Symptoms and Signs of

Cardiovascular disease
400L Medical Students
August 2024

Dr Amusa Ganiyu A
MBChB, MSC, MD, ATSF, FMCP, FWACP, FRCP (London)
Senior Lecturer and Consultant Physician/ Cardiologist
University of Jos / Jos University Teaching Hospital
 Symptoms of Cardiovascular Diseases

Importance of History / Major Symptoms

Objectives Signs / Approach to Patients with Cardiovascular

disease

General Examination

Cardiovascular Examination
 Importance of the history and examination
• The history and physical examination
• The clinical examination
• Cornerstone of the assessment of the patient
• provides information necessary to make
with known or suspected cardiovascular disease.
decisions on the appropriateness of clinical
• History investigative procedures.
• The richest source of information concerning the • There may be little correlation between the intensity
patients’ illness of symptoms and the severity of heart disease
• Establishes a bond with the patient • Asymptomatic persons may have a life-
• Permits evaluation of the results of diagnostic threatening condition
tests • Persons with many complaints referable to the
• Allows evaluation of the impact of the disease cardiovascular system may have no or mild heart
on the various aspects of patient’s life disease.
 Symptoms of heart disease
• Specific symptoms of heart disease • Non-specific symptoms
• Dyspnoea – on accustomed exertion, progressive
• General: Pallor, cold extremities, flushing etc
• Chest pain or discomfort of cardiac origin
• CNS: headaches, visual blurring, vomiting etc
• Palpitations
• Respiratory: dyspnea, cough, frothy sputum,
• Oedema – leg, face, abdomen
cyanosis etc
• Cough productive of frothy sputum
• GIT: Early satiety, nausea, vomiting,
• Haemoptysis
abdominal pain and swelling etc
• Easy Fatigability

• Early satiety • Urogenital: Facial puffiness, nocturia,

• Syncope oliguria, polyuria, etc

• Palpitations etc • Musculoskeletal: Cold extremities, weakness,

leg swelling etc
 Dyspnea, chest pain, palpitations
NYHA Functional Classification of Heart failure ACC/AHA Classification of Heart failure
 Dyspnoea • slowly progressive

• Abnormal uncomfortable awareness of breathing • Chronic heart failure, obesity, bilateral

• Abnormal when it occurs at rest or pleura effusion
• At level of accustomed exertion • Exertional dyspnoea – suggests organic
• Progressive, intermittent, rest, paroxysmal, orthopnoea, disease
platypnoea
• left ventricular failure, chronic
• Major causes
obstructive lung disease
• sudden onset
• Dyspnoea developing at rest
• embolism, pneumothorax, acute pulmonary oedema,
• pneumothorax, pulmonary embolism,
pneumonia, airway obstruction
pulmonary oedema
• Inspiratory dyspnoea

• upper airways obstruction • Dyspnoea occurring at rest but not during

• expiratory dyspnoea exertion

• lower airways obstruction • functional

 Dyspnoea: Pathophysiology(Cardiac vs pulmonary
causes)
Coronary Coronary insufficiency Air flow Mechanical limitation to
Valvular Cardiac output limitation (decreased limitation ventilation, mismatching of
effective stroke volume) V/Q, hypoxic stimulation to
Myocardial Cardiac output limitation (decreased breathing
ejection fraction and stroke volume)
Anaemia Reduced O2-carrying capacity
Peripheral Inadequate O2 flow to metabolically
circulation active muscle Restrictive Mismatching V/Q, hypoxic
Obesity Increased work to move body; if severe, stimulation to breathing
respiratory restriction and pulmonary
insufficiency Chest wall Mechanical limitation to
Psychogenic Hyperventilation with precisely regular ventilation
respiratory rate
Malingering Hyperventilation and hypoventilation Pulmonary Rise in physiological dead
with irregular respiratory rate
circulation space as fraction of VT,
Deconditioning Inactivity or prolonged bed rest; loss of
capability for effective redistribution of
exercise hypoxemia
systemic blood flow
Causes of Acute and Chronic dyspnoea • Chronic, Progressive

