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CINDY D. LLARENA, MDUST Section of Cardiology

CARDIOVASCULAR HISTORY AND

PHYSICAL EXAMINATION

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COMMUNITY OF CARDIOLOGYFaculty of Medicine and SurgerySanto Tomas University Hospital

CHEST PAIN

Cardiac Vascular Pulmonary

coronary artery

disease

aortic stenosis

hypertrophic

cardiomyopathy

pericarditis

aortic dissection

pulmonary embolism

pulmonaryhypertension

right ventricular

strain

pleuritis or

pneumonia

tracheobronchitis

pneumothorax

tumor

mediastinitis or

mediastinalemphysema

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CHEST PAIN

GIT Musculoskeletal Others

Esophageal reflux

Esophageal spasm

Mallory-Weiss tear

Peptic ulcer

disease

Biliary disease

Pancreatitis

cervical disk disease

arthritis of shoulderor spine

costochondritis

intercostal musclecramps

interscalene orhyperabductionsyndromes

subacromial bursitis

disorders of thebreast

chest walltumors

herpes zoster

emotional

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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 orupset?

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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. No angina with ordinary activity. Angina withstrenuous, rapid, or prolonged exertion

II. Slight limitation of ordinary activity; angina whenwalking up stairs briskly, or walking on a cold orwindy day

III. Marked limitation; angina when walking atnormal pace up flight of stairs, or walking 1-2

blocks distance

IV. Angina on minimal exertion or at rest

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Factors affecting Oxygen Supply and Demand

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Stable Angina

Acute CoronarySyndrome

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Stable Plaque

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Unstable Plaque

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Cardiovascular Causes of Chest Pain

Stable Angina

retrosternal region; radiates to or occasionally

isolated to the neck, jaw, epigastrium,

shoulder, or arms - left commonpressure, burning, squeezing, heaviness, indigestion

< 2-10 min duration

precipitated by exercise, cold weather or stress

relieved by rest or nitroglycerin

PE may be normal.

CORONARY ARTERY DISEASE

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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.

CORONARY ARTERY DISEASE ACUTE CORONARY SYNDROME

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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

CORONARY ARTERY DISEASE ACUTE CORONARY SYNDROME

PE: soft S1, positive S3 and S4, systolic murmur at the apex

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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

forward

PE: pericardial friction rub

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Heart is surrounded byadherent fibrin and is

stained diffusely green

from bilirubin in a

patient with sepsis andliver failure.

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Macroscopic view of the left

ventricular wall in a patient

with fungal septicemia; ther

is a thick white fibrin

exudate of pericarditis.

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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 Marfans syndrome

PE: murmur of aortic insufficiency, pulse or blood

pressure asymmetry, neurologic deficit

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Pulmonary embolism

substernal or over region of pulmonary infarctionpleuritic (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, pleuralrub, hemoptysis with with pulmonary infarction

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Massive pulmonary embolus filling the left main

pulmonary artery.

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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?

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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 feelingshort of breath.

often accompanied by cough, wheezing, and sweating.

ameliorated by the patients sitting on the side of the bed or

getting out of bed.

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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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DYSPNEA

RespiratoryCardiovascular

High Output Normal Output Low Output Controller Pump Gas Exchange

Anemia

Hyperthyroidism

Arteriovenous

shunt

Deconditioning

obesity

diastolic dysfunction

Congestive

heart failure

myocardial

ischemia

constrictive

pericarditis

Pregnancy

metabolic

acidosis

COPD

Asthma

kyphoscoliosis

Pulmonary

embolism

pneumonia

interstitial l

disease

H t F il

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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 Pulmona

Edema

Clinical SpectrumCareful History and Physical Exam

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2 major or 1 major + 2 minor criteria have to be present concurrently.

Framingham Criteria for Congestive Heart Failure

Major Criteria Minor Criteria

paroxysmal nocturnal dyspnea or orthopnea

neck-vein distension

crackles

cardiomegaly

acute pulmonary edema

S3 gallop murmurincreased venous pressure > 12 mmHg

circulation time > 25 sec

hepatojugular reflex

ankle edema

night cough

dyspnea on exertion

hepatomegaly

pleural effusion

vital capacity decreased by 1/3 from maximutachycardia (HR > 120 bpm)

* major or minor criteria: weight loss > 4.5 kg in 5 days in response to treatment

Q ti t A k

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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 ?

Are there acompanying

symptoms such as chest pacalf 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 gainingweight ?

How do they sleep ?

C Ri k F t

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Common Risk Factors

Based on 18 year follow-up data from FraminghamCohort Study :

Hypertension ( BP > 140/90 mm/Hg )

Myocardial Infarction

Angina

Diabetes

Left Ventricular Hypertrophy ( ECG )

Valvular Heart Disease

JAMA, 1996

Left Heart Failure

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Right Heart Failure

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Elevated jugular venous pressure

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Peripheral edema

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Jaundice in a patient with severe heart failure.

