Symptoms Signs & Investigations in Cardiovascular Diseases

1,957 views
1,866 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,957
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
91
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Symptoms Signs & Investigations in Cardiovascular Diseases

  1. 1. Symptoms Signs and Investigations in Cardiovascular Disease Prof:Nooruddin Jaffer Hamdard Medical College Karachi
  2. 2. Importance of the history <ul><li>The richest source of information concerning the patients’ illness </li></ul><ul><li>Establishes a bond with the patient & improves his co-operation </li></ul><ul><li>Allows evaluation of the impact of the disease </li></ul>
  3. 3. Breathlessness(dyspnoea) <ul><li>abnormally uncomfortable awareness of breathing </li></ul><ul><li>regarded as abnormal only when it occurs </li></ul><ul><ul><li>at rest or </li></ul></ul><ul><ul><li>at level of physical activity not expected to cause it </li></ul></ul><ul><li>associated with diseases of </li></ul><ul><ul><li>heart </li></ul></ul><ul><ul><li>lungs </li></ul></ul><ul><ul><li>chest wall </li></ul></ul><ul><ul><li>respiratory muscles </li></ul></ul><ul><li>also associated with anxiety </li></ul>
  4. 4. Breathlessness(dyspnoea) <ul><li>Exertional dyspnoea </li></ul><ul><ul><li>Comes on during exertion and subsides with rest </li></ul></ul><ul><ul><li>Commonly due to HF or lung disease </li></ul></ul><ul><li>Orthopnoea </li></ul><ul><ul><li>breathlessness on lying flat </li></ul></ul><ul><ul><li>A symptom of left ventricular failure </li></ul></ul><ul><ul><li>due to redistribution of fluid from the lower extremities to the lungs </li></ul></ul>
  5. 5. Breathlessness(dyspnoea) <ul><li>Paroxysmal Nocturnal dyspnoea </li></ul><ul><ul><li>a variant of orthopnoea </li></ul></ul><ul><ul><li>patient awakes from sleep </li></ul></ul><ul><ul><ul><li>severely breathless </li></ul></ul></ul><ul><ul><ul><li>persistent cough, may have white frothy sputum </li></ul></ul></ul><ul><ul><li>a manifestation of left ventricular failure </li></ul></ul>
  6. 6. Chest Pain or Discomfort <ul><li>history is very important </li></ul><ul><li>although a cardinal manifestation of heart disease, also originates from </li></ul><ul><ul><li>Non-cardiac intrathoracic structures </li></ul></ul><ul><ul><ul><li>aorta, pulmonary artery, bronchopulmonary tree, pleura, mediastinum, oesophagus and diaphragm </li></ul></ul></ul><ul><ul><li>tissues of the neck and thoracic wall </li></ul></ul><ul><ul><ul><li>skin, thoracic muscles, cervicodorsal spine, costochondral junctions, breasts, sensory nerves and spinal cord </li></ul></ul></ul><ul><ul><li>subdiaphragmatic organs </li></ul></ul><ul><ul><ul><li>stomach, duodenum, pancreas and gallbladder </li></ul></ul></ul><ul><ul><li>Functional or factitious </li></ul></ul>
  7. 7. Chest Pain <ul><li>Points to note in the history </li></ul><ul><ul><li>location </li></ul></ul><ul><ul><li>radiation </li></ul></ul><ul><ul><li>character </li></ul></ul><ul><ul><li>aggravating factors </li></ul></ul><ul><ul><li>relieving factors </li></ul></ul><ul><ul><li>time relationships </li></ul></ul><ul><ul><ul><li>duration, frequency and pattern of occurrence </li></ul></ul></ul><ul><ul><li>setting in which it occurs </li></ul></ul><ul><ul><li>associated factors </li></ul></ul>
  8. 8. Differential diagnosis of chest pain according to location