• Chronic obstructive pulmonary disease

• Acute

• Pulmonary oedema • Left ventricular failure

• Asthma • Diffuse interstitial fibrosis

• Injury to chest wall and intrathoracic structures • Asthma

• Spontaneous pneumothorax • Pleural effusions

• Pulmonary embolism • Pulmonary thromboembolic disease

• Pneumonia • Pulmonary vascular disease

• Acute respiratory distress syndrome • Psychogenic dyspnoea

• Pleural effusion • Anaemia, severe

• Pulmonary haemorrhage • Postintubation tracheal stenosis

• Hypersensitivity disorders
American Thoracic Society Scale of
Dyspnoea
Descriptions Grade Degree

Not troubled by shortness of breath when hurrying on the level or walking up 0 None
a slight hill

Troubled by shortness of breath when hurrying on the level or walking up a 1 Mild

slight hill

Walks more slowly than people of the same age on the level because of 2 Moderate
breathlessness or has to stop for breath when walking at own pace on the
level

Stops for breath after walking about 100 yards or after a few minutes on the 3 Severe
level

Too breathless to leave the house; breathless on dressing or undressing 4 Very severe
 Paroxysmal nocturnal dyspnoea
Dyspnoea
• Due interstitial pulmonary oedema and sometimes intra-
• In heart failure alveolar oedema

