A common question I get is “How do I know I have a heart problem”? Today, we will explore the common symptoms that may indicate that you have a heart problem.

 

Before we get into the specific symptoms that you may experience, one key point to remember, is that heart disease may be silent, and so regular check-up with your family physician is a good way to determine this. This is especially true for younger persons. At this time of year, as school children go on holidays, and parents grapple with all of the expenses of the summer break and back-to school preparations, the “Back-to-school Medical” is one big item on the agenda.

 

The “Back-to-School Medical” is probably the most important thing that you can do for your child, and it should not be short-changed. Do not ask a “doctor friend” to just sign the child’s form without actually examining the child. This exercise, that parents find annoying, expensive can make the difference between finding out your child has a health condition, or collapsing on the field at school from un-detected heart or other health condition. We will spend some time on the “Back-to-School Medical” in the future, but for today, suffice it to say, don’t scrimp. Save on that expensive book bag and get the child examined properly!

 

For older persons, who do not have any symptoms it is recommended that you get a medical examination at age 20 years with your family doctor and every five (5) years thereafter if this baseline medical is normal. This medical examination should include the following:

• Complete review of your history or what we call a symptom review
• Detailed Physical examination – weight, height, blood pressure, heart rate, heart examination, chest examination
• Blood tests – Kidney and electrolytes, Cholesterol profile, Fasting Blood Glucose and Complete Blood count
• ECG – especially if you have a family history of heart disease, or any hypertension is detected on your screening
• Additional tests determined by your physician

 

For persons who have heart disease, the symptoms that one might experience include

• Shortness of Breath
• Chest pain
• Palpitations
• Cough
• Fainting or near fainting spells

 

Shortness of Breath

Shortness of breath is often described as breathing faster than usual, or having difficulty catching one’s breath. There are certain circumstances under which shortness of breath will be “normal”, for example during or after physical exertion such as climbing flight of stairs, running, brisk walking, swimming, or playing a strenuous sport. Shortness of breath becomes significant if it occurs while sitting, or lying down, or if there is a change in your level of fitness. For example if you were able to climb a flight of stairs without feeling short of breath and now you have to stop several times to catch your breath before you get to the top.

 

While shortness of breath may indicate the presence of significant heart disease, it may also indicate the following

• Anaemia or low blood count
• Lung disease – example Asthma

It is therefore very important that you see your family physician to explore some of these possibilities, before assuming it is a heart problem

 

Chest pain

Chest pain may be caused by several different conditions

• Heart disease
• Lung disease – example pneumonia,
• Muscle/Joint problems – example inflammation of the joints between the breast plate and the ribs called costo-chondritits
• Acid reflux or stomach ulcer

Chest pain that is likely to be coming from the heart may be due to Coronary Artery disease(poor circulation to the heart) known as Angina or Inflammation of the lining of the heart – called pericarditis. Angina pain tends to have the following characteristics

Usually just below the breast plate

Heavy, or pressing feeling

Usually brought by exertion but may occur at rest

If you have been experiencing this type of pain, you need to visit your physician.

If you experience chest pain at rest, which fits these criteria, this is considered a medical emergency and should be treated as such! You should call for help and get someone to drive you to the ER or call an ambulance. It could mean that you are having a heart attack. Chest pain emergency if

• Chest pain at rest or with minimal exertion
• Lasts more than 10 minutes
• Is pressing/heavy in nature
• You are 40 years or older
• You have a history of hypertension, diabetes, high cholesterol, you smoke or have family history of heart attack

 

A heart attack, or suspected heart attack is a medical emergency. You will need to have an urgent ECG and blood tests to confirm, or rule out the heart attack, or other potentially life-threatening causes of persistent chest pain such as clot on the lung or pulmonary embolism or tear in the major artery (Aortic dissection).

 

 

 

Part II – Palpitations, Fainting and Cough

 

Palpitations

A palpitation is the sensation that the heart is beating faster or stronger or an increased awareness of your heart beat, or that the heart is “skipping a beat”. Under normal circumstances, the heart beats in the background and we are not usually aware that it is there. It is “normal” to feel the heart beat stronger during or after physical exertion, as it is working harder to pump blood around the body to meet the increased demands that exercise places for oxygen and other nutrients.

