Dr Tanveer Hj Iqbal
At the end of this lecture student should be
able to :
Identify common cases that will be seen in
ward related to cardiovascular system
Know the common presenting complaint
patient presents with in cardiovascular
disease
Learn how to take proper history for each
complaint
Identify sign and symptoms that are related
to cardiovascular systems
Acute coronary syndrome
Unstable Angina
NSTEMI
MI (usually in CCU /CRW)
Heart failure
Hypertensive heart failure
Cardiomyopathy –ischemic and non-ischemic
Valvular heart disease
Chronic rheumatic heart disease
with/without valve replacement
Infective endocarditis
Acute rheumatic fever( possible but rare)
Coronary artery disease - Elective admission
for coronary angiogram
Congenital heart condition – cyanotic and
acyanotic
Arrhythmias
SVT
Fast AF
AF admitted for overwarfarinization
Sinus bradycardia secondary to beta blockers
First degree and second degree heart block
Complete heart block
Major symptoms
Chest pain or heaviness
Dyspnoea: exertional (note degree of exercise
necessary),
orthopnoea, paroxysmal nocturnal dyspnoea
Ankle swelling
Palpitations
Syncope
Intermittent claudication
Fatigue
Past history
History of ischaemic heart disease: myocardial
infarction,
coronary artery bypass grafting
Rheumatic fever, chorea, sexually transmitted
disease, recent
dental work, thyroid disease
Prior medical examination revealing heart
disease (e.g. military,school, insurance)
Drugs
Social history
Tobacco and alcohol use
Occupation
Family history
Myocardial infarcts, cardiomyopathy, congenital
heart disease,
mitral valve prolapse, Marfan‘s syndrome
Coronary artery disease risk factors
Previous coronary disease
Smoking
Hypertension
Hyperlipidaemia
Family history of coronary artery disease
Diabetes mellitus
Obesity and physical inactivity
Male sex and advanced age
Raised homocysteine levels
Functional status in established heart
disease (New York Heart Association-NYHA)
Class I—disease present but no symptoms, or
angina* or
dyspnoea† during unusually intense activity
Class II—angina or dyspnoea during ordinary
activity
Class III—angina or dyspnoea during less than
ordinary activity
Class IV—angina or dyspnoea at rest
CHEST PAIN
Dyspnea
Palpitation
Giddiness
Provokes urgent attention
Pain of angina similar to myocardial
infarction
Due to accumulation of metabolites from
ischemic muscle following complete or
partial obstruction of a coronary artery
Site
Onset
Character of the pain
Severity of pain: Pain score (1-10/10)
Radiation of the pain
Duration of the pain
Precipitating and aggravating factor
Relieving factor
Associated symptoms
Sweating
Nausea
Vomiting
Palpitation
Shortness of breath
Definition
•Comes from Latin word ―choking‖
•Crushing pain, heaviness, discomfort or a choking sensation
in the retrosternal area or in the throat
Character of pain
•Use the word ―discomfort‖ rather than pain
•Angina pain is often dull and aching in nature may not be
perceived as pain
Site of pain
•The pain/discomfort is usually central rather then left-sided
•Patient may dismiss the pain as non-cardiac because it is not
left-sided
Radiation
• It may radiate to the jaw or to the arms but very rarely travel
below umbilicus
Severity
• Varies
Precipitating factor
• Characteristically occurs with exertion
• Rapid relief once pt. rest or slow down
• Typically occurs on exertion can also occur at rest or wake
patient from sleep
Pattern of onset
• The amount of exertion necessary to produce the pain may be
predictable to the patient
• A change in the pattern of onset of previously stable angina
should be taken seriously
Aggravating factor & Relieving factor
• Usually unaffected by respiration
• Sublingual GTN characteristically bring relief in couple of
minutes but not specific as nitrates also relieve esophageal
spasm
Often comes on rest , usually more
severe and last much longer
Pain present more than half an hour
more likely myocardial infarct than
to angina but if continuously for
days unlikely to be either
Associated symptoms include
dyspnea , sweating , anxiety ,
nausea and faintness
Chest pain made worse by inspiration is called pleuritic pain.
This may be due to pleurisy or pericarditis .
