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Symptoms Signs and Symptoms Signs and Investigations in Cardiovascular Investigations in Cardiovascular
DiseaseDisease
Prof:Nooruddin JafferProf:Nooruddin Jaffer
Hamdard Medical CollegeHamdard Medical College
KarachiKarachi
22
Importance of the historyImportance of the history
The richest source of information The richest source of information concerning the patients’ illnessconcerning the patients’ illness
Establishes a bond with the patient & Establishes a bond with the patient & improves his co-operationimproves his co-operation
Allows evaluation of the impact of the Allows evaluation of the impact of the diseasedisease
33
Breathlessness(dyspnoea)Breathlessness(dyspnoea)
abnormally uncomfortable awareness of abnormally uncomfortable awareness of breathingbreathingregarded as abnormal only when it occurs regarded as abnormal only when it occurs – at rest or at rest or – at level of physical activity not expected to cause itat level of physical activity not expected to cause it
associated with diseases of associated with diseases of – heart heart – lungslungs– chest wallchest wall– respiratory musclesrespiratory muscles
also associated with anxietyalso associated with anxiety
44
Breathlessness(dyspnoea)Breathlessness(dyspnoea)
Exertional dyspnoeaExertional dyspnoea– Comes on during exertion and subsides with Comes on during exertion and subsides with
restrest– Commonly due to HF or lung diseaseCommonly due to HF or lung disease
OrthopnoeaOrthopnoea– breathlessness on lying flatbreathlessness on lying flat– A symptom of left ventricular failureA symptom of left ventricular failure– due to redistribution of fluid from the lower due to redistribution of fluid from the lower
extremities to the lungsextremities to the lungs
55
Breathlessness(dyspnoea)Breathlessness(dyspnoea)
Paroxysmal Nocturnal dyspnoeaParoxysmal Nocturnal dyspnoea– a variant of orthopnoeaa variant of orthopnoea– patient awakes from sleep patient awakes from sleep
severely breathlessseverely breathless
persistent cough, may have white frothy sputumpersistent cough, may have white frothy sputum
– a manifestation of left ventricular failurea manifestation of left ventricular failure
66
Chest Pain or DiscomfortChest Pain or Discomfort
history is very importanthistory is very importantalthough a cardinal manifestation of heart although a cardinal manifestation of heart disease, also originates fromdisease, also originates from– Non-cardiac intrathoracic structuresNon-cardiac intrathoracic structures
aorta, pulmonary artery, bronchopulmonary tree, pleura, aorta, pulmonary artery, bronchopulmonary tree, pleura, mediastinum, oesophagus and diaphragmmediastinum, oesophagus and diaphragm
– tissues of the neck and thoracic walltissues of the neck and thoracic wallskin, thoracic muscles, cervicodorsal spine, costochondral skin, thoracic muscles, cervicodorsal spine, costochondral junctions, breasts, sensory nerves and spinal cordjunctions, breasts, sensory nerves and spinal cord
– subdiaphragmatic organssubdiaphragmatic organsstomach, duodenum, pancreas and gallbladderstomach, duodenum, pancreas and gallbladder
– Functional or factitiousFunctional or factitious
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Chest PainChest Pain
Points to note in the historyPoints to note in the history– locationlocation– radiationradiation– charactercharacter– aggravating factorsaggravating factors– relieving factorsrelieving factors– time relationshipstime relationships
duration, frequency and pattern of occurrenceduration, frequency and pattern of occurrence
– setting in which it occurssetting in which it occurs– associated factorsassociated factors
88
Differential diagnosis of chest pain Differential diagnosis of chest pain according to location according to location
99
OedemaOedema
Peripheral OedemaPeripheral Oedema– a feature of chronic heart failurea feature of chronic heart failure– due to excessive salt and water retentiondue to excessive salt and water retention– In ambulant patientsIn ambulant patients
found in the ankles, legs, thighs and lower abdomenfound in the ankles, legs, thighs and lower abdomen
– In patients who are recumbentIn patients who are recumbent over the sacrumover the sacrum
