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A.

PRESENTATION
(Language function - introducing the subject)
Chairman: Good morning, Ladies and Gentlemen and welcome to this cardiology refr
esher course. Our first speaker this morning is Jeff Gardener who is going to ta
lk about cardiac symptoms. Jeff...
Dr Gardener: Thank you. Good morning Ladies and Gentlemen. This morning I'd like
to give you a brief overview of some of the more common symptoms of cardiac dis
ease. Before I begin, I'd just like to say that many organic and inorganic disea
ses may mimic the symptoms of heart disease and it is a difficult and challengin
g task for the physician to distinguish between them. Broadly speaking, the symp
toms associated with heart disease result from three types of dysfunction: one,
myocardial ischemia; two, disturbance of cardiac contraction; and three, abnorma
l heart rate or rhythm. As a general rule, the more serious the disease, the mor
e severe the symptoms.
So, to begin, I'd like to look at myocardial ischemia, which is usually manifest
ed as chest pain, and is called angina pectoris. Angina pectoris is central and
crushing in nature like a "tight band". It often radiates across the chest and,
in about a third of patients, to the arms. On the ECG, there is associated ST se
gment depression. Stable angina occurs on effort and is relieved by rest. Unstab
le angina increases on exercise and occurs without warning at rest. Many patient
s with unstable angina need coronary angiography with a view to possible angiopl
asty or surgery. Decubitus angina occurs on lying down at night. During REM slee
p, spasm of the coronary vessels sometimes occurs.
Next, I want to discuss symptoms related to deficiencies in the pumping ability
of the heart. Fatigue and weakness are common symptoms, but are difficult to ass
ess because they are so subjective. Dyspnea on effort or at rest is very common
and is usually classified according to the New York Heart Association criteria o
f effort tolerance. As disability increases, orthopnea and paroxysmal nocturnal
dyspnea, or PND, can occur. PND is caused by pulmonary edema and is usually acco
mpanied by pink frothy sputum or streaky hemoptysis.
Peripheral cyanosis may be present when there is a poor cardiac output and centr
al cyanosis of cardiac origin may be caused by pulmonary atresia or by right to
left shunting. Pitting edema of the ankles, or of the sacrum in the bedridden, i
s a sign of congestive cardiac failure or pericardial constriction.
Another common symptom of heart disease is syncope or loss of consciousness. The
re are many causes of syncope; the most common is vasovagal or fainting. Syncope
of cardiac origin results from a sudden reduction in cardiac output, often caus
ed by a cardiac arrhythmia. As I said, there are other possible causes and, for
example, it is important to distinguish between a Stokes-Adams attack and epilep
sy. In the former there is no warning and the period of unconsciousness is short
with a rapid recovery.
Finally, let me say a few words about cardiac rhythm disturbances. The symptoms
often develop suddenly. Many patients complain of palpitations and will tell you
that their heart stopped suddenly and then restarted with a thump. Missed beats
are the commonest type of palpitation and are caused by ectopics or premature b
eats. They can be atrial or ventricular in origin. Tachycardias are often felt a
s a fluttering sensation in the chest, sometimes accompanied by pain. Supraventr
icular tachycardias tend to start and stop suddenly while bradycardias are less
common and the patient may be unaware of them. With any arrhythmia a 12-lead ECG
or 24-hour ECG monitoring is usually needed.
I hope that you found this brief summary of some benefit and I would be happy to
answer any questions that you might have.

B. QUESTION SESSION
(Language function - disagreeing)
Chairman: Thank you, Dr Gardener, for that very interesting and informative talk
. Now, if anyone has any questions, I'm sure Dr Gardener would be happy to answe
r them. Yes...
Dr Evans: Muriel Evans, Bloomington, Indiana. Dr Gardener, I'm not sure I agree
with what you said at the start of the lecture, that the severity of the symptom
s indicates the seriousness of the disease. I know of several patients who have
never complained of chest pain, but have ECG evidence of previous infarction.
Dr Gardener: That's a good example, but I would tend to disagree with your inter
pretation. Severe symptoms often reflect serious disease, but this is not necess
arily the case. I was trying to point out that this was a general rule and shoul
dn't be taken too literally. We should remember, for example, that on routine Ho
lter monitoring, 2.5 percent of the male population has been shown to have asymp
tomatic ST depression.
Mr Pearson: Frank Pearson, senior-year student, Michigan State University. Dr Ga
rdener, I disagree with you about ST depression and angina. In Prinzmetal's angi
na, which you did not mention, ST elevation occurs. How can you explain this fac
t?
Dr Gardener: I can't say that I share your point of view. Where time is limited,
such as on this course, it is inevitable that there will be omissions. Prinzmet
al's, or variant angina, is not common and so was not included. As you point out
, it does have associated ST elevation, but this is thought to be due to transmu
ral ischemia caused by coronary artery spasm. In stable angina the ST depression
is caused by subendocardial ischemia. I hope that answers your question.
Chairman: Well, it's time for our break now. There are refreshments next door an
d if you have any further questions, we can continue the discussion there.

C. CONVERSATION
(Language function - introducing oneself)
In the break after Dr Gardener's presentation, the delegates are standing around
the refreshments table.
Marius: I don't think we've met before. How do you do. I'm Marius Wardell . I'm
doing my residency in general medicine here at the Rockefeller.
Robert: Pleased to meet you. My name is Robert Miller. I'm a resident too, in ca
rdiology at Richmond, Virginia. Say, you're not American, are you?
Marius: No, I'm British and I haven't been here for long. Look, could I ask you
something? In the last session, that reference to Prinzmetal's angina, do you kn
ow much about it?
Robert: A bit, I guess. I know it occurs without warning at rest and it responds
well to vasodilators. There are several theories. I remember one that points to
abnormal mast cell infiltrates which release histamine and serotonin within the

coronary adventia.
Maggie: Hello, excuse me for interrupting, but I was interested in what you were
saying about Prinzmetal's angina. Oh, Perhaps I should introduce myself. I'm Ma
rgaret Holder, Maggie for short. I'm from Bristol originally.
Robert: Hi! Pleased to meet you. Is that lady over there a friend of yours?
Maggie: No, I don't know her at all.
Robert: Excuse me, I saw you looking our way. Have we met somewhere before? I'm
Robert Miller.
Kate: No, I don't think so. I was trying to catch your colleague's attention. I
met him a few weeks ago at a friend's party. Let me introduce myself. Kate Ruben
s. I'm at Mount Sinai...
Symptoms of Heart Disease
Source: English For Cardiology, Unit 1
Professional Language Training, 1995
Meeting Presentation No.00C01ex01