  9. 9. Oedema <ul><li>Peripheral Oedema </li></ul><ul><ul><li>a feature of chronic heart failure </li></ul></ul><ul><ul><li>due to excessive salt and water retention </li></ul></ul><ul><ul><li>In ambulant patients </li></ul></ul><ul><ul><ul><li>found in the ankles, legs, thighs and lower abdomen </li></ul></ul></ul><ul><ul><li>In patients who are recumbent </li></ul></ul><ul><ul><ul><li>over the sacrum </li></ul></ul></ul><ul><ul><li>associated with other features of heart failure </li></ul></ul><ul><ul><li>Usually pitting except if it has been long standing </li></ul></ul>
  10. 10. Oedema <ul><li>Causes of peripheral oedema </li></ul><ul><ul><li>cardiac failure </li></ul></ul><ul><ul><li>Chronic venous insufficiency </li></ul></ul><ul><ul><li>Hypoalbuminaemia – nephrotic syndrome, liver disease, protein losing enteropathy </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>retaining sodium (fludrocortisone, NSAID) </li></ul></ul></ul><ul><ul><ul><li>increasing capillary permeability (nifedipine) </li></ul></ul></ul>
  11. 11. Palpitations <ul><li>definition </li></ul><ul><ul><li>unpleasant awareness of forceful or rapid beating of the heart </li></ul></ul><ul><ul><li>caused by disorders of cardiac rhythm and rate </li></ul></ul><ul><li>history in palpitation </li></ul><ul><ul><li>isolated jump or skips </li></ul></ul><ul><ul><ul><li>extrasystoles </li></ul></ul></ul><ul><ul><li>attacks with abrupt beginning, rapid heart rate with regular or irregular rhythm </li></ul></ul><ul><ul><ul><li>paroxysmal tachycardias </li></ul></ul></ul><ul><ul><li>independent of exercise or excitement to account for the symptom </li></ul></ul><ul><ul><ul><li>atrial fibrillation, atrial flutter, thyrotoxicosis, anaemia, anxiety states </li></ul></ul></ul>
  12. 12. Palpitations <ul><ul><li>associated with drug use </li></ul></ul><ul><ul><ul><li>tobacco, coffee, tea, alcohol epinephrine, aminophylline, MAOI </li></ul></ul></ul><ul><ul><li>on standing </li></ul></ul><ul><ul><ul><li>postural hypotension </li></ul></ul></ul><ul><ul><li>middle aged women, associated flushes and sweats </li></ul></ul><ul><ul><ul><li>menopausal syndrome </li></ul></ul></ul><ul><ul><li>associated with normal rate and rhythm </li></ul></ul><ul><ul><ul><li>anxiety state </li></ul></ul></ul>
  13. 13. Syncope <ul><li>definition </li></ul><ul><ul><li>sudden temporary loss of consciousness </li></ul></ul><ul><ul><li>associated with loss of postural tone </li></ul></ul><ul><ul><li>with spontaneous recovery </li></ul></ul><ul><ul><li>not requiring electrical or chemical cardioversion </li></ul></ul><ul><li>due to sudden vasodilation or sudden fall in cardiac output or both simultaneously </li></ul>
  14. 14. Cough <ul><li>defined as explosive expiration for clearing the tracheobronchial tree of secretions and foreign bodies </li></ul><ul><li>cardiovascular causes include those that lead to </li></ul><ul><ul><li>pulmonary venous hypertension </li></ul></ul><ul><ul><li>interstitial and alveolar oedema </li></ul></ul><ul><ul><li>pulmonary infarction </li></ul></ul><ul><ul><li>compression of the tracheobronchial tree </li></ul></ul>
  15. 15. Cough <ul><li>the nature of the sputum is often helpful </li></ul><ul><ul><li>pink frothy sputum - pulmonary oedema </li></ul></ul><ul><ul><li>clear white mucoid sputum –viral infection or longstanding bronchial irritation </li></ul></ul><ul><ul><li>thick, yellowish sputum – infection </li></ul></ul><ul><ul><li>rusty sputum – pneumococcal pneumonia </li></ul></ul><ul><ul><li>blood streaked sputum – tuberculosis, bronchiectasis, Ca lung or pulmonary infarction </li></ul></ul>