– associated with other features of heart failureassociated with other features of heart failure– Usually pitting except if it has been long standingUsually pitting except if it has been long standing
1010
OedemaOedema
Causes of peripheral oedemaCauses of peripheral oedema– cardiac failurecardiac failure– Chronic venous insufficiencyChronic venous insufficiency– Hypoalbuminaemia – nephrotic syndrome, Hypoalbuminaemia – nephrotic syndrome,
liver disease, protein losing enteropathyliver disease, protein losing enteropathy– DrugsDrugs
retaining sodium (fludrocortisone, NSAID)retaining sodium (fludrocortisone, NSAID)
increasing capillary permeability (nifedipine)increasing capillary permeability (nifedipine)
1111
PalpitationsPalpitations
definitiondefinition– unpleasant awareness of forceful or rapid beating of the heartunpleasant awareness of forceful or rapid beating of the heart– caused by disorders of cardiac rhythm and ratecaused by disorders of cardiac rhythm and rate
history in palpitationhistory in palpitation– isolated jump or skipsisolated jump or skips
extrasystolesextrasystoles– attacks with abrupt beginning, rapid heart rate with regular or attacks with abrupt beginning, rapid heart rate with regular or
irregular rhythmirregular rhythmparoxysmal tachycardiasparoxysmal tachycardias
– independent of exercise or excitement to account for the independent of exercise or excitement to account for the symptomsymptom
atrial fibrillation, atrial flutter, thyrotoxicosis, anaemia, anxiety atrial fibrillation, atrial flutter, thyrotoxicosis, anaemia, anxiety statesstates
1212
PalpitationsPalpitations
– associated with drug useassociated with drug usetobacco, coffee, tea, alcohol epinephrine, tobacco, coffee, tea, alcohol epinephrine, aminophylline, MAOIaminophylline, MAOI
– on standingon standingpostural hypotensionpostural hypotension
– middle aged women, associated flushes and middle aged women, associated flushes and sweatssweats
menopausal syndromemenopausal syndrome
– associated with normal rate and rhythmassociated with normal rate and rhythmanxiety stateanxiety state
1313
SyncopeSyncope
definitiondefinition– sudden temporary loss of consciousnesssudden temporary loss of consciousness– associated with loss of postural toneassociated with loss of postural tone– with spontaneous recovery with spontaneous recovery – not requiring electrical or chemical not requiring electrical or chemical
cardioversioncardioversion
due to sudden vasodilation or sudden fall due to sudden vasodilation or sudden fall in cardiac output or both simultaneouslyin cardiac output or both simultaneously
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CoughCough
defined as explosive expiration for clearing defined as explosive expiration for clearing the tracheobronchial tree of secretions and the tracheobronchial tree of secretions and foreign bodiesforeign bodiescardiovascular causes include those that cardiovascular causes include those that lead to lead to – pulmonary venous hypertensionpulmonary venous hypertension– interstitial and alveolar oedemainterstitial and alveolar oedema– pulmonary infarctionpulmonary infarction– compression of the tracheobronchial treecompression of the tracheobronchial tree
1515
CoughCough
the nature of the sputum is often helpfulthe nature of the sputum is often helpful– pink frothy sputum - pulmonary oedemapink frothy sputum - pulmonary oedema– clear white mucoid sputum –viral infection or clear white mucoid sputum –viral infection or
longstanding bronchial irritationlongstanding bronchial irritation– thick, yellowish sputum – infectionthick, yellowish sputum – infection– rusty sputum – pneumococcal pneumoniarusty sputum – pneumococcal pneumonia– blood streaked sputum – tuberculosis, blood streaked sputum – tuberculosis,
bronchiectasis, Ca lung or pulmonary bronchiectasis, Ca lung or pulmonary infarctioninfarction
1616
fatiguefatigue
non-specificnon-specificcommon in patients with impaired cardiovascular common in patients with impaired cardiovascular functionfunctionconsequent to a reduced cardiac outputconsequent to a reduced cardiac outputassociated with muscular weaknessassociated with muscular weaknessmay be caused by drugs e.g. may be caused by drugs e.g. ββ-blockers-blockersmay also result for excessive blood pressure may also result for excessive blood pressure reduction in patients with hypertension or heart reduction in patients with hypertension or heart failurefailurecaused by excessive diuresis or diuretic induced caused by excessive diuresis or diuretic induced hypokalaemiahypokalaemia
