Paroxysmal nocturnal dyspnoea (PNO)

This occurs when there is an accumulation of fluid in the lungs (pulmonary oedema) at night. The mechanism is similar to orthopnoea, but because sensory awareness is depressed during sleep, severe interstitial and alveolar oedema can accumulate. The patient is woken from sleep fighting for breath, a dramatic and frightening experience. The breathlessness may be relieved by sitting on the side of the bed or getting up. Sometimes the patient will get up and open a window to gasp for fresh air. Wheezing, due to bronchial endothelial oedema, is common (cardiac asthma), and a cough, often productive of frothy or blood-tinged sputum, usually occurs. Initially these episodes terminate spontaneously. Episodes of ‘PND’, often with coughing, can occur in asthma, but conventionally the term is reserved for cardiac problems.

The New York Heart Association grading of 'cardiac status'.
The New York Heart Association grading of
‘cardiac status’.

Cheyne-Stokes respiration

In very severe heart failure, alternate hyperventilation and apnoea known as Cheyne-Stokes respiration may occur. This may also develop in the elderly without obvious heart failure. It is related to depression of the respiratory centre, which is partly due to prolonged circulation time and cerebrovascular disease. This type of respiration is also seen after morphine administration.

Chest pain

Pain in the chest is the most common symptom associatedwith ischaemic heart disease .

Angina pectoris

Angina pectoris literally means a strangling sensation (angina) in the chest (pectoris). It is a gripping or crushing central chest pain (or discomfort) that may be felt around the whole chest or deep within the chest. The pain may radiate into the neck or jaw and, rarely, into the teeth, back or abdomen. It is associated with heaviness, paraesthesia or pain in one (usually the left) or both arms. It is typically provoked by exercise and is promptly relieved by rest. A pain of similar distribution and type also occurs at rest in myocardial infarction.
The mechanism of the pain is myocardial hypoxia secondary to inadequate coronary blood flow. Sharp pains over the heart are not usually angina. Angina should be classified according to the Canadian Cardiovascular Society grading of angina of effort although most physicians find that a verbal description is adequate. Other causes of chest pain The pain of pericarditis is felt in the centre of the chest and, lilee that of pleurisy, is aggravated by movement, posture, respiration and coughing. It is sharp and severe. Central chest pain that radiates to the back is characteristic of a dissecting or enlarging aortic aneurysm and can mimic the pain of myocardial infarction. It is important to consider and exclude a dissection since the administration of a thrombolytic agent in this circumstance would be catastrophic.
Left, sub mammary stabbing pain, known as ‘precordial catch’ is usually associated with anxiety and is sometimes known as effort (Da Costa’s) syndrome. Occasionally, cardiac conditions such as mitral valve prolapse cause similar pain. Central chest pain similar to angina can occur with oesophageal disease and can be difficult to differentiate.
Other causes of chest pain are pulmonary embolism, pulmonary hypertension, costochondritis, pleurisy, pneumothorax and mediastinitis.

The Canadian Cardiovascular Society grading of angina of effort.
The Canadian Cardiovascular Society grading of
angina of effort.


A palpitation is an increased awareness of the normal heart beat or the sensation of slow or rapid heart rate or an irregular heart rhythm. The normal heart beat is sensed when the patient is anxious, excited, exercising, or lying on the left side. The most common arrhythmias to be felt as palpitations are premature ectopic beats and paroxysmal tachycardias.

Premature beats

These are usually felt as ‘missed beats’ because the premature beat is followed by a pause before the next normal  beat, which is rather forceful because of the longer diastolic filling period. Premature beats often occur in clusters and may cause the patient much anxiety. Paroxysmal tachycardias. These start abruptly and may terminate equally suddenly. Often, however, the tachycardia slows before terminating and therefore seems to fade away. Paroxysmal atrial fibrillation is noticeably irregular, whereas other forms of paroxysmal supraventricular or ventricular tachycardia are regular. Paroxysms of rapid tachycardia, especially when prolonged, may be associated with syncope, presyncope, dyspnoea or chest pain. Palpitations can be graded in a similar way to the grading of dyspnoea or angina. Supraventricular tachycardias, such as atrial fibrillation or junctional tachycardias, may produce polyuria. Bradycardias An unduly slow heart rate may be appreciated as slow, regular, ‘heavy’ or forceful beats. Most often bradycardias are not felt as palpitations.


Syncope can be due to many causes, the most common of which is situational or vasovagal syncope. These attacks may be provoked by fright, anxiety, phobias or other situations such as micturition or coughing. The basic mechanism is vasodilatation leading to venous pooling followed by emptying of the heart. Vigorous contraction of the near-empty heart stimulates mechanoreceptors in the infero-posterior wall of the left ventricle. Consequent reflexes via the central nervous system leads to further vasodilatation and sometimes profound bradycardia. This is known as ‘neurocardiogenic’ syncope. The episodes are usually associated with a prodome that consists of dizziness, nausea, sweating, ringing in the ears, a sinking feeling and yawning. Recovery occurs within a few seconds. Cardiovascular syncope is usually sudden and brief. The classical variety is known as a Stokes-Adams attack and is due to a disturbance of cardiac rhythm, e.g. a profound bradycardia related to complete heart block. Without warning the patient falls to the ground, pale and deeply unconscious. The pulse is usually very slow or absent. After a few seconds the patient flushes brightly and recovers consciousness as the pulse quickens. If the period of unconsciousness is prolonged the patient may suffer a generalized convulsion but this is not usual. Often there are no sequelae but patients may injure themselves during falls.
Other causes of syncope due to heart disease can be grouped as cardiac arrhythmias or valvular or vascular obstruction.


This symptom, which consists of tiredness and lethargy, is associated with heart failure, persistent cardiac arrhythmias and cyanotic heart disease. It is due to poor cerebral and peripheral perfusion and poor oxygenation. When severe cardiac disorders are not present, an active infection such as infective endocarditis may be responsible.  However, disorders of most systems may produce this non-specific symptom. Drugs prescribed for angina or hypertension, particularly J3-blockers, may cause fatigue.


Heart failure results in salt and water retention. Retained fluid accumulates in the feet and ankles of ambulant patients and over the sacrum of bed-bound patients. The oedema associated with heart failure becomes progressively worse during the day and is often absent on initial rising as the fluid is reabsorbed on lying down. When severe, the calf and thigh may become oedema to us and ascites or a pleural effusion may develop.

Cardiac causes of syncope.
Cardiac causes of syncope.

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