  16. 16. fatigue <ul><li>non-specific </li></ul><ul><li>common in patients with impaired cardiovascular function </li></ul><ul><li>consequent to a reduced cardiac output </li></ul><ul><li>associated with muscular weakness </li></ul><ul><li>may be caused by drugs e.g. β -blockers </li></ul><ul><li>may also result for excessive blood pressure reduction in patients with hypertension or heart failure </li></ul><ul><li>caused by excessive diuresis or diuretic induced hypokalaemia </li></ul>
  17. 17. Other symptoms <ul><li>Nocturia </li></ul><ul><ul><li>common in early heart failure </li></ul></ul><ul><li>Anorexia </li></ul><ul><li>Abdominal fullness </li></ul><ul><li>right upper quadrant abdominal discomfort </li></ul><ul><li>weight loss </li></ul><ul><li>cachexia </li></ul>
  18. 18. Physical Examination <ul><li>General examination </li></ul><ul><ul><li>pallor indicate anaemia </li></ul></ul><ul><ul><li>cyanosis: bluish discolouration of the mucous mucosa and skin due to arterial hypoxaemia </li></ul></ul><ul><ul><ul><li>central cyanosis </li></ul></ul></ul><ul><ul><ul><ul><li>poor gaseous exchange in the lungs– pulmonary disease or pulmonary oedema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>right to left shunt in congenital heart disease </li></ul></ul></ul></ul><ul><ul><ul><li>peripheral cyanosis </li></ul></ul></ul><ul><ul><li>obesity </li></ul></ul><ul><ul><ul><li>associated with hyperlipidaemia and diabetes </li></ul></ul></ul><ul><ul><li>features of hyperlipidaemia </li></ul></ul><ul><ul><ul><li>corneal arcus </li></ul></ul></ul><ul><ul><ul><li>xanthelasma </li></ul></ul></ul>
  19. 19. Physical Examination <ul><ul><li>facial abnormalities </li></ul></ul><ul><ul><ul><li>ptosis and frontal baldness –dystonia myotonica(cardiomyopathy and conduction defects) </li></ul></ul></ul><ul><ul><ul><li>high arched palate and ocular lens abnormalities – Marfan’s syndrome(Aortic aneurysm) </li></ul></ul></ul><ul><ul><ul><li>unusual facial features(congenital heart diseases) </li></ul></ul></ul><ul><ul><li>finger clubbing </li></ul></ul><ul><ul><ul><li>cyanotic congenital heart diseases </li></ul></ul></ul><ul><ul><ul><li>infective endocarditis(advanced) </li></ul></ul></ul><ul><ul><li>Splinter haemorrhages </li></ul></ul><ul><ul><ul><li>trauma </li></ul></ul></ul><ul><ul><ul><li>infective endocarditis </li></ul></ul></ul><ul><ul><li>Moist palms </li></ul></ul><ul><ul><ul><li>cold – anxiety </li></ul></ul></ul><ul><ul><ul><li>warm – thyrotoxicosis </li></ul></ul></ul>
  20. 20. CVS examination <ul><li>Pulse </li></ul><ul><ul><li>Rate </li></ul></ul><ul><ul><ul><li>bradycardia </li></ul></ul></ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul><ul><ul><li>Rhythm </li></ul></ul><ul><ul><ul><li>regular </li></ul></ul></ul><ul><ul><ul><li>irregular </li></ul></ul></ul><ul><ul><ul><ul><li>regular with dropped beats </li></ul></ul></ul></ul><ul><ul><ul><ul><li>completely irregular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>sinus arrhythmia (speeds up in inspiration and slows with expiration) </li></ul></ul></ul></ul><ul><ul><li>Volume </li></ul></ul><ul><ul><ul><li>depend on the cardiac stroke volume and the compliance of the arterial system </li></ul></ul></ul><ul><ul><li>State of the arterial wall </li></ul></ul><ul><ul><li>Synchronicity </li></ul></ul><ul><ul><ul><li>radio-femoral delay </li></ul></ul></ul><ul><ul><li>Other pulses </li></ul></ul><ul><ul><ul><li>brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis </li></ul></ul></ul>
