Common Presentations of

Cardiovascular Diseases
Dr. Fasika Yimer
Internal Medicine Physician and Neurologist
School of Medicine, Department of Medical Sciences
Normal Heart Anatomy and Blood Flow
Cardiac Cycle
Understanding Heart Failure Pathophysiology
Initial myocardial insult
• Decreased cardiac outputand /or mean arterial pressure
• Increasaed wall stress

Activation of Renin-Angiotensin- Aldosteron System (RAAS) and

Sympathetic Nervous System (SNS)

Positive Chronotropy and Myocardial Sodium and Water

inotropy remodeling
•
retension
Increased myocardial work • Hypertrophy • Ventricular volume load
• Tachycardia • Fibrosis • Venous congestion
• Arrythmia • Apoptosis

Activation of Natriuretic Peptide (NP) system

 Heart Failure (HF)
• HF is a complex clinical syndrome that can result from any structural
or functional cardiac disorder that impairs the ablity of the ventricle
to fill with or to eject blood
• Congestive Heart Failure describes a condition where the heart
muscle is weakened and cannot pump as strongly as before.
• refers to the state in which abnormal circulatory congestion exists a result of
heart failure
• This means less oxygen is reaching the organs and muscles which can
make feel tired and short of breath
 Etiology of Heart Failure

• Heart failure is caused by systemic hypertension.

• Structural heart changes, such as valvular dysfunction, cause pressure
or volume overload on the heart.
• Heart is unable to pump enough blood to meet tissues O2 requirements
• Congenital heart defects
• Severe lung disease
• Diabetes
• Severe anaemia
• Overactive thyroid gland (hyperthyroidism)
• Abnormal heart rhythms
 Etiology…
• Increase in Pulmonary pressure results fluid in alveoli
(PULMONARY EDEMA)
• Increase in Systemic pressure results in fluid in tissues
(PERIPHERAL EDEMA)
• Health conditions that either damage the heart or make it work too
hard
• Coronary artery disease
• Heart attack
• Heart muscle diseases (cardiomyopathy)
• Heart inflammation (myocarditis)
Common Cardiac Symptoms
 Chest pain

Character of the pain: Dull, Constricting, choking or heavy and is usually

described as squeezing, crushing, burning or aching and not sharp
stabbing or Knife- like
• The sensation can be described as
breathelessness
• Patients often emphasise that it is
a discomfort rather than a pain
• They typically use characteristic
hand gesture ( eg. Open hand or clenched fist)
when describing the ischemic pain
 Chest pain…

Angina Pectoris:
• Diffuse Dull discomfort felt in the centre of anterior chest
• Duration less than 10 minutes
• Tightness, pressure similar to carrying heavy weight
• May radiate to left arm, jaw and teeth
• Associated with sweating, palpitation
• Triggered by exercise, cold weather
• Relieved by rest, or nitro-glycerine sublingual
 Chest pain of Unstable angina

•Angina of recent onset

•Increasing in severity
•Angina at rest
•Is a medical emergency
as it precedes Myocardial
infarction
 Chest pain…
Characteristics of Ischemic chest pain:
• Site of origin: cardiac pain is typically located in the centre of the chest
• Radiation: radiates to the neck, jaw, and upper or even lower arms, epigastric
region,
• Occasionally cardiac pain
may be experianced only at the
site of radiation or in the back
 Chest pain…
Aggraviatinfg and relieving factors:
• Anginal pain occurs during (not after) exertion and is promptly relieved in less than 5 minutes
by rest
• exacerbated by emotion and tends to occur more readily during exertion, after a large meal,
or in a cold wind
• In unstable angina, similar pain may be precipitated by minimal exertion and may occur at rest
• Decubitus angina is a variant of angina pectoris that occurs at night while the patient is
recumbent
• The pain of myocardial infarction may be preceded by a period of stable or unstable angina
 Chest pain…
Pattern of onset:
• pain of myocardial infarction typically takes several minutes or even longer to develop
• Similarly, angina builds on gradually in proportion to the intensity of exertion
• Pain that occurs after, rather than during exertion, is usually musculoskeletal or psychological in
origin
• The pain of aortic dissection, massive pulmonary embolism or pneumothorax is usually very
sudden or instantaneous in onset
 Chest pain…

Angina Equivalent:
• The sensation of breathlessness is a common feature of angina
• Patients will sometimes describe chest tightness as ’ breathlessness’
• However, myocardial ischemia may also induce true breathlessness by providing
transient left ventricular dysfunction or heart failure

• When breathlessness is the dominant feature of myocardial ischemia,it is known as

