Chapter 5: Approach to Cardiac Disease Diagnosis

General Considerations

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.

A. Common Symptoms

1. Chest pain

Chest pain is one of the cardinal symptoms (Table 5–1) 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 as follows:

• Anginal pain usually has a substernal location but may extend to the left or right chest, shoulders, neck, jaw, arms, epigastrium, and, occasionally, 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 stress.

• The pain is relieved by resting or taking sublingual nitroglycerin.

2. Dyspnea

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 cardiac disease.

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 ...