how to differentiate between cardiac and respiratory dyspnea

Dyspnea can also occur as a somatic manifestation of psychiatric disorders, such as an anxiety disorder, with resultant hyperventilation. The https:// ensures that you are connecting to the All Rights Reserved. WALTER C. MORGAN, M.D., AND HEIDI L. HODGE, M.D. Reduced diffusing capacity can occur in a variety of alveolar or interstitial abnormalities, such as edema, inflammation, infection, infiltration and malignancy. Auscultation of the lungs provides information regarding the character and symmetry of breath sounds such as rales, rhonchi, dullness or wheezing. The broad differential diagnosis of dyspnea contains four general categories: cardiac, pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary (Table 1). Do I have any risk factors for heart failure, such as high blood pressure or coronary artery disease? Coronary artery disease is when the arteries that supply blood to the heart become narrowed or blocked, unable to deliver blood and even closing completely due to a heart attack. It is a common finding in many different conditions. N Engl J Med 2005;353:278896. Ann Emerg Med 2005;46:S38S39. Cleveland Clinic is a non-profit academic medical center. Results: Patients with pulmonary dyspnea had a significantly lower mean PEF than patients with cardiac dyspnea (144 6 66 vs 267 6 97 L/min, respectively; p < 0 . We aimed to assess the utility of easily applicable diagnostic tools in the differential diagnosis of cardiac and pulmonary causes of dyspnea in patients presenting with shortness of breath. The differential diagnosis is presented in Table 1.9,10, Studies of pleuritic chest pain have shown that pulmonary embolism is the most common life-threatening cause and the source of the pain 5% to 21% of the time.11,12 A recent prospective trial of 7,940 patients evaluated for pulmonary embolism revealed that pleuritic-type chest pain was significantly associated with confirmed pulmonary embolism (adjusted odds ratio of 1.53).13 The most commonly occurring symptoms of pulmonary embolism were dyspnea and pleuritic chest pain in 73% and 66% of patients, respectively.11 Physicians should use validated clinical decision rules (e.g., Wells, PERC [pulmonary embolism rule-out criteria], Geneva) to evaluate for pulmonary embolism, as discussed in a previous article in American Family Physician.14, Physicians can evaluate patients for myocardial infarction and coronary artery disease using electrocardiography and troponin levels. Acute coronary syndrome, congestive heart failure, pericarditis, postcardiac injury syndrome, postmyocardial infarction syndrome, postpericardiotomy syndrome, Inflammatory bowel disease, pancreatitis, spontaneous bacterial pleuritis, Malignancy, malignant pleural effusion, sickle cell crisis, Asbestosis, cardiothoracic surgery, medications, pericardiocentesis, Mediterranean spotted fever (caused by a rickettsial organism [, Adenovirus, coxsackieviruses, cytomegalovirus, Epstein-Barr virus, herpes zoster, influenza, mumps, parainfluenza, respiratory syncytial virus, Ankylosing spondylitis, collagen vascular diseases, familial Mediterranean fever, fibromyalgia, reactive eosinophilic pleuritis, rheumatoid arthritis, systemic lupus erythematosus, Chronic obstructive pulmonary disease, hemothorax, pleural adhesions, pneumothorax, pulmonary embolism, Chronic renal failure, renal capsular hematoma, Lupus pleuritis, rheumatoid pleuritis, Sjgren syndrome, Age and sex (male 55 years or older or female 65 years or older), Known vascular disease (coronary artery disease, occlusive vascular disease, cerebrovascular disease), Patient assumes pain is of cardiac origin, Tearing sensation, pain radiates to back/abdomen, most severe at onset, Blood pressure/radial pulse discrepancy, aortic murmur, possible cardiac tamponade, CTA with obvious defect, CXR only sensitive with intrathoracic catastrophe, History of malignancy, night sweats, older age, tobacco use, weight loss, CXR with unilateral or bilateral effusions, Apply Light criteria to thoracentesis fluid, pleural fluid cytology, Angina, headache, arm/neck pain, nausea/vomiting, Diaphoresis, hypotension, third heart sound, ECG with ST elevation in contiguous leads, abnormal cardiac enzyme studies, Recent or current viral infection, prior pericarditis, Diffuse concave upward ST segments, PR segment depression without T wave inversion, positional chest pain, Egophony, leukocytosis, rhonchi, pleural rub, Decreased breath