Cardiac Evaluation

Mohammad Zubaid MB, ChB, FRCPC, FACC

Associate Professor of Medicine

Head, Division of Cardiology

Mubarak Al-Kabeer HospitalDone by : Shaikha AL-Faresi

- Doctor slides are written by this font.-My additional notes are written by this font.

MON. 18-sept.-2006

Symptoms of cardiovascular DiseaseRisk factors for CAD and other cardiac diseasesRelated old historyMedications

A clue about their disease

Side effectsSmoking and Alcohol

-Doctor said u have to concentrate at the symptoms of cardiovascular diseases(CVDs).The risk of medications is extremely important.

History

Symptoms of cardiovascular disease•Chest pain

•Dyspnea (shortness of breath)

•Palpitation

•Syncope

•Edema

History

Symptoms

Types of cardiac pain

TypeCause Characteristics

AnginaCoronary stenosis (rarely aortic stenosis, hypertrophic

cardiomyopathy)

Precipitated by exertion, eased by rest, characteristic

distribution

Myocardial infarction

Coronary occlusionSimilar sites to angina, more severe, persists at

rest

Pericarditic pain

PericarditisSharp, raw or stabbing varies with movement or

breathing

Dissecting aneurysm

Dissecting aneurysmSevere, sudden onset, felt first in back, persists at rest

-Angina comes with exertion and goes away with rest.-Myocardial Infraction(MI) is ischemia started at rest

and not related to exercise -Angina & MI are similar in some characteristics such

as heaviness and shaking.-Pericarditic pain is distinct sharp, knife stabbing, can

be persisted and related to breathing & posture. -Dissecting aneurysm is quite different, distinct, very

severe onset,back pain starts at the upper back then to the front.

Acute left heart failure

Myocardial infarction

Mitral valve disease

Aortic stenosis

Arrhythmia

Cardiomyopathy

Over transfusion

Left atrial pressure

Pulmonary edema

Hypoxia Reflex

vasoconstriction

Further LV function

Causes Mechanism

Cardiac dyspnea

-The major cause of cardiac dyspnea is increasing in left atrial pressure.

-Whatever acute left heart failure, MI, mitral valve disease, aortic stenosis, arrhythmia, cardiomyopathy or over transfusion all lead to increase left atrial pressure.

- -Over transfusion happens in post operative patient when they give him fluid overdose and over transfuses him causing increase in the left atrial pressure and concequensely pulmonary edema and hypoxia which makes patient feeling dyspnea.This large atrial pressure will reach the pulmonary vein and then to the pulmonary bronchioles and capillaries leading to accumulation of the fluid in the alveoli and as a result

pulmonary edema occures .

-Right side heart failure does not cause dyspnea. However, it is presented with congestion, swelling of legs and abdominal pain due to congested liver which is very painful. Usually, the cause of right heart failure is related to hypooxygenation. for ex. Somebody has severe pulmonary hypertension because of pulmonary emboli or COPD lung disease causing right heart failure, he will suffer from dyspnea not because of right heart failure, well it is due to pulmonary hypertension and COPD

disease .-It is not common and rare in case of pure tricuspid

valve regurgitation to have right heart failure symptoms like jugular venous pulsation, abdominal pain and leg swelling, we shouldn’t have dyspnea.

Exertional dyspnea – what distance? Orthopnea Paroxysmal nocturnal dyspnea (PND) Cough Pulmonary edema

Dyspnea

--Exertional dyspnea is related to distance so we ask the patient whether he feels dyspnea when he walks for example for 10 or 100 meters.

-Orthopnea is feeling of shortness of breath when u lie down-.-In (PND) patient wakes up suddenly feeling shortness of

breath and he tells u I go to bed fine and suddenly I wake up feeling shortness of breath then he goes for example to open the window, usually it takes 10-15 min then he gets back to bed.

-Usually patients wake up at night due to prostate enlargement, night mare or due to snoring which causes sleep apnea, major problem in which patients wake up suddenly and get sleep again

بـ يفتح sleep apnea يعني و يحوس مايروح ينام يرد و يصحى المريضويتهوى الدرايش

بـ - هوا PNDلكن يدور الدرايش يفتح الفراش من يقوم و يصحى المريضتقريبا . 15-10ياخذ بين تتخربطون ال بليز ينام الفراش يرجع بعدين دقيقة

الحالتين

--Cough is extremely important because most patients come to casualty coughing and it worsens at night, the dr gives them anti-cough medications because they don’t feel shortness of breath!!.They sleep at up right position on the chair if they lie down they will cough because they actually have heart failure .

- -pulmonary edema is due to impairment of LVF(left ventricular function),fluid in alveoli patient looks very sick having acute shortness of breath.