‘angina equivalent’
• A history of chest tightness, the close correlation with exercise and objective evidence of
myocardia ischemia from stress testing may help to establish the diagnosis
 Chest pain of myocaradial infarction

• Severe chest pain

• Prolonged duration
• Not relieved by rest or nitro-glycerine
• Pallor, nausea, vomiting
• Pain may be absent in
30% particularly in the
diabetics and old age
 Chest pain…
• Pleural
• a sharp or ‘catching’ sensation that is exacerbated by breathing coughing or movement
• Chest pain of musculoskeletal in origin:
• asssociated with a specific movement
(bending, streching, turning)

• Chest pain of pericardial origin:

• Sharp stitching anterior central chest pain
• Increases by inspiration and movement
• Decreases by leaning forward
 Chest pain…

• Chest pain of aortic dissection:

• Tear in the intimae of the aortic wall
• Abrupt severe chest pain (interscapular)
radiates to back
• MI if ascending aorta is involved
• Syncope and focal neurological defects

• Gastro-esophagial reflux disease (GERD)

• Retrosternal or epigastric pain
• Burning sensation
• Increased on lying down, eating, drinking
• Relieved by antacids
• Radiates to the back
 Breathlessness ( Dyspnea)
• Dyspnea is the clinical word for breathlessness
• It is defined as difficult, laboured and uncomfortable breathing,
• It ia an unpleasant type of breahing, usually not painful.
• Dyspnea of cardiac origin may vary in severity from an uncomfortable awareness of breathing to a
frightening sesation of “ fighting for breath’
• Also described as shortness of breath
• Usually worsen with exertion
• There are several causes of cardiac dyspnea
• Acute left heart failure
• Chronic heart failure arrythmia and
• Angina equivalent
Heart Failure Staging based on Shortness of Breath
(New York Heart Association (NYHA) Classification)

Depending on the severity of shortness of breath on the patients’ symptom, heart failure can be
classified as class I to IV
• Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath
when walking, climbing stairs etc.
• Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during
ordinary activity.
• Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity,
e.g. walking short distances (20—100 m).
Comfortable only at rest.
• Class IV - Severe limitations. Experiences symptoms even while at rest.
Mostly bedbound patients.
 Some causes of Dsypnea
• Cardiovascular system:
• Acute pulmonary edema
• Congestive cardiac failure
• Myocardial Ischemia

• Respiratory system
• Acute severe asthma
• Acute exacerbation of Chronic Obstructive Piulmonary disease
• Pneumonia
• Pulmonary embolus
• Acute respiratory distress syndrome
• Foreign body aspiration (especiallyinthe child)
• Lobar colapse
• Laryngeal edema
 Causes of Dsypnea….

Chronic causes:
• Obstructive pulmonary disease
• Chronic pulmonary thrombo-embolism
• Bronchial Carcinoma
• Interstitial lung disease: Sarcoidosis, fibrosing alveolitis, Extrinsic allergic alveolitis,
Pneumoconiosis
• Lymphatic carcinomatosis (may cause interolable dyspnoea)
• Large pleural effusion
 Acute heart failure
• Triggered by Myocardial infarction
in a previously healthy person

• Or onset of fibrillation in
a diseases heart
 Acute heart failure…
Acute left ventricular failure:
• A terrifyinfg experience
• Sensation of ‘fighting for breathing’
• Sitting upright or standing may provide some relief by helping to reduce congestion at
the apices of the lungs
• The patient may be unable to speak and is typically distressed, agitated, cyanosed,
sweaty and pale
• Respiration is rapid with recruitment of accessary muscles coughing and wheezing
• Sputum may be profuse, frothy and blood-streaked or pink
• Extensive crepitations and rhonchi are usually audible in the chest and there may also be
signes of right heart failure
 Chronic heart failure
• Most common cardiac causes of chronic dyspnea
• Symptoms may first present on moderatel severe exertion, such as, walking up a steep hill,
and may be described as a difficulty in ‘catching my breath’
• As the heart failure progresses, the dyspnea is provoked by a lessor exertion and ultimately
the patient may be breathless walking from room to room, washing, dressing or trying to hold
a converastion
 Orthopnea
• Shortness of breath on lying flat relieved by sitting

• Lying down increases the venous return to the heart and may provoke breathlessness in patients
with heart failure

• The patient may use more

pillow to prevent this

• Can be graded by the number

of pillows
 Paroxysmal Nocturnal Dyspnea (PND)
• Sudden breathlessness which wakes the patient from sleep choking or gasping air
• Caused by gradual accumulation of alveolar fluid during sleep
• Patients may sit on the edge of the bed and open windows in an attempt to relieve their distress.
• Cough with frothy blood stained sputum
• Chest wheeze
• In patients with severe heart failure, fluid shifts from the interstitial tissues in the peripheries to
the circulation within 1-2 hours of lying down in bed
• Pulmonary oedema may supervene, causing the patient to wake and sit upright, profoundly
breathless
 Systemic venous congestive symptoms