 

If you notice palpitations as described, while you are sitting, or lying down, or if you get these symptoms long after exercise has stopped, or you feel dizzy or light-headed during this time, it may indicate a heart problem. Palpitations may be an indication that your heart rhythm may not be normal – what we call an arrhythmia – abnormal or irregular beating of the heart. Occasional skipping of the heart beat at rest, without the accompanying symptoms of chest pain or light-headedness may be an indication of and extra-heart beat. Usually after this extra heart beat, the timer in the heart “re-sets” itself so you may feel a little pause right after, like there is no heart beat, and then a strong beat. This can be “ normal” for up to 30% of normal persons. It is important though to have it checked out with your physician.

 

Otherwise from heart disease, palpitations may be an indicator of another general medical problem such as Anemia (low blood count) or an overactive Thyroid gland.

There are also some foods, drinks and over-the-counter medications that have stimulants, and may trigger palpitations. It is recommended that you cut these from your diet or treatment plan if palpitations are bothersome to you.

• Caffeine – tea ( not herbal), example green or black tea, pepsi, coca-cola, chocolate, energy drinks( example red-bull)
• Pseudo-ephedrine – this is a common component of Over-The-Counter (OTC) cough and cold and sinus medications such as Tylenol cold and sinus and Allegra-D. This is the active ingredient that helps to dry up secretions, and make you feel less congested. It is also a potent stimulant for the heart and can make the heart beat faster or stronger
• Side effect of Prescribed medications – such as high blood pressure medications

 

See your doctor for palpitations if

• Palpitations while sitting or lying down
• Not taking any caffeine or over the counter medications for cold or sinus
• Palpitations last for more than a few seconds
• You feel light headed, faint or have chest pain during or after the palpitations

Your doctor will take a detailed history and examination, and an ECG should be done, with expert interpretation. Depending on these findings, the doctor may refer you to a cardiologist for further testing which may include additional tests such as an Echocardiogram (Ultrasound of the heart) or 24 Hour Holter ( 24 hour ECG recording).

 

Fainting (Syncope) or Near-fainting (Pre-syncope) and Dizziness

Fainting is a sudden, brief loss of consciousness, usually lasting a few seconds. It usually results with the person falling to the floor with prompt recovery of consciousness when the person is lying or sitting down. Loss of consciousness that is longer than a few seconds is not truly a fainting spell and could be seizure or other indication of a brain problem. Some persons may not experience loss of consciousness, but may feel light-headed, like they are going to black out, but do not actually black out. This is referred to as near-fainting.

 

This is to be distinguished from dizziness which in medical language we call vertigo and is classically described as a feeling of being unsteady, or that the person is spinning relative to the room, or the room is spinning. Dizziness (vertigo) is more an indication that the balance mechanism is out of whack and could indicate an inner/middle ear problem or brain problem affecting the balance mechanism.

 

Fainting or near fainting may be what is referred to a simple faint (vaso-vagal syncope) – which has no underlying heart problem, can be due to dehydration or other easily remediable fixes. A simple faint, does not usually indicate a heart problem, but if the person who has fainted has never had a medical examination, it should be done and then the person can be re-assured if normal. When not due to vaso-vagal syncope (or simple faint), fainting may indicate the following potentially serious underlying heart conditions

• Arrhythmias – abnormal fast or irregular heart beat
• Severe heart valve problems
• Other severe problems of heart structure

 

Any episode of fainting should be reviewed by a physician

 

Cough

A cough that is lasting more than a few days, and not in association with flu-like symptoms may be an indication of heart disease, particularly heart failure. A cough occurs in heart failure, when the heart is not pumping strong enough, it leads to a build-up of fluid in the lungs. The cough associated with heart failure has the following features

• Usually at night or while lying down
• Usually-wet sounding
• May be dry, or wet sounding
• The mucus that comes up tends to be frothy or even pink-ish

 

As a reminder – if you experience any of these symptoms and are concerned – see your family physician right away. For chest pain lasting more than 10 minutes, for persons over 40 years old, especially with any underlying medical problems such as high cholesterol, diabetes or hypertension – and Emergency Room visit is a must. Do not wait to see your physician during regular hours, or “watch it”.

