病 史

　　A thorough history is fundamental to the diagnosis of cardiovascular disease and cannot be replaced by routine or random noninvasive and invasive testing, which is expensive and inefficient. A thorough family history should be taken because many cardiac disorders (eg, coronary artery disease [CAD], systemic hypertension, bicuspid aortic valve, hypertrophic cardiomyopathy, mitral valve prolapse) have a heritable basis.

　　Major cardiac diseases have relatively few symptoms, including pain; dyspnea; weakness and fatigue; palpitations; light-headedness, presyncope, and syncope; and other symptoms that may be due to the cardiac disease or may accompany it. Subtle variations in these symptoms require close attention.

　　一份详尽的病史是心血管疾病诊断的基础，是常规或任意的有创性和无创性检测所不能取代的，况且，这些检测既昂贵又无效。很多心脏疾病(如冠状动脉疾病(CAD)、全身性高血压、二叶主动脉瓣疾病、肥厚型心肌病、二尖瓣脱垂)都有遗传基础，因此应收集详尽的家族病史。

　　一些主要的心脏疾病症状相对较少，包括疼痛、呼吸困难、虚弱和乏力、心悸、头晕、晕厥先兆和晕厥；其他一些症状，有的可能是由心脏疾病引起的，有的则是伴随心脏病发生的。这些症状的细微变化都应密切关注。

　　PAIN

　　Cardiac pain can be arbitrarily categorized as ischemic, pericardial, or atypical. Although cardiac pain is sometimes characteristic of an underlying cardiac disorder, there is often significant overlap with other disorders in terms of character, quality, location, pattern of radiation, severity, and duration. Cardiac pain is transmitted to the cerebral cortex along autonomic nerve fibers and has a variable referral area that can extend from the ear to the umbilicus. Extracardiac chest pain of cardiovascular origin includes pain arising from the great vessels and pain due to pulmonary embolism.

　　Myocardial ischemic pain is usually described as pressing, squeezing, or weightlike. The pain is usually greatest in the central precordium and may be demonstrated by the patient placing a clenched fist over the center of the sternum. The pain frequently radiates in the distribution of the lower cervical nerves and may therefore be felt in the neck, lower jaw, or either shoulder or arm (most commonly the left shoulder and left arm). If the arm and hand are involved, pain is usually on the ulnar side. Myocardial ischemic pain often induces an autonomic response (eg, nausea or vomiting, sweating). A sense of impending doom may be present. Myocardial ischemic pain due to coronary arteriosclerosis is usually exertion-related, at least initially. However, the pain of acute MI may occur suddenly when the patient is at rest. Pain due to dynamic coronary narrowing from arterial spasm, although ischemic, tends to occur at rest or nocturnally. Myocardial ischemic pain usually lasts only minutes. form www.med66.com

　　疼痛

　　心脏性疼痛可在主观上分为缺血性、心包性或非典型性几类。尽管心脏性疼痛有时是某种基础性心脏疾病的特征性表现，但其疼痛特点、性质、部位、放射类型、程度和持续时间等也常常与其他一些疾病产生明显的重叠。心脏性疼痛沿着自主神经纤维传到大脑皮层，其范围可自耳部延伸至脐部。源于心血管的心外性胸痛包括来自大血管的疼痛和由肺栓塞引起的疼痛。

　　心肌缺血性疼痛常被描述为压迫、挤榨或负重样，通常以心前区中央为最重，表现为，病人握拳放在胸骨中央。疼痛常常放射至颈下神经分布区，因此在颈部、下颌、肩或臂部都可以感觉到(以左肩和左臂最常见)。如累及臂和手时，以尺侧为常见。心肌缺血性疼痛经常诱导一些自主反应(如恶心或呕吐、出汗)，并呈濒死感。由冠状动脉硬化引起的心肌缺血性疼痛通常与劳力有关，至少在初期是这样。不过，急性心肌梗死的疼痛也可在病人休息时突然发生。动脉痉挛引起动力性冠状动脉狭窄并产生的疼痛，虽然是缺血性的，也往往在休息或夜间发生。心肌缺血性疼痛通常只持续几分钟。

　　Atypical chest pain tends to be stabbing or burning and is often quite variable in position and intensity from one episode to another. It tends to be unrelated to physical exertion and unresponsive to nitroglycerin. Its duration may be evanescent (measured in seconds) or persistent over many hours or days. Some persons with atypical chest pain have physical signs or echocardiographic evidence of mitral valve prolapse. Whether the pain is related to the mitral valve prolapse or whether it is an epiphenomenon is controversial because it is common in the absence of evident prolapse. Vague atypical chest discomfort is also common in those with isolated atrial tachycardia in the absence of significant underlying heart disease. Although atypical chest pain may be debilitating, there is no objective evidence that it indicates serious heart disease, except when due to disease of the great vessels or to pulmonary embolism.

