Chest discomfort or chest pain is the cardinal symptom associated with heart disease because it can be a sign of a heart attack (myocardial infarction).
The importance of this symptom (usually called “angina”) lies in the fact that it may be a sign of coronary artery disease. Chest discomfort emanating from the heart or angina can be mild and it is often mistaken for “indigestion”. Confusingly, heart pains can masquerade as pain in the neck, jaw, left arm, back or even stomach. Angina may sometimes produce no pain or discomfort at all, and may manifest as breathlessness (angina equivalent).
However not all symptoms of chest pain or discomfort are due to heart disease. A careful assessment by a heart specialist will allow chest symptoms which are benign to be distinguished from heart pains or angina.
Coronary artery disease, also known as ischaemic heart disease is a condition in which plaque builds up inside the coronary (heart) arteries and the blood supply to the heart muscle is restricted. Plaque is made up of cholesterol, fat, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis and it restricts the flow of oxygen-rich blood to the heart and thereby predisposing to heart attacks.
Diseases of the heart and circulatory system (such as heart attacks and strokes) remains the most common cause mortality in the United Kingdom (British Heart Foundation Coronary Heart Disease Statistics 2012.). It is the main cause of premature death before the age of 75.
We can investigate this diagnosis with non-invasive tests including stress test, cardiac magnetic resonance imaging or nuclear perfusion scanning. If the non-invasive test proves to be abnormal then coronary angiography may be needed to determine the best way to restore blood supply to the heart.
The word “palpitation” is commonly used by doctors, but it’s meaning is not well defined when used in everyday language, leading to potential confusion. It is probably one of the most common symptoms presenting to heart specialists.
Palpitations is most simply defined as an awareness of one’s heart beat. It is frequently described as a fluttering in the chest, thumping or a forceful heart beat, a racing heart beat, missed beats or extra beats. It can last from seconds to a few days. It may cause other symptoms such as breathlessness, a feeling of anxiety, a hollow feeling in the chest, chest tightness, dizzy spells or even blackouts. Palpitations can come out of the blue without any provocation, and may be felt during the night while trying to get to sleep. Palpitations can be quite debilitating, and occasionally it may require to emergency treatment in hospital especially when associated symptoms such as dizziness occur.
Palpitations may be due to a change in the electrical activity of the heart. The usual sequence of electrical activation in the heart produces the normal regular rhythm of the heart but this electrical rhythm may change and produce an abnormal electrical rhythm – called an arrhythmia.
We can investigate this symptom with blood tests, echocardiogram and heart monitor. If these symptoms are related to exercise a stress test is helpful.
Atrial fibrillation is an important arrhythmia. It occurs when disorganized electrical signals cause the heart's two upper chambers—called the atria to contract very fast and irregular pattern. It can cause palpitations, but it may be discovered during a routine health check when the pulse is noted to be irregular. This arrhythmia is especially important because it is a common condition and crucially, in some cases, it may predispose to strokes.
Strokes are dangerous because it can lead to paralysis, coma and are potentially life threatening. Fortunately atrial fibrillation is an easily treatable condition and the stroke risk can be neutralised with appropriate medication. Atrial fibrillation can occur across all age ranges. Although it is more common with increasing age, it can cause troublesome palpitations in the younger age group. If the medication option is not helping with palpitations due to atrial fibrillation then procedures such as catheter ablation for atrial fibrillation can be useful.
The symptom of feeling faint, dizzy or light headed is common. In some cases it may be a sign of heart disease. In the extreme form this type of symptom, a full-blown blackout may be experienced. Patients who have a blackout (syncope) or near blackout (pre-syncope) usually come to the attention of heart specialists. Heart rhythm disturbances (either too slow or too fast) can cause dizzy spells. Heart valve disease such as aortic stenosis, and heart muscle disease (cardiomyopathy) are important causes for dizzy spells which can lead to harm, if not detected and treated early.
We can investigate this symptom with an echocardiogram, heart monitor and/or implantable loop recorders (Reveal and Reveal Linq).
Breathlessness is a very common symptom and can have a very insidious course. It is often ignored and attributed to “getting old” or “poor fitness”. Some breathless patients may have underlying heart disease. The most common cardiac cause for breathlessness is a weakness in the contractility of the heart muscle – 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 (angina equivalent).
A heart murmur is common reason to seek specialist advice from a heart specialist. A murmur is a sound emanating from heart heard using a stethoscope. There may or may not be any associated heart symptoms such as breathlessness, chest pain or dizzy spells. Heart murmurs are frequently picked up during a routine medical check-up.
It may be harmless sign because heart murmurs may occur in normal individuals without any structural heart disease. This is usually called a “flow murmur” and can occur specifically when overall blood flow through the heart is increased such as during pregnancy or during a high fever. However a heart murmur may represent a pathological condition of the heart whereby the heart valves are not functioning normally. This sound or murmur is generated by a leaking heart valve or turbulent flow through a narrowed valve. Heart murmurs can sometimes also be due to a condition affecting the heart muscle (hypertrophic cardiomyopathy) - in which there is obstruction of blood flow through the left ventricular outflow tract due to abnormal thickening of the heart muscle.
