Cardiac History 2004

CARDIOVASCULAR HISTORY AND PHYSICAL EXAMINATION CINDY D. LLARENA, MD UST Section of Cardiology

COMMON SYMPTOMS OF CARDIOVASCULAR DISEASE

• Chest pain • Dyspnea • Palpitation • Syncope • Cyanosis COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

CHEST PAIN

Cardiac • coronary artery disease • aortic stenosis • hypertrophic cardiomyopathy • pericarditis

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Vascular • aortic dissection • pulmonary embolism • pulmonary hypertension • right ventricular strain

Pulmonary • pleuritis or pneumonia • tracheobronchitis • pneumothorax • tumor • mediastinitis or mediastinal emphysema

CHEST PAIN

GIT

Musculoskeletal

• Esophageal reflux

• cervical disk disease

• Esophageal spasm

• arthritis of shoulder or spine

Others • disorders of the breast

• Mallory-Weiss tear

• costochondritis

• chest wall tumors

• Peptic ulcer disease

• intercostal muscle cramps

• herpes zoster

• Biliary disease

• interscalene or hyperabduction syndromes

• Pancreatitis COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

• subacromial bursitis

• emotional

Question to ask about Angina • Do you get pain in your chest on exertion, (e.g.

climbing stairs) • Whereabouts in the chest do you feel it? • Is it worse in cold weather? • Is it worse if you exercise after a big meal? • Is it bad enough to stop you from exercising? • Does it go away when you rest? • Do you ever get similar pain if you get excited or upset? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Clinical Features of Anginal Pain • Brought on by physical or emotional exertion • relieved by rest • usually crushing, squeezing or constricting in nature • usually retrosternal • often worse after food or in cold winds • often relieved by nitrates

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Canadian Cardiovascular Society Classification of Angina I.

Angina occurs with greater than ordinary physical activity II. Angina occurs with ordinary physical activity III. Angina occurs with less than ordinary physical activity IV. Angina may be present even at rest

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Canadian Cardiovascular Society Classification of Angina I.

No angina with ordinary activity. Angina with strenuous, rapid, or prolonged exertion II. Slight limitation of ordinary activity; angina when walking up stairs briskly, or walking on a cold or windy day III. Marked limitation; angina when walking at normal pace up flight of stairs, or walking 1-2 blocks distance IV. Angina on minimal exertion or at rest COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Causes of Chest Pain at Rest • Myocardial infarction • Unstable angina • Dissecting aortic aneurysm • Esophageal pain • Pericarditis • Pleuritic pain • Musculoskeletal pain • Herpes zoster (shingles) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Factors affecting Oxygen Supply and Demand

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Stable Angina

Acute Coronary Syndrome

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Stable Plaque

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Unstable Plaque

Cardiovascular Causes of Chest Pain CORONARY ARTERY DISEASE Stable Angina • retrosternal region; radiates to or occasionally isolated to the neck, jaw, epigastrium, shoulder, or arms - left common • pressure, burning, squeezing, heaviness, indigestion • < 2-10 min duration • precipitated by exercise, cold weather or stress • relieved by rest or nitroglycerin • PE may be normal. COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Cardiovascular Causes of Chest Pain CORONARY ARTERY DISEASE – ACUTE CORONARY SYNDROME

Rest or unstable angina • same location as angina • same quality as angina but may be more severe and frequent • usually < 20 min duration • same precipitating factor as angina, with decreasing tolerance for exertion or at rest • same associated symptoms and signs as angina, but may be pronounced, transient cardiac failure can occur. COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Cardiovascular Causes of Chest Pain CORONARY ARTERY DISEASE – ACUTE CORONARY SYNDROME