  21. 21. Blood pressure <ul><li>use of a sphygmomanometer </li></ul><ul><ul><li>inflatable cuff connected to mercury or aneroid manometer </li></ul></ul><ul><ul><li>stethoscope over the branchial artery </li></ul></ul><ul><ul><li>inflate cuff above the POP </li></ul></ul><ul><ul><li>reduce the pressure in the cuff slowly </li></ul></ul><ul><ul><li>reappearance of Korotkov sound – systolic pressure </li></ul></ul><ul><ul><li>disappearance of Korotkov sounds – diastolic pressure </li></ul></ul>
  22. 22. Blood pressure <ul><li>Pitfalls in BP measurement </li></ul><ul><ul><li>apparatus </li></ul></ul><ul><ul><ul><li>small cuff – overestimation of the BP by 20 - 30 mmHg </li></ul></ul></ul><ul><ul><ul><li>large cuff – underestimation of the blood pressure </li></ul></ul></ul><ul><ul><ul><li>calibration of the sphygmomanometer </li></ul></ul></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><ul><li>emotional state of the patient </li></ul></ul></ul><ul><ul><ul><li>anxiety(white coat hypertension) </li></ul></ul></ul><ul><ul><ul><li>posture and the position of the sphyg </li></ul></ul></ul><ul><ul><li>observer </li></ul></ul><ul><ul><ul><li>auscultatory gap </li></ul></ul></ul>
  23. 23. Jugular venous pulse <ul><li>observed from the right internal jugular vein </li></ul><ul><li>usually examined with patient at 45 ° </li></ul><ul><li>2 major pulsations can be observed – ‘a’ and ‘v’ waves </li></ul><ul><li>measurement of the JVP </li></ul><ul><ul><li>height above the sternal angle – usually < 4cm </li></ul></ul><ul><li>Abdomino-jugular reflux </li></ul><ul><ul><li>seen in right heart failure </li></ul></ul><ul><li>Causes of raised JVP </li></ul><ul><ul><li>Rt heart failure </li></ul></ul><ul><ul><li>Tricuspid incompetence </li></ul></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>SVC obstruction </li></ul></ul><ul><ul><li>Constrictive pericarditis </li></ul></ul><ul><ul><li>Tricuspid stenosis </li></ul></ul>
  24. 24. Praecordium <ul><li>Inspection </li></ul><ul><ul><li>evidence of respiratory difficulty </li></ul></ul><ul><ul><li>visible veins – obstruction of SVC </li></ul></ul><ul><ul><li>praecordial bulge or prominence – long standing cardiac enlargement before puberty </li></ul></ul><ul><ul><li>abnormalities of the chest wall </li></ul></ul><ul><ul><li>Praecordial hyperactivity – suggests severe valvular abnormality </li></ul></ul><ul><ul><li>Apex beat </li></ul></ul>
  25. 25. Praecordium: palpation <ul><li>apex beat </li></ul><ul><ul><li>lowermost and outermost point of cardiac impulse </li></ul></ul><ul><ul><li>normally in the 5LICS at the mid-clavicular line </li></ul></ul><ul><ul><li>when displaced suggests cardiac enlargement </li></ul></ul><ul><ul><li>heaving apex – LVH </li></ul></ul><ul><ul><li>tapping apex beat (palpable 1 st heart sound) – mitral stenosis </li></ul></ul>
  26. 26. Praecordium: palpation <ul><li>Right ventricle </li></ul><ul><ul><li>left parasternal heave indicate RVH </li></ul></ul><ul><li>Palpable sounds </li></ul><ul><ul><li>Palpable 2 nd heart sound –loud P2 or A2 </li></ul></ul><ul><li>Thrills </li></ul><ul><ul><li>palpable murmurs with low frequency components </li></ul></ul>
