1 Sudden onset of tearing chest pain radiating to the back
could be aortic dissection.
2 Sudden onset of syncope with palpitations and brisk
recovery is typical of an arrhythmia.
3 Always include infective endocarditis in your differential
for fever, weight loss and night sweats.
4 Central, crushing chest pain is MI until proved otherwise.
5 Exercise-induced chest pain needs rapid referral to exclude
myocardial ischaemia.
6 Attacks of anxiety, flushing and palpitations in a
hypertensive patient may signify a curable cause of
hypertension.
7 Sudden onset of shortness of breath and pleuritic chest
pain – think of pulmonary embolus.
8 Shortness of breath on walking or lying down could be
heart failure.
9 Thyroid patients with palpitations may require
anticoagulation to prevent stroke.
10 Investigate the heart in a young stroke (< 65 years old).
_____________________________________________________________________
1 Thoracic aorta dissection
If a patient presents with sudden onset, tearing chest pain radi-
ating to the back, think of acute dissection of the thoracic aorta.
Although rare, it carries a high mortality if untreated. Thrombo-
lysis will kill in this condition, so always look for mediastinal
widening on CXR before thrombolysing. The patient is usually
very unwell, with nausea, sweating and pallor. If the spinal
arteries are involved, there may be weakness; if the subclavian
is involved, there may be radio-radial pulse delay. ST elevation
may be seen on the ECG. Disorders of connective tissue, such as
Marfan’s syndrome, predispose. CT angiogram confirms the
diagnosis, and emergency surgery may be required.
Action: Refer immediately to cardiology or cardiothoracic
surgery (mortality increases by 2% every hour).
2 Arrhythmic syncope
History, especially from a witness, is crucial in the diagnosis of
syncope. Cardiogenic syncope is likely when the onset is ab-
rupt, dysrhythmia occurs, and recovery is quick when normal
rhythm and circulation are restored. Syncope could be due to
either a brady (e.g. asystole) or tachy (e.g. ventricular tachy-
cardia) arrhythmia, and if palpitations are reported, their
nature may provide a clue (slow, fast, regular or irregular).
Structural heart disease (e.g. hypertrophic cardiomyopathy) or
ischaemic heart disease often coexist with arrthymias and syn-
cope. Remember that a broad complex tachycardia in a patient
with ischaemic heart disease is ventricular tachycardia until
proved otherwise.
Action: Take a detailed history about the event, cardiovascular
risk factors, family and medication history. Perform a cardio-
vascular examination. Do an ECG. If the patient is haemo-
dynamically compromised, unwell, or the ECG shows an
arrhythmia, refer immediately; otherwise refer urgently to
cardiology.
3 Infective endocarditis
C A R D I O L O G Fever, weight loss and night sweats are features of infective
endocarditis, lymphoma and tuberculosis. For all these condi-
tions, the presentation is stealthy, and missing the diagnosis
can prove disastrous. Risk factors for infective endocarditis
include damaged native valves, prosthetic valves, permanent
pacemakers and intravenous drug abuse. Untreated, infective
endocarditis is fatal, resulting in haemodynamic compromise
or systemic sepsis. Emboli from marantic vegetations can lodge
anywhere within the circulation, resulting in stroke, peripheral
limb ischaemia or gut infarction. The patient is often unwell
and may have a new murmur.
Action:Take a detailed history and perform a full systematic
examination. Listen for new murmurs. Refer immediately to
the medical team.
4 Acute myocardial infarction
MI is a common medical emergency. Typically, patients pre-
sent with central, crushing chest pain, radiating to the arms
and jaws. Often these symptoms are accompanied by nausea,
sweating, pallor and a sense of impending death. Younger
patients may not have known risk factors.
Action: Give aspirin, Do an ECG and thrombolyse
immediately if there are no contraindications.
5 Chronic stable angina
Chest pain on exertion may indicate myocardial ischaemia due
to coronary atherosclerosis. Patients at high risk include those
with diabetes, hypertension, hyperlipidaemia, and those who
smoke. Age is also an important risk factor.
Action:Take a detailed history and perform a cardiovascular
examination, looking out for signs of valvular heart disease
and heart failure. Do an ECG. Address risk factors, and
commence aspirin and a beta blocker if there are no contrain-
dications. Refer to the rapid access chest pain clinic.
6 Phaeochromocytoma
Phaeochromocytoma is a rare cause of secondary hyperten-
sion, but one that is often overlooked. It should be considered
in hypertensive patients who suffer from attacks of anxiety,
flushing and palpitations. Many patients report weight loss.
The anxiety symptoms are sometimes discounted as panic
attacks, but are due to sudden release of catecholamines from
the adrenal tumour. This may be precipitated by stress, or even
moving in bed. Removal of the adrenal tumour can cure the
hypertension, so early diagnosis can prevent hypertensive
complications.
Action:Send off a 24-h urine collection for catecholamines.
Refer urgently to a hypertension clinic.
7 Pulmonary embolism
The severity of a PE will reflect the degree of obstruction to the
pulmonary circulation. Presentation may range from a rela-
tively well-looking patient to cardiovascular collapse. Tachyp-
noea is almost always present. Sudden onset of shortness of
breath with pleuritic chest pain is typical. Risk factors include
prolonged immobility, recent surgery, malignancy, central
venous cannulation, dehydration, clotting disorders (e.g. anti-
cardiolipin syndrome in lupus) and oral contraception. There
may be a unilateral swollen leg pointing to a deep venous
thrombosis. Untreated, PE can be fatal or lead to severe
pulmonary hypertension.
Action: If arrested, start CPR. Give oxygen. Refer immediately
to medical admissions.
8 Heart failure
Heart failure can be caused by coronary artery and valvular
heart disease, and idiopathic cardiomyopathies. Characteristic
symptoms are shortness of breath on exertion, orthopnoea and
paroxysmal nocturnal dyspnoea. Patients may have deteriorated gradually or may present suddenly to the emergency department. Occasionally, treatment can restore cardiac function
to normal (e.g. mitral valve replacement) if the diagnosis is
made early enough.
Action: In the acute setting, refer immediately to medical
admissions. In other cases, refer urgently to cardiology.
9 Atrial fibrillation and thyroid disease
AF is the commonest arrhythmia, can occur as a complication
of hyperthyroidism, and predisposes to stroke. Be alert, there-
fore, to thyroid patients who complain of palpitations. The risk
of stroke increases with age and cardiovascular risk factors
(e.g. diabetes, hypertension, valvular heart disease). Treatment
involves managing the hyperthyroidism, controlling the ven-
tricular rate and anticoagulating with warfarin.
Action: Ask patient to tap out rhythm (typically irregular) and
identify other risk factors for stroke. Perform a full cardiovas-
cular examination. A 12-lead ECG may identify the arrhythmia
but ambulatory ECG monitoring may be required.
10 ‘Cardiogenic’ stroke
A number of structural heart defects may predispose to stroke.
These include atrial septal defects, congenital valvular defects,
cardiomyopathy with ventricular thrombus and left atrial
myxoma. Many of these can be easily treated (e.g. closure of
an atrial septal defect). They must always be considered in a
patient under 65 who presents with stroke.
Action: Refer for transthoracic or transoesophageal echocardi-
ography.
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