• Secondary to left ventricular failure

• a clinical expression of pulmonary
• Begins 2 - 4 hrs after sleep onset
venous and capillary hypertension
• Accompanied by
• occurs
• cough, wheezing and sweating.
• during exertion
• Relieved
• recumbency – relieved by sitting • by patient sitting on the side of bed
upright or standing (orthopnoea) • or getting out of bed
• requires up to 15 -30 minutes
• accompanied by oedema, upper
abdominal pain and nocturia • Note that dyspnoea precedes the cough
• Patients with pulmonary disease may wake up at night
but cough and expectoration precedes the dyspnoea
 Chest Pain or Discomfort
• history is very important • Points to note in the history
• although a cardinal manifestation of heart • location
disease, also originates from • radiation
• Non-cardiac intrathoracic structures
• aorta, pulmonary artery,
• character
bronchopulmonary tree, pleura, • aggravating factors
mediastinum, oesophagus and
diaphragm • relieving factors
• tissues of the neck and thoracic wall • time relationships
• skin, thoracic muscles, cervicodorsal • duration, frequency and pattern of
spine, costochondral junctions, breasts, occurrence
sensory nerves and spinal cord
• setting in which it occurs
• subdiaphragmatic organs
• stomach, duodenum, pancreas and • associated factors
gallbladder
• Functional or factitious
Characteristics of Typical and atypical Angina Pectoris
• Typical
• Substernal
• Characterised by a burning, heavy,
or squeezing feeling
• Precipitated by exertion or emotion
• Promptly relieved by rest or
nitroglycerin
• Atypical
• Located in the left chest, abdomen,
back, or arm in the absence of mid-
chest pain
• Sharp or fleeting
• Repeated, very prolonged
• Unrelated to exercise
• Not relieved by rest or nitroglycerin
• Relieved by antacids
• Characterised by palpitations
without chest pain
Differential diagnosis of chest pain according to
location
Syncope
• definition
• sudden temporary loss of consciousness
• associated with loss of postural tone
• with spontaneous recovery
• not requiring electrical or chemical cardioversion
Syncope • Cardiovascular disorders
• Cardiac arrhythmias
• Disorders of vascular tone or blood volume • Bradyarrhythmias
• Vasovagal (vasodepressor, neurocardiogenic)
• Sinus bradycardia, sinoatrial block, sinus arrest,
• Postural (orthostatic) hypotension
sick-sinus syndrome
• Drug induced (especially antihypertensive or vasodilator drugs)
• Peripheral neuropathy (diabetic, alcoholic, nutritional, amyloid) • Atrioventricular block
• Idiopathic postural hypotension • Tachyarrhythmias
• Multisystem atrophies etc • Supraventricular tachycardia with structural
• Glossopharyngeal Neuralgia cardiac disease
• Atrial fibrillation associated with the Wolff-
• Carotid sinus hypersensitivity Parkinson-White syndrome
• Atrial flutter with 1:1 atrioventricular conduction
• Situational
• Ventricular tachycardia
• Cough
• Micturition • Cerebrovascular disease
• Defecation • Vertebrobasilar insufficiency
• Valsalva • Basilar artery migraine
• Deglutition • Other disorders that may resemble syncope
• Glossopharyngeal Neuralgia • Metabolic
• Hypoxia
• Other cardiopulmonary aetiologies • Anaemia
• Pulmonary embolism • Diminished carbon dioxide due to hyperventilation
• Pulmonary hypertension • Hypoglycemia
•
• Psychogenic
Atrial myxoma
• Anxiety attacks
• Myocardial disease (massive myocardial infarction) • Hysterical fainting
• Left ventricular myocardial restriction or constriction • Seizures
• Pericardial constriction or tamponade
 Palpitations
• associated with drug use
• definition • tobacco, coffee, tea, alcohol
• unpleasant awareness of forceful or rapid beating epinephrine, aminophylline, MAOI
of the heart • on standing
• caused by disorders of cardiac rhythm and rate
• postural hypotension
• history in palpitation
• middle aged women, associated
• isolated jump or skips
• extrasystoles flushes and sweats
• attacks with abrupt beginning, rapid heart rate • menopausal syndrome
with regular or irregular rhythm • associated with normal rate and
• paroxysmal tachycardias rhythm
• independent of exercise or excitement to account • anxiety state
for the symptom
• atrial fibrillation, atrial flutter, thyrotoxicosis,
anaemia, anxiety states
Oedema
• dependent oedema is xteristic of heart failure
• cardiac oedema is symmetrical and progressive
• sacral oedema in patients who are confined to bed
 Cough
• the nature of the sputum is often helpful
• defined as explosive expiration for clearing the
• pink frothy sputum - pulmonary oedema
tracheobronchial tree of secretions and foreign
• clear white mucoid sputum –viral infection
bodies
or longstanding bronchial irritation
• cardiovascular causes include those that lead to
• thick, yellowish sputum – infection
• pulmonary venous hypertension
• rusty sputum – pneumococcal pneumonia
• interstitial and alveolar oedema • blood streaked sputum – tuberculosis,
• pulmonary infarction bronchiectasis, Ca lung or pulmonary
• compression of the tracheobronchial tree infarction
fatigue
• non-specific
• common in patients with impaired cardiovascular function
• consequent to a reduced cardiac output
• associated with muscular weakness
• may be caused by drugs e.g. β-blockers
• may also result for excessive blood pressure reduction in patients with
hypertension or heart failure
• caused by excessive diuresis or diuretic induced hypokalaemia
Other symptoms
• Nocturia
• common in early heart failure

• Anorexia

• Abdominal fullness

• right upper quadrant abdominal discomfort

• weight loss

• cachexia
Assessment of Cardiovascular Disability

• New York Heart Association functional classification

• Canadian Cardiovascular society functional classification

• limited to angina

• specific activity scale

• classification is based on the estimated metabolic cost of various activities.
New York Heart Association
Functional Classification
Class New York Heart Association Functional Classification

I Patients with cardiac disease but without resulting limitations of

physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnoea, or anginal pain.
II Patients with cardiac disease resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary physical
activity results in fatigue, palpitation, dyspnoea, or anginal pain.
III Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than ordinary
physical activity causes fatigue, palpitation, dyspnoea, or anginal
pain.
IV Patient with cardiac disease resulting in inability to carry on any
physical activity without discomfort. Symptoms of cardiac
insufficiency or of the anginal syndrome may be present even at
rest. If any physical activity is undertaken, discomfort is increased.
Canadian Cardiovascular Society Functional
Classification

Class Canadian Cardiovascular Society Functional Classification

I Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina with
strenuous or rapid or prolonged exertion at work or recreation.

II Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or
stair climbing after meals, in cold, in wind, or when under emotional stress, or only during the few
hours after awakening. Walking more than two blocks on the level and climbing more than one
flight of ordinary stairs at a normal pace and in normal conditions.

III Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing
more than one flight in normal conditions.

IV Inability to carry on any physical activity without discomfort—anginal syndrome may be present at
rest.
Specific Activity Scale

Class Specific Activity Scale

I Patients can perform to completion any activity requiring 7 metabolic equivalents (e.g., can carry
24 lb up eight steps; carry objects that weigh 80 lb; do outdoor work [shovel snow, spade soil]; do
recreational activities [skiing, basketball, squash, handball, jog/walk 5 mph]).

II Patients can perform to completion any activity requiring 5 metabolic equivalents (e.g., have
sexual intercourse without stopping, garden, rake, weed, roller skate, dance fox trot, walk at 4
mph on level ground) but cannot and do not perform to completion activities requiring 7 metabolic
equivalents.

III Patients can perform to completion any activity requiring 2 metabolic equivalents (e.g., shower
without stopping, strip and make bed, clean windows, walk 2.5 mph, bowl, play golf, dress
without stopping) but cannot and do not perform to completion any activities requiring 5 metabolic
equivalents.

IV Patients cannot or do not perform to completion activities requiring 2 metabolic equivalents.

Cannot carry out activities listed above (Specific Activity Scale, Class III).
Physical Examination
General examination
• weight loss
• pallor
• cyanosis
• central
• peripheral
• face
• dull facies of myxedema
• dull expressionless facies with ptosis seen in myotonic dystrophy
General
examination
• eyes
• exophthalmos and starring gaze in
thyrotoxicosis
• finger clubbing
• cyanotic congenital heart disease
• infective endocarditis
General
examination
• Osler’s nodes – small tender
erythematous skin lesions in the
pads of the fingers and toes and
in the palms and soles –
infective endocarditis
• Janeway lesions - slightly raised,
non-tender haemorrhagic
lesions in the palms and soles of
the feet – endocarditis
• Peripheral oedema
 Arterial Pulse Abnormal Pulses
• Rate • Unequal pulses
• Carotid
• Rhythm • Carotid atherosclerosis
• Volume • Dis. of the aortic arch eg aortic disection, Takayasu’s disease

• State of the arterial wall • aortic aneurysm

• supravalvular aortic stenosis (rt > lt)

• Synchronicity • Arms
• radio-femoral delay
• arterial embolus or thrombosis
• Other pulses • anomalous origin or aberrant path of the major vessels
• brachial, carotid, femoral, popliteal, • cervical rib or scalenus anticus syndrome
posterior tibial and dorsalis pedis • Popliteal pulses

• iliofemoral obstruction

• Radiofemoral delay

• Coarctation of the aorta

 Abnormal Pulses • other signs seen in aortic incompetence
• Traube’s sign – pistol shot sounds over the
• slow rising pulse
femoral artery when a stethoscope is placed on
Pulsus tardus • valvular aortic stenosis
it
• congenital fibrous sub-aortic stenosis
• Duroisez’s sign – diastolic murmur heard over
the femoral artery when gradually compressed
• small amplitude pulse b/c of reduction of
Pulsus parvus stroke volume
distally
• Quinke’s sign – phasic blanching of the nail bed
• Hill sign – systolic pressure in the lower
Pulsus parvus • small pulse with a delayed systolic peak extremeties exceeds that in the arm by
et tardus • severe aortic stenosis >20mmHg
• Becker’s sign – visible pulsations of the retinal
• due to a wide pulse pressure
arteries
Bounding pulse • anxiety, anaemia, fever, pregnancy, high • Mueller’s sign – pulsating uvula
cardiac output states, bradycardia