  27. 27. Cardiac auscultation <ul><li>Areas for auscultation </li></ul><ul><ul><li>cardiac apex </li></ul></ul><ul><ul><li>right and left sternal borders interspace by interspace </li></ul></ul>
  28. 28. Heart sounds <ul><li>4 basic heart sounds </li></ul><ul><li>other sounds i.e. clicks, prosthetic valve sounds </li></ul><ul><li>time the sounds with palpation of the carotid artery </li></ul>
  29. 29. Heart sound <ul><li>1 st heart sound </li></ul><ul><ul><li>two major components </li></ul></ul><ul><ul><li>due to closure of the atrio-ventricular valves </li></ul></ul><ul><ul><li>loud in </li></ul></ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul><ul><ul><ul><li>short PR interval </li></ul></ul></ul><ul><ul><ul><li>short circle lengths in AF </li></ul></ul></ul><ul><ul><ul><li>mitral stenosis with a pliable leaflet </li></ul></ul></ul><ul><li>2 nd heart sound </li></ul><ul><ul><li>due to closure of the semi-lunar valves </li></ul></ul><ul><ul><li>normally two components A 2 and P 2 </li></ul></ul><ul><ul><li>splitting of the 2 nd heart sound in inspiration </li></ul></ul>
  30. 30. 2nd Heart sound: abnormal splitting <ul><li>single 2 nd heart sound </li></ul><ul><ul><li>inaudible pulm. component </li></ul></ul><ul><ul><ul><li>pulmonary atresia </li></ul></ul></ul><ul><ul><ul><li>due to emphysema </li></ul></ul></ul><ul><ul><ul><li>severe pulm. stenosis </li></ul></ul></ul><ul><ul><li>inaudible aortic component </li></ul></ul><ul><ul><ul><li>severe calcific aortic stenosis </li></ul></ul></ul><ul><ul><ul><li>aortic atresia </li></ul></ul></ul><ul><ul><li>persistent synchrony of the two components </li></ul></ul><ul><ul><ul><li>Eisenmenger’s complex </li></ul></ul></ul>
  31. 31. 2nd Heart sound: abnormal splitting <ul><li>Persistent splitting </li></ul><ul><ul><li>delay in the pulm. component </li></ul></ul><ul><ul><ul><li>complete RBBB </li></ul></ul></ul><ul><ul><li>early timing of the first component </li></ul></ul><ul><ul><ul><li>mitral regurgitation </li></ul></ul></ul><ul><li>Fixed splitting </li></ul><ul><ul><li>ostium secundum atrial septal defect </li></ul></ul><ul><li>Paradoxical splitting </li></ul><ul><ul><li>complete LBBB </li></ul></ul><ul><ul><li>right ventricular pacemaker </li></ul></ul><ul><ul><li>severe aortic outflow obstruction </li></ul></ul><ul><ul><li>a large aorta-to-pulmonary artery shunt </li></ul></ul>
  32. 32. 2nd Heart sound: abnormal intensity <ul><li>Increased A 2 </li></ul><ul><ul><li>systemic hypertension </li></ul></ul><ul><li>increased P 2 </li></ul><ul><ul><li>pulmonary hypertension </li></ul></ul>
  33. 33. 3 rd heart sound <ul><li>due to sudden limitation of ventricular expansion during early diastolic filling </li></ul><ul><ul><li>heard normally in children </li></ul></ul><ul><ul><li>and in patients with high cardiac output </li></ul></ul><ul><ul><li>in patients over 40 years old </li></ul></ul><ul><ul><ul><li>an S3 usually indicates </li></ul></ul></ul><ul><ul><ul><ul><li>impairment of ventricular function </li></ul></ul></ul></ul><ul><ul><ul><ul><li>AV valve regurgitation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>other conditions that increase the rate or volume of ventricular filling </li></ul></ul></ul></ul>
