The patient’s history is a critical feature in the evaluation of suspected or overt heart disease. It includes information about
the present illness, past illnesses, and the patient’s
family. From this information, a chronology of the patient’s
disease process should be constructed. Determining what information
in the history is useful requires a detailed knowledge of the pathophysiology
of cardiac disease. The effort spent on listening to the patient
is time well invested because the cause of cardiac disease is often
discernible from the history.
Chest pain is one of the cardinal symptoms (Table
1–1) of ischemic heart disease, but it can also occur
with other forms of heart disease. The five characteristics of ischemic chest
pain, or angina pectoris, are
- Anginal pain usually has a substernal location but may
extend to the left or right chest, the shoulders, the neck, jaw, arms,
epigastrium, and, occasionally, the upper back.
- The pain is deep, visceral, and intense; it makes the patient
pay attention but is not excruciating. Many patients describe it
as a pressure-like sensation or a tightness.
- The duration of the pain is minutes, not seconds.
- The pain tends to be precipitated by exercise or emotional
- The pain is relieved by resting or taking sublingual nitroglycerin.
Table 1–1. Commom Symptoms of Potential Cardiac Origin.
| Save Table
Table 1–1. Commom Symptoms of Potential Cardiac Origin.
|Chest pain or pressure|
|Dyspnea on exertion|
|Paroxysmal nocturnal dyspnea|
|Syncope or near syncope|
|Transient neurologic defects|
A frequent complaint of patients with a variety of cardiac diseases, dyspnea is ordinarily one of four types. The most common is exertional dyspnea, which usually means that the underlying condition is mild because
it requires the increased demand of exertion to precipitate symptoms.
The next most common is paroxysmal nocturnal dyspnea, characterized
by the patient awakening after being asleep or recumbent for an
hour or more. This symptom is caused by the redistribution of body fluids
from the lower extremities into the vascular space and back to the
heart, resulting in volume overload; it suggests a more severe condition.
Third is orthopnea, a dyspnea that occurs immediately on assuming
the recumbent position. The mild increase in venous return (caused
by lying down) before any fluid is mobilized from interstitial spaces
in the lower extremities is responsible for the symptom, which suggests
even more severe disease. Finally, dyspnea at rest suggests severe
Dyspnea is not specific for heart disease, however. Exertional dyspnea, for example, can be due to pulmonary disease, anemia, or
deconditioning. Orthopnea is a frequent complaint in patients with chronic
obstructive pulmonary disease and postnasal drip. A history of “two-pillow
orthopnea” is of little value unless the reason for the
use of two pillows is discerned. Resting dyspnea is also a sign
of pulmonary disease. Paroxysmal nocturnal dyspnea is perhaps the
most specific for cardiac disease because few other conditions cause
Lightheadedness, dizziness, presyncope, and syncope are important indications of a reduction in cerebral blood flow. These symptoms are nonspecific and can be due to primary central nervous system disease, metabolic
conditions, dehydration, or inner-ear problems. Because bradyarrhythmias
and tachyarrhythmias are important cardiac causes, a history of palpitations
preceding the event is significant.
Transient Central Nervous System Deficits
Deficits such as transient ischemic attacks (TIAs) suggest emboli from the heart or great vessels or, rarely, from the venous circulation through an intracardiac shunt. A TIA should prompt the search for
cardiovascular disease. Any sudden loss of blood flow to a limb
also suggests a cardioembolic event.
These symptoms are not specific for heart disease but may be due to reduced cardiac function. Typical symptoms are peripheral
edema, bloating, weight gain, and abdominal pain from an enlarged liver or spleen. Decreased appetite, diarrhea, jaundice, and nausea and vomiting can also occur from gut and hepatic dysfunction due to fluid engorgement.
Normal resting cardiac activity usually cannot be appreciated by the individual. Awareness of heart activity is often referred
to by patients as palpitation. Among patients there is no standard
definition for the type of sensation represented by palpitation,
so the physician must explore the sensation further with the patient.
It is frequently useful to have the patient tap the perceived heartbeat
out by hand. Commonly, unusually forceful heart activity at a normal
rate (60–100 bpm) is perceived as palpitation. More forceful
contractions are usually the result of endogenous catecholamine
excretion that does not elevate the heart rate out of the normal
range. A common cause of this phenomenon is anxiety. Another common sensation
is that of the heart stopping transiently or of the occurrence of
isolated forceful beats or both. This sensation is usually caused
by premature ventricular contractions, and the patient either feels
the compensatory pause or the resultant more forceful subsequent
beat or both. Occasionally, the individual feels the ectopic beat
and refers to this phenomenon as “skipped” beats.
The least common sensation reported by individuals, but the one most
linked to the term “palpitation” is rapid heart
rate that may be regular or irregular and is usually supraventricular in
Although cough is usually associated with pulmonary disease processes, cardiac conditions that lead to pulmonary abnormalities may be the root cause of the cough. A cardiac cough is usually dry or nonproductive.
Pulmonary fluid engorgement from conditions such as heart failure
may present as cough. Pulmonary hypertension from any cause can
result in cough. Finally, angiotensin-converting enzyme inhibitors, which are frequently used in cardiac conditions, can cause cough.