New York Heart Association Classification of 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.

Objective Assessment

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Objective Assessment

A. No Objective evidence of cardiovascvular diseaseB. Objective evidence of minimal cardiovascular

disease

C. Objective evidence of moderately severe

cardiovascular disease

D. Objective evidence of severe cardiovascular

disease

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PALPITATION

Symptoms of

palpitations

Underlying Heart

Disease

Precipitating

Factors

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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?


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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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Precipitating Factors

Psychologic stress

Exercise

caffeine, alcohol, cocaine,

amphetamines

thyroid disease

anemia, hypoxemia

Questions to ask about Palpitation

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Q p

Please could you tap out on the table the rate you think your

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?

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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?

CAUSES OF SYNCOPE

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Reflex-Mediated Vasomotor Instability

Vasovagal

Situationalmicturition

cough

swallow

defecation

Carotid sinus syncope

Neuralgias

High altitude

Psychiatric disorders

Others (exercise, selected drugs)

CAUSES OF SYNCOPE

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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

CAUSES OF SYNCOPE

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Other Heart Disease

pump failure

MI, CAD, coronary spasm

tamponade, aortic dissection

CAUSES OF SYNCOPE

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Arrhthymias

Bradyarrhythmias

Sinus node disease

Second- and third-degree AV block

Pacemaker malfunction

Drug-induced bradyarrhythmias

CAUSES OF SYNCOPE

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Arrhythymias

Tachyarrhythmias

Ventricular tachycardia

Torsades de pointes (e.g. associated with

congenital long QT syndromes or acquired

QT prolongation)

Supraventricular tachycardia

CLINICAL FEATURES SUGGESTIVE OF SPECIFIC CAUSES

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Symptom or Finding Diagnostic Consideration

After unexpected pain, unpleasant Vasovagal syncope sight, sound,

smell

During or immediately after micturition, Situational syncope

cough, swallow, or defecation

On Standing Orthostatic Hypotension

Prolonged standing at attention Vasovagal

CYANOSIS

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both a symptom and a sign

bluish discoloration of the skin and mucous

membrane

due to increased quantity of reduced

hemoglobin or of abnormal hemoglobinpigments in blood perfusing these areas

more commonly described by a family

member and may go unnoticed by patient

CYANOSIS

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CYANOSIS

Central Peripheral

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Central Cyanosis

decreased arterial oxygen saturation due to right-to-leftshunting 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

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Peripheral cyanosis

FAMILY HISTORY

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FAMILY HISTORY

age and health, or age and cause ofdeath, of each immediate family member

data on grandparents or grandchildren may

also be useful

QUESTIONS TO ASK ABOUT THE FAMILY

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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?

FAMILY HISTORY

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Hypertension

Congenital heart disease

Heart attack

Stroke

Diabetes mellitus

PERSONAL HISTORY

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Smoking history number of pack years

Alcohol use amount and frequency

Dietary habits/ food preferences

Exercise and lifestyle

History of illicit drug use

PAST MEDICAL HISTORY

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General Medical Condition

Hypertension, Diabetes Mellitus, Asthma/COPD,

Endocrine disorders, Cerebrovascular

diseases, Renal disorders, Peripheral

vascular disease

Previous Hospitalizations

Previous Surgeries

Current Medications

OBSTETRICAL/ GYNECOLOGICALHISTORY

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Gravidity, Parity ( Obstetrical score )

Pre/Eclampsia, Gestational DM, Thyroid

disorders in pregnancy

Menopausal age

Use of Contraceptive pills

GENERAL SURVEY

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observe patients state of health, stature and

habitus, and sexual development

get height and weight

observe skin and its characteristics, identify

any lesion, study patients hands

inspect and palpate cervical nodes, note any

unusual pulsations in the neck

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Marfans Syndrome

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Xanthelasmata around eyelids (Familial hypercholesterolemia)

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Typical malar flush o

mitral stenosis. This

a non-specific finding

due to low cardiac

output.

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Central cyanosis of the tongue

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Subconjunctival hemorrhage (Infective endocarditis)

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Peripheral cyanosis

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Cyanosis and finger clubbing in a girl withEisenmengers syndrome

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Clubbing of fingers in a patient with ventricular septal

defect and cyanosis.

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Splinter hemorrhages in infective endocarditis

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Splinter hemorrhage in the ring finger (Infective Endocarditis)

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Dermal infarcts from

septic emboliOslers nodes

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Gangrene of toes in peripheral vascular disease

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Clinically, rheumatic

fever presents with

swollen, tender joints.

Summary

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Symptoms

Chest pain

Dyspnea

Palpitations

syncope

Signs

Vital signs

Complete physical examinatin

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