The most common symptoms of heart disease are chest pain, dyspnea, palpitations, syncope or presyncope, and fatigue. None is 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. A HEART score (History, ECG, Age, Risk factors and Troponin) has been proposed and validated to help distinguish coronary chest pain in the emergency department from noncoronary causes.
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.
MH. Evaluation of chest pain in primary care ...