sounds locally, hypotension, hypoxia, possible tracheal deviation, hyperresonance, Abnormal CXR indicating air in pleural space, Tension pneumothorax is often a clinical diagnosis before imaging, Acute onset dyspnea, history of deep venous thrombosis, history of malignancy, unilateral leg swelling, Hypotension, hypoxia, sinus tachycardia, respiratory distress, CXR with abrupt hilar cutoff, oligemia, or pulmonary infarction Filling defect often detectable with CTA, Dedicated clinical decision algorithm, d-dimer, hypoxia with alveolar-arterial gradient, ECG with right heart strain, Exposure to tuberculosis, hemoptysis, fever, night sweats, weight loss, Egophony, leukocytosis, pleural rub, rhonchi, Often consolidation, lymphadenopathy, and/or unilateral pleural effusion; cavitation common, Acid-fast bacilli Gram stain, sputum culture, purified protein derivative. DOI: Litzinger MHJ, et al. Atypical chest pain must be differentiated from other types of chest pain, including chest wall pain, pleurisy, gallbladder pain, hiatal hernia, and chest pain associated with anxiety disorders. Thromb Haemost 2000;83:41620. You should go to the ER if youre having trouble breathing and nothing you try makes it better. Most cases of dyspnea are due to cardiac. Your healthcare provider can work with you to find a treatment that makes sense for you. PubMedGoogle Scholar, Department of Anesthesiology and Critical Care Medicine, Lariboisire University Hospital, Assistance Publique-Hpitaux de Paris, Universit Paris Diderot, Paris, France, Alexandre Mebazaa MD, PhD (Professor of Medicine) (Professor of Medicine), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA, Mihai Gheorghiade MD, FACC (Professor of Medicine and Surgery, Associate Chief, Division of Cardiology and Chief, Cardiology Clinical Service) (Professor of Medicine and Surgery, Associate Chief, Division of Cardiology and Chief, Cardiology Clinical Service), Department of Cardiology Centre dInvestigation Clinique (CIC), INSERM U-684, Centre Hospitalier Universitaire, University Henri Poincar, Nancy, France, Faiez M. Zannad MD, PhD, FESC (Professor of Medicine) (Professor of Medicine), Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Camden, NJ, USA, Joseph E. Parrillo MD (Professor of Medicine, Chief, Department of Medicine Edward D. Viner MD Chair, Department of Medicine and Director) (Professor of Medicine, Chief, Department of Medicine Edward D. Viner MD Chair, Department of Medicine and Director), Cooper Heart Institute, Cooper University Hospital, Camden, NJ, USA, Picard, C.R., Tazi, A. See additional information. Sometimes other symptoms occur before sudden cardiac arrest. Wheezing isn't always due to true asthma. Cardiac asthma is a sign of a larger condition: heart failure. This fluid comes from pulmonary hypertension, which happens in left-sided heart failure. blockpnea [8]. Professor of Medicine Nonsteroidal anti-inflammatory drugs should be used to control pleuritic pain. Ron Levine/Getty Images. Most patients presenting with pleuritic chest pain will require imaging with chest radiography to fully define their diagnosis.1 If pleural fluid is seen on a chest radiograph, the fluid can be aspirated and examined for additional clues about the source of the pleuritic chest pain.25,26 Lung ultrasonography can guide thoracentesis, as well as localize a small pneumothorax and identify other pulmonary conditions.27,28, When a cardiac or vascular source is considered, electrocardiography, cardiac enzyme studies, and echocardiography are useful tests. Eat foods that are good for your heart, like fruits and vegetables. You may not have given much thought to your sleeping position, but the way you spend your night can have an impact on your overall health, including. Acad Emerg Med. Loss of consciousness. Ann Emerg Med 2004;44:S5. When the results are equivocal or difficult to interpret, further diagnostic testing or consultation should be considered.7,8. CrossRef Psychiatric examination can reveal anxiety accompanied by tremulousness, sweating or hyperventilation.2,4,8, Many diagnostic modalities used to evaluate dyspnea can be performed in the family physician's office.10 The basic evaluation is directed by the probable causes suggested in the history and physical examination. . Drazner MH, Rame JE, Stevenson LW, et al. Author disclosure: No relevant financial affiliations. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. al [10]. For example, in a patient with pulmonary edema, the accumulated fluid activates neural fibers in the alveolar interstitium and reflexively causes dyspnea.2 Inhaled substances that are irritating can activate receptors in the airway epithelium and produce rapid, shallow breathing, coughing and bronchospasm. Epub 2018 Oct 1. Springer, London. Gallavardin L. Y a-t-il un quivalent non douloureux de langine de Symptoms can get worse without warning. Predictors of elevated B-type natriuretic peptide concentrations in dyspneic patients without heart failure: an analysis from the breathing not properly multinational study. Bronchial asthma is a long-term disease in your lungs. Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examination. A family history of asthma, lung problems (e.g., chronic bronchitis, bronchiectasis, serious pulmonary infections), allergies or hay fever must also be considered.9. Thyroid abnormalities rarely present with dyspnea and can be assessed by measurement of the serum thyroid-stimulating hormone level.4,8. Weakness. Definition. The visceral pleura does not contain pain receptors, whereas the parietal pleura is innervated by somatic nerves that sense pain due to trauma or inflammation. Viruses are common causative agents of pleuritic chest pain. It can be particularly useful in cases where obesity, anxiety, deconditioning, exercise-induced asthma or other problems preclude standard exercise treadmill testing. Is my breathing trouble keeping me awake. Patients may present with an initial normal examination even when serious conditions are present. Heart failure can cause fluid to build up in the lungs (pulmonary edema) and in and around the airways. How often do I need follow-up appointments? Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Cardiac asthma is a collection of asthma-like respiratory symptoms caused by congestive heart failure. McMurray JJ, Pfeffer MA. CrossRef Whats the Difference Between a Heart Attack and Heart Failure? doi:10.1001/jama.1977.03280200078032. A total of 243 citations were identified using the key words pleurisy and pleuritic chest pain, and the search was limited to human studies. Gallavardin in as early as 1924 [7]. The most common cause of heart failure in adults is coronary artery disease. (2008). 1,2 However, in both cardiac and pulmonary disease, the most common cause is disordered lung mechanics. In an attempt to compensate for the low cardiac output, heart rate and arte- rIovenous oxygen difference increase. The history, physical examination and preliminary diagnostic modalities such as chest radiography and electrocardiography usually reveal the underlying cause or causes of dyspnea, but in selected cases further diagnostic evaluation may be needed. A family history of similar symptoms increases the likelihood of rare diagnoses such as familial Mediterranean fever. CAS 2002 Oct;3(10):1034-41. Certain heart conditions gradually leave the heart too weak or stiff to fill and pump blood properly. Unauthorized use of these marks is strictly prohibited. Cardiopulmonary exercise testing (CPET) may potentially differentiate heart failure (HF) with preserved ejection fraction (HFpEF) from noncardiac causes of dyspnea (NCD). It is exacerbated by deep breathing, coughing, sneezing, or laughing. . The site is secure. To make your symptoms better and improve your quality of life, follow your healthcare providers advice: Contact your healthcare provider if you start to get new symptoms or your symptoms get worse. Clinical practice. A validated clinical decision rule should be applied to guide the use of additional tests such as d-dimer assays and imaging studies. Boccardi L, Bisconti C, Camboni C, Chieffi M, Putini RL, Macali L, Spina A, Lukic V, Ciferri E. Ital Heart J Suppl. It may arise as a result of numerous mechanisms. 1 If symptoms persist for . Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus are likely pathogens. On the basis of the medical investigations, the patients were classified, independently of the BNP value, into two categories: cardiac dyspnea and respiratory dyspnea. 2018 Oct;9(5):687-694. doi: 10.1007/s13244-018-0654-x. When pleuritic inflammation occurs near the diaphragm, pain can be referred to the neck or shoulder. Gholamrezanezhad A, Moinian D, Eftekhari M, Mirpour S, Hajimohammadi H. Int J Cardiovasc Imaging. Tsung O. Cheng, M.D. Ailani RK, Ravakhah K, DiGiovine B, et al. Mueller C, Scholer A, Laule-Kilian K, et al. This reflects the interaction between chemical and neural influences on breathing.2,3. Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are two conditions that can cause dyspnea (shortness of breath), exercise intolerance, and fatigue. Last reviewed by a Cleveland Clinic medical professional on 03/04/2022. Accessibility Statement, Our website uses cookies to enhance your experience. As heart failure gets worse, it takes very little exertion to bring on difficult breathing. Living an overall healthy lifestyle may help improve your heart failure symptoms or prevent heart failure in the first place. A finger-stick hemoglobin determination or a complete blood count can quantify the severity of suspected anemia. Circulatory system mainly includes the heart, blood vessels, blood, lymph and lymph vessels. In most patients, the cause or causes of dyspnea can be determined in a straightforward fashion by using the history and physical examination to identify common cardiac or pulmonary etiologies. Learn about the many differences between heart, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Pleuritic chest pain has many etiologies. 1993 Oct;41(10):439-44. To perform the test, most patients require specific demonstration of the appropriate technique and coaching during the test in order to produce a maximal effort. It is helpful to use a clinical approach that aids physicians in immediately distinguishing between six life-threatening causes of pleuritic chest pain and other more common indolent causes. The absence of a clear diagnosis warrants additional diagnostic testing. It means it cant keep up with your bodys demand for blood. Download preview PDF. The test is usually performed on a treadmill or bicycle ergometer and requires that the patient breathe into a mouthpiece during exercise. 9.Type 1 and 2 respiratory failure - Arterial blood gas will differentiate the cause. The most useful methods of evaluating dyspnea are the electrocardiogram and chest radiographs. Separating Cardiac From Pulmonary Dyspnea. Validated clinical decision rules are available to help exclude coronary artery disease. Care for your other conditions, like high blood pressure and diabetes. Turnipseed SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, Smith DS, Main DN, Amsterdam EA. Congestive heart failure (right, left or biventricular), Myocardial infarction (recent or past history), COPD with pulmonary hypertension and cor pulmonale, Cardiac or pulmonary disease, deconditioning, Severe cardiopulmonary disease or noncardiopulmonary disease (e.g., acidosis), Orthopnea, paroxysmal nocturnal dyspnea, edema, Congestive heart failure, chronic obstructive pulmonary disease, Beta blockers may exacerbate bronchospasm or limit exercise tolerance. Atypical chest pain must be differentiated from other types of chest pain, including chest wall pain, pleurisy, gallbladder pain, hiatal hernia, and chest pain associated with anxiety disorders. In patients diagnosed with pneumonia who smoke tobacco, have persistent symptoms, or are older than 50 years, it is important to document resolution of the abnormality with repeat chest radiography performed six weeks after initial treatment.42 These patients are at increased risk of developing pneumonia secondary to an obstructing lesion such as lung cancer. Abidov A, Rozanski A, Hachamovitch R, et al: Prognostic significance In contrast, less immediately lethal causes of pleuritic chest pain (e.g., infection, malignancy, inflammatory processes) progress over hours to days or weeks.4 Pain that worsens when the patient is supine and lessens when the patient is upright and leaning forward should prompt consideration for pericarditis.46 True dyspnea should also increase suspicion for a pulmonary embolus, pneumothorax, or pneumonia.1,7,8 It is clinically useful to distinguish true dyspnea from patient-perceived dyspnea caused by a desire to suppress respirations to avoid pain.22,23, Cardiac symptoms such as diaphoresis, nausea, and palpitations should be elucidated. It's caused by a buildup of fluid in the lungs due to . McNamara RM, Cionni DJ. equivalent [5,6]. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. 