Treatment of Heart Failure

HIATUS HERNIAIn the present investigation, though many of the patients were elderly, none of the 70 from whom the first series is taken had pain which could be confused with that of myo- cardial ischaemia.The seven patients in the second series were referred privately to a cardiologist, as their symptoms were thought to be due to heart disease.In Case 1 pain and " wind in the chest " on walking, and relieved by stopping to belch, was suggestive of cardiac effort pain.However, the exertion necessary to provoke an attack varied consider- ably from day to day.This with the history of dyspepsia and the normal cardiological finding led to the correct diag- nosis.Pain in the chest (Case 5), in the chest and left arm (Case 4), and at the xiphisternum (Case 6) could have been mistaken for the pain of myocardial ischaemia, had the patient been seen in the first attack only.Again, diagnosis was assisted by the variation of the attacks over a period of time, the dyspeptic symptoms, and absence of significant cardiac disease.In Case 7 a history of genuine cardiac effort pain was related to anaemia and disappeared following iron treatment.No confusion arose in Cases 2 and 3.It would appear, therefore, from the present study and from the literaturereviewed here that hiatus hernia (in the absence of associated anaemia) may only rarely be responsible for pain in, or spreading to, the chest, arms, neck, and jaw.When this does occur it may have the same distribution as the pain of cardiac ischaemia, and the type of pain may be similar.Direct relationship to exertion, however, is very inconstant, and when present the effort required to produce the pain varies much more than in myocardial disease.Furthermore, it often lasts for hours.The pre- dominant aggravating factors are the taking of food, the horizontal position, and, as most authors stress, anxiety.Its relief with belladonna and antacids is usually better than with nitroglycerin.