| Cardiac patient History | 心 臟 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 , systemic hypertension, bicuspid aortic valve, hypertrophic cardiomyopathy, mitral valve prolapse） have a heritable basis. | 一份詳盡的病史是心血管疾病診斷的基礎(chǔ)，是常規(guī)或任意的有創(chuàng)性和無創(chuàng)傷性檢測所不能取代的，況且，這些檢測既昂貴又無效。很多心臟疾?。ㄈ绻跔顒?dòng)脈疾病（CAD）、全身性高血壓、二葉主動(dòng)脈瓣疾病、肥厚型心肌病、二尖瓣脫垂）都有遺傳基礎(chǔ)，因此應(yīng)收集詳盡的家族病史?！?/td> |
| 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. | 一些主要的心臟疾病癥狀相對(duì)較少，包括疼痛、呼吸困難、虛弱和乏力、心悸、頭暈、暈厥先兆和暈厥；其他一些癥狀，有的可能是由心臟疾病引起的，有的則是伴隨心臟病發(fā)生的。這些癥狀的細(xì)微變化都應(yīng)密切關(guān)注。 |
| PAIN | 疼痛 |
| 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. | 心臟性疼痛可在主觀上分為缺血性、心包性或非典型性幾類。盡管心臟性疼痛有時(shí)是某種基礎(chǔ)性心臟疾病的特征性表現(xiàn)，但其疼痛特點(diǎn)、性質(zhì)、部位、放射類型、程度和持續(xù)時(shí)間等也常常與其他一些疾病產(chǎn)生明顯的重疊。心臟性疼痛沿著自主神經(jīng)纖維傳到大腦皮層，其范圍可自耳部延伸至臍部。源于心血管的心外性胸痛包括來自大血管的疼痛和由肺栓塞引起的疼痛?！?/td> |
| 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. | 心肌缺血性疼痛常被描述為壓迫、擠榨或負(fù)重樣，通常以心前區(qū)中央為最重，表現(xiàn)為，病人握拳放在胸骨中央。疼痛常常放射至頸下神經(jīng)分布區(qū)，因此在頸部、下頜、肩或臂部都可以感覺到（以左肩和左臂最常見）。如累及臂和手時(shí)，以尺側(cè)為常見。心肌缺血性疼痛經(jīng)常誘導(dǎo)一些自主反應(yīng)（如惡心或嘔吐、出汗），并呈瀕死感。由冠狀動(dòng)脈硬化引起的心肌缺血性疼痛通常與勞力有關(guān)，至少在初期是這樣。不過，急性心肌梗死的疼痛也可在病人休息時(shí)突然發(fā)生。動(dòng)脈痙攣引起動(dòng)力性冠狀動(dòng)脈狹窄并產(chǎn)生的疼痛，雖然是缺血性的，也往往在休息或夜間發(fā)生。心肌缺血性疼痛通常只持續(xù)幾分鐘?！?/td> |
| Pericardial pain, which is due to inflammation involving the parietal pericardium, feels like stabbing, burning, or cutting and is made worse by coughing, swallowing, deep breathing, or lying down. It is less variable in character, position, and referral area than myocardial ischemic pain. It is diminished by leaning forward and remaining still. Pericardial pain can last for hours or days. It is not relieved by nitroglycerin. | 心包性疼痛為炎癥侵犯心包壁層所致，其感覺呈針刺樣、燒灼或刀割樣，咳嗽、吞咽、深呼吸或躺臥位均可使之加重。其疼痛性質(zhì)、部位、涉及區(qū)域變化較心肌缺血性疼痛少。前傾并保持靜止不動(dòng)即可使疼痛減輕。心包性疼痛可持續(xù)數(shù)小時(shí)或數(shù)天。硝酸不能緩解這種疼痛。 |
