for peripheral artery disease.

Finally central cyanosis is also due to cardiogenic shock – shock caused by the heart’s failure to pump adequately (usually in an acute heart attack when the extent of damaged heart muscle is extensive).

NAUSEA, INDIGESTION, HEART BURN OR STOMACH PAIN

These are symptoms that are not usually associated with a heart disease.  Most of the time, it is usually due to a stomach upset or something you ate or a stomach ulcer or a reflux of acid from the stomach to the oesophagus (gullet) coming up and causing  a burning sensation in the lower middle line of the chest.

However some people have these symptoms during a heart attack or are symptoms of coronary artery disease.  Women are more likely to report this type of symptoms than men.

If you feel these symptoms, you may be at risk for heart problems.  Let a doctor find out what is going on especially if you also have other symptoms on the list (see figure 1) and other risk factors associated with heart disease.

DIZZY OR LIGHT-HEADEDNESS

There are many reasons that can cause you to feel this way.  You may momentarily lose your balance or feel faint.  Probably this may be due to the fact that you didn’t have enough to eat or drink or you stood up too fast.  It could be an ear infection, or insufficient blood supply to the brain or anaemia due to blood loss.

But if you suddenly feel light-headedness, unsteady gait, dizziness and faintness with other symptoms such as chest discomfort and/or shortness of breath – this may be due to heart disease.  Do see a doctor.  It could mean you blood pressure has dropped because your heart isn’t able to pump the way it should.