Dyspnoea at rest

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This represents the most advanced form of cardiac dyspnoea and indicates the presence of severe heart failure. When it occurs in patients with known cardiac disease and is preceded by a history of worsening effort dyspnoea, orthopnoea and PND and perhaps ankle swelling, a cardiac cause is self-evident. However, patients presenting de novo with acute dyspnoea at rest or who have both lung and heart disease may be more difficult to assess. Other causes include pneumothorax and pulmonary embolism. Unlike patients with acute pulmonary oedema, those with pulmonary embolism are often more comfortable lying flat and may even become unconscious if made to sit upright.

Mechanism

Fluid redistributed Reabsorption of into lungs fluid from tissues into plasma

Fluid redistributed Reabsorption of into lungs fluid from tissues into plasma

Orthopnoea

Rise in left atrial pressure and tall in PO2 during sleep

Causes

Rise in left atrial pressure and tall in PO2 during sleep

Features

Causes

1 Ischaemic heart disease ■ Aortic valve disease

> Hypertension

• Cardiomyopathy

> Atrial fibrillation

1 Rarely in mitral valve disease or atrial tumours

Fig. 3.2 Paroxysmal nocturnal dyspnoea.

CASE HISTORY

A 65-year-old man gave a 6-month history of progressive breathlessness on exertion to such an extent that he had difficulty climbing the stairs to his bedroom. For 2 weeks, he had felt more breathless in bed and had begun to sleep with two extra pillows. On the night of admtssion, he had woken gasping for breath,

On examination, he was dyspnoeic with a regular tachycardia and a weak thready pulse, There was pitting oedema over the ankles and sacrum. The liver was palpably enlarged and the jugular venous pressu re was elevated to 8 cm with a normal waveform, There were fine expiratory crackles at the lung bases. The ECG showed a sinus tachycardia of 120 per minute with evidence of a previous anterior myocardial Infarction (Fig. 3.3). The chest X-ray (Fig. 3.4) showed cardiac enlargement with pulmonary oedema. The urea and electrolytes, the haemoglobin and the cardiac enzymes were normal.

He was treated with diuretics and an angiotensin-converting enzyme inhibitor. An echocardiogram subsequently showed significant Impairment of left ventricular function with an extensive scar over the anterior wall of the ventricle (Fig. 3.5).

Learning poinls

• The first priority was to establish that the breathlessness was caused by cardiac failure.

• The second was to exclude any acute precipitating factor, such as a recent myocardial infarct, the development of an arrhythmia or anaemia.

PALPITATIONS

Palpitations are the sensation of the heart beating in the chest. Terms such as thumping, pounding, fluttering, jumping, racing and bumping are often used by the patient. Palpitations may be dtie to a heightened awareness of the heart beating in sinus rhythm, awareness of occasional irregularities of the heart beat (e.g. ventricular extrasystoles) or awareness of the heart beating in an abnormal rhythm. Most patients complaining of palpitations do not have an arrhythmia and not all patients with arrhythmia have palpitations, e.g. atrial fibrillation is commonly asymptomatic. Although investi gation is commonly required to confirm the diagnosis, the history can frequently distinguish between the different types of palpitations (Table 3.13). Important aspects of the history include:

• the frequency

• the duration of attacks

• the awareness of the heart beat and its regularity.

The rate and rhythm may be clarified by asking the patient to tap out tlie sensation experienced during an attack. Additional specific questions may he required to obtain further information

Crepitations

Fig Paroxysmal Nocturnal Dyspnea

Crepitations

Dyspnoea Cough

Frothy sputum Pallor Sweating Tachycardia

Lead Ecg Anterior Infarct
Fig. 3.3 12-lead ECG showing 0 waves In leads V1-V4 indicative of established anterior myocardial infarction.
Fig Paroxysmal Nocturnal Dyspnoea

Fig. 3.5 Still frame from the echocardiogram in a parasternal long axis view. This shows thinning of the interventricular septum which has an irregular shape and bright echoes indicating fibrous scarring. This is the site of an old infarct. LA = left atrium, LV = left ventricle. Ao = aortic root.

Fig. 3.4 Chest x-ray showing cardiomegaly with left ventricular predominence and fluffy opacification in both lung fields, particularly on the right side, indicative of pulmonary oedema. The veins to both upper lobes are distended.

Fig. 3.5 Still frame from the echocardiogram in a parasternal long axis view. This shows thinning of the interventricular septum which has an irregular shape and bright echoes indicating fibrous scarring. This is the site of an old infarct. LA = left atrium, LV = left ventricle. Ao = aortic root.

TABLE 3.13 Descriptions of a rrhyth mias

Arrhythmia

Patient's description

Ventricular or atrial exfrasysloles

'Heart misses a beat' Heart 'jumps' or 'flutters'

Atrial fibrillation

Heart 'jumping about' or 'racing' Associated brealhlessness May be unnoticed

Supraventricular tachycardia

Heart racing or fluttering Associated polyuria

Ventricular tachycardia

Heart racing or fluttering. Associated brealhlessness

Ventricular tachycardia may present as syncope rather than as palpitation

regarding the nature of the palpitations and also possible underlying pathology.

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Responses

  • ariam
    What is dyspnoeic with a regular tachycardia and a weak thready pulse?
    7 years ago

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