Myocardial Infarction • substernal and may radiate like angina • heaviness, pressure, burning, constricting • sudden onset, 30 min or longer but variable • unrelieved by rest or nitroglycerin • shortness of breath, sweating, weakness, nausea, vomiting •PE: soft S1, positive S3 and S4, systolic murmur at the apex COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Cardiovascular Causes of Chest Pain Pericarditis • usually begins over sternum or toward cardiac apex and may radiate to neck or left shoulder; often more localized than the pain of myocardial ischemia. • sharp, stabbing, knifelike • lasts many hour to days; may wax and wane • aggravated by deep breathing, rotating chest, or supine position; relieved by sitting up and leaning • PE: pericardial friction rub COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

forward

Heart is surrounded by adherent fibrin and is stained diffusely green from bilirubin in a patient with sepsis and liver failure.

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Macroscopic view of the left ventricular wall in a patient with fungal septicemia; there is a thick white fibrin exudate of pericarditis.

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Cardiovascular Causes of Chest Pain Aortic dissection • anterior chest; may radiate to the back • excruciating, tearing, knifelike • sudden onset, unrelenting • usually occurs in setting of hypertension or predisposition such as Marfan’s syndrome • PE: murmur of aortic insufficiency, pulse or blood pressure asymmetry, neurologic deficit COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Cardiovascular Causes of Chest Pain Pulmonary embolism • substernal or over region of pulmonary infarction • pleuritic (with pulmonary infarction) or angina-like • sudden onset; minutes to < 1 hr • may be aggravated by breathing • dyspnea, tachypnea, tachycardia; hypotension, signs of acute right heart failure, and pulmonary hypertension with large emboli; rales, pleural rub, hemoptysis with with pulmonary infarction COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Massive pulmonary embolus filling the left main pulmonary artery.

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Cardiovascular Causes of Chest Pain Pulmonary hypertension • substernal • pressure; oppressive • aggravated by effort • pain usually associated with dyspnea; signs of pulmonary hypertension

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

DYSPNEA • difficult,

labored, uncomfortable breathing • an awareness of respiratory distress • the feeling of air hunger • an uncomfortable sensation of breathing

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Questions to ask about Breathlessness • Do you ever feel short of breath? • Does this happen on exertion? • How much can you do before getting breathless? • Do you ever wake up gasping for breath? • If so, do you have to sit up or get out of bed? • How many pillows do you sleep on? • Do you cough or wheeze when you are short of breath? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

The Language of Dyspnea - Association of Qualitative Descriptors and Pathophysiologic Mechanisms of Shortness of Breath Descriptor

Pathophysiologic Mechanisms

• chest tightness or constriction

•Bronchoconstriction, interstitial edema (asthma, myocardial ischemia

• increased work or effort of breathing

• airways obstruction, neuromuscular disease, chest wall disease (COPD, mod to severe asthma, myopathy, kyphoscoliosis)

• air hunger, need to breathe, urge to breathe • heavy breathing, rapid breathing, breathing more COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

• increased drive to breathe (CHF, pulmonary embolism, mod to severe airways obstruction) • deconditioning

SPECIAL FORMS OF DYSPNEA

Paroxysmal nocturnal dyspnea • due to interstitial pulmonary edema and sometimes intra-alveolar edema • secondary to left ventricular failure • 2 to 4 hours after onset of sleep the patient awakens feeling short of breath. • often accompanied by cough, wheezing, and sweating. • ameliorated by the patient’s sitting on the side of the bed or getting out of bed. COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

SPECIAL FORMS OF DYSPNEA

Orthopnea • presence of dyspnea when lying flat • relieved promptly by sitting upright or standing • patients learn to sleep on two or more pillows to avoid this symptom • most commonly a sign of heart failure.