Pleurisy may occur because of inflammation of the pleura as a primary
problem (usually due to viral infection), or secondary to pneumonia or
pulmonary embolism.
Pleuritic pain is not usually brought on by exertion and is often
relieved by sitting up and leaning forwards. It is caused by the
movement of inflamed pleural or pericardial surfaces on one another.
Chest wall pain is usually localised to a small area of the chest
wall, is sharp and is associated with respiration or movement of
the shoulders rather than with exertion. It may last only a few
seconds or be present for prolonged periods.
Disease of the cervical or upper thoracic spine may also cause
pain associated with movement. This pain tends to radiate
around from the back towards the front of the chest.
Pain due to a dissecting aneurysm of the aorta is usually
very severe and may be described as tearing.
This pain is usually greatest at the moment of onset and
radiates to the back.
These three features—quality, rapid onset and radiation—are
very specific for aortic dissection.
A proximal dissection causes anterior chest pain and
involvement of the descending aorta causes interscapular pain.
A history of hypertension or of a connective tissue disorder
such as Marfan‘s syndrome or Ehlers-Danlos syndrome puts the
patient at increased risk of this condition.
Massive pulmonary embolism causes pain of very sudden
onset which may be retrosternal and associated with
collapse, dyspnoea and cyanosis
It is often pleuritic, but can be identical to anginal pain,
especially if associated with right ventricular ischaemia.
Spontaneous pneumothorax may result in pain and severe dyspnoea
The pain is sharp and localised to one part of the chest.
Gastro-oesophageal reflux can quite commonly cause angina-like pain
without heartburn.
It is important to remember that these two relatively common conditions may
co-exist.
Oesophageal spasm may cause retrosternal chest pain or discomfort and
can be quite difficult to distinguish from angina, but is rare.
The pain may come on after eating or drinking hot or cold fluids, may be
associated with dysphagia (difficulty swallowing) and may be relieved by
nitrates.
Cholecystitis can cause chest pain and be confused with myocardial
infarction.
Right upper quadrant abdominal tenderness is usually present
The cause of severe, usually unilateral, chest pain may not be apparent
until the typical vesicular rash of herpes zoster appears in a thoracic
nerve root distribution.
Shortness of breath may be due to cardiac
disease.
Dyspnoea (Greek dys‗bad‘, pnoia ‗breathing‘)
is often defined as an unexpected awareness
of breathing.
It occurs whenever the work of breathing is
excessive, but the mechanism is uncertain.
It is probably due to a sensation of increased
force required of the respiratory muscles to
produce a volume change in the lungs,
because of a reduction in compliance of the
lungs or increased resistance to air flow.
As it becomes more severe, cardiac dyspnoea
occurs at rest.
Orthopnoea (from the Greek ortho ‗straight‘) or dyspnoea
that develops when a patient is supine, occurs because
in an upright position the patient‘s interstitial oedema is
redistributed;
the lower zones of the lungs become worse and the upper zones
better.
This allows improved overall blood oxygenation.
Paroxysmal nocturnal dyspnoea (PND) is severe
dyspnoea that wakes the patient from sleep so
that he or she is forced to get up gasping for
breath.
Acute rise in
Sudden failure of Transudation of
pulmonary venous Increase work of
left ventricular fluid into the
and capillary breathing
output interstitial tissue
pressure
Due to resorption of peripheral edema at night
while supine
Some patients present with bilateral ankle swelling due to oedema from
cardiac failure.
Patients with the recent onset of oedema and who take a serious interest
in their weight may have noticed a gain in weight of 3 kg or more.
Ankle oedema of cardiac origin is usually symmetrical and worst in the
evenings, with improvement during the night.
It may be a symptom of biventricular failure or right ventricular failure
secondary to a number of possible underlying aetiologies.
As failure progresses, oedema ascends to involve the legs, thighs,
genitalia and abdomen.
There are usually other symptoms or signs of heart disease.
It is important to find out whether the patient is taking a vasodilating
drug (e.g. a calcium channel blocker), which can cause peripheral
oedema.
