Breathlessness

What breathlessness feels like, and the patterns that matter

Breathlessness is a word that covers a lot of ground. Some people mean they are puffed doing something that used to be easy. Others mean a sense of air hunger, of not being able to fill their lungs, or of having to sit up before they can breathe comfortably. All of it counts, and the useful detail is when it happens and how quickly it came on.

Three patterns are worth separating out, because they carry different weight. Breathlessness brought on by exertion. Breathlessness that arrives within minutes of lying flat, which doctors call orthopnoea. And waking suddenly short of breath an hour or two after falling asleep, which is called paroxysmal nocturnal dyspnoea, usually shortened to PND.

There is a fourth pattern that is easy to miss entirely, because nothing dramatic ever happens. The heart has a remarkable ability to compensate when something is not quite right, and people adjust their daily routines without realising it. They walk more slowly, stop more frequently, avoid hills or avoid certain activities, and put it down to ageing or a busy lifestyle. Because the change is gradual, a drop in what you can manage is one of the earliest and most overlooked warning signs of all.

• On exertion. Getting out of breath on a hill, on the stairs or carrying shopping, when the same thing was comfortable a few months ago.
• Lying flat, or orthopnoea. Breathlessness that comes on within minutes of lying down and typically eases within a few minutes of sitting up. People often notice they need two, three or even four pillows to sleep comfortably, or that they have started sleeping in a chair.
• Waking at night, or PND. A sudden episode that wakes you one to two hours after going to bed and forces you to sit up, get out of bed or go to a window for fresh air. It can be genuinely frightening, and it takes longer to settle than orthopnoea, typically 15 to 30 minutes.
• At rest. Breathlessness with no effort at all behind it, which belongs in the emergency list above rather than being something to keep an eye on.
• A gradual loss of stamina. Activities that were once easy starting to feel more demanding, without any single moment where things changed.

The common causes that are not the heart

It is worth saying plainly that a great many breathless people do not have a heart problem. The lungs, the airway, the gut and the nervous system can all produce the same sensation, and several of these causes are very common indeed.

Obstructive sleep apnoea deserves a particular mention. It is probably the single most common non-cardiac cause of waking up breathless, and it also overlaps heavily with heart disease. Untreated sleep apnoea is itself a risk factor for high blood pressure, atrial fibrillation and heart failure, so the two frequently sit in the same person at the same time. CPAP is highly effective, and where sleep apnoea has been driving the breathlessness the improvement can be striking within weeks.

None of these causes rule each other out. Plenty of people have more than one thing going on, and reflux, asthma and anxiety all have effective, evidence based treatments once the diagnosis is confirmed. Often the fastest way to resolve the symptom is to treat one of these directly rather than assuming the heart is at fault. This page does not cover every possible cause of breathlessness, so a cause that is not listed here is not a cause that has been ruled out.

• Obstructive sleep apnoea. The airway repeatedly closes during sleep, causing pauses in breathing and often waking you gasping. Loud snoring, daytime sleepiness, morning headaches and being told you stop breathing during sleep are the typical clues.
• Asthma. Nocturnal asthma is well described and produces wheezing, chest tightness and breathlessness that often responds to inhalers. A previous history of asthma or hay fever points in this direction.
• Acid reflux. Stomach acid rising up the food pipe when you are lying down can cause coughing, wheezing and a sensation of being unable to breathe, usually alongside heartburn, a sour taste or a chronic cough.
• Anxiety and panic attacks. These can produce a sudden sensation of breathlessness, particularly during a stressful or difficult period. The sensation is very real, and it deserves to be taken seriously even when the cause is not physical.
• Other lung conditions. COPD, pulmonary fibrosis and, occasionally, a clot on the lung, which is a medical emergency rather than something to wait out.
• Anaemia and thyroid problems. Neither is a heart condition, and both are checked on the blood tests taken as part of a cardiac assessment, alongside kidney function and inflammatory markers. Thyroid problems are one of the recognised non-cardiac causes of ongoing tiredness.

When breathlessness may be coming from the heart

When breathlessness does come from the heart, there is usually a reason it shows up at particular moments, and fluid is a large part of the explanation. During the day, gravity pulls fluid downwards into the legs. When you lie flat at night, that fluid gradually redistributes back into the chest and lungs. A healthy heart handles this without any noticeable difference. A heart that is not pumping as efficiently as it should can be overwhelmed by the extra volume, and the lungs become congested.

That is why breathlessness lying flat and waking at night short of breath are treated as more specific cardiac warning signs than daytime breathlessness on its own. Whenever Dr Jogiya hears a clear story of pillow stacking, or of waking to sit on the edge of the bed, it moves heart failure and related conditions towards the top of his list.

Even then it is far from a foregone conclusion. From working with the patients he sees in clinic, Dr Jogiya would say that roughly four in ten patients who come to him specifically because of nocturnal breathlessness turn out to have a cardiac cause, with the remaining six in ten falling into the various non-cardiac categories. That is his own clinical impression of nocturnal breathlessness rather than a published figure, and it is not a guide to breathlessness in general. The point of a proper assessment is to work out which group you are in, so you can be treated appropriately.

