CARDIOVASCULAR EXAMINATION

Taking theCARDIOVASCULARHISTORYDr. J.A. CoetserGKV 353CoetserJA@ufs.ac.za0833542861

CASE STUDYA 56 year old white male presents to casualties at 3h40am, complaining of severe chest pain that started 30min earlier.

WHICH IMPORTANT ASPECTS WOULD YOU ELICIT FROM THE HISTORY?Presenting symptoms:Chest painWhen evaluating symptomatic complaintsSiteOnsetCharacterRadiationAlleviating factorsTimingExacerbating factorsSeverityPresenting symptoms:Chest painDetermine the cause!4 cardinal featuresDuration (timing)Location (site)Quality (character)Precipitating and aggravating factorsPresenting symptoms:Chest painAnginaCrushing pain, heaviness, discomfort or choking sensation in retrosternal areaCentral rather than left chestMay radiate to jaw and/or armsRarely below umbilicusTypical vs. atypical angina

Typical vs. atypical anginaTypical anginaMeets all 3:Characteristic restrosternal chest discomfort typical quality and durationProvoked by exertion or emotionRelieved by rest or GTN or bothAtypical anginaMeets 2 of above Non cardiac chest painMeets 1 or none of abovePresenting symptoms:Chest painPain from acute coronary syndromes (myocardial infarction and unstable angina)Often comes on at restPain present >30min

Clot dissolves Coronary blood flow returns No cardiac muscle damage Clot persists Coronary blood flow cut off Cardiac muscle diesUNSTABLE ANGINAMYOCARDIAL INFARCTAnginaAcute coronary syndromes

Presenting symptoms:Chest painPleuritic painDue to movement of pleural surfaces on one anotherInflammation of pleura or pericardiumViral infection of pleuraPneumoniaPulmonary embolismMade worse by inspirationOften relieved by sitting up and leaning forward

Presenting symptoms:Chest painDissecting aneurysm3 featuresSevere, tearing painRapid onsetRadiates to backProximal aorta dissection = anterior chest painDescending aorta dissection = interscapular painHx of HPT, or connective tissue disorder e.g. Marfans syndrome

Presenting symptoms:Chest painMassive pulmonary embolismSudden onsetMay be retrosternal/angina-likeCan be associated with dyspnoea, collapse and cyanosis

Presenting symptoms:Chest painSpontaneous pneumothoraxSharp pain and severe dyspnoeaLocalized to one part of chest

Presenting symptoms:Chest painOesophageal disordersReflux disease can mimic anginaOesophageal spasmEspecially after drinking hot or cold fluidAssociated with dysphagiaRelieved by nitratesPresenting symptoms:Chest painDont forget:CholecystitisHerpes zoster

Presenting symptoms:DyspnoeaDyspnoea definition: unexpected awareness of breathingSensation of increased force needed for work of breathingNeed to distinguish between cardiac and respiratory causesPresenting symptoms:DyspnoeaCardiac dyspnoeaLV output fails to rise during exerciseIncreased LV end-diastolic pressureRaised pressure in LARaised pressure in pulmonary venous systemLeakage of fluid into interstitial spaceDecreased lung compliance

NYHA classification of dyspnoeaClass IDisease is present, but no dyspnoea ORDyspnoea only on heavy exertionClass IIDyspnoea on moderate exertion (climbing stairs)Class IIIDyspnoea on minimal exertion (getting dressed, washing)Class IVDyspnoea at restPresenting symptoms:DyspnoeaOrthopnoeaDyspnoea in the supine positionIn supine position, interstitial oedema distributes to all lung zones, decreasing overall oxygenationIn sitting position, oedema redistributes to lower zones, leaving upper zones free for oxygenationOther causes of orthopnoeaMassive ascitesPregnancyBilateral diaphragmatic paralysisLarge pleural effusionSevere pneumoniaPresenting symptoms:DyspnoeaParoxysmal nocturnal dyspnoea (PND)Severe dyspnoea that wakes patient from sleepHas to sit up and gasps for breathMechanismSudden failure of LVReabsorption of peripheral oedema at night while supine with overload of LV

Dont forget anxiety as cause of dyspnoeaInability to take deep enough breath to fill lungs in satisfying wayPresenting symptoms:Ankle swellingAnkle oedema of cardiac originUsually symmetricalWorst in evenings, improves during nightAs failure progresses, involves legs, thighs, genitalia and abdomenFind out if pt is on a calcium channel blocker, i.e. Adalat XL (nifedipine), amlodipine, etc., which can also cause ankle oedemaIf oedema also involves face, think of nephrotic syndromePresenting symptoms:PalpitationsDefinition palpitations: unexpected awareness of the heartbeatAsk pt to tap out beat with fingerAsk if palpitations are slow or fast, regular or irregular, and what the duration isAny fast arrhythmia can produce angina if pt also has ischaemic heart disease

Presenting symptoms:PalpitationsAtrial fibrillationCompletely irregular rhythmAtrial or ventricular ectopic beatSensation of skipped beat, followed by particularly heavy beatVentricular tachycardiaRapid palpitations followed by syncopePresenting symptoms:Syncope, presyncope and dizzinessSyncope = transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate cerebral blood flowPresyncope = transient sensation of weakness without loss of consciousness (Im about to faint)NB: ask about family history of sudden deathLong QT syndrome / Brugada syndromePresenting symptoms:Syncope, presyncope and dizzinessPostural syncopeLOC when standing for long periods or standing up suddenlyAsk about drugs that can cause postural hypotensionMicturition syncopeLOC when passing urineVasovagal syncopeLOC with emotional stressSyncope due to arrhythmiaLOC regardless of positionExertional syncopeAortic stenosisHypertrophic cardiomyopathyPresenting symptoms:Intermittent claudication and peripheral vascular diseaseClaudication = pain in one or both calves (thighs or buttocks) on walking more than a certain distance (claudication distance)6 Ps of peripheral vascular diseasePainPallorPulselessnessParasthesiaePerishingly coldParalysedLumbar spinal stenosis (pseudo claudication)Pain relieved by flexing spineExacerbated by walking downhillPresenting symptoms:FatigueCommon symptom of cardiac failureRemember other causesLack of sleepAnaemiaDepression Risk factors for coronary artery diseasePrevious ischaemic heart diseaseHypercholesterolaemiaSmokingHypertensionFamily history1st degree relatives (parents of siblings)Especially if