　　非典型性胸痛多呈刺痛或灼痛样，每次发作之间的疼痛部位与程度变化通常都很大。疼痛往往与体力活动无关，对硝酸甘油也无反应。疼痛时间可以是瞬间(以秒计)的，也可持续数小时或数天。一些非典型胸痛患者可有二尖瓣脱垂的体征或超声心动图证据。不过，疼痛是否与二尖瓣脱垂相关，抑或只是一种偶发现象，对此人们尚有争议，因为这种疼痛即便是在无明显脱垂时也很常见。在无重基础性心脏病的特发性房性心动过速者中也常见不明显非典型性胸痛。.尽管非典型性胸痛有损健康，由此确定其为严重心脏病缺仍乏客观证据，除非这是由大血管病变或肺栓塞所引起的。

　　Pain from dissection of the aorta (or rarely the pulmonary artery) is usually very severe and of a tearing or rending character. Pain usually begins with the start of dissection, followed by a quiescent period of hours or days, then recurs with extension of the dissection. It is central in the chest, radiates through to the back or neck, and is unaffected by position unless dissection into the pericardium with hemopericardium has produced an acute pericarditis. If the ostia of the coronary arteries are involved, myocardial ischemic pain may be superimposed on the pain of dissection.

　　Pulmonary embolism pain may be pleuritic when infarction of the lung results in pleuritis or may be anginal when right ventricular ischemia occurs secondary to sudden onset of pulmonary hypertension. If pulmonary embolism is suspected, the history should address unilateral swelling or pain in the legs, recent surgery, or illness requiring prolonged bed rest. If pericarditis is suspected, the history should address exposure to infectious agents, connective tissue and immune diseases, and previous diagnosis of neoplasia.

　　主动脉剥离引起的疼痛(或肺动脉，但罕见)通常很剧烈，有撕裂或裂开特征，疼痛常始于剥离初期，随后是数小时或数天的无症状期，剥离扩大时再次发作。疼痛位于胸部中央，放射至颈或背部。体位对疼痛无影响，除非剥离至心包产生心包出血引起急性心包炎。如累及冠状动脉开口处，则剥离痛上还会增加心肌缺血的疼痛。

　　肺栓塞性疼痛可因肺梗死引起胸膜炎而呈胸膜性，也可因继发于突发性肺动脉高压的右心室缺血而呈绞痛样。当怀疑有肺栓塞时，病史应注重腿部的单侧性浮肿或疼痛，近期手术史或需长期卧床休息的疾病。当怀疑有心包炎时，病史应注重感染原接触史，结缔组织和免疫性疾病史和以往的肿瘤诊断史。

　　CARDIAC DYSPNEA

　　Dyspnea is the perception of uncomfortable, distressful, or labored breathing. Cardiac dyspnea results from edema in bronchiolar walls and stiffening of the lung due to parenchymal or alveolar edema, which interfere with airflow. Dyspnea also results when cardiac output is inadequate for the body's metabolic demands and can occur without pulmonary edema.

　　Cardiac dyspnea is always worsened by exertion and partly or completely relieved by rest. Dyspnea due to elevated pulmonary venous pressure and pulmonary edema is increased in the recumbent position and decreased by sitting or standing (orthopnea). If orthopnea causes awakening during the night and is relieved by sitting, it is called paroxysmal nocturnal dyspnea. Dyspnea in the presence of bronchiolar edema is associated with wheezing due to airflow obstruction; frothy and sometimes blood-tinged sputum is expectorated. A common manifestation of bronchiolar edema and stiff lungs due to heart failure is a dry cough, which must be differentiated from that occurring in 5% of patients treated with ACE inhibitors.