There are other (more) common causes of ankle oedema than heart
failure that also need to be considered
Oedema that affects the face is more likely to be related to nephrotic
syndrome
Unexpected awareness of the heart beat
Ask patient describe exactly what she notices
Whether palpitation are
slow or fast ,
regular or irregular and
how long they last
There maybe sensation of a missed beat
followed by a particularly heavy beat due to
atrial premature contraction or ventricular
premature beat (which produces little cardiac
output) followed by compensating pause then a
normally conducted beat (which is more forceful
than usual because there is longer diastolic
filling period for ventricle
1. Is the sensation one of the heart beating abnormally, or something
else?
2. Does the heart seem fast or slow? Have you counted how fast? Is it
faster than it ever goes at any other time, e.g. with exercise?
3. Does the heart seem regular or irregular—stopping and starting? If it is
irregular, is this the feeling of normal heart beats interrupted by missed
or strong beats—ectopic beats; or is it completely irregular?—Atrial
fibrillation
4. How long do the episodes last?
5. Do the episodes start and stop very suddenly?—Supraventricular
tachycardia (SVT)
6. Can you terminate the episodes by deep breathing or holding your
breath?—SVT
7. Is there a sensation of pounding in the neck?—some types of SVT9
8. Has an episode ever been recorded on an ECG?
9. Have you lost consciousness during an episode?—Ventricular
arrhythmias
10. Have you had other heart problems such as heart failure or a heart
attack in the past?—Ventricular arrhythmias?
11. Is there heart trouble of this sort in the family?
If the patient complains of a rapid heartbeat,
it is important to find out whether the
palpitations are of sudden or gradual onset
and offset.
Cardiac arrhythmias are usually
instantaneous in onset and offset, whereas
the onset and offset of sinus tachycardia is
more gradual.
A completely irregular rhythm is suggestive
of atrial fibrillation, particularly if it is
rapid.
It may be helpful to ask the patient to tap
the rate and rhythm of the palpitations with
his or her finger.
Associated features including pain, dyspnoea
or faintness must be inquired about.
The awareness of rapid palpitations followed
by syncope suggests ventricular tachycardia.
These patients usually have a past history of
significant heart disease.
Any rapid rhythm may precipitate angina in a
patient with ischaemic heart disease.
Patients may have learned manoeuvres that
will return the rhythm to
normal. Attacks of supraventricular
tachycardia (SVT) may be suddenly
terminated by increasing vagal tone with the
Valsalva manoeuvre ( page 70),
carotid massage, by coughing, or by
swallowing cold water or ice cubes.
Syncope is a transient loss of consciousness
resulting from cerebral anoxia, usually due
to inadequate blood flow.
Presyncope is a transient sensation of
weakness without loss of consciousness.
Syncope may represent a simple faint or be a
symptom of cardiac or neurological disease.
One must establish whether the patient actually
loses consciousness and under what
circumstances the syncope occurs—e.g.
on standing for prolonged periods or standing up
suddenly (postural syncope)
while passing urine (micturition syncope),
on coughing (tussive syncope), or
with sudden emotional stress (vasovagal syncope).
Find out whether there is any warning, such as
dizziness or palpitations, and how long the
episodes last.
Recovery may be spontaneous or the patient may
require attention from bystanders.
If the patient‘s symptoms appear to be
postural, inquire about the use of anti-
hypertensive or anti-anginal drugs and other
medications that may induce postural
hypotension.
If the episode is vasovagal, it may be
precipitated by something unpleasant like
the sight of blood, or occur in a crowded, hot
room; patients often sigh and yawn and feel
nauseated and sweaty before fainting and
may have previously had similar episodes,
especially during adolescence and young
adulthood.
If syncope is due to an arrhythmia, there is a sudden loss
of consciousness regardless of the patient‘s posture; chest
pain may also occur if the patient has ischaemic heart
disease or aortic stenosis.Recovery is equally quick.
Exertional syncope may occur with obstruction to left
ventricular outflow by aortic stenosis or hypertrophic
cardiomyopathy .
Profound and sudden bradycardia, usually a result of
complete heart block, causes sudden and recurrent
syncope (Stokes-Adams attacks).
These patients may have a history of atrial fibrillation.
Typically they have periods of tachycardia (fast heart rate)
as well as periods of bradycardia (slow heart rate).