 

The school medical examination has been practiced in Jamaica for several years, and in September 2012 Minister of Education the Rev Hon Ronald Thwaites made mandatory for all children entering Grade One (1) and Grade seven (7).  Jamaica is not the only country that practices mandatory health screening for school-age children. This practice is also observed in Germany, Bahamas, Australia to name a few. The US does not have mandatory screening, however annual well-child Paediatrician visits are encouraged and widely practiced. The UK instituted mandatory routine screening in the early 1960’s and then changed in favour of selective screening. Selective screening is where the child is only taken for a physical exam if they exhibit symptoms.

 

While routine screening is controversial, at best, it is useful in guiding parents and children about the child’s involvement in physical activity and sports. These children, and their parents would have otherwise had no knowledge of the existence of any sort of health or heart problems. The child and the parent can then be counseled re participation in physical activity and sports, and not be caught off guard in the middle of the school year, or at worse be faced with a child who collapses during Physical Education classes or other physical activity.

 

 

The objectives of such a screening program are:

1. To detect silent medical problems that may interfere with the child’s learning and performance at school including
   1. Abnormal hearing.
   4. Abnormal vision.
   5. Referral and detected dental caries.
   6. Heart disease.
   7. Sickle cell.
2. To determine immunization coverage.
3. To list any other pertinent health information.

 

 

The school medical may be performed at child’s paediatrican, Family doctor or community health centre. Schools will usually provide the form which has two (2) parts. The first part asks the parents to document details of the child’s medical history and the second is the part to be completed by the Physician or Nurse Practitioner.

 

In Jamaica, the school medical exam includes the following

1. Comprehensive medical and family history completed by parent
2. Immunization History
3. Weight, Height, Vision screening, Urine testing, Blood Pressure
4. Head-to-toe examination performed by a physician or Nurse Practitioner
5. Recommendations for physical activity and or referrals for further evaluation and treatment for children who have abnormal findings during screening.

 

 

While some parents my find the school medical a nuisance or expensive, it is one of the best things you can do for your child and should be placed above the new uniforms, and new Jansport® Bags. The American Pediatric association reports that one in four 1:4 children may have vision problems. Children with these problems may exhibit poor school performance or behavioural problems. It is recommended that each child receive an annual examination on his birthday by Paediatrician or Family Physician. Here in Jamaica, lots of other things take priority, and so the school medical is the ideal opportunity to get this done. In addition to picking up vision and hearing problems, one of the major benefits is the early detection of silent heart disease.

 

 

Although the evidence is mixed regarding screening for hypertension before 18 years of age, many experts recommend checking blood pressure annually beginning at three years of age. The American Academy of Pediatrics recommends vision and hearing screening annually or every two years in school-aged children. One study has shown that physical examination in an asymptomatic, school-aged child will find a new abnormality in less than 4 percent of patients, and most of these abnormalities are not clinically significant. This is the argument used against routine screening of children who do not exhibit any symptoms. This has to be interpreted with caution – noting that this is a single research study, and it is based on information in communities where rheumatic heart disease is extinct etc.

 

 

In our population, Rheumatic fever and rheumatic heart disease are still prevalent and may lead to heart valve damage. Each year, in September, we see a spike in the number of children referred to our heart clinic for echocardiogram to further define a heart murmur detected on routine school medical.

 

Last year, we performed routine screening of school age children for the purposes of the school entrance medical exam. We screened roughly 100 children, up to 7% had abnormal vision screening and were referred to ophthalmologist for further in-depth evaluation and glasses. This is in keeping with figures from other communities and this is one of the major benefits of routine screening.

 

Do your child and yourself a favour, and get a comprehensive health screen on at least these two occasions.