Corrigan’s or • consists of an abrupt upstroke followed by

water-hammer a rapid collapse later in systole
• aortic incompetence
pulse
 Abnormal Pulses • Pulsus alternans
• Bisferiens pulse • alternating strong and weak pulses
• seen in severe depression myocardial
• xterised by two systolic peaks function
• seen in pts with combination of aortic • Pulsus bigeminus
incompetence and stenosis
• seen in patients with bigeminal rhythm
• Hypertrophic obstructive • caused by premature contractions usually
cardiomyopathy ventricular after every other beat
• Dicrotic pulse • Pulsus paradoxus
• xterised by two peaks – systolic and • exaggeration of normal
diastolic • reduction in the strength of the arterial
pulse during normal inspiration or an
• seen in hypotensive subjects reduced exaggerated inspiratory fall in systolic
peripheral resistance, cardiac blood pressure >10 mmHg during quiet
tamponade, severe heart failure, breathing
hypovolaemic shock
 Jugular venous pulse
Aortic pulsation JVP
• observed from the right internal Medial Lies under the antr.
jugular vein border of the
• usually examined with patient at 45° sternomastoid

• 2 major pulsations can be observed – Usually palpable but Visible but not
‘a’ and ‘v’ waves not visible palpable
• measurement of the JVP Single upstroke 2 peaks and 2 troughs
• height above the sternal angle –
usually < 4cm No change with Reduces with
• Abdomino-jugular reflux posture or respiration inspiration and upright
• seen in right heart failure posture

Pressure on the root Abolished by pressure

of neck has no effect on the root of neck
The JVP
 Alteration of JVP in disease
• Elevation • Cannon waves (amplified ‘a’
• right heart failure
waves)
• hypervolaemia
• seen in atrioventricular dissociation
• tricuspid stenosis
• SVC obstruction – non pulsatile • no ‘a’ waves
• Kussmaul’s sign • atrial fibrillation
• paradoxical rise in JVP with inspiration
• prominent ‘v’ wave or ‘c-v’ wave
• seen chronic constrictive pericarditis
• seen in tricuspid incompetence
• Large ‘a’ waves
• seen in right ventricular hypertrophy, pulmonary
hypertension and tricuspid stenosis
 Praecordium Palpation

• Inspection • apex beat

• evidence of respiratory difficulty • lowermost and outermost point of cardiac impulse

• normally in the 5LICS at the mid-clavicular line

• visible veins – obstruction of SVC
• when displaced suggests cardiac enlargement
• praecordial bulge or prominence – long
• heaving apex – LVH
standing cardiac enlargement before • tapping apex beat (palpable 1st heart sound) – mitral stenosis
puberty • Right ventricle

• abnormalities of the chest wall • left parasternal heave indicate RVH

• Praecordial hyperactivity – suggests • Palpable sounds

severe valvular abnormality • Palpable 2nd heart sound –loud P2 or A2

• Thrills
• Apex beat
• palpable murmurs with low frequency components
Cardiac auscultation
• Areas for auscultation
• cardiac apex
• right and left sternal borders interspace by interspace
Heart sounds
• 4 basic heart sounds
• other sounds i.e. clicks, prosthetic valve sounds
• time the sounds with palpation of the carotid artery
 Heart sound
• 1st heart sound
• two major components
• due to closure of the atrio-ventricular valves
• loud in
• tachycardia
• short PR interval
• short circle lengths in AF
• mitral stenosis with a pliable leaflet
• 2nd heart sound
• due to closure of the semi-lunar valves
• normally two components A2 and P2
• splitting of the 2nd heart sound in inspiration
2nd Heart sound: abnormal splitting
• single 2nd heart sound
• inaudible pulm. component
• pulmonary atresia
• due to emphysema
• severe pulm. stenosis
• inaudible aortic component
• severe calcific aortic stenosis
• aortic atresia
• persistent synchrony of the two components
• Eisenmenger’s complex
2nd Heart sound: abnormal splitting
• Persistent splitting
• delay in the pulm. component
• complete RBBB
• early timing of the first component
• mitral regurgitation
• Fixed splitting
• ostium secundum atrial septal defect
• Paradoxical splitting
• complete LBBB
• right ventricular pacemaker
• severe aortic outflow obstruction
• a large aorta-to-pulmonary artery shunt
2nd Heart sound: abnormal intensity

