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Friday, March 22, 2013

Difficulty breathing - one of the symptoms of heart failure

difficulty breathing breathlessness dyspnoeaDyspnoea or Breathlessness can be defined as an awereness of increased drive to breathe. It is normal on exercise. It is pathological if it occurs while doing something that does not require much exertion.

Breathlessness is a non-specific symptom as it can be caused by cardiac, respiratory, neuromuscular and metabolic conditions. Today we will look at the cardiac causes of difficulty breathing.

There are several caused of difficulty breathing  due to heart problems:
  1. Acute left heart failure
  2. Chronic heart failure
  3. Arrythmia
  4. Angina equivalent

Acute left heart failure:

Acute left heart failure can be caused by myocardial infarction in a normal heart or atrial fibrillation in a diseased heart.

Breathlessness is one of the main symptoms of heart failure.

In heart failure, the heart is unable to pump blood effectively and blood starts to accumulate in the pulmonary vessels leading to venous congestion. When the hydrostatic pressure of the pulmonary vessels increase more than the oncotic pressure of plasma (25-30mmHg), blood starts to move out from the capillaries into the lung alveoli causing acute pulmonary edema. This stimulates the respiration producing rapid shallow breathing. Wheeze may be present (cardiac asthma).

The patient describes it as 'fighting for breath' and sitting upright or standing may provide some relief by reducing the congestion from the lung apices. The patient is unable to speak, agitated, distressed and pale. Sputum may be frothy and blood streaked.

Chronic heart failure:

Chronic heart failure is the most common cause of difficulty breathing due to cardiac cause. The degree of breathlessness increases with time as the heart failure progresses.

Patients may initially complain of breathless on moderate exertion, such as walking uphill. As heart failure becomes worse, breathless becomes more frequent and occurs with less exertion such as walking from room to room or even talking.

Other symptoms that are present in chronic heart failure are:

  • Orthopnea
  • Paroxysmal nocturnal dyspnoea
  • Cheyne-Stokes respiration

Arrhythmia:

Any arrhythmia can cause breathlessness if it occurs in a heart which is structurally abnormal, for example, a heart with mitral stenosis.

Angina equivalent:

Breathlessness is a common feature of angina (chest pain due to low blood supply to the heart or myocardial ischemia), where patients describe chest tightness as 'breathlessness' which is really not breathlessness. However, myocardial ischemia can also cause true breathless by provoking left ventricular dysfunction or heart failure. When breathlessness is the dominant feature of myocardial ischemia, it is called 'angina equivalent'.

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