Symptoms
No single symptom unmistakably indicates heart (cardiac) disease, but certain symptoms suggest the possibility, and several symptoms together may make the diagnosis almost certain. Doctors identify symptoms by interviewing the person to obtain the medical history and by performing a physical examination. Often, diagnostic procedures are performed to confirm the diagnosis. However, sometimes heart disease, even when serious, may produce no symptoms until it reaches a late stage. Routine health checkups or a visit to the doctor for another reason may uncover heart disease that has caused no symptoms. Sometimes doctors perform procedures to screen for heart disease even when there is no evidence of it.
The symptoms of heart disease include certain types of pain, shortness of breath, fatigue, palpitations (awareness of slow, fast, or irregular heartbeats), light-headedness, fainting, and swelling in the legs, ankles, and feet. However, these symptoms do not necessarily indicate heart disease. For example, chest pain may be due to a respiratory or digestive disorder rather than to heart disease.
Symptoms of peripheral blood vessel disorders vary depending on where the affected blood vessels are located. Symptoms may include pain, shortness of breath, muscle cramps, muscle fatigue, light-headedness, swelling, numbness, and a change in skin color of the affected part of the body.
Pain
When muscles do not get enough blood (a condition called ischemia), they do not get enough oxygen, which is carried to tissues by the blood. In addition, waste products, which are carried away from tissues by the blood, accumulate. As a result, cramps occur.
An inadequate blood supply to the heart can cause a tightness or squeezing sensation in the chest (angina). However, the type, location, and severity of pain or discomfort vary greatly from person to person. Some people with an inadequate blood supply have no pain at all. This condition is called silent ischemia.
An inadequate blood supply to other muscles, particularly to the calf muscles, usually causes a tightening and fatiguing pain in the muscle during exercise (claudication).
An inflammation of the sac that envelops the heart (pericarditis) causes pain that worsens when the person lies down and decreases when the person sits up and leans forward. Exertion does not increase the pain, but inhaling deeply does. Pain increased by inhaling deeply can also be caused by an inflammation of the membranes covering the lungs (pleurisy).
Disorders affecting arteries can cause a sharp pain that comes and goes fairly quickly; the pain may be unrelated to physical activity. Pain due to an aneurysm (a bulge in a weakened area of an artery's wall) or a dissection (separation of the layers of an artery's wall) is sudden and excruciating. The pain is often felt in the back of the neck, between the shoulder blades, down the back, or in the abdomen, depending on the location of the damage.
The valve between the left atrium and left ventricle (mitral valve) may bulge back into the left atrium when the left ventricle contracts. This disorder, called mitral valve prolapse, sometimes causes brief episodes of stabbing or needle-like pain. Usually, the pain is centered below the left breast regardless of the person's position or physical activity.
Shortness of Breath
Shortness of breath (dyspnea) (see Section 4, Chapter 39) is a common symptom of heart failure. It results from fluid seeping into the air spaces of the lungs--a condition called pulmonary congestion or pulmonary edema. Ultimately, this process is similar to drowning. In the early stages of heart failure, shortness of breath may occur only during physical activity. As heart failure worsens, shortness of breath occurs with less and less activity and eventually occurs at rest. Shortness of breath at rest occurs mostly when people lie down because fluid seeps throughout the lung tissue. When they sit up, gravity causes fluid to collect at the base of the lungs, causing less difficulty. Nocturnal dyspnea is shortness of breath that occurs when the person is lying down at night; it is relieved by sitting up and dangling the legs. Consequently, people with nocturnal dyspnea usually sleep propped up by pillows to avoid lying flat.
Shortness of breath occurs in people who have coronary artery disease. It usually occurs during physical activity, but in people with severe disease, it may occur during minimal activity or during rest.