　　心源性呼吸困难

　　呼吸困难是病人对呼吸不适、呼吸困苦或费力的自我感觉。心源性呼吸困难是由细支气管壁水肿和肺实质或肺泡水肿所致的肺硬变引起，妨碍气流通行。当心排血量不能满足身体代谢需要，甚或无肺水肿患者，也可出现呼吸困难。

　　劳力可加剧心源性呼吸困难，休息则可部分或完全使之缓解。由肺水肿和肺静脉压升高引起的呼吸困难在卧位时加剧，在坐位,立位(端坐呼吸)时减轻。如果端坐呼吸引起夜间觉醒，经坐起缓解，是为阵发性夜间呼吸困难。细支气管水肿性呼吸困难与气流梗阻引起的喘息关，可咳出泡沫痰，有时则咳带血痰。心力衰竭引起的细支气管水肿和硬肺常表现为干咳，必须与发生率为5%的ACE抑制剂使用病人的干咳相鉴别。

　　Dyspnea due exclusively to inadequate cardiac output is not affected by posture but varies with physical exertion and may be associated with weakness and fatigue. In many cardiac disorders, dyspnea due to a fixed cardiac output and that due to pulmonary congestion occur simultaneously (eg, in mitral stenosis). The onset of dyspnea in heart disease usually signifies an ominous prognosis. Dyspnea due to CAD may coexist with that due to another cardiac disease. Orthopnea and paroxysmal nocturnal dyspnea are unusual in pulmonary disease, except in a very advanced phase when the increased efficiency of breathing in the upright position is manifest.

　　完全由心排血量不足引起的呼吸困难不受体位影响，但随体力活动而变，可伴有虚弱和乏力。在许多心脏疾病中，由固定心排血量引起的呼吸困难常与肺充血引起的呼吸困难同时发生(如二尖瓣狭窄)。心脏病患者出现呼吸困难通常提示预后不良。由CAD引起的呼吸困难也可与其他疾病引起的呼吸困难同时存在。肺病患者的端坐呼吸和阵发性夜间呼吸困难不常见，除非是在很晚期，此时，直立位呼吸功率增加明显。

　　WEAKNESS AND FATIGUE

　　Weakness and fatigue result from inadequate cardiac output for the body's metabolic needs, initially on exertion and eventually at rest. They occur in disorders that limit cardiac output and are not relieved by rest and sleep. It is common for patients with congenital heart disease to deny weakness and fatigue because they consider a limited state to be normal and only recognize the symptoms retrospectively, after surgical correction.

　　虚弱和乏力

　　虚弱和乏力是由心排血量不能满足机体代谢需要所引起的，初期只会在活动时出现，最终在休息时也会出现。心排血量限制性疾病也会出现虚弱和乏力，休息或睡眠均不能使之缓解。先天性心脏病病人常常否认有虚弱和乏力,因为他们认为这种受限状态是正常的，是在外科纠正术后回顾时才认识到这些症状。

　　PALPITATIONS

　　Palpitations are the perception of heart action by the patient. Careful inquiry into the rate and the rhythm of palpitations helps differentiate pathologic from physiologic palpitations. Palpitations due to an arrhythmia may be accompanied by weakness, dyspnea, or light-headedness. Atrial or ventricular extrasystoles are often described as skipped beats, whereas atrial fibrillation is identified as an irregularity. Supraventricular or ventricular tachycardia is most often perceived as being rapid and regular and of sudden onset and termination. Onset of atrial tachyarrhythmia is often followed by the need to urinate because of increased production of atrial natriuretic factor.

　　Cardiac activity is controlled by the autonomic nervous system and is thus commonly sensed only by persons with abnormally heightened awareness of their body functions, eg, in anxiety states. It may also be sensed in healthy persons during exercise when stroke volume or heart rate increases. Palpitations can occur in disorders such as aortic regurgitation or thyrotoxicosis; the most common cause is abnormal cardiac rhythm. Palpitations accompanied by myocardial ischemia-type chest pain may be indicative of CAD, in which decreased diastolic coronary flow and ischemia result from the tachycardia.