1717
Other symptomsOther symptoms
NocturiaNocturia– common in early heart failurecommon in early heart failure
AnorexiaAnorexia
Abdominal fullnessAbdominal fullness
right upper quadrant abdominal discomfortright upper quadrant abdominal discomfort
weight lossweight loss
cachexiacachexia
1818
Physical ExaminationPhysical Examination
General examinationGeneral examination– pallor indicate anaemiapallor indicate anaemia– cyanosis: bluish discolouration of the mucous mucosa cyanosis: bluish discolouration of the mucous mucosa
and skin due to arterial hypoxaemiaand skin due to arterial hypoxaemiacentral cyanosiscentral cyanosis
– poor gaseous exchange in the lungs– pulmonary disease or poor gaseous exchange in the lungs– pulmonary disease or pulmonary oedemapulmonary oedema
– right to left shunt in congenital heart diseaseright to left shunt in congenital heart diseaseperipheral cyanosisperipheral cyanosis
– obesityobesityassociated with hyperlipidaemia and diabetesassociated with hyperlipidaemia and diabetes
– features of hyperlipidaemiafeatures of hyperlipidaemiacorneal arcuscorneal arcusxanthelasmaxanthelasma
1919
Physical ExaminationPhysical Examination– facial abnormalitiesfacial abnormalities
ptosis and frontal baldness –dystonia myotonica(cardiomyopathy ptosis and frontal baldness –dystonia myotonica(cardiomyopathy and conduction defects)and conduction defects)high arched palate and ocular lens abnormalities – Marfan’s high arched palate and ocular lens abnormalities – Marfan’s syndrome(Aortic aneurysm)syndrome(Aortic aneurysm)unusual facial features(congenital heart diseases)unusual facial features(congenital heart diseases)
– finger clubbingfinger clubbingcyanotic congenital heart diseasescyanotic congenital heart diseasesinfective endocarditis(advanced)infective endocarditis(advanced)
– Splinter haemorrhagesSplinter haemorrhagestraumatraumainfective endocarditisinfective endocarditis
– Moist palmsMoist palmscold – anxietycold – anxietywarm – thyrotoxicosiswarm – thyrotoxicosis
2020
CVS examinationCVS examination
PulsePulse– RateRate
bradycardiabradycardiatachycardiatachycardia
– RhythmRhythmregularregularirregularirregular
– regular with dropped beatsregular with dropped beats– completely irregularcompletely irregular– sinus arrhythmia (speeds up in inspiration and slows with expiration)sinus arrhythmia (speeds up in inspiration and slows with expiration)
– VolumeVolumedepend on the cardiac stroke volume and the compliance of the arterial depend on the cardiac stroke volume and the compliance of the arterial systemsystem
– State of the arterial wallState of the arterial wall– SynchronicitySynchronicity
radio-femoral delayradio-femoral delay– Other pulsesOther pulses
brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedisbrachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis
2121
Blood pressureBlood pressure
use of a sphygmomanometeruse of a sphygmomanometer– inflatable cuff connected to mercury or inflatable cuff connected to mercury or
aneroid manometeraneroid manometer– stethoscope over the branchial arterystethoscope over the branchial artery– inflate cuff above the POPinflate cuff above the POP– reduce the pressure in the cuff slowlyreduce the pressure in the cuff slowly– reappearance of Korotkov sound – systolic reappearance of Korotkov sound – systolic
pressurepressure– disappearance of Korotkov sounds – diastolic disappearance of Korotkov sounds – diastolic
pressure pressure
2222
Blood pressureBlood pressure
Pitfalls in BP measurementPitfalls in BP measurement– apparatusapparatus
small cuff – overestimation of the BP by 20 - 30 mmHgsmall cuff – overestimation of the BP by 20 - 30 mmHg
large cuff – underestimation of the blood pressurelarge cuff – underestimation of the blood pressure
calibration of the sphygmomanometercalibration of the sphygmomanometer
– PatientPatientemotional state of the patientemotional state of the patient
anxiety(white coat hypertension)anxiety(white coat hypertension)
posture and the position of the sphygposture and the position of the sphyg
– observerobserverauscultatory gapauscultatory gap
2323
Jugular venous pulseJugular venous pulse
