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No single symptom unmistakably indicates a heart disorder, 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 a heart disorder, even when serious, produces no symptoms until it reaches a late stage. Routine health checkups or a visit to the doctor for another reason may uncover a heart disorder that has caused no symptoms. Sometimes doctors perform procedures to screen for a heart disorder even when there is no evidence of it.
The symptoms of heart disorder 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 a heart disorder. For example, chest pain may be due to a respiratory or digestive disorder rather than to a heart disorder.
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.
Chest
Pain
Pain due to a disorder of the heart, lungs, esophagus, or large blood vessels of the trunk is usually felt in the chest, although it can seem to be located anywhere between the upper abdomen and the jaw, including the arms or shoulders. The discomfort may be described as pressure, gas, burning, aching, or sometimes sharp pain.
Causes
Chest pain has many causes. Immediately life-threatening causes include a heart attack, separation of the layers of the aorta's wall (aortic dissection), rupture of the esophagus, a blood clot in the lungs (pulmonary embolism), and a type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax). Less immediately dangerous causes include an inadequate blood supply to the heart (ischemia), inflammation of the sac that envelops the heart (pericarditis), pneumonia, inflammation of the pancreas (pancreatitis), and certain cancers. Uncomfortable but rarely dangerous causes include acid reflux in the esophagus, peptic ulcer, inflammation of rib cartilage (costochondritis) or of the membranes covering the lungs (pleuritis), strained chest muscles, and a gallbladder disorder. In some people, the valve between the left atrium and left ventricle (mitral valve) bulges 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.
Evaluation
Sometimes the symptoms suggest a cause to the doctor. For example, tightness or a squeezing sensation in the chest that occurs during physical activity and that is relieved by a few minutes of rest suggests angina, which results from an inadequate blood supply to the heart. A sharp pain that worsens when the person lies down or breathes deeply, decreases when the person sits up and leans forward, and is not related to physical activity suggests pericarditis. Pain increased by inhaling deeply can also be caused by pleuritis. A sudden sharp, excruciating pain in the back of the neck, between the shoulder blades, down the back, or in the abdomen that begins fairly quickly may be due to an aortic dissection.
Symptoms due to dangerous and not dangerous chest disorders overlap and vary greatly. Consequently, tests are usually done if people have chest pain. Evaluation and testing are usually done in the hospital or emergency department if a dangerous cause is suspected. The tests are chosen based on the person's physical examination, age, overall health, other symptoms, and risk factors. But most often, an electrocardiogram (ECG), chest x-ray, and measurement of oxygen levels with a small sensor placed over a finger (pulse oximetry) are done. If the doctor suspects a heart attack, blood tests to measure levels of heart muscle enzymes and proteins may be done several times. High levels of these enzymes indicate damage to heart muscle. If angina is suspected, exercise stress testing may be done (see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Exercise Stress Testing).
Pain in the Limbs
Pain may occur when tissues do not get enough blood (a condition called ischemia). Pain occurs because the tissues do not get enough oxygen, which is carried to tissues by the blood, and because waste products, which are carried away from tissues by the blood, accumulate.
If blood flow is completely blocked, as from a blood clot in a large artery, severe constant pain occurs suddenly, and the affected arm or leg becomes pale and cool. If blood flow is only partly blocked, as may occur with atherosclerosis (usually a problem in the legs), the person usually feels a tightening, fatiguing pain in the calf muscle during physical activity. This pain, called claudication, is rapidly relieved by rest and comes back during similar activity.
Pain in the limbs may also result from strained muscles, injury to certain nerves near the spinal cord, formation of blood clots in veins (venous thrombosis), or skin or muscle infections. If the doctor suspects that the pain is caused by a blood vessel disorder, ultrasonography to evaluate blood flow in the affected area may be done.
Shortness
of Breath
Shortness of breath (dyspnea) is the sensation of difficult or labored breathing (see Symptoms and Diagnosis of Lung Disorders: Dyspnea).
Causes
Any disorder that upsets the normal, delicate balance between the body's oxygen supply and oxygen requirement can cause shortness of breath. It is a common symptom of lung disorders, including infections, asthma, and allergies. Shortness of breath can also occur in people who have a disorder of the respiratory muscles, a disorder of the nervous system that interferes with breathing, or too few red blood cells to carry oxygen to tissues (anemia).
Shortness of breath is also a common symptom of heart disorders, mainly heart failure (Heart Failure) and coronary artery disease (Coronary Artery Disease).
In heart failure, shortness of breath 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. This symptom often occurs at night and is then called nocturnal dyspnea. When people sit up and dangle their legs, gravity causes fluid to collect at the base of the lungs, reducing symptoms. Consequently, people with nocturnal dyspnea usually sleep propped up by pillows to avoid lying flat.
In coronary artery disease, shortness of breath usually occurs during physical activity, but in people with severe disease, it may occur during minimal activity or during rest.
Evaluation
Sometimes the symptoms suggest a cause to the doctor. Nocturnal dyspnea that is relieved by sitting up and dangling the legs suggests heart failure. Shortness of breath that occurs during physical activity and is accompanied by chest pain suggests coronary artery disease. Shortness of breath with cough and fever suggests a lung infection. Shortness of breath that seems to be triggered by exposure to something in the environment, such as smoke or animal hair, suggests asthma or an allergic disorder.
