In this month’s Your Questions Answered series we take a look at some of the common heart conditions that people experience.
Dr Roby Rakhit is clinical director of cardiology at St John & St Elizabeth Hospital. His scope of practice includes all aspects of general cardiology including cardiovascular prevention, diagnosis and treatment of hypertension, hyperlipidaemia, heart failure, valvular heart disease and arrhythmia, and he is responsible for setting up one of the UK’s first direct access 24/7 Heart Attack Centres. Here, he takes us through the signs and effects of some of the most common heart conditions.
What is it?
Angina is a symptom of chest pain which may imply underlying coronary heart disease, meaning that one or more of the three coronary arteries that supply blood and oxygen to the heart may have become narrowed or blocked. This occurs due to a build-up of plaque, which includes cholesterol, fat and/or calcium.
How can you identify angina?
Angina is typically a constricting central chest pain, which is often provoked by exertion. There are certain features which would be typical of angina, for example if that pain radiates and moves to the base of the throat or the jaw, and if it moves to the inner aspect of the left arm, that would be suggestive of angina.
Sometimes the chest pain can occur unprovoked at night, or it can occur after a heavy meal – which is why many patients often mistake this for indigestion. The term for this is postprandial angina.
A hallmark of something potentially serious is any angina chest pain at rest or under minimal exertion, or angina which has come on recently and is worsening rapidly. That would potentially be an indication of a serious situation and possibly a forerunner to a heart attack. We term this worsening pain over a short period of time ‘crescendo angina’.
What are they?
A heart murmur is a sound which is audible with a stethoscope, normally due to turbulence of blood flow through one of the four heart valves. Up to 20% of heart murmurs are what we call ‘innocent’, and they just reflect turbulence across normally functioning valves.
In pregnancy, as the mother has the child and the circulation enlarges to support the placenta, it is quite common to have heart murmurs in a high percentage of patients; up to a third of pregnant women can have heart murmurs due to their increased circulation or pregnancy, and they’re innocent.
We must distinguish an innocent murmur from a murmur which is normally due to a structural abnormality of one of the four heart valves. That abnormality can either be a narrowing – we call that a stenosis – of a heart valve, or a leak, and we call that regurgitation of a heart valve.
Can you tell if you have a heart murmur?
No – a murmur is a clinical sign, it’s not a symptom. However, in those patients who may have a significant underlying valvular heart disease, we would expect symptoms of breathlessness, chest pain or palpitations and – rarely – dizziness or blackouts. Those would be potential symptoms of a significant heart valve problem.
Can caffeine cause or affect a heart murmur?
Caffeine is a stimulant and it can increase the heart rate and it can also decrease the blood pressure. By decreasing the blood pressure, the heart has to work a bit stronger, and therefore one might hear a heart murmur increase in intensity due to the physiological effects of caffeine on the circulation and the heart.
What is it?
Heart failure is a bad term because it implies the heart is going to fail. There is a spectrum; heart failure is really a clinical syndrome, which encompasses three things. First, there are the symptoms: the heart is weakened, and the principal symptom of that would be breathlessness.
Secondly, there are the clinical signs on examination, which may include a more rapid heart rate, more rapid pulse, or swelling (oedema) – primarily involving the ankles and the lower limbs below the knee. There may also be signs of fluid within the chest, which we call crepitations and are audible on a stethoscope.
The third aspect of the clinical syndrome of heart failure is objective investigation, normally with echocardiography – which is an ultrasound examination of the heart – to confirm that there is weakness of the heart muscle.
So a combination of appropriate symptoms, appropriate clinical signs and echocardiographic examination showing a weakened heart muscle would fulfil the criteria for heart failure.
Can heart failure lead to a stroke?
No, these are two separate conditions. Stroke, in conjunction with heart disease, is normally due to a clot forming within the heart. We would typically see that either in the context of a valvular heart condition, after a heart attack where clots can rarely form within the cavity of the heart muscle after an acute heart attack, and thirdly in the context of abnormal rhythm disturbance of the heart.
What should you do if you suspect you have heart failure?
Heart failure is very common, it affects 20% of the elderly population and it has a very poor prognosis. Anyone with signs, symptoms or concerns should seek cardiology advice quickly, because we know that appropriate investigation and treatment can have an enormous impact on prolonging life expectancy and improving symptoms.
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