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

DYSPNEA Cardiovascular

High Output

Normal Output

Anemia

Deconditioning

Hyperthyroidism Arteriovenous shunt

obesity diastolic dysfunction

Respiratory

Low Output

Congestive heart failure myocardial ischemia constrictive pericarditis

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Controller

Pump

Pregnancy

COPD

metabolic acidosis

Asthma

Gas Exchanger

kyphoscoliosis

Pulmonary embolism pneumonia interstitial lung disease

Differential diagnosis of dyspnea

• Heart failure

• Ischemic heart disease (atypical angina) • Pulmonary embolism • Lung disease • Severe anemia

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Heart Failure • A CLINICAL SYNDROME • Cardinal symptoms of heart failure : – SHORTNESS OF BREATH – FATIGUE at rest and/or exertion Shortness of Breath

Severe Acute Pulmonary Edema

Clinical Spectrum Careful History and Physical Exam COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

2 major or 1 major + 2 minor criteria have to be present concurrently. Framingham Criteria for Congestive Heart Failure Major Criteria paroxysmal nocturnal dyspnea or orthopnea neck-vein distension crackles cardiomegaly acute pulmonary edema S3 gallop murmur increased venous pressure > 12 mmHg circulation time > 25 sec hepatojugular reflex

Minor Criteria ankle edema night cough dyspnea on exertion hepatomegaly pleural effusion vital capacity decreased by 1/3 from maximum tachycardia (HR > 120 bpm)

* major or minor criteria: weight loss > 4.5 kg in 5 days in response to treatment COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Questions to Ask • When did the symptoms start ? • Are the symptoms stable or are they getting worse ? • Are the symptoms provoked or do they occur at rest ? • Is orthopnea or paroxysmal nocturnal dyspnea present ? • How far can they walk ?

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• Are there acompanying symptoms such as chest pain, calf claudication ? • Do they retain fluid ? • Do they restrict sodium in their diet ? • What sorts of activity can they no longer do ? • Are they losing or gaining weight ? • How do they sleep ?

Common Risk Factors • Based on 18 year follow-up data from Framingham Cohort Study : – – – – – –

Hypertension ( BP > 140/90 mm/Hg ) Myocardial Infarction Angina Diabetes Left Ventricular Hypertrophy ( ECG ) Valvular Heart Disease

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JAMA, 1996

Left Heart Failure

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Causes of Left Heart Failure

Right Heart Failure

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Causes of Right Heart Failure

Elevated jugular venous pressure

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Peripheral edema

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Jaundice in a patient with severe heart failure.

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New York Heart Association Classification of Heart Failure Grade I

No symptoms at rest, dyspnea only on vigorous exertion

II

No symptoms at rest, dyspnea on moderate exertion

III

May be mild symptoms at rest, dyspnea on mild exertion, severe dyspnea on moderate exertion.

IV

Significant dyspnea at rest, severe dyspnea even on very mild exertion. Patient often bed bound.

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New York Heart Association Classification of Heart Failure Grade I

No limitations during ordinary activity

II

Slight limitation during ordinary activity, e.g. mild or occasional angina/ dyspnea

III

Marked limitation of normal activities without symptoms at rest

IV

Unable to undertake physical activity without symptoms; symptoms may be present at rest

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Objective Assessment A. B. C. D.

No Objective evidence of cardiovascvular disease Objective evidence of minimal cardiovascular disease Objective evidence of moderately severe cardiovascular disease Objective evidence of severe cardiovascular disease

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Palpitation Definition: • uncomfortable awareness of heartbeat

• heart is beating abnormally fast or irregularly

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PALPITATION

Symptoms of palpitations

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Underlying Heart Disease

Precipitating Factors

Clinical History in Evaluation of Palpitations Symptoms of palpitations • duration of episode

• frequency of episodes • associated chest pain, dyspnea, lightheadedness? • How does episode start? How does episode stop? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Clinical History in Evaluation of Palpitations Underlying Heart Disease • Angina, prior myocardial infarction • Valvular heart disease • Congenital heart disease • cardiomyopathy • coronary risk factors • congestive heart failure • prior antiarrhythmic therapy

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Clinical History in Evaluation of Palpitations Precipitating Factors • Psychologic stress

