The most common symptoms of heart disease are dyspnea, chest pain, palpitations, syncope or presyncope, and fatigue. None are specific, and interpretation depends on the entire clinical picture and, in many cases, diagnostic testing.
Chest pain and other forms of discomfort are common symptoms
that can occur as a result of pulmonary, pleural, or musculoskeletal
disease, esophageal or other gastrointestinal disorders, or anxiety
states, as well as many cardiovascular diseases. Myocardial ischemia
is a frequent cause of cardiac chest pain and is usually described
as dull, aching, or as a sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather
than as sharp or spasmodic. Ischemic symptoms frequently
are first noted only with exercise or cardiac stress from cold exposure,
meals, or a combination of factors and often resolve quickly once
the inciting event is over. Progressive symptoms or symptoms at
rest may represent unstable angina due to coronary plaque rupture
and thrombosis. Protracted episodes often represent myocardial infarction, although one-third
of patients with acute myocardial infarction do not have chest pain.
When present, the pain is commonly accompanied by a sense of anxiety
or uneasiness. The location is usually retrosternal or left precordial.
Because there are not the appropriate sensory nerves on the heart,
the central nervous system interpretation of pain location often
results in pressure or “heaviness” being referred
to the throat, lower jaw, shoulders, inner arms, upper abdomen,
or back. Ischemic pain is not related to position or respiration
and is usually not elicited by chest palpation. One clue that the
pain may be ischemic is the presence of other symptoms associated
with the pain, such as shortness of breath, dizziness, a feeling
of impending doom, and vagal symptoms, such as nausea and diaphoresis.
Of importance, depression may mask symptoms, especially in women. When compared to men, women do appear to have a higher frequency of atypical angina (even with significant coronary disease) and, in some cases, evidence for microvascular coronary disease even when epicardial coronary disease is not evident at cardiac catheterization.
Hypertrophy of either ventricle, such as in aortic stenosis or
hypertrophic cardiomyopathy, may result in subendocardial underperfusion
during stress and may also give rise to atypical ischemic pain.
Myocarditis, pulmonary hypertension, and mitral valve prolapse are
also associated with chest pain atypical for angina pectoris. Pericarditis
may produce pain that is greater supine than upright, and may increase
with respiration, or swallowing. Pleuritic chest pain is not ischemic, and
pain on palpation should signal a musculoskeletal etiology. Aortic
dissection classically produces an abrupt onset of tearing pain
of great intensity that often radiates to the back.
Anderson JL et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management ...