Approach to Cardiac Disease Diagnosis

Approach to Cardiac Disease Diagnosis
CURRENT Diagnosis & Treatment in Cardiology

Approach to Cardiac Disease Diagnosis

Michael H. Crawford, MD

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 1–1) 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

Table 1–1. Common symptoms of potential cardiac origin.

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


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 unless the reason for the use of two pillows is discerned. Resting dyspnea is also a sign of pulmonary disease. Paroxysmal nocturnal dyspnea is perhaps the most specific for cardiac disease because few other conditions cause this symptomatology.

3. Syncope and presyncope—These signs (light-headedness, dizziness, etc) are important symptoms of a reduction in cerebral blood flow. These symptoms are nonspecific and can be due to primary central nervous system disease, metabolic conditions, dehydration, or inner-ear problems. Because brady- and tachyarrhythmias are important cardiac causes, a history of palpitations preceding the event is significant.

4. Transient central nervous system deficits—Deficits such as transient ischemic attacks (TIAs), suggest emboli from the heart or great vessels or, rarely, from the venous circulation through an intracardiac shunt. A TIA should prompt the search for cardiovascular disease. Any sudden loss of blood flow to a limb also suggests a cardioembolic event.

5. Fluid retention—These symptoms are not specific for heart disease but may be due to reduced cardiac function. Typical symptoms are peripheral edema, bloating, weight gain, and abdominal pain from an enlarged liver or spleen. Decreased appetite, diarrhea, jaundice, and nausea and vomiting can also occur from gut and hepatic dysfunction due to fluid engorgement.

6. Palpitation—Normal resting cardiac activity usually cannot be appreciated by the individual. Awareness of heart activity is often referred to by patients as palpitation. Among patients there is no standard definition for the type of sensation represented by palpitation, so the physician must explore the sensation further with the patient. It is frequently useful to have the patient tap the perceived heartbeat out by hand. Commonly, unusually forceful heart activity at a normal rate (60–100 bpm) is perceived as palpitation. More forceful contractions are usually the result of endogenous catecholamine excretion that does not elevate the heart rate out of the normal range. A frequent cause of this phenomenon is anxiety. Another frequent sensation is that of the heart stopping transiently or of the occurrence of isolated forceful beats or both. This sensation is usually caused by premature ventricular contractions and the patient either feels the compensatory pause or the resultant more forceful subsequent beat or both. Occasionally, the individual feels the ectopic beat and refers to this phenomenon as “skipped” beats. The least frequent sensation reported by individuals, but the one most linked to the term palpitation is rapid heart rate that may be regular or irregular and is usually supraventricular in origin.

7. Cough—Although cough is usually associated with pulmonary disease processes, cardiac conditions that lead to pulmonary abnormalities may be the root cause of the cough. A cardiac cough is usually dry or nonproductive. Pulmonary fluid engorgement from conditions such as heart failure may present as cough. Pulmonary hypertension from any cause can result in cough. Finally, angiotensin-converting enzyme inhibitors, which are frequently used in cardiac conditions, can cause cough.

B. HISTORY

1. The present illness—This is a chronology of the events leading up to the patient's current complaints. Usually physicians start with the chief complaint and explore the patient's symptoms. It is especially important to determine the frequency, intensity, severity, and duration of all symptoms; their precipitating causes; what relieves them; and what aggravates them. Although information about previous related diseases and opinions from other physicians are often valuable, it is essential to explore the basis of any prior diagnosis and ask the patient about objective testing and the results of such testing. A history of prior treatment is often revealing because medications or surgery may indicate the nature of the original problem. A list should be made of all the patient's current medications, detailing the dosages, the frequency of administration, whether they are helping the patient, any side effects, and their cost.

2. Antecedent conditions—Several systemic diseases may have cardiac involvement. It is therefore useful to search for a history of rheumatic fever, which may manifest as Sydenham's chorea, joint pain and swelling, or merely frequent sore throats. Other important diseases that affect the heart include metastatic cancer, thyroid disorders, diabetes mellitus, and inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus. Certain events during childhood are suggestive of congenital or acquired heart disease; these include a history of cyanosis, reduced exercise tolerance, or long periods of restricted activities or school absence. Exposure to toxins, infectious agents, and other noxious substances may also be relevant.

3. Atherosclerotic risk factors—Atherosclerotic cardiovascular disease is the most common form of heart disease in industrialized nations. The presenting symptoms of this ubiquitous disorder may be unimpressive and minimal, or as impressive as sudden death. It is therefore important to determine from the history whether any risk factors for this disease are present. The most important are a family history of atherosclerotic disease, especially at a young age; diabetes mellitus; lipid disorders such as a high cholesterol level; hypertension; and smoking. Less important factors include a lack of exercise, high stress levels, the type-A personality, and truncal obesity.

4. Family history—A family history is important for determining the risk for not only atherosclerotic cardiovascular disease but for many other cardiac diseases as well. Congenital heart disease, for example, is more common in the offspring of parents with this condition, and a history of the disorder in the antecedent family or siblings is significant. Other genetic diseases, such as neuromuscular disorders or connective tissue disorders (eg, Marfan's syndrome) can affect the heart. Acquired diseases such as rheumatic valve disease can cluster in families because of the spread of the streptococcal infection among family members. The lack of a history of hypertension in the family might prompt a more intensive search for a secondary cause. A history of atherosclerotic disease sequelae such as limb loss, strokes, and heart attacks may provide a clue to the aggressiveness of an atherosclerotic tendency in a particular family group.


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