• Exercise • caffeine, alcohol, cocaine, amphetamines • thyroid disease • anemia, hypoxemia COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Questions to ask about Palpitation • Please could you tap out on the table the rate you think heart goes at during an attack? • Is the heart beat regular or irregular? • Is there anything that sets attacks off? • Can you do anything to stop an attack? • What do you do when you have an attack? • Are there any foods that seem to make symptoms worse? • What medicines are you taking? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

your

Sinus Tachycardia

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Atrial Fibrillation

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QUESTIONS TO ASK ABOUT SYNCOPE

(Wherever possible history should be taken from a family member or observer as well as the patient.) • What were the exact circumstances of the blackout? • Did you have any warning of the attack? • How quickly did you recover? • Did you go pale or red during or after the attack? • Are you taking any medication? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

CAUSES OF SYNCOPE Reflex-Mediated Vasomotor Instability • Vasovagal

• Situational micturition cough swallow defecation • Carotid sinus syncope • Neuralgias • High altitude • Psychiatric disorders • Others (exercise, selected drugs) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

CAUSES OF SYNCOPE Decreased Cardiac Output Obstruction to flow • Obstruction to LV outflow or inflow Aortic stenosis, obstructive hypertrophic cardiomyopathy, mitral stenosis, myxoma • Obstruction to RV outflow or inflow Pulmonic stenosis PE, pulmonary hypertension Myxoma COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

CAUSES OF SYNCOPE Decreased Cardiac Output Other Heart Disease • pump failure MI, CAD, coronary spasm • tamponade, aortic dissection

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CAUSES OF SYNCOPE Decreased Cardiac Output Arrhthymias • Bradyarrhythmias Sinus node disease Second- and third-degree AV block Pacemaker malfunction Drug-induced bradyarrhythmias

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CAUSES OF SYNCOPE Decreased Cardiac Output Arrhythymias • Tachyarrhythmias Ventricular tachycardia Torsades de pointes (e.g. associated with congenital long QT syndromes or acquired prolongation) Supraventricular tachycardia COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

QT

CLINICAL FEATURES SUGGESTIVE OF SPECIFIC CAUSES Symptom or Finding After unexpected pain, unpleasant

Diagnostic Consideration Vasovagal syncope sight, sound, or

smell During or immediately after micturition,

Situational syncope

cough, swallow, or defecation On Standing

Orthostatic Hypotension

Prolonged standing at attention

Vasovagal

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CYANOSIS

• both a symptom and a sign • bluish discoloration of the skin and mucous membrane • due to increased quantity of reduced hemoglobin or of abnormal hemoglobin blood perfusing these areas • more commonly described by a family member and may go unnoticed by patient

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pigments in

CYANOSIS

Central

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Peripheral

Central Cyanosis • decreased arterial oxygen saturation due to right-to-left shunting of blood or impaired pulmonary function

Peripheral Cyanosis • secondary to cutaneous vasoconstriction due to low cardiac output or exposure to cold air or water

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Central cyanosis of the tongue COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Peripheral cyanosis

FAMILY HISTORY • age and health, or age and cause of death, of each immediate family member • data on grandparents or grandchildren may also be useful

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QUESTIONS TO ASK ABOUT THE FAMILY HISTORY • Is there any heart disease in the family? • Are your parents still alive? • Did they live to a good age? • Do you know what they died from? • Have you any brothers or sisters? • Do any of them have a heart problem? COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

FAMILY HISTORY

• Hypertension • Congenital heart disease • Heart attack • Stroke • Diabetes mellitus

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PERSONAL HISTORY

• Smoking history – number of pack years • Alcohol use – amount and frequency • Dietary habits/ food preferences • Exercise and lifestyle • History of illicit drug use

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PAST MEDICAL HISTORY

• General Medical Condition • Hypertension, Diabetes Mellitus, Asthma/COPD, Endocrine disorders, Cerebrovascular diseases, Renal disorders, Peripheral vascular disease • Previous Hospitalizations • Previous Surgeries • Current Medications COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