Heart murmurs can also be due to congenital heart conditions due as a hole in the heart although these are usually picked up early in life. The diagnosis of the cause for a heart murmur requires a detailed history and examination and investigations including an electrocardiogram and echocardiogram.
High blood pressure also known as hypertension is estimated to affect 30% of the U.K. population and is notable for its lack of symptoms. It is unusual for patients to complain of headaches and nose bleeds – commonly sought symptoms of high blood pressure.
The lack of symptoms means that hypertension can often be found for the first time, when damage has already occurred such as after a heart attack or stroke. Hypertension can also cause heart failure, 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 pressure 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”.
Medication used in the treatment for hypertension are wide ranging and usually do not produce significant side effects. Recently published medical research has enhanced our knowledge about effective treatment of hypertension and also broaden the scope of drugs available to treat resistant case of hypertension.
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 (white coat hypertension). 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).
Raised blood cholesterol also known as hypercholesterolaemia is a very important risk factor in the development of heart attacks and stroke (cardiovascular disease). It is one of the most easily treatable risk factors for coronary artery disease. The condition usually has no signs or symptoms. Thus, patients don’t know that their cholesterol levels are too high. The higher the level of cholesterol (specifically LDL cholesterol) in the blood, the greater the chance of getting heart 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 treat 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 solely 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 additional cardiac protective effects of statin medication.
Screening for the presence of early signs of coronary artery disease using CT coronary calcium scans or CT coronary angiography may help inform the decision for statin treatment in certain patients.
The primary purpose of screening for coronary heart disease (CHD) is to identify patients whose prognosis could be improved with an intervention (medication for risk factor modification or coronary revascularization). Screening for CHD should be distinguished from estimation of risk for CHD (or overall cardiovascular disease [CVD]). Both are performed in asymptomatic persons, and both aim to improve outcomes with interventions, if indicated.
Coronary heart disease risk assessment is now more systematic and more precise. This has been made possible by the development of more accurate risk assessment tools such as the Joint British Societies recommendations on the prevention of Cardiovascular Disease (JBS3) Risk Calculator and the atherosclerotic cardiovascular disease (ASCVD) Risk Estimator based on the 2013 American College Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. These tools allow estimation of the risk of Cardiovascular Disease and the benefits of interventions, whether they are lifestyle or pharmacological. It can help illustrate the benefits that can arise from interventions such as reducing blood pressure, or stopping smoking.
Unlike CHD risk assessment, screening for CHD identifies existing disease, while estimating the risk of CHD (or CVD) does not directly identify existing disease but rather the likelihood of any future event related to CHD. The introduction of advanced cardiac imaging such as CT coronary calcium scanning and CT coronary angiography allows non-invasive detection of atherosclerosis in the coronary arteries for the first time. CT coronary calcium scans detect and quantify calcification in the coronary arteries and this correlates with the extent and severity of coronary atherosclerosis. Importantly, this information provides additional prognostic information over and above the traditionally calculated coronary heart disease risk score. In carefully selected patients, CT coronary calcium scan can be helpful in screening for coronary heart disease. This and other clinical information will guide treatment to protect against the risk of future heart attacks.
Cardiovascular disease remains the leading cause of death in women. Cardiovascular disease, of which coronary heart disease is the most common manifestation, causes twice as many deaths as breast cancer and all other cancers combined. Although there have been significant reduction in cardiovascular death rates in developed countries, the incidence of heart attacks (myocardial infarction) has not declined and has actually increased amongst women.
However, the good news is that heart disease is largely preventable.
Why should heart disease in women be regarded as a special case?
Research shows that women are less likely to receive effective cardiovascular care compared to male counterparts, and this may contribute to worse outcomes in women compared with men. Women with heart symptoms do not have text-book symptoms and have a greater tendency to present with atypical symptoms. For example, women with angina (heart pain) complain of indigestion, abdominal pain, breathlessness, nausea, and unexplained fatigue. Women often describe a “fullness” or “tightness” in the chest rather than pain. Women have chest symptoms which spread to back or stomach or have isolated discomfort in the jaw, left or right arm, or abdomen. Dizziness or light-headedness may occur with heart pain.
Heart attack symptoms may be more often silent in women and the proportion of unrecognized heart attack is greater in women than in men. Diagnostic tests such as exercise stress testing and procedures may not be as accurate in women. Women are less likely to receive coronary angiography and are less likely to be referred for revascularization procedures such as coronary angioplasty. Women were also less likely to receive secondary preventive therapies.
Since Coronary heart disease can be fatal on first presentation, and because nearly two thirds of women who die suddenly have no previously recognized symptoms, it is essential to prevent coronary heart disease.
Prevention of Cardiovascular Disease is paramount to the health of every woman and fortunately, most Cardiovascular Disease in women is preventable. Dr Koh is committed to improving the cardiovascular health of women.
Read Dr Koh's contribution to article in Women and Home titled 'What doctors get wrong'.