Shortness of breath also occurs in people who have other disorders, such as a lung disorder, a disorder of the respiratory muscles, or a disorder of the nervous system that interferes with breathing. Any disorder that upsets the normal, delicate balance between oxygen supply and oxygen requirement can cause shortness of breath. For example, in anemia, the blood may not be able to carry enough oxygen because there are too few red blood cells.
Fatigue
When the heart pumps inefficiently as it does in heart failure, blood flow to the muscles may be inadequate during physical activity, causing feelings of weakness and fatigue. Symptoms are often subtle. People usually compensate by gradually reducing their activity level, or they may blame the symptoms on increasing age.
Limitation of Physical Activity
Heart disease can limit a person's ability to perform physical activities. One way to evaluate the severity of heart disease is to determine how limited this ability is. Doctors may use the New York Heart Association (NYHA) functional class system to make this evaluation. In mild disease (class I), ordinary physical activity may not be limited. In moderate disease (class II), ordinary activity causes symptoms, and in moderately severe disease (class III), less-than-ordinary activity causes symptoms. In severe disease (class IV), symptoms occur during rest, and any physical activity makes them worse. However, this system is not foolproof, because even serious heart disease may produce no symptoms if people reduce their activity level to compensate for the disease.
Palpitations
Ordinarily, people do not notice the beating of their heart. However, most people can feel heartbeats when they lie on their left side. Also, under certain circumstances--for example, when exercising strenuously or having a dramatic emotional experience--healthy people may become aware of their heartbeat. They may feel the heart beating very forcefully or rapidly or sense an irregular heartbeat.
Determining whether palpitations are abnormal depends on answers to a number of questions, such as whether they started suddenly or gradually, whether something seems to trigger them, how fast the heart beats, and whether and to what extent the beat seems to be irregular. Palpitations that occur with other symptoms, such as shortness of breath, pain, weakness, fatigue, or fainting, are more likely to result from an abnormal heart rhythm or a serious disorder. Doctors also listen to the heart with a stethoscope and may suggest other procedures, such as electrocardiography (ECG).
Light-Headedness and Fainting
If blood flow is inadequate because the heart rate or rhythm is abnormal or because the heart cannot pump adequately, light-headedness, faintness, or fainting (syncope) may result. These symptoms can also result from brain or spinal cord disorders, or they may have no serious cause. For example, healthy soldiers may feel faint or may faint when standing still for long periods (a phenomenon called parade ground syncope), because the leg muscles have to be active to help return blood to the heart. Strong emotion or pain, which activates part of the nervous system, also can cause fainting. Sitting or standing up too quickly can cause a feeling of faintness or fainting, because the change in position causes blood to pool in the legs, resulting in a fall in blood pressure. Normally, the body quickly adjusts to maintain blood pressure. Inability to adjust quickly is called orthostatic hypotension. This disorder is particularly common among older people.
People are more likely to feel faint or to faint when they are standing up. When they lie or fall down, blood flow to the brain is increased, generally ending the faint.
Doctors must distinguish fainting caused by heart disease from a seizure disorder, in which a loss of consciousness results from a brain disorder.
Swelling, Numbness, and Changes in Skin Color
Swelling is due to the accumulation of fluid (edema) in tissues. It occurs when blood pools in the leg veins, increasing pressure in the leg veins and forcing fluids out of the veins into tissues. Blood may pool because the heart cannot pump out all of the blood it receives from the rest of the body (in heart failure) or because a deep vein in the leg is blocked (in deep vein thrombosis).
Swelling in the legs, ankles, and feet or in the abdomen may indicate heart failure or a venous disorder, such as deep vein thrombosis. However, such swelling is most commonly caused by standing or sitting in one position too long or by age-related changes in leg veins. Swelling of the legs is also common during pregnancy. Swelling may also be due to liver or kidney disorders.
If the blood supply is inadequate, the affected part of the body may feel numb.
If the blood supply is inadequate, if anemia is present, or if the veins do not drain adequately, the skin may appear pale or bluish (or purplish).
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