History
Patients with a cardiovascular disorder may present with one or more of eight symptoms relevant but not exclusive to this system (Table 22).
Table 22. Principal symptoms related to diseases of cardiovascular system
| Symptoms | Important questions |
| 1. Chest pain | Mode of onset, site, nature, duration, radiation, precipitating and relieving factors, influence of movement and breathing |
| 2. Breathlessness | Onset - either acute, slow or persistent; relation to activity; associated symptoms |
| 3. Dizziness/faint | Description of an episode; relation to posture activity, movements; precipitating factors; associated symptoms and conditions |
| 4. Palpitations | Mode of onset and termination; duration; associated symptoms; smoking; coffee and tea consumption |
| 5. Ankle swelling | Unilateral or bilateral; episodic or persistent; worse with activity |
| 6. Cough | Frequency; dry or productive; associated symptoms |
| 7. Haemoptysis | Onset; frothy, pink or frank blood; amount; frequency; associated symptoms |
| 8. Fatigue | Tiredness, exhaustion, lack of will or drive; degree of effort causing fatigue etc. |
Many patients with heart disease are symptom free until a relatively late stage in the illness when a catastrophic event may occur. This is particularly the case when the progression of atheroma is concerned. Early lesions may be present from the early teens, but patients usually present with myocardial infarction, stroke or peripheral arterial disease in middle or old age. Valve diseases, congenital lesions, hyperlipidaemia and hypertension may also be asymptomatic for many years.
Always note any family history of congenital heart disease or genetic disorders with cardiac implications. Premature death in near relatives from myocardial infarction, stroke or hyperlipidaemia or hypertension in family members are important findings.
Chest pain
Chest pain is caused by a variety of other disorders (Table 23), and the patient should be asked some specific questions under the following headings. However, there are two main causes of cardiac pain: myocardial ischaemia and pericarditis. Ischemic pain is usually of sudden onset, located centrally and stabbing or constricting; it may radiate to the left arm, occasionally to the right, into the neck and to the back. It may be brought on by exercise, emotion, fright or sexual intercourse. Angina pectoris usually lasts less than 30 minutes and may be relieved by rest or administration of nitrates. The pain of myocardial infarction usually lasts for more than 30 minutes, often as long as several hours.
Table 23. Causes of chest pain with associated symptoms
| Cause | Clinical features |
| 1. Cardiac ischaemia • Angina • Infarction | Dull ache, burning, pressure or band-like; radiates to the left arm; often precipitated by exertion and relieved by rest and nitrates; may be associated with breathlessness and sweating. Prolonged; not relieved by rest or nitrates; often associated with anxiety, sweating, dizziness and/or breathlessness. |
| 2. Pericarditis | Worse on breathing and lying; alleviated by sitting up |
| 3. Dissecting aneurysm | Often abrupt onset; a tearing sensation radiating down the back; history of hypertension; shock; associated symptoms - numbness, weakness, apprehension, etc. |
| 4. Pneumothorax | Sudden onset, worse on breathing; may by breathless |
| 5. Costochondritis | Mostly over the left 3-6 costochondral junctions; local tenderness |
| 6. Chest wall pain | Worse on movement and breathing; history of injury or unaccustomed exercise, etc. |
| 7. Pneumonia and pulmonary embolism | Worse on breathing; cough; haemoptysis; may be febrile and breathless |
| 8. Neuralgia | Sharp pain along the nerve distribution |
| 9. Oesophagitis | History of indigestion and heartburn; radiating to the back; relieved by milk and alkalis |