　　心悸

　　心悸是病人对心脏活动的自我感觉。仔细询问心悸的速率和节律有助于鉴别病理性和生理性心悸。由心律失常引起的心悸可伴有虚弱、呼吸困难或头晕。房性或室性早搏常被描述为“蹦跳”，房性纤颤则被确认为不规则。室上性或室性心动过速的感觉是快速、有规律，来去突然。由于心房利钠因子产生增加，房性快速性心律失常发作后常需排尿。

　　心脏活动受自主神经系统控制，因此，通常也只有对身体功能高度异常敏感的人才常会感觉到，如忧虑状态病人。健康人在运动时也可感觉心悸，因为这时的每搏量和心率才有增加。有些疾病如主动脉瓣反流或甲状腺功能亢进症等，也会出现心悸，但最常见的原因是心律异常。心悸伴有心肌缺血型胸痛提示有冠状动脉疾病(CAD)，因为此时心动过速将引起缺血和舒张期冠脉血流减少。

　　LIGHT-HEADEDNESS, PRESYNCOPE, AND SYNCOPE

　　Serious heart disease or arrhythmias that significantly limit cardiac output may cause light-headedness, presyncope, or syncope (a sudden brief loss of consciousness, with loss of postural tone). When associated with palpitations, any of these symptoms indicates an abrupt drop in cardiac output and denotes a serious arrhythmia or underlying organic heart disease. Exertional syncope occurs in aortic stenosis or hypertrophic cardiomyopathy, both of which limit increased cardiac output on exertion. Ventricular tachycardia or fibrillation or severe bradycardias or asystole may cause these symptoms in the form of a Stokes-Adams attack. Onset of syncope denotes a poor prognosis in patients with CAD, myocarditis, cardiomyopathy, and known ventricular arrhythmias. Intracardiac tumors or ball-valve thrombi can intermittently obstruct blood flow within the heart, producing presyncope or syncope. Postural hypotension and vasovagal syncope are the major benign causes of syncope. Syncope must be differentiated from epileptic seizures, although seizures due to brain hypoxia can occur in a syncopal episode.

　　头晕，晕厥先兆和晕厥

　　严重限制心排血量的严重心脏病或心律失常可引起头晕，晕厥先兆和晕厥(意识的短暂性突然丧失伴姿势张力丧失)。这些症状若伴有心悸，则表明有心排血量的急骤下降，是严重心律失常的标志，或提示有器质性基础心脏病。劳力性晕厥见于主动脉瓣狭窄或肥厚型心肌病，两者都限制活动时心排血量的增加。室性心动过速及心室纤颤或严重的心搏除缓或心搏停止均可引起这些症状，表现为Strokes-Adams发作。CAD、心肌炎、心肌病、已知的室性心律失常等病人，晕厥发作均提示预后不良。心内肿瘤或球状样瓣膜血栓可间歇性阻断心内血流，引起晕厥先兆或晕厥。体位性低血压和血管迷走神经性晕厥是晕厥的主要原因，呈良性。晕厥必须与癫痫发作相鉴别，尽管在晕厥发作时也会发生脑缺氧引起的癫痫发作。

　　OTHER SYMPTOMS

　　A history of infections (eg, streptococcal with or without rheumatic fever, viral, syphilitic, protozoan) may raise suspicion of a cardiac disorder resulting from active or temporally remote infectious agents. Endocarditis should be considered in any patient with an unexplained fever and a heart murmur. A cardiac cause should be sought for peripheral or cerebral emboli or in any stroke, which can be caused by emboli arising from a recent MI, valvular disease (particularly mitral stenosis with atrial fibrillation), or cardiomyopathy. A history of cerebrovascular or peripheral vascular disease increases the likelihood of associated CAD. Central cyanosis makes a congenital cardiac disorder highly likely.

　　其他症状

　　感染史(链球菌感染伴或不伴风湿热、病毒、梅毒、原生物)可增加对活动性或暂时性远端感染源引起的心脏疾病的怀疑。任何一个出现不明热和心脏杂音的病人都应考虑是否有心内膜炎。卒中病人都应寻找周围或脑栓塞的心脏原因，因为由最近的MI、瓣膜疾病（特别是二尖瓣狭窄伴房性纤颤）、或心肌所引起的栓塞都 可导致这些情况。脑血管或周围血管病病史可增加相关CAD的可能性。中央型发绀提示先天性心脏病的可能性极高。