OBSTETRICAL/ GYNECOLOGICALHISTORY

• Gravidity, Parity ( Obstetrical score ) • Pre/Eclampsia, Gestational DM, Thyroid disorders in pregnancy • Menopausal age • Use of Contraceptive pills

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GENERAL SURVEY • observe patient’s state of health, stature and habitus, and sexual development • get height and weight • observe skin and its characteristics, identify any lesion, study patient’s hands • inspect and palpate cervical nodes, note any unusual pulsations in the neck

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Marfan’s Syndrome

Xanthelasmata around eyelids (Familial hypercholesterolemia) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Typical malar flush of mitral stenosis. This is a non-specific finding due to low cardiac output.

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Central cyanosis of the tongue COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Subconjunctival hemorrhage (Infective endocarditis) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Peripheral cyanosis

Cyanosis and finger clubbing in a girl with Eisenmenger’s syndrome COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Clubbing of fingers in a patient with ventricular septal defect and cyanosis.

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Splinter hemorrhages in infective endocarditis COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Splinter hemorrhage in the ring finger (Infective Endocarditis) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Dermal infarcts from COMMUNITY CARDIOLOGY septicOFemboli Faculty of Medicine and Surgery Santo Tomas University Hospital

Osler’s nodes

Gangrene of toes in peripheral vascular disease

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Clinically, rheumatic fever presents with swollen, tender joints.

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COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Relationship between cuff pressure, Korotkoff sounds and COMMUNITY OF CARDIOLOGY pulse Faculty of Medicine andarterial Surgery Santo Tomas University Hospital

Summary • Symptoms – – – –

Chest pain Dyspnea Palpitations syncope

• Signs – Vital signs – Complete physical examinatin COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

TECHNIQUES OF BP MEASUREMENT • PATIENTS SHOULD BE SEATED IN A CHAIR WITH THEIR BACKS AND ARMS BARED AND SUPPORTED AT HEART LEVEL. • REFRAIN FROM SMOKING OR INGESTING CAFFEINE 30 MINUTES PRIOR TO MEASUREMENT

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TECHNIQUES OF BP MEASUREMENT • UNDER SPECIAL CIRCUMSTANCES, MEASUREMENT IN THE SUPINE AND STANDING POSITIONS MAY BE INDICATED • MEASUREMENT SHOULD BEGIN AFTER 5 MINUTES REST • APPROPRIATE CUFF SIZE (ENCIRCLE OF THE ARM) COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

AT LEAST 80%

TECHNIQUES OF BP MEASUREMENT • PREFERABLY A MERCURY SPHYGMO-MANOMETER OR RECENTLY CALIBRATED ANAEROID MANOMETER OR VALIDATED ELECTRONIC DEVICE MAY BE USED • BOTH SBP AND DBP SHOULD BE RECORDED • TWO OR MORE READINGS SEPARATED BY 2 MINUTES SHOULD BE AVERAGED

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Important points about measuring blood pressure

• remove all clothing from arm • support arm comfortably at heart level • use correct size of cuff: wide cuff for obese arms, pediatric cuff for children • check systolic pressure by palpation

COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

Important points about measuring blood pressure • release pressure no faster than 1mmHg/s • Take phase 5 (disappearance of sounds) as diastolic pressure • check aneroid monometers regularly against mercury monometer • if using a mercury monometer, it must be absolutely upright

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PHYSICAL EXAM • TWO OR MORE BP MEASUREMENTS SEPARATED BY 2 MINUTES WITH THE PATIENT EITHER SUPINE OR SEATED AND AFTER STANDING FOR AT LEAST 2 MINUTES • VERIFY IN CONTRALATERAL ARM • HEIGHT, WEIGHT, WAIST CIRCUMFERENCE • FUNDUSCOPY COMMUNITY OF CARDIOLOGY Faculty of Medicine and Surgery Santo Tomas University Hospital

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