Shortness of Breath

Yes — particularly in diabetics, women, and the elderly. Cardiac ischaemia often presents atypically: breathlessness or epigastric discomfort alone, without classic chest pain. Diabetics have autonomic neuropathy that reduces anginal perception, so any new breathlessness or exercise intolerance in a diabetic should be treated as possible cardiac ischaemia until proven otherwise. Heart failure also commonly presents with progressive exertional dyspnoea, orthopnoea (breathlessness lying flat), and paroxysmal nocturnal dyspnoea — waking up gasping for air at night.

Cardiac dyspnoea is typically exertional, progressive over weeks to months, associated with orthopnoea (worse lying flat), PND (waking up gasping), and leg swelling. Respiratory dyspnoea is more commonly associated with cough, wheeze, sputum production, and a prior smoking history. However, the overlap is substantial — heart failure and COPD frequently coexist. Formal testing including ECG, echo, BNP, and pulmonary function tests is the only reliable way to distinguish cardiac from respiratory causes.

Initial evaluation: resting 12-lead ECG (detects ischaemia, arrhythmia, LVH), high-sensitivity troponin (rules out NSTEMI), chest X-ray (cardiomegaly, pulmonary congestion), 2D echocardiography (LV function, wall motion, valve disease, pulmonary pressures), and BNP or NT-proBNP (heart failure marker). If these are normal, pulmonary function tests (asthma, COPD), D-dimer (pulmonary embolism), and full blood count (anaemia) help identify non-cardiac causes. Stress testing or CT coronary angiography may be indicated if CAD is suspected.

You should see a cardiologist if you experience: progressive breathlessness on exertion that has worsened over weeks to months; orthopnoea (needing extra pillows to sleep); waking up gasping for air; breathlessness with chest discomfort or palpitations; or any new breathlessness if you have diabetes, hypertension, or a family history of heart disease. Unexplained breathlessness in anyone over 40 with risk factors warrants cardiac evaluation. Do not wait — early diagnosis of heart failure or CAD dramatically improves outcomes.

Cardiac breathlessness (dyspnoea from heart disease) typically worsens with exertion and is associated with orthopnoea — difficulty breathing when lying flat, requiring extra pillows at night. Patients often wake up suddenly gasping for air (paroxysmal nocturnal dyspnoea) and may have ankle swelling. Respiratory breathlessness is more often associated with cough, wheeze, sputum production, and a history of smoking or asthma. However, the symptoms overlap substantially — many patients have both cardiac and respiratory disease (cardiometabolic syndrome). Formal testing with ECG, echocardiography, BNP blood test, chest X-ray, and pulmonary function tests is the only reliable way to distinguish cardiac from respiratory causes.

Yes — anaemia is a common and under-recognised cause of breathlessness. Haemoglobin carries oxygen from the lungs to the tissues. When haemoglobin levels drop, the body compensates by increasing heart rate and breathing rate — leading to the sensation of breathlessness, especially on exertion. Severe anaemia (haemoglobin below 8 g/dL) can closely mimic heart failure, causing fatigue, pallor, breathlessness, and even elevated heart rate. A complete blood count is a simple test that should be part of the initial evaluation for any patient presenting with unexplained dyspnoea. Treating the underlying cause of anaemia (iron deficiency, vitamin B12 deficiency, chronic disease) often significantly improves symptoms.

Paroxysmal nocturnal dyspnoea (PND) is a classic symptom of heart failure. The patient goes to bed breathing comfortably but wakes up 1–3 hours later suddenly gasping for air, with a feeling of suffocation. This occurs because lying flat causes fluid from the legs and abdomen to redistribute into the central circulation. A failing heart cannot handle this increased volume, causing fluid to accumulate in the lungs (pulmonary congestion). Patients typically sit up, dangle their legs, or go to a window for fresh air, and symptoms gradually resolve over 15–30 minutes. PND is distinct from simple orthopnoea (breathlessness on lying flat) — it is a more severe indicator of elevated left ventricular filling pressures and warrants urgent medical evaluation.

Emergency evaluation of acute shortness of breath follows a structured pathway. The first step is clinical assessment including vital signs, oxygen saturation, lung auscultation, and examination for signs of heart failure (elevated JVP, leg oedema). Immediate tests include: 12-lead ECG (to detect ischaemia, arrhythmia, or LVH), chest X-ray (cardiomegaly, pulmonary congestion, pneumonia), and high-sensitivity troponin (to rule out heart attack). BNP or NT-proBNP blood test is the key biomarker to distinguish cardiac from respiratory causes — a normal BNP effectively rules out heart failure. If pulmonary embolism is suspected, D-dimer and CT pulmonary angiography are performed. This systematic approach allows rapid identification of life-threatening causes.