Symptoms of Diseases of the Circulatory System

Pains in chest
Pain due to angina pectoris
Pericardial pain
Pain in dissection of aortal aneurysm
Functional precordial pain
 
Palpitations
 
Breathlessness
Exertion breathlessness – NYHA criteria
Paroxysmal breathlessness
 
Cyanosis
 
Oedemas
 
Syncopation
Cardiac syncopation
Circulatory syncopation
Extra-cardiac syncopation
 
Haemoptysis
 
Abdominal pains

Pain
 
is an important clinical sign. consider. The following can be assessed:
 
1) Character
 
2) Localisation
 
3) Irradiation
 
4) Provocation
 
5) Relieving movements
 
Chest pain
 
Anginal pain - 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 operation.
 
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 air.
 
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.
 
Palpitations
 
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.
 
Breathlessness
 
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 load.
	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 in inactivity.

 
Paroxysmal 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 further more.
 
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 exertion.
 
Cyanosis
 
is classified to central and peripheral - for further details see section "Complete examination".
 
Mixed cyanosis, combination of central and peripheral, manifests in left heart insufficiency.
 
Oedema
 
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").
 
Syncope
 
is short-term unconsciousness lasting several minutes, caused by insufficient perfusion of the brain.
 
Cardiac syncope
 

	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.

 
Circulatory syncope
 
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.
 
Extra-cardiac syncope
 
is usually caused by arteriosclerosis, coughing, or hyperventilation.
 
Haemoptysis
 

	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 heart insufficiency.

 
Abdominal Pain
 
in right hypochondrium is caused by an acute distension of the fibrous capsule of the liver in right heart insufficiency.
 
Literature:
 
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