| 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樣，每次發(fā)作之間的疼痛部位與程度變化通常都很大。疼痛往往與體力活動(dòng)無關(guān)，對(duì)硝酸甘油也無反應(yīng)。疼痛時(shí)間可以是瞬間（以秒計(jì)）的，也可持續(xù)數(shù)小時(shí)或數(shù)天。一些非典型胸痛患者可有二尖瓣脫垂的體征或超聲心動(dòng)圖證據(jù)。不過，疼痛是否與二尖瓣脫垂相關(guān)，抑或只是一種偶發(fā)現(xiàn)象，對(duì)此人們尚有爭議，因?yàn)檫@種疼痛即便是在無明顯脫垂時(shí)也很常見。在無重基礎(chǔ)性心臟病的特發(fā)性房性心動(dòng)過速者中也常見不明顯非典型性胸痛。.盡管非典型性胸痛有損健康，由此確定其為嚴(yán)重心臟病缺仍乏客觀證據(jù)，除非這是由大血管病變或肺栓塞所引起的?！?/td> |
| 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. | 主動(dòng)脈剝離引起的疼痛（或肺動(dòng)脈，但罕見）通常很劇烈，有撕裂或裂開特征，疼痛常始于剝離初期，隨后是數(shù)小時(shí)或數(shù)天的無癥狀期，剝離擴(kuò)大時(shí)再次發(fā)作。疼痛位于胸部中央，放射至頸或背部。體位對(duì)疼痛無影響，除非剝離至心包產(chǎn)生心包出血引起急性心包炎。如累及冠狀動(dòng)脈開口處，則剝離痛上還會(huì)增加心肌缺血的疼痛。 |
| 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. | 肺栓塞性疼痛可因肺梗死引起胸膜炎而呈胸膜性，也可因繼發(fā)于突發(fā)性肺動(dòng)脈高壓的右心室缺血而呈絞痛樣。當(dāng)懷疑有肺栓塞時(shí)，病史應(yīng)注重腿部的單側(cè)性浮腫或疼痛，近期手術(shù)史或需長期臥床休息的疾病。當(dāng)懷疑有心包炎時(shí)，病史應(yīng)注重感染原接觸史，結(jié)締組織和免疫性疾病史和以往的腫瘤診斷史。 |
| CARDIAC DYSPNEA | 心源性呼吸困難 |
| 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. | 呼吸困難是病人對(duì)呼吸不適、呼吸困苦或費(fèi)力的自我感覺。心源性呼吸困難是由細(xì)支氣管壁水腫和肺實(shí)質(zhì)或肺泡水腫所致的肺硬變引起，妨礙氣流通行。當(dāng)心排血量不能滿足身體代謝需要，甚或無肺水腫患者，也可出現(xiàn)呼吸困難?！?/td> |
| 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. | 勞力可加劇心源性呼吸困難，休息則可部分或完全使之緩解。由肺水腫和肺靜脈壓升高引起的呼吸困難在臥位時(shí)加劇，在坐位,立位（端坐呼吸）時(shí)減輕。如果端坐呼吸引起夜間覺醒，經(jīng)坐起緩解，是為陣發(fā)性夜間呼吸困難。細(xì)支氣管水腫性呼吸困難與氣流梗阻引起的喘息關(guān)，可咳出泡沫痰，有時(shí)則咳帶血痰。心力衰竭引起的細(xì)支氣管水腫和硬肺常表現(xiàn)為干咳，必須與發(fā)生率為5%的ACE抑制劑使用病人的干咳相鑒別?！?/td> |
| 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難不受體位影響，但隨體力活動(dòng)而變，可伴有虛弱和乏力。在許多心臟疾病中，由固定心排血量引起的呼吸困難常與肺充血引起的呼吸困難同時(shí)發(fā)生（如二尖瓣狹窄）。心臟病患者出現(xiàn)呼吸困難通常提示預(yù)后不良。由CAD引起的呼吸困難也可與其他疾病引起的呼吸困難同時(shí)存在。肺病患者的端坐呼吸和陣發(fā)性夜間呼吸困難不常見，除非是在很晚期，此時(shí)，直立位呼吸功率增加明顯?！?/td> |
| WEAKNESS AND FATIGUE | 虛弱和乏力 |
