Essential differential diagnoses and work-up for functional cardiac symptoms
| Symptom | Medical differential diagnosis | Work-up |
|---|---|---|
| Transient loss of consciousness | Trauma Epilepsy Syncope (cerebral hypoperfusion with rapid onset, short duration of loss of consciousness and complete recovery) including reflex syncope, postural syncope and cardiac syncope | History (personal or collateral): preceding symptoms, onset, timings, prodrome, triggers, abnormal movements, associated symptoms, recovery period, previous episodes, PMH and FH Examination: general, musculoskeletal, cardiac and neurological Lying/standing BP 12-lead ECG If recurrent, consider outpatient echocardiography, cardiac rhythm monitoring, tilt-table testing and video encephalography If high-risk, admit for further investigations and/or treatment |
| Palpitations | Arrhythmia (ectopic beats, atrial fibrillation, atrial flutter, other SVT, VT or bradycardia) Sensing own heartbeat (may be normal or could be result of physiological tachycardia or hyperdynamic circulation) | History: description of palpitation and associated symptoms Examination: general and cardiac 12-lead ECG Blood tests: FBC, renal function, TFT, bone profile and troponin Echocardiography Ambulatory monitoring for appropriate time, depending on frequency Implantable loop recorder if palpitations associated with syncope |
| Chest pain | Cardiac (eg angina, acute coronary syndrome, myo-pericarditis, coronary emboli or mitral prolapse) Gastrointestinal (eg gastro-oesophagitis, reflux, peptic ulcer, pancreatitis or cholecystitis) Psychological (eg anxiety, depression, hyperventilation or panic attacks) Musculoskeletal (eg chest wall pain, rib fractures, costochondritis or fibromyalgia) Respiratory (eg pulmonary embolism, pneumothorax or pneumonia) Vascular (eg aortic dissection or aortitis) Neurological (eg cervical or thoracic root pain) Haematological (eg sickle cell disease) | History: description of pain, associated symptoms, exacerbating/relieving factors, frequency, similarity to previous episodes, and risk factors for IHD, VTE and GORD. Examination: general, respiratory and cardiac 12-lead ECG Blood tests: FBC, renal profile, LFT, CRP, fasting lipids, glucose, troponin I/T and D-dimer Chest X-ray, if suspected respiratory or musculoskeletal pathology OGD CT coronary angiography |
BP = blood pressure; CRP = C-reactive protein; CT = computed tomography; ECG = electrocardiography; FBC = full blood count; FH = family history; GORD = gastro-oesophageal reflux disease; IHD = ischaemic heart disease; LFT = liver function tests; OGD = oesophago-gastro-duodenoscopy; PMH = past medical history; SVT = supraventricular tachycardia; TFT = thyroid function tests; VT = ventricular tachycardia; VTE = venous thromboembolism.