This condition is called the sick sinus syndrome.
The patient must be asked about drug treatment that
could cause bradycardia, e.g. beta-blockers, digoxin,
calcium channel blockers.
It is important to ask about a family history
of sudden death.
An increasing number of ion channelopathies
are being identified as a cause of syncope
and sudden death.
These inherited conditions include the long
QT syndrome and the Brugada syndrome
They are often diagnosed from typical ECG
changes.
In addition, certain drugs can cause the
acquired long QT syndrome
Neurological causes of syncope are associated
with a slow recovery and often residual
neurological symptoms or signs.
Bystanders may also have noticed abnormal
movements if the patient has epilepsy.
Dizziness that occurs even when the patient is
lying down or which is made worse by
movements of the head is more likely to be of
neurological origin, although recurrent
tachyarrhythmias may occasionally cause
dizziness in any position.
One should attempt to decide whether the
dizziness is really vertiginous (where the world
seems to be turning around), or whether it is a
presyncopal feeling.
The word claudication comes from the Latin meaning
to limp.
Patients with claudication notice pain in one or both
calves, thighs or buttocks when they walk more than
a certain distance.
This distance is called the ‗claudication distance‘.
The claudication distance may be shorter when
patients walk up hills.
A history of claudication suggests peripheral vascular
disease with a poor blood supply to the affected
muscles.
The most important risk factors are smoking,
diabetes, hypertension and a history of vascular
disease elsewhere in the body, including
cerebrovascular disease and ischaemic heart disease
More severe disease causes the feet or legs
to feel cold, numb and finally painful at rest.
Rest pain is a symptom of severely
compromised arterial supply.
Remember the six P‘s of peripheral vascular
disease:
Pain
Pallor
Pulselessness
Paraesthesiae
Perishingly cold
Paralysed.
Questions to ask the patient with suspected peripheral vascular
disease
1. Have you had problems with walking because of pains in the legs?
2. Where do you feel the pain?
3. How far can you walk before it occurs?
4. Does it make you stop?
5. Does it go away when you stop walking?
6. Does the pain ever occur at rest?—Severe ischaemia may threaten the
limb
7. Have there been changes in the colour of the skin over your feet or
ankles?
8. Have you had any sores or ulcers on your feet or legs that have not
healed?
9. Have you needed treatment of the arteries of your legs in the past?
10. Have you had diabetes, high blood pressure, or problems with strokes
or heart attacks in the past?
11. Have you been a smoker?
Popliteal artery entrapment can occur,
especially in young men with intermittent
claudication on walking but not running.
Also, lumbar spinal stenosis causes pseudo-
claudication: unlike vascular claudication,
the pain in the calves is not relieved by
standing still, but is relieved by sitting
(flexing the spine) and may be exacerbated
by extending the spine (e.g. walking
downhill).
Fatigue is a common symptom of cardiac
failure.
It may be associated with a reduced cardiac
output and poor blood supply to the skeletal
muscles.
There are many other causes of fatigue,
including lack of sleep, anaemia and
depression.
Increase in the soft tissue of the distal part
of the fingers or toes
Why clubbing occurs ? Mechanism?
Several theories:
Unknown Dilatation of
Arterial humoral the vessels of
hypoxemia substance the fingertips
released or toes
Platelet derived growth factor, released from
megakaryocyte and platelet emboli in the nail bed
has been implicated in the pathogenesis
Janeway lesions are non-tender, small
erythematous or haemorrhagic macular or
nodular lesions on the palms or soles only a few
millimeters in diameter that are indicative of
infective endocarditis.
Pathologically, the lesion is described to be a
microabscess of the dermis with marked necrosis
and inflammatory infiltrate not involving the
epidermis.
They are caused by septic emboli which deposit
bacteria, forming microabscesses.
Janeway lesions are distal, flat, ecchymotic, and
painless.
Osler's nodes and Janeway lesions are similar,
but Osler's nodes present with tenderness
and are of immunologic origin.
Osler‘s nodes are painful, red, raised lesions
found on the hands and feet.
They are associated with a number of
conditions, including infective endocarditis,
and are caused by immune complex
deposition.