| 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. | 虛弱和乏力是由心排血量不能滿足機(jī)體代謝需要所引起的，初期只會(huì)在活動(dòng)時(shí)出現(xiàn)，最終在休息時(shí)也會(huì)出現(xiàn)。心排血量限制性疾病也會(huì)出現(xiàn)虛弱和乏力，休息或睡眠均不能使之緩解。先天性心臟病病人常常否認(rèn)有虛弱和乏力,因?yàn)樗麄冋J(rèn)為這種受限狀態(tài)是正常的，是在外科糾正術(shù)后回顧時(shí)才認(rèn)識(shí)到這些癥狀。 |
| PALPITATIONS | 心悸 |
| 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. | 心悸是病人對(duì)心臟活動(dòng)的自我感覺。仔細(xì)詢問心悸的速率和節(jié)律有助于鑒別病理性和生理性心悸。由心律失常引起的心悸可伴有虛弱、呼吸困難或頭暈。房性或室性早搏常被描述為“蹦跳”，房性纖顫則被確認(rèn)為不規(guī)則。室上性或室性心動(dòng)過速的感覺是快速、有規(guī)律，來去突然。由于心房利鈉因子產(chǎn)生增加，房性快速性心律失常發(fā)作后常需排尿?！?/td> |
| 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. | 心臟活動(dòng)受自主神經(jīng)系統(tǒng)控制，因此，通常也只有對(duì)身體功能高度異常敏感的人才常會(huì)感覺到，如憂慮狀態(tài)病人。健康人在運(yùn)動(dòng)時(shí)也可感覺心悸，因?yàn)檫@時(shí)的每搏量和心率才有增加。有些疾病如主動(dòng)脈瓣反流或甲狀腺功能亢進(jìn)癥等，也會(huì)出現(xiàn)心悸，但最常見的原因是心律異常。心悸伴有心肌缺血型胸痛提示有冠狀動(dòng)脈疾?。–AD），因?yàn)榇藭r(shí)心動(dòng)過速將引起缺血和舒張期冠脈血流減少?！?/td> |
| LIGHT-HEADEDNESS, PRESYNCOPE, AND SYNCOPE | 頭暈，暈厥先兆和暈厥 |
| 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. | 嚴(yán)重限制心排血量的嚴(yán)重心臟病或心律失?？梢痤^暈，暈厥先兆和暈厥（意識(shí)的短暫性突然喪失伴姿勢張力喪失）。這些癥狀若伴有心悸，則表明有心排血量的急驟下降，是嚴(yán)重心律失常的標(biāo)志，或提示有器質(zhì)性基礎(chǔ)心臟病。勞力性暈厥見于主動(dòng)脈瓣狹窄或肥厚型心肌病，兩者都限制活動(dòng)時(shí)心排血量的增加。室性心動(dòng)過速及心室纖顫或嚴(yán)重的心搏除緩或心搏停止均可引起這些癥狀，表現(xiàn)為Strokes-Adams發(fā)作。CAD、心肌炎、心肌病、已知的室性心律失常等病人，暈厥發(fā)作均提示預(yù)后不良。心內(nèi)腫瘤或球狀樣瓣膜血栓可間歇性阻斷心內(nèi)血流，引起暈厥先兆或暈厥。體位性低血壓和血管迷走神經(jīng)性暈厥是暈厥的主要原因，呈良性。暈厥必須與癲癇發(fā)作相鑒別，盡管在暈厥發(fā)作時(shí)也會(huì)發(fā)生腦缺氧引起的癲癇發(fā)作?！?/td> |
| OTHER SYMPTOMS | 其他癥狀 |
| 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. | 感染史（鏈球菌感染伴或不伴風(fēng)濕熱、病毒、梅毒、原生物）可增加對(duì)活動(dòng)性或暫時(shí)性遠(yuǎn)端感染源引起的心臟疾病的懷疑。任何一個(gè)出現(xiàn)不明熱和心臟雜音的病人都應(yīng)考慮是否有心內(nèi)膜炎。卒中病人都應(yīng)尋找周圍或腦栓塞的心臟原因，因?yàn)橛勺罱腗I、瓣膜疾?。ㄌ貏e是二尖瓣狹窄伴房性纖顫）、或心肌所引起的栓塞都 可導(dǎo)致這些情況。腦血管或周圍血管病病史可增加相關(guān)CAD的可能性。中央型發(fā)紺提示先天性心臟病的可能性極高?！?/td> |
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