• Heart failure. By far the most common cardiac cause of nocturnal breathlessness. It does not mean the heart has stopped, only that it is not pumping as strongly or filling as efficiently as it should. Fluid builds up gradually in the lungs and the rest of the body, and the classic picture is orthopnoea and PND alongside swollen ankles, unexplained fatigue and reduced exercise tolerance.
• Coronary artery disease and angina. Narrowed coronary arteries can leave the heart muscle short of blood, which may show up as chest discomfort, breathlessness or both, and can sometimes wake you from sleep. Breathlessness, sweating, nausea or unusual fatigue can also come alongside the chest discomfort of angina.
• Atrial fibrillation and other rhythm disorders. An irregular or fast rhythm can cause breathlessness, palpitations and a sense of being unable to catch your breath. These are increasingly picked up by wearable devices, and Dr Jogiya now sees a steady flow of patients who have noticed something unusual overnight on a smartwatch.
• Heart valve disease. Significant leakiness or narrowing of a valve, particularly the mitral or aortic valve, can produce the same fluid build up in the lungs.
• Cardiomyopathy. Disease of the heart muscle itself, whether inherited or acquired, can present with breathlessness as one of its earliest symptoms, whether at night or during physical activity.
• Ventricular hypertrophy. A thickened heart muscle wall, of which long standing high blood pressure is the clearest cause. It can show itself as shortness of breath during physical activity, a drop in exercise tolerance or fatigue, although some people notice nothing at all.

Telling the two apart

The good news is that the clinical pattern is often quite different between cardiac and non-cardiac causes. A careful history combined with a proper examination can usually point in the right direction before a single test is run.

This is also why an experienced cardiology consultation works better than piecemeal symptom checking online. The picture only becomes clear when everything is looked at together, including how the breathlessness comes on, what makes it better, what other symptoms sit alongside it and what your background risk looks like. The categories below are not mutually exclusive either. A mix is common, particularly heart failure combined with sleep apnoea, and the plan has to address whichever contributors are genuinely relevant.

These pointers describe symptoms that have been building over time. They are not a way of talking yourself out of an emergency, and none of them cancel out the red flags listed above.

• Points towards the heart. A classic PND pattern, pillow stacking, ankle swelling, breathlessness on exertion, a history of high blood pressure, a previous heart attack, atrial fibrillation or diabetes, or a family history of heart problems.
• Points towards sleep apnoea. Heavy snoring, witnessed pauses in breathing, daytime sleepiness, being overweight, a large neck circumference.
• Points towards asthma. Wheeze, a response to inhalers, a history of atopy or previous asthma.
• Points towards reflux. Heartburn, a sour taste, symptoms triggered by eating late, improvement with antacids.
• Points towards anxiety. Clear links to stress, other anxiety symptoms, symptoms arriving in a specific emotional context.

What Dr Jogiya would do about it

If a cardiac cause is on the table, the initial assessment is usually straightforward and can often be completed within a single consultation. The history and the examination do much of the work, because the pattern of the breathlessness, the symptoms sitting alongside it and your background risk together give a strong indication before anything else is done.

After that, Dr Jogiya will usually arrange an ECG, blood tests and an echocardiogram. The echocardiogram is the single most useful test for investigating suspected heart failure, valve disease and structural causes of breathlessness, because it gives a live picture of how well the heart is pumping, how the valves are working and whether there is any fluid or structural abnormality. Blood tests typically include a natriuretic peptide called NT-proBNP, a marker of heart strain that can be very helpful in confirming or ruling out heart failure.

It is rarely one test that gives the answer. It is the combination of history, examination and investigations that identifies the cause, and that includes ruling the heart out where the heart is not the problem. Dr Jogiya sees private patients across Kingston upon Thames, Wimbledon and central London, in person and virtually.

• A careful history and examination, which is the single most important part of the assessment.
• A 12 lead ECG, a quick and painless recording of the electrical activity of the heart that can pick up rhythm problems, signs of a previous heart attack or evidence of strain.
• An echocardiogram, an ultrasound scan of the heart muscle and valves.
• Blood tests, including NT-proBNP, and checks for anaemia, thyroid problems, kidney function and inflammatory markers.
• A chest X ray, where it is useful to look for fluid on the lungs, an enlarged heart or lung disease.
• Further investigations where the initial results raise concern, which may include a cardiac MRI, ambulatory ECG monitoring, an exercise test or a sleep study, depending on the clinical picture.

When to arrange an assessment rather than wait

The symptoms below are not emergencies, and the red flags above always come first. Short of those, breathlessness that is new, getting worse or unexplained should not be filed away as stress, being unfit or simply getting older. It deserves a proper cardiology assessment.

The earlier these symptoms are properly investigated, the more straightforward the answers tend to be, and the more options there are for treatment. That holds whether the eventual answer turns out to be cardiac or not. This page is general information rather than advice about your own heart, so if something about your own symptoms does not fit what you have read here, get it looked at.

• Breathlessness that has been getting steadily worse
• Needing extra pillows to sleep, or having started sleeping in a chair
• Waking regularly gasping for breath
• New swelling in the ankles or legs, particularly when it affects both legs and comes with breathlessness
• A noticeable drop in your exercise tolerance
• Breathlessness alongside palpitations, especially if a wearable device has shown irregular readings