2. An abnormality of arterial blood gas parameters may sometimes be seen only during exercise, with a rapid return to normal during rest. All Rights Reserved. A systolic murmur can indicate aortic stenosis or mitral insufficiency; a third heart sound can indicate congestive heart failure and an irregular rhythm can indicate atrial fibrillation. Pain that is described as sharp and stabbing is typical of noncardiac chest pain.22 Radiation of pain to the shoulders or arms has a positive likelihood ratio of 4.07 (95% confidence interval, 2.53 to 6.54) for acute myocardial infarction.22 In contrast, pain that radiates to the back and is maximal in intensity at onset is more commonly associated with aortic dissection than cardiac ischemia.22. Ann Biol Clin (Paris) 2005;63:37784. Classic coronary pain--or angina--involves a substernal pressure that commonly begins with exertion and is relieved by rest. Cardiac vs pulmonary origin. In COPD, the air sacs in the lungs lose their elasticity, and the airways become inflamed and narrowed, making it difficult to breathe. It is helpful to use a clinical approach that aids physicians in immediately distinguishing between six life-threatening causes of pleuritic chest pain and other more common indolent causes.18 Pulmonary embolism, myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are the six serious conditions that must be initially considered. Chest pain of cardiac and noncardiac origin. Inflammatory mediators released into the pleural space trigger local pain receptors. Int J Heart failure. Professor of Medicine and Surgery, Associate Chief, Division of Cardiology and Chief, Cardiology Clinical Service, Professor of Medicine, Chief, Department of Medicine Edward D. Viner MD Chair, Department of Medicine and Director, https://doi.org/10.1007/978-1-84628-782-4_16, Tax calculation will be finalised during checkout. As with all undifferentiated symptoms, a carefully taken history is important because it yields clues, if not the actual diagnosis, in many cases (Table 2). Differentiate between systolic and diastolic heart failure. Clipboard, Search History, and several other advanced features are temporarily unavailable. What treatments would you recommend for my specific situation? Cardiac asthma is often misdiagnosed as asthma, but a proper diagnosis is critical for receiving proper treatment maximizing your outlook. However, some patients experience angina in the absence of physical exertion or emotional stress, and not all chest pain that begins after exertion is angina. This is called advanced heart failure. It may arise as a result of numerous mechanisms.1,2 However, in both cardiac and pulmonary disease, the most common cause is disordered lung mechanics. Other conditions that can cause or contribute to the development of heart failure include: Classic asthma medications like bronchodilators are thought to have limited effectiveness for treating cardiac asthma. HHS Vulnerability Disclosure, Help Patients may demonstrate shallower breaths as they attempt to avoid deep breathing that triggers pain.23 Likewise, hypotension and a markedly widened pulse pressure should raise concerns for aortic dissection or severe myocardial infarction. It is often described as a sensation of running out of air or not being able to breathe deep enough or breathing too fast. Voltage abnormality suggests left or right ventricular hypertrophy if the voltage is excessive, or pericardial effusion or obstructive lung disease with increased chest diameter if the voltage is diminished. Int J Cardiol 2005;105:349 The prevalence and significance of increased gastric wall radiotracer uptake in sestamibi myocardial perfusion SPECT. 5. This process is experimental and the keywords may be updated as the learning algorithm improves. Although a class effect is assumed, studies on the treatment of pleuritic chest pain in humans have focused on the use of indomethacin at dosages of 50 to 100 mg orally up to three times per day. Whats the outlook for people with cardiac asthma? For example, if youre having a lot of trouble breathing, would you want a breathing tube in your throat? This measurement is more commonly used for the evaluation of acute dyspnea but it can also be used in the evaluation of patients who have gradually become dyspneic or who are chronically dyspneic. National Library of Medicine Heart failure doesn't mean your heart isn't working. Pleuritic chest pain is caused by inflammation of the parietal pleura and can be triggered by a variety of causes. Symptoms of cardiac asthma may be the initial symptoms of heart failure, or they may be present along with other signs of heart failure, such as: Cardiac asthma can be difficult to diagnose due to its similarity to asthma. This site needs JavaScript to work properly. Kyphosis and scoliosis can cause pulmonary restriction. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. However, with cardiac asthma, the cause is fluid buildup in your lungs. [3] pointed out recently, weight loss is a common accompaniment of the This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. While contemporary . Careful examination of the chest wall is essential, and abnormal heart sounds can tell you a great deal. N Engl J Med 2001;345:57481. of dyspnea in patients referred for cardiac stress testing. Federal government websites often end in .gov or .mil. The modalities of treating Covid-19, malaria, and . Part of Springer Nature. Cardiac asthma treatments include: Side effects vary by medication, although some may be similar. 2009 Jun;16(6):495-9. doi: 10.1111/j.1553-2712.2009.00420.x. BRIAN V. REAMY, MD, PAMELA M. WILLIAMS, MD, AND MICHAEL RYAN ODOM, MD. Since heart failure causes cardiac asthma, lowering your risk of heart failure cuts your risk of cardiac asthma, too. Blaivas M. Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Jane Carissa Ali Dr. Bahadori NR 507 November 1, 2022 Week 2: Discussion 1.) Ital Heart J Suppl. COVID-19 primarily posed a threat to the respiratory system and violated many different organs, including the heart, kidney, liver, and blood vessels with the development of the disease. 7. Utility of the peak expiratory flow rate in the differentiation of acute dyspnea. No competing interests, George Washington University, Washington, D.C. 20037, Copyright 2023 BMJ Publishing Group Ltd, https://doi.org/10.1136/bmj.38664.661181.55, Womens, childrens & adolescents health. During exercise, oxygenation is measured by using either a pulse oximeter or an arterial line, and interpretation of the complete test requires analysis of oxygen consumption, carbon dioxide production, anaerobic threshold, heart rate and rhythm, blood pressure, minute ventilation, continuous monitoring of gas exchange, severity of perceived exertion, dyspnea, chest pain and leg discomfort. The beta 1 effects can increase myocardial oxygen demand and worsen an acute CHF event. I However, the percentage of oxygen saturation does not always correspond to the partial pressure of arterial oxygen (PaO2). Shortness of breath. The differential diagnosis is composed of four general categories: cardiac, pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary. 2005;353:1889-1898. described four clinical parameters (history of ischemic heart disease, laterally displaced apex beat, high body mass index, and raised heart rate) and two laboratory tests (natriuretic peptide measurements and electrocardiography) that help to recognize congestive heart failure (CHF) progression of treated CHF. Disclaimer. Ann Emerg Med 2004;44:1608. Difference between cardiac asthma and bronchial asthma pdf Bronchial asthma vs. Treatment methods. You can manage heart failure with lifestyle changes and medicines for a while. Heart attack and heart failure share many of the same risk factors and underlying health conditions. Tests that may be performed to help diagnose heart failure include: If you think you may be experiencing cardiac asthma, its critical to seek medical attention immediately. In: Mebazaa, A., Gheorghiade, M., Zannad, F.M., Parrillo, J.E. (eds) Acute Heart Failure. Fluid in your lungs makes it hard to breathe, especially when youre lying down. 1 A consensus statement from the American Thoracic Society defines dyspnea as a "subjective experience. Arch Intern Med 1983;143:42933. Strangely enough, this prominent equivalent of angina People Who Survive Cancer May Have Increased Heart Disease Risk, rales (abnormal sounds heard when listening to the lung with a stethoscope), paroxysmal nocturnal dyspnea (waking up at night gasping for air). People with either condition can experience coughing, shortness of breath, and wheezing. Unlike bronchial asthma, cardiac asthma is difficulty breathing because of pulmonary edema or fluid in your lungs. The DLCO is used to indirectly measure the gas exchange of oxygen and carbon dioxide across the alveolar surface. All parameters had statistically significant differences between cardiac and pulmonary dyspnea groups, with DDI and %DDI being the most prominent . However, these treatments arent necessary if youre able to breathe well enough to get adequate oxygen. If the ECG is abnormal at rest, the patient should undergo a thallium stress test or exercise echocardiography. They both also progress over time and tend to affect smokers over the age of 60.
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