observed from the right internal jugular veinobserved from the right internal jugular veinusually examined with patient at 45usually examined with patient at 45°°2 major pulsations can be observed – ‘a’ and ‘v’ waves2 major pulsations can be observed – ‘a’ and ‘v’ wavesmeasurement of the JVPmeasurement of the JVP– height above the sternal angle – usually < 4cmheight above the sternal angle – usually < 4cm
Abdomino-jugular refluxAbdomino-jugular reflux– seen in right heart failureseen in right heart failure
Causes of raised JVPCauses of raised JVP– Rt heart failureRt heart failure– Tricuspid incompetenceTricuspid incompetence– Pericardial effusionPericardial effusion– SVC obstructionSVC obstruction– Constrictive pericarditisConstrictive pericarditis– Tricuspid stenosisTricuspid stenosis
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PraecordiumPraecordium
InspectionInspection– evidence of respiratory difficultyevidence of respiratory difficulty– visible veins – obstruction of SVCvisible veins – obstruction of SVC– praecordial bulge or prominence – long praecordial bulge or prominence – long
standing cardiac enlargement before pubertystanding cardiac enlargement before puberty– abnormalities of the chest wallabnormalities of the chest wall– Praecordial hyperactivity – suggests severe Praecordial hyperactivity – suggests severe
valvular abnormalityvalvular abnormality– Apex beat Apex beat
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Praecordium: palpationPraecordium: palpation
apex beatapex beat– lowermost and outermost point of cardiac lowermost and outermost point of cardiac
impulseimpulse– normally in the 5LICS at the mid-clavicular normally in the 5LICS at the mid-clavicular
lineline– when displaced suggests cardiac when displaced suggests cardiac
enlargementenlargement– heaving apex – LVHheaving apex – LVH– tapping apex beat (palpable 1tapping apex beat (palpable 1stst heart sound) – heart sound) –
mitral stenosismitral stenosis
2626
Praecordium: palpationPraecordium: palpation
Right ventricleRight ventricle– left parasternal heave indicate RVHleft parasternal heave indicate RVH
Palpable soundsPalpable sounds– Palpable 2Palpable 2ndnd heart sound –loud P2 or A2 heart sound –loud P2 or A2
ThrillsThrills– palpable murmurs with low frequency palpable murmurs with low frequency
componentscomponents
2727
Cardiac auscultationCardiac auscultation
Areas for auscultationAreas for auscultation– cardiac apexcardiac apex– right and left sternal borders interspace by right and left sternal borders interspace by
interspaceinterspace
2828
Heart soundsHeart sounds
4 basic heart sounds4 basic heart sounds
other sounds i.e. clicks, prosthetic valve other sounds i.e. clicks, prosthetic valve soundssounds
time the sounds with palpation of the time the sounds with palpation of the carotid arterycarotid artery
2929
Heart soundHeart sound
11stst heart sound heart sound– two major componentstwo major components– due to closure of the atrio-ventricular valvesdue to closure of the atrio-ventricular valves– loud inloud in
tachycardiatachycardiashort PR intervalshort PR intervalshort circle lengths in AFshort circle lengths in AFmitral stenosis with a pliable leafletmitral stenosis with a pliable leaflet
22ndnd heart sound heart sound– due to closure of the semi-lunar valvesdue to closure of the semi-lunar valves– normally two components Anormally two components A22 and P and P22
– splitting of the 2splitting of the 2ndnd heart sound in inspiration heart sound in inspiration
3030
2nd Heart sound: abnormal splitting2nd Heart sound: abnormal splitting
single 2single 2ndnd heart sound heart sound– inaudible pulm. componentinaudible pulm. component
pulmonary atresiapulmonary atresiadue to emphysemadue to emphysemasevere pulm. stenosissevere pulm. stenosis
– inaudible aortic componentinaudible aortic componentsevere calcific aortic stenosissevere calcific aortic stenosisaortic atresiaaortic atresia
– persistent synchrony of the two componentspersistent synchrony of the two componentsEisenmenger’s complexEisenmenger’s complex
3131
2nd Heart sound: abnormal splitting2nd Heart sound: abnormal splitting
Persistent splittingPersistent splitting– delay in the pulm. componentdelay in the pulm. component
complete RBBBcomplete RBBB– early timing of the first componentearly timing of the first component