If the cause is not obvious, tests are usually done. The tests are chosen based on the person's particular symptoms, physical examination, and other factors suggesting a specific disorder. But most often, a chest x-ray and measurement of oxygen levels with a small sensor placed over a finger (pulse oximetry) are done. Electrocardiography (ECG) is commonly performed in adults, particularly if they have risk factors for heart disorders.
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 disorders can limit a person's ability to perform physical activities. One way to evaluate the severity of a heart disorder 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 disorders may produce no symptoms if people reduce their activity level to compensate for the disorder.
Palpitations
Palpitations are the awareness of heart activity. The sensation may feel like pounding, fluttering, racing, or skipping beats.
Causes
Ordinarily, people do not notice the beating of their heart, but sometimes awareness of normal heart activity is heightened. Many 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 heartbeats. They may feel the heart beating very forcefully or rapidly or sense an irregular heartbeat.
Palpitations may result from a disturbance of heart rhythm (arrhythmia). Arrhythmias range from harmless to life threatening. The most common are premature atrial contractions (PACs) and premature ventricular contractions (PVCs), which are usually harmless. These arrhythmias usually occur in people without a heart disorder, as does paroxysmal supraventricular tachycardia.
Other arrhythmias, such as atrial fibrillation, atrial flutter, and ventricular tachycardia, usually occur in people with a heart disorder such as coronary artery disease, a heart valve disorder, or a disorder that affects the heart's electrical conduction system.
Caffeine, alcohol, and some drugs (such as amphetamines, cocaine, epinephrine, ephedrine, and theophylline) can cause palpitations. Palpitations may also result from an overactive thyroid gland (hyperthyroidism), anemia, a low oxygen level in the blood (hypoxia), and a low potassium level in the blood (hypokalemia).
Evaluation
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. An occasional skipped heartbeat suggests PACs or PVCs. A constant sensation of irregular heartbeats suggests atrial fibrillation. Regular heartbeats that suddenly become rapid, then suddenly slow to the normal rate, suggest supraventricular or ventricular tachycardia. 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. Electrocardiography (ECG) is usually done, but unless symptoms occur during the test, ECG does not usually help with a diagnosis. If symptoms are significant but intermittent, continuous ambulatory ECG may be done (see Holter Monitor: Continuous ECG Readings ). Other possible tests include ultrasonography of the heart (echocardiography) and certain blood tests.
Light-Headedness
and Fainting
Light-headedness (near-syncope) is the feeling that one is about to faint. Fainting (syncope) is a sudden, brief loss of consciousness followed by spontaneous return of consciousness.
Causes
The causes of light-headedness and fainting tend to be the same. A person cannot lose consciousness unless brain function is generally disturbed. This disturbance usually occurs because blood flow to the brain is reduced. Brain blood flow can be reduced by a heart disorder or, more commonly, by something that interferes with the normal return of blood to the heart and thus reduces blood flow to the brain. Older people are particularly susceptible because blood flow to the brain decreases as people age. Brain disorders by themselves rarely cause fainting, unless they also affect the blood vessels. Seizures, a brain disorder, can cause loss of consciousness but are not considered fainting.
In heart disorders, blood flow to the brain may be reduced when the heart rate or rhythm is abnormal (too slow or too fast) or when the heart cannot pump blood adequately because blood flow is blocked. Blood flow can be blocked by a defective heart valve (most commonly, the aortic valve), by blood clots in the lungs or sometimes the heart, and, rarely, by certain heart tumors such as an atrial myxoma.
Many factors can interfere with the return of blood to the heart. Coughing or straining during bowel movements can increase chest pressure, reducing the return of blood to the heart. Healthy soldiers may feel faint or may faint when standing still for a long time (a phenomenon called parade ground syncope), because the leg muscles have to be active to help return blood to the heart. Strong emotion (particularly that triggered by viewing a bloody or gruesome scene) or pain can activate the vagus nerve. As a result, blood vessels widen (dilate), reducing the return of blood to the heart and sometimes causing fainting (called vasovagal syncope). Certain brain and spinal cord disorders and drugs (particularly those used to treat blood pressure) can also dilate blood vessels and 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, usually restoring consciousness.
Evaluation
Doctors must distinguish dangerous causes of fainting from relatively harmless ones. If fainting is preceded by brief warning symptoms such as light-headedness, nausea, yawning, blurred vision, or sweating and occurs during a painful or unpleasant situation, it is probably vasovagal, which is not dangerous. In such cases, doctors perform a physical examination. If results are normal, usually no further testing is needed. Fainting is worrisome in adolescents because it more often indicates a serious heart disorder.
Further testing is needed if fainting occurs without any warning symptoms (particularly during physical activity), is accompanied by shortness of breath or chest pain, or results in injury to the person or if the results of a heart or neurologic examination are abnormal. Electrocardiography (ECG) is often done. Other tests, such as ultrasonography of the heart (echocardiography), tilt table testing, and electrophysiologic testing (see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Electrophysiologic Testing) are sometimes useful.
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).
Last full review/revision April 2006 by Paul H. Tanser, MD
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