Pains in chest
Pain due to angina pectoris
Pain in dissection of aortal aneurysm
Functional precordial pain
Exertion breathlessness – NYHA criteria
is an important clinical sign. consider. The following can be assessed:
5) Relieving movements
- stenocardia, occurs in ischaemic heart disease. Usually caused by physical
activity (walk, walk up the hill) or by excitement. It is worsened
by cold, e.g. transition from warmth to cold. After stopping of effort the pain
eases off. It may happen also during inactivity.
It is compressive, seizing or stinging flat pain localised behind the sternum, sometimes in the whole precordium.
It irradiates into the neck, lower jaw, left shoulder, ulnar side of
the left arm, but also into the back and epigastrium.
It lasts a few minutes (angina pectoris), but if it lasts more than
20 minutes and it happens during inactivity, it is necessary to consider
myocardial infarction. (The intensity of pain is then higher, the pain
is usually accompanied by vegetative reactions, such as nausea,
anxiety, and sweating). The effect of nitrates given sublingually in angina
pectoris should appear in 5 minutes, if the pain lasts longer; myocardial
infarction should be suspected.
Pericardial pain is sharp, localised
rather precordially; it has long-lasting duration. It worsens after changing
position and is dependent on breathing. It is usually not related to physical
activity, easing of pain occurs when sitting or bending forward. It is usually
caused by viral infection, myocardial infarction and following cardiosurgical
Pain in dissection of aortal aneurysm
is very sharp, intensive, myocardial-infarction-like-pain, irradiating to
the back or abdomen, happens suddenly, as "snap of a whip", often
after effort (example: lifting the weight).
Functional precordial pain is
stinging, pricking pain, localised to the area of the heart apex,
occurring in inactivity or in psychical activity in young people; it is
often accompanied by the feeling of impossibility to breathe enough
Within the frame of differential diagnostics of chest pain, it is necessary
to exclude extra-cardiac causes, mainly vertebrogenic ones, intercostal
neuralgia, and pain in gastrooesophageal reflux disease.
are unpleasant, intensively perceived manifestations of heart activity characterised mainly by:
- short-term irregular pulse
- "skipped" heart beats
- feeling of "short-term stopped beats"
- fast regular heart pounding (paroxysmal tachycardia)
- fast irregular pounding heart (atrial fibrillation)
They can be caused by arrhythmia (extra-systoles, atrial fibrillation, paroxysmal
tachycardia); therefore it is necessary to investigate their causes.
is a serious clinical sign of left heart insufficiency in ischaemic heart disease, hypertension, and valve defects.
It manifests during exertion, or inactivity, and can be paroxysmal.
It is classified according to NYHA criteria (New York Heart
Association) from 1964 (1):
||NYHA class I - ordinary physical activity does not
cause breathlessness or stenocardia; it is caused only by enormous
||NYHA class II - grade - ordinary physical activity
causes breathlessness or anginal pain (but tolerance of ordinary daily
activity is good).
||NYHA class III - grade - small physical activity (slow
walk on the level, dressing up, toilette)causes breathlessness,
but without difficulties during inactivity.
||NYHA class IV - grade - manifestation of breathlessness
Cardiac asthma originates in acute
left heart insufficiency, which leads to the gathering of blood (haemostasis)
in lungs. The patient wakes up by a feeling of a lack of
air approximately 2-3 hours after falling asleep, moves to orthopneic position,
breathlessness can ease off (decreasing of vein return) or can progress
Pulmonary oedema (caused by a leakage of
fluid into the interstitium and alveoli). It is marked by extreme breathlessness,
anxiety, raucous breathing, often well audible from distance (resembles
gurgling), presence of pinkish fluid in oral cavity.
It occurs at night; in mitral stenosis at the time of the maximum
is classified to central and peripheral - for further details see section "Complete
Mixed cyanosis, combination of central and peripheral, manifests in left heart insufficiency.
is usually caused by an increased pressure in pulmonary veins due to
right heart insufficiency with contribution of hormonal mechanisms (rennin
- angiotensin - aldosterone system).
Mild oedema affect both lower limbs, in initial stages of heart failure
it usually ease off during the night.
(For further information see "Complete examination").
is short-term unconsciousness lasting several minutes, caused by insufficient perfusion of the brain.
|| Caused by arrhythmia - extreme tachyarrythmia and bradyarrhythmia cause sudden decrease of minute volume (Adam-Stockes syndrome is the name of syncope occurring in temporary asystolia or ventricular tachycardia)
||Caused byaortal stenosis
- manifests induring or following xertion syncope is caused by
a limited blood flow through stenosis.
||Caused by obstruction
of the mitral orifice - due to - myxoma or a big thrombus
in the left vestibule; atrium; occurrence of syncope depends
on position or exertion.
Orthostatic syncope - may occur when standing, due to accumulation
of blood in lower limbs, it is associated with a defect of baroreceptors.
Dehydration, varicose veins in lower limbs, or medication (diuretics, hypotensives,
nitrates) are contributing factors.
Vasovagal syncope - manifests usually in healthy people is related
to pain, fear, hunger, or stuffiness. Syncope happens suddenly; after a fall
or being horizontally positioned, the consciousness recovers quickly.
The syndrome of carotic sinus is manifested
by irritation of carotic sinus especially in sensitive people; it leads
to bradycardia, hypotension, and unconsciousness. It is caused by head turning
or moving back, or by apressure of a tight collar.
is usually caused by arteriosclerosis, coughing, or hyperventilation.
|| Caused by stasis - manifests in mitral stenosis due to rupture of endobronchial collaterals.
||Caused by lung infarction
- is recognised expectoration of dark red blood, simultaneous breathlessness,
and pleural pain
|| Caused by lung oedema
- expectoration of pinkish sputum in acute left
in right hypochondrium is caused by an acute distension of the fibrous
capsule of the liver in right heart insufficiency.
The Criteria Committee of the New York Heart Association: Physical capacity with heart disease, in Diseases of the Heart and Blood Vessels, Nomenclature and Criteria for Diagnosis, ed 6. Boston, Little, Brown & Co, 1964, pp 110-114
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