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Breathlessness - Management
What are the clinical features of the common cardiac causes of breathlessness?

  • Silent myocardial infarction
    • Risk factors — smoking, high blood lipid levels, hypertension, obesity, diabetes, family history.
    • Symptoms — breathlessness, general malaise, sudden collapse, upper body discomfort.
    • Signs — breathless (sometimes), abnormal pulse rate, sweating, reduced peripheral perfusion.
    • Electrocardiogram (ECG) — features suggestive of acute MI include ST depression with T-wave inversion, persistent ST elevation, or new left bundle branch block. Q-waves are characteristic of a resolved MI.
  • Cardiac arrhythmia
    • Risk factors — heart failure, valvular heart disease, ischaemic heart disease.
    • Symptoms — palpitations, breathlessness, chest pain, syncope (or near syncope).
    • Signs — bradycardia or tachycardia.
    • ECG — changes that are evident when the person is symptomatic are diagnostic. Typical ECG features of supraventricular tachycardia (SVT) that are treatable in primary care include:
      • P-waves (usually not identifiable), regular narrow QRS complex tachycardia (unless the person has a bundle branch block as well), and a rate that is usually 130–250 bpm.
      • For an image of a typical SVT trace, see Wikimedia Commons.
  • Acute pulmonary oedema
    • Risk factors — chronic heart failure, ischaemic heart disease, valvular heart disease.
    • Symptoms — severe breathlessness, orthopnea, coughing (rarely frothy blood-stained sputum).
    • Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (occasionally) wheeze. Peripheral circulation is shut down (in contrast to people with an acute exacerbation of chronic obstructive pulmonary disease).
  • Chronic heart failure
    • Risk factors — hypertension, ischaemic heart disease, valvular heart disease, chronic cardiac arrhythmia.
    • Symptoms — fatigue and breathlessness, including orthopnea and paroxysmal nocturnal dyspnoea.
    • Signs — basal crackles, displaced apex beat, third heart sound, and (if congestive cardiac failure is present) increased jugular venous pressure, dependent oedema, and hepatomegaly.

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