Symptoms

Angina

Symptoms of heart disease are often ignored because of the common misconception of the nature of cardiac symptoms. The best example of this is the symptom of “chest pain” – the most well known symptom of heart disease. If the chest pain is due to coronary artery disease, the medical term “angina” is used. The vast majority of patients with angina do not regard their chest symptom as sufficiently severe to warrant the term “pain”. Patients usually believe heart related chest pains should be severe, debilitating and recurrent. None of these features are necessarily true, but can sometimes serve to reassure patients who may be in denial. 

The term chest “discomfort” is a more likely to elicit an accurate history of angina. Other colorful descriptions include “lump in the chest”, “feeling of heat in chest”, “as if I had just swallowed boiled sweet which was has got stuck”, “heavy weight on my chest”, “belt tightening around my chest” or “throat soreness in cold weather” or “Doctor I get indigestion when I walk in cold weather”. Patients will frequently describe their heart symptoms as “indigestion” or “heartburn”.

Angina may not present with symptoms in the chest at all and can occur at the following sites:

Throat discomfort

Jaw discomfort

Teeth discomfort

Both arm, more often the left arm

Both Shoulders

Back discomfort

Upper abdomen

Breathlessness is well recognized as surrogate for angina (so called angina-equivalent), especially in diabetic patients.  The diagnosis of cardiac related chest pains (angina) usually requires a stress test. The gold standard test is coronary angiography which allows X-Ray visualization of the coronary arteries supplying blood to the heart. Other tests include CT coronary calcium scan, nuclear myocardial perfusion scan, MRI perfusion scan and stress echocardiography.

Breathlessness

Some breathless patients have heart disease as the underlying cause. The most common cardiac cause for breathlessness is a weakness in the contractility of the heart muscle contraction – left ventricular systolic dysfunction. The underlying causes for heart muscle dysfunction include coronary artery disease, high blood pressure and intrinsic heart muscle disease (cardiomyopathy). 

Occasionally, the heart valves may either leak or be significantly narrowed. Breathlessness is a common feature in heart valve disease. Heart valve disease may not cause symptoms but a heart murmur is found incidentally during a medical check-up. 

The diagnosis of a cardiac cause of breathlessness requires an ultrasound scan of the heart (echocardiogram). This will shows the how well the heart muscle contracts and also demonstrate heart valve structure and function. Other tests (exercise test or coronary angiogram) may be required, if an underlying cause such as coronary artery disease is suspected.

Palpitations

BHF booklet on palpitations

Link to BUPA health factsheet “Arrhythmia”

My heart is missing a beat

I feel a fluttering or thumping sensation in my chest

My partner (or I am) is aware that my heart beat is irregular when in bed

The awareness of an irregular heart beat is a frequent cause for concern, particularly as it can occur unpredictably and may be quite troublesome.  Associated symptoms include dizziness, blackouts, breathlessness, and fatigue or chest discomfort. There may be triggering factors such as stress, exercise or dietary intake. The diagnosis of palpations includes the recording of the heart rhythm over a period which may range between 24 hours (Holter monitor) or longer (7 day event monitor). A small device inserted under the skin may record the heart rhythm for 1 year in the event of very infrequent symptoms (Reveal device). Other tests required include blood tests, echocardiography and stress testing.

Dizziness or Blackouts

Link to BUPA health factsheet “Pacemaker”  

 Link to BUPA health factsheet “Heart Block”

 Dizziness can a very debilitating symptom. This need not progress to be a full blown blackout but can come close to complete loss of consciousness. An abnormal heart rhythm can cause dizziness. The heart rhythm may either be too slow (treatable by pacemaker) or too fast. If there is a structural abnormality with the heart such as coronary artery disease, heart valve disease, heart muscle disease including various forms of cardiomyopathy, dizziness may be a serious feature of heart disease. 

The diagnosis of dizziness includes the recording of the heart rhythm - 24 hours (Holter monitor) or longer (7 day event monitor). A small device inserted under the skin may record the heart rhythm for 1 year in the event of very infrequent symptoms.

Fatigue, Lethargy, Loss of energy

We all experience fatigue and lethargy from time to time and this ubiquitous symptom is not in itself a sign of heart disease. However, some common heart conditions such as left ventricular dysfunction (heart failure) or arrhythmias (heart rhythm disturbance) or heart valve disease, are frequently associated with such symptoms.

High Blood Pressure

Link to British Heart Foundation (BHF) factsheet “Hypertension”

 Link to BUPA health factsheet “High Blood Pressure”

 High Blood pressure is estimated to affect 30% of the U.K. population and is notable for its lack of symptoms in patients. It is unusual for patients to complain of headaches and nose bleeds – commonly sought symptoms.  The almost complete lack of symptoms means that hypertension is often only found when damage has already occurred – such as after a heart attack. Other than heart attack risk, hypertension can cause heart failure, strokes, brain haemorrhage, kidney failure and peripheral vascular disease. High blood pressure frequently runs in families and even mildly elevated blood pressure can cause long term damage to heath, if not treated.

It is self evident that if blood pressure is not measured, then the opportunity to diagnose hypertension and treat accordingly is lost. An important message is that even mildly elevated blood should not be ignored, especially if there is a family history of hypertension. It is not infrequent to find patients who have suffered a cardiac event or a small stroke to mention that their blood pressure was “a little high, a few years ago”.

Hypertension requires investigations to check for underlying causes (uncommon) and to detect any existing organ damage. Sometimes making the diagnosis of hypertension is difficult because of artificially high clinic BP recordings as a result of anxiety. 

In such situations a 24 hour blood pressure monitor is invaluable. This is also useful to monitor the effectiveness of drug treatment of hypertension.

A heart scan (echocardiogram) checks the effect of high blood pressure on the muscle of the heart (left ventricular hypertrophy).

High Cholesterol

Link to British Heart Foundation factsheet “Cholesterol”Link to BUPA health factsheet “High Cholesterol”

This is one of the most easily treatable risk factors for coronary artery disease. 

Treatment involves dietary modification and highly effective drugs called statins. It is a common misconception that diet alone is sufficient to treat hypercholesterolaemia. 

This is because dietary modification can only account for a 15% change in the blood cholesterol level. The main determinant of the blood cholesterol level is the body’s own liver production - cholesterol is an essential building block for our cells.

The decision to treated a high cholesterol requires a full assessment including other risk factors, existing medical conditions and the finding of signs of cardiovascular and cerebrovascular  disease. Rarely, does the decision to treat hypercholesterolaemia depend sole on the cholesterol level, except in cases of severe hereditary hypercholesterolaemia (heterozygous or homozygous familial hyperchlesterolaemia).

Statin medication (prescribed for high cholesterol) do not only reduce the risk of heart disease by its effect on cholesterol lowering alone - although this is a major reason for its efficacy. 

Other beneficial effects (known as pleiotropic effects) are thought to be important - such as improving the health of the lining of arteries to avoid a thrombotic event. 

Thus treating high cholesterol with diet alone may not be sufficient and you may need the addition cardiac protective effect of statin medication.