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Taking heart about breathlessness

When a patient comes to see me complaining of unexplained breathlessness, different possibilities immediately go through my mind. The first thing to rule out is lung disease, like asthma, COPD or lung cancer. Early lung cancer symptoms are often mild and can be mistaken for bronchitis or ‘smokers cough’ but later stage disease often presents as acute breathlessness.

But I am also very aware that the breathlessness may also be caused by other underlying issues, like anxiety, anaemia, or heart disease. In fact, when I see a patient on the first consultation for breathlessness, it is most commonly lung disease or heart disease. Patients with heart problems causing their breathlessness are typically older – it is uncommon to see heart disease in people under the age of 40 – and may have smoked in the past, if not the present. They may have already had a heart attack which has damaged the heart wall muscle, known as ischaemic heart disease. Heart disease can lead to an enlarged heart, known as cardiomegaly when the ventricles, which control the flow of blood through the heart, become floppy and no longer contract properly.

Clubbing of the fingers is actually uncommon, but they will often tell me that they wake up at night gasping for breath, a condition known as paroxysmal nocturnal dyspnoea. Generally, when we are sleeping, the heart slows down, which exacerbates the problem of too little oxygenated blood getting to the tissues of the body.

Essentially, if the heart is not pumping properly, blood flow around the body slows and stagnates. I use an analogy of a central heating systems where the pump isn’t working as it should. Some of the radiators don’t work. It is the same with heart failure.

When I suspect heart disease, I refer a patient for a chest X-ray and blood tests which can accurately show if the heart is damaged. Quick diagnosis is important because treatment can be very effective at reducing the problem of breathlessness which can interfere with quality of life. Many people who suffer from breathlessness find it hard to eat. Imagine going for a half mile sprint and then sitting down for a three-course meal. That is what it feels like to someone who is breathless at the slightest exertion. Furthermore, the intestines themselves become congested as they lose an adequate blood supply and are no longer able to absorb nutrients effectively.

Everyone is individual but usual treatments for heart disease include ACE inhibitors and beta blockers which give the heart respite by slowing it down. Diuretics can also be used to get rid of excess fluid. No one is going to return to peak fitness, but their symptoms should improve significantly.

If someone is concerned about breathlessness which isn’t resolving, but feels that their GP has dismissed it too quickly, I advise them to ask for another appointment in a few weeks time and explain that the problem has not gone away. Most doctors will take symptoms of breathlessness seriously and will do the follow-ups that are required to find the root cause of the problem.

Dr Ian Watson, is supporting this year’s Be Clear on Cancer campaign, which is raising awareness of the symptoms of a persistent cough and inappropriate breathlessness, as they could be a sign of lung disease, including cancer or even heart disease. 

Dr Ian Watson
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