mitral regurgitationmitral regurgitation
Fixed splittingFixed splitting– ostium secundum atrial septal defectostium secundum atrial septal defect
Paradoxical splittingParadoxical splitting– complete LBBBcomplete LBBB– right ventricular pacemakerright ventricular pacemaker– severe aortic outflow obstruction– a large aorta-to-pulmonary artery shunt
3232
2nd Heart sound: abnormal 2nd Heart sound: abnormal intensityintensity
Increased AIncreased A2 2
– systemic hypertensionsystemic hypertension
increased Pincreased P22
– pulmonary hypertensionpulmonary hypertension
3333
33rdrd heart sound heart sound
due to sudden limitation of ventricular due to sudden limitation of ventricular expansion during early diastolic fillingexpansion during early diastolic filling– heard normally in childrenheard normally in children– and in patients with high cardiac output– in patients over 40 years old
an S3 usually indicates– impairment of ventricular function– AV valve regurgitation– other conditions that increase the rate or volume of
ventricular filling
3434
44thth heart sound heart sound
a low-pitched, presystolic sound produced in the ventricle during ventricular fillingit is associated with an effective atrial contraction and is best heard with the bell piece of the stethoscopeabsent atrial fibrillationoccurs when diminished ventricular compliance increases the resistance to ventricular fillingseen in– patients with systemic hypertension– aortic stenosis– hypertrophic cardiomyopathy– ischemic heart disease– acute mitral regurgitation
3535
MurmursMurmursresult from vibrations set up – in the blood stream – and the surrounding heart and great vessels – as a result of
turbulent blood flow, formation of eddies, cavitation (bubble formation as a result of sudden decrease in pressure)
graded I – VI– grade I faint, heard only with special effort– grade II soft– grade III loud– grade IV loud with thrill– grade V audible with stethoscope barely touching the chest– grade VI murmur is audible with the stethoscope removed from contact
with the chest
3636
MurmursMurmurs
for a murmur, determine itsfor a murmur, determine its– timingtiming– intensityintensity– pitchpitch– site of maximal intensitysite of maximal intensity– radiationradiation– configurationconfiguration– relationship with posture and respirationrelationship with posture and respiration
three major categories of murmursthree major categories of murmurs– systolic, diastolic and continuoussystolic, diastolic and continuous
3737
other cardiac soundsother cardiac sounds
Pericardial rubsPericardial rubs– the hallmark of acute pericarditisthe hallmark of acute pericarditis– generated by the parietal and visceral pleura generated by the parietal and visceral pleura
rubbing against each otherrubbing against each other
3838
Other relevant examinationOther relevant examination
lung bases lung bases – crepitations in left heart failurecrepitations in left heart failure
abdomenabdomen– hepatomegaly in right heart failurehepatomegaly in right heart failure
3939
Cardiac Investigations and Cardiac Investigations and ProceduresProcedures
Electrocardiogram (ECG)Electrocardiogram (ECG)
Chest X-Ray (CXR)Chest X-Ray (CXR)
EchocardiographyEchocardiography
Trans-oesophagealEchocardiography (TEE)Trans-oesophagealEchocardiography (TEE)
Treadmill TestingTreadmill Testing
Tilt Table TestTilt Table Test
t
4040
Cardiac Investigations and Cardiac Investigations and ProceduresProcedures
Other New Imaging Techniques Other New Imaging Techniques
Cardiac CatherizationCardiac Catherization
Percutanous Transluminal Coronary Percutanous Transluminal Coronary Angioplasty (PTCA)Angioplasty (PTCA)
Stenting (PTCS), Stenting (PTCS),
drug eluting stentsdrug eluting stents
Brachytherapy (radiation) Brachytherapy (radiation)
4141
Cardiac Investigations and Cardiac Investigations and ProceduresProcedures
Electrophysiological Study of the Heart Electrophysiological Study of the Heart (EPS) and Radio-frequency Ablation (RF) (EPS) and Radio-frequency Ablation (RF)
Permanent Pacemaker Implantation Permanent Pacemaker Implantation (PPM) (PPM)
Automatic Implantable Cardiovertor-Automatic Implantable Cardiovertor-Defibrillator (AICD) Defibrillator (AICD)
Automated External Defibrillators (AEDs) Automated External Defibrillators (AEDs)
4242
4343
4444
4545
4646
4747
4848
4949
5050
5151
5252
5353
5454