• Oedema: Generalized edema is due to an increase in the volume of extracelluar

fluid
• This is caused by excessive renal tubular reabsorption of sodium and water

• The mechanism for this reabsorption is the renin- angiotensin-aldosteron system

being the main factor (refer pathophysiology of heart failure)

• The accumulation of fluids in the extracelluar space is governed by the relation

ship between hydrostatic pressure and oncotic pressure
 Oedema…
• Oedema of heart failure:
• Typically dependent
• Affect initially the ankles which ascends as the extent increases
• The edema is usually symmetrical but, sometimes, it is more marked in the
left leg than the right
• this is said to be due to pressure on the left common iliac vein by the
right common iliac as it crosses it
• Oedema of renal disease:
• usually becomes generalised as the cause for the edem is significant
protein/albumin loss through urine (proteinuria or albuminuria)
• They will have associated perorbital oedema
 Systemic venous congestive symptoms

Lower limb edema:

• Caused by systemic venous congestion
• Dependent oedema, lower limbs and sacral
• Bilateral pitting oedema

Differential diagnosis:
• Congestive heart failure
• Nephrotic syndrome
• Liver cirrhosis
• Renal failure
 Oedema…
• Oedema of liver disease:
• Fluid retention in hepatic failure is common
• It is due to impaired protein synthesis and consequent hypoalbuminaemia
• Portal hypertension is the other mechanism of ascites formation
• Uaually starts with abdominal distension first before they develop peripheral
edema

• Picture showing abdominal distension

• Ascites secondary to systemic
venous congestion
 Oedema…

• Othe causes of generalized edema include:

• proetein lossin enteroathy
• Protein energy malnutrition
• idiopathicoedema

Anasarca
(generalized body swelling)
 Differential diagnosis of unilateral leg swelling
• DVT

Lymphatic obstruction

• Cellulitis
Cough of cardiac origin
• Usually dry and sometimes with
fresh blood or frothy sputm

• Most of the time nocturnal

exacerbated in lying position

• Mostly seen in advanced

cardiac failure, acute heart failure
with pulmonary congestion

• Improves with heart failure

management
 Syncope and presyncope
• Syncope is defined as transient loss of consciousness due to a reduction in the cerebral
blood flow
• Presyncope is "feeling like one was going to pass out but without actual loss of
consciousness."
• It is nearly fainting or the prodrome of syncope
• A wide variety of cardiovascular disorders can cause an abrupt fall in cerebral perfusion
that may manifest as recurrent or isolated episode of syncope and presycope
Commuon causes of syncope:
• Vassomotor:
• vasovagal attacks
• Postural hypotension
• Carotid sinus syncope
 Syncope…

• Cardiac Syncope:
• Stokes- adams attacks in atrioventricular block (due to cardiac arrest due to
asystole or ventricular fibrillation on the basis of AV-block)
• Paroxysmal dysrhythmias
• Central circulatory obstruction (eg. Aortic stenosis)
• Cyanotic attacks in cogenital heart disease

• Miscellaneous:
• cough syncope
• Micturation syncope
• Breath holding attacks
 Typical Features of Syncope, Vasovagal Syncope and
Seizures

Cardiac Syncope Vasovagal syncope Seizure

Often no typical feature lightheadedness confusion

Light headedness Sweating hyperexcitability
palpitaation olfactory
Chest pain hallucinations
breathlessness Aura
Nausea
Extreme death like pallor Prolonged > 1min. Pallor Motor seizure activity
Rapid recovery (< 1 min.) Slow recovery Tongue biting
Urinary incontinence
Prolonged confusion (>
5min), headache, neurologic
deficits
 Palpitation

• Palpitation is awareness of heart beats

• Change in the rate or the rhythm
• Check onset, duration, relation to exertion, irregularities
• Normal during exercise, anxiety, coffee, nicotine

Common causes of palpitation include:

 Atrial/ ventricular extrasystole
 Atrial fibrillation,
 sinus tachycardia/brady cardia
 Ventricular tachycardia,
 Heart blocks
 Palpitation…

• Causes of palpitation with high pulse volume:

• Aortic regurgitation
• Thyrotoxicosis
• Pregnancy
• Anaemia
 References

• French ‘s Index of Differetial Diagnosis, An A-Z 14th edition

• Internet Sources
Thank you!