  34. 34. 4 th heart sound <ul><li>a low-pitched, presystolic sound produced in the ventricle during ventricular filling </li></ul><ul><li>it is associated with an effective atrial contraction and is best heard with the bell piece of the stethoscope </li></ul><ul><li>absent atrial fibrillation </li></ul><ul><li>occurs when diminished ventricular compliance increases the resistance to ventricular filling </li></ul><ul><li>seen in </li></ul><ul><ul><li>patients with systemic hypertension </li></ul></ul><ul><ul><li>aortic stenosis </li></ul></ul><ul><ul><li>hypertrophic cardiomyopathy </li></ul></ul><ul><ul><li>ischemic heart disease </li></ul></ul><ul><ul><li>acute mitral regurgitation </li></ul></ul>
  35. 35. Murmurs <ul><li>result from vibrations set up </li></ul><ul><ul><li>in the blood stream </li></ul></ul><ul><ul><li>and the surrounding heart and great vessels </li></ul></ul><ul><ul><li>as a result of </li></ul></ul><ul><ul><ul><li>turbulent blood flow, </li></ul></ul></ul><ul><ul><ul><li>formation of eddies, </li></ul></ul></ul><ul><ul><ul><li>cavitation (bubble formation as a result of sudden decrease in pressure) </li></ul></ul></ul><ul><li>graded I – VI </li></ul><ul><ul><li>grade I faint, heard only with special effort </li></ul></ul><ul><ul><li>grade II soft </li></ul></ul><ul><ul><li>grade III loud </li></ul></ul><ul><ul><li>grade IV loud with thrill </li></ul></ul><ul><ul><li>grade V audible with stethoscope barely touching the chest </li></ul></ul><ul><ul><li>grade VI murmur is audible with the stethoscope removed from contact with the chest </li></ul></ul>
  36. 36. Murmurs <ul><li>for a murmur, determine its </li></ul><ul><ul><li>timing </li></ul></ul><ul><ul><li>intensity </li></ul></ul><ul><ul><li>pitch </li></ul></ul><ul><ul><li>site of maximal intensity </li></ul></ul><ul><ul><li>radiation </li></ul></ul><ul><ul><li>configuration </li></ul></ul><ul><ul><li>relationship with posture and respiration </li></ul></ul><ul><li>three major categories of murmurs </li></ul><ul><ul><li>systolic, diastolic and continuous </li></ul></ul>
  37. 37. other cardiac sounds <ul><li>Pericardial rubs </li></ul><ul><ul><li>the hallmark of acute pericarditis </li></ul></ul><ul><ul><li>generated by the parietal and visceral pleura rubbing against each other </li></ul></ul>
  38. 38. Other relevant examination <ul><li>lung bases </li></ul><ul><ul><li>crepitations in left heart failure </li></ul></ul><ul><li>abdomen </li></ul><ul><ul><li>hepatomegaly in right heart failure </li></ul></ul>
  39. 39. Cardiac Investigations and Procedures <ul><li>Electrocardiogram (ECG) </li></ul><ul><li>Chest X-Ray (CXR) </li></ul><ul><li>Echocardiography </li></ul><ul><li>Trans- oesophagealEchocardiography (TEE) </li></ul><ul><li>Treadmill Testing </li></ul><ul><li>Tilt Table Test </li></ul>t
  40. 40. Cardiac Investigations and Procedures <ul><li>Other New Imaging Techniques </li></ul><ul><li>Cardiac Catherization </li></ul><ul><li> Percutanous Transluminal Coronary Angioplasty (PTCA) </li></ul><ul><li>Stenting (PTCS), </li></ul><ul><li>drug eluting stents </li></ul><ul><li> Brachytherapy (radiation) </li></ul>
  41. 41. Cardiac Investigations and Procedures <ul><li>Electrophysiological Study of the Heart (EPS) and Radio-frequency Ablation (RF) </li></ul><ul><li>Permanent Pacemaker Implantation (PPM) </li></ul><ul><li>Automatic Implantable Cardiovertor -Defibrillator (AICD) </li></ul><ul><li>Automated External Defibrillators ( AEDs ) </li></ul>

×