• Increased A2
• systemic hypertension
• increased P2
• pulmonary hypertension
3rd heart sound
• due to sudden limitation of ventricular expansion during early
diastolic filling
• heard 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
4th heart sound
• a low-pitched, presystolic sound produced in the ventricle during ventricular filling
• it is associated with an effective atrial contraction and is best heard with the bell piece of the
stethoscope
• absent atrial fibrillation
• occurs when diminished ventricular compliance increases the resistance to ventricular filling
• seen in
• patients with systemic hypertension
• aortic stenosis
• hypertrophic cardiomyopathy
• ischemic heart disease
• acute mitral regurgitation
 Murmurs • for a murmur, determine its
• result from vibrations set up
• in the bloodstream
• and the surrounding heart and great vessels
• timing
• as a result of
• turbulent blood flow, • intensity
• formation of eddies,
• cavitation (bubble formation as a result of sudden • pitch
decrease in pressure)
• graded I – VI • site of maximal intensity
• grade I faint, heard only with special effort
• grade II soft • radiation
• grade III loud
• grade IV loud with thrill • configuration
• grade V audible with stethoscope barely touching the
chest
• grade VI murmur is audible with the stethoscope • relationship with posture and respiration
removed from contact with the chest
• three major categories of murmurs
• systolic, diastolic and continuous
 systolic murmurs • holosystolic (pansystolic)

• starts with the first heart sound and ends with the second
• classified according to onset and termination
heart sound
• midsystolic (ejection systolic) • causes

• causes • mitral incompetence

• obstruction to ventricular outflow eg aortic • tricuspid incompetence

stenosis • ventricular septal defect

• dilation of the aortic root or pulmonary trunk • early systolic murmur
• accelerated systolic flow into the aorta or
• decrescendo type
pulmonary trunk eg pregnancy, fever,
• seen in some forms of mitral and tricuspid incompetence
thyrotoxicosis
• late systolic murmur
• innocent midsystolic murmurs
• begins in mid to late systole and proceeds up to the second
• some mitral incompetence
heart sound

• Mitral valve prolapse is an example

 Diastolic Murmurs Continous murmurs
• early diastolic murmurs • begins in systole and continue
without interruption into diastole
• begins with the A2 or P2 depending on origin
• seen in
• decrescendo type of murmur
• aortopulmonary connections e.g.
• seen in aortic or pulmonary incompetence PDA
• arterio-venous connections
• mid-diastolic murmurs
• disturbances of flow pattern in
• begins at a clear interval after the 2nd heart sound arteries
• seen in mitral and tricuspid stenosis • disturbances of flow pattern in veins
• also seen in presence of augmented volume and
velocity of blood across unobstructed AV valves
eg large ASD
diagram showing timing of murmurs
Sites for heart sounds

• http://www.bioscience.org/sound

• http://members.aol.com/kjbleu/

• http://www.medlib.com/spi/coolstu
ff2.htm
 other cardiac Other relevant
sounds examination
• Pericardial rubs
• lung bases
• the hallmark of acute pericarditis
• crepitations in left heart failure
• generated by the parietal and
visceral pleura rubbing against • abdomen
each other • hepatomegaly in right heart failure
Conclusion
• The understanding of the workings of the cardiovascular system is the bedrock of
knowing cardiovascular medicine and medicine in general

• Any part of the cardiovascular system can malfunction and lead to a disease in
any part of the body

• Diseases of the cardiovascular system can affect any system in the body and vice
versa – there are blood vessels everywhere!

• Life begins with onset of cardiovascular activity and ends at final stoppage of
cardiovascular activity
Live well and purposefully too!
Comments and Questions