Descriptions of palpitation

ArrhythmiaPatient’s description

Ventricular or atrial extrasystoles

“Heart misses a beat “

Heart “jumps” or “flutters”

Atrial fibrillationHeart “jumping about” or “racing ”

May be unnoticed

Supraventricular tachycardia

Heart racing or fluttering

Asystole, complete heart block and ventricular tachycardia often present as syncope rather than as palpitation

-Palpitation is extremely common symptom.-In ventricular or atrial extrasystoles, the patient

feels his heart beats and this is very annoying!! this doesn’t mean they are abnormal.

extrasystoles و فجاة يطمر قلبي احس الدكتور قولة على!! بطني في ينزل

-Most important thing for u as a doctor when u see a patient with palpitations is to recognize whether patient feels his normal or abnormal beats so he asks him if they are fast or strong

beats ?

Syncope – most difficult to investigate

•Vasovagal – common faint

•Nuerologic – seizures, stroke, bleed

•Arrhythmia

•Hypotension

History

Symptoms

--Syncope is loss of consciousness and its very difficult to investigate.

--Vasovagal syncope is the commonest type and it occurs due to sudden bad or god news causes vasodilation of periphery.It can happen also in people who stand for very long time for ex. police,army,and security where all blood pulled to veins of legs causing vasovagal syncope.

- -Neurological syncope is distinct like tongue biting in tonic clonic seizure and so on, however, it is important to know whether the patient lost control of urine or feces during syncope so u ask him did u wet ur self?if yes a lot of times it indicates true deep syncope. It is better to find a wetness to describe for u what happened. Most patients who tell that they had syncope, they actually had dizziness or vertigo not syncope because syncope is complete loss of consciousness and it is brief in most cases.

--Most elderly lose conscious in bathroom due to constipation or enlarged prostate.

--In arrhythmia,u will be lucky if a patient tells u I feel my heart racing then I lost consciousness.They don’t always say that.

Edema

•Peripheral edema

•Generalized edema

•Possible causes

-Peripheral edema is like leg swelling & Generalized edema is severe heart failure either in left or right side. Possible causes of edema could be cardiac,renal and hepatic.

History

Symptoms

Symptoms of cardiovascular Disease

Risk factors for CAD and other cardiac diseasesRelated old history

Medications

A clue about their disease

Side effectsSmoking and Alcohol

History

Risk factors – depends on the disease

•Risk factors for CAD

•Risk factors for valve disease

•Risk factors for cardiomyopathy

• Dilated cardiomyopathy (DCM)

• Hypertrophic obstructive cardiomyopathy (HOCM)

•Risk factors for Syncope

•Risk factors for pericardial disease

History

-Risk factors for coronary artery disease(CAD)are traditional hypertension, diabetes, smoking, hyperlipidemia, male gender and family history of premature CAD.

--Risk factor for valve disease: rheumatic fever as child .--Rik factor of cardiomyopathy is family history of DCM.--Risk factors of DCM is previous MI or known history of

valve disease.--Main risk factor of HOCM is family history.

- -Risk factor for cardiac syncope is presence of old MI because these people are prone to arrhythmias.

--Risk factor for pericardial disease is TB which causes pericardial calcification usually seen in young bangaladishi and indian people.Viral infections may lead to the disease.

-

Ischemic heart disease HypertensionRheumatic heart diseaseAbdominal aortic aneurysm

-Family history in CVDs is not mandalian relationship but it is gene interaction .

Cardiovascular diseases in which several genes may interact

Symptoms of cardiovascular DiseaseRisk factors for CAD and other cardiac diseases

Related old historyMedications

A clue about their disease

Side effectsSmoking and Alcohol

History

Related old history – very important

•Congestive heart failure

•Syncope

•Ischemia-For ex. Hypertension, diabetes and heart attack

are important old history for congestive heart failure.

History

Symptoms of cardiovascular DiseaseRisk factors for CAD and other cardiac diseasesRelated old history

Medications

A clue about their disease

Side effectsSmoking and Alcohol

History

Medications

•A clue about their disease

•Side effects

• Aspirin – bleeding

• Betablockers – fatigue, nightmares, impotence, syncope

• Calcium blockers – leg edema, constipation, syncope

• Nitrates – headaches

• Statins – muscle aches, raised liver function tests

• ACE inhibitors – renal impairment, hyperkalemi

History

-It is extremely important to know all the medications that patient use, even in casualty tell to his family to go back to home and get all the patient medications.

Symptoms of cardiovascular DiseaseRisk factors for CAD and other cardiac diseasesRelated old history

Medications

A clue about their disease

Side effects

Smoking and Alcohol

History

Smoking and Alcohol – don’t be deceived by looks

•Smoking – need a whole week to talk about

•Alcohol

•Atrial fibrillation (binge drinking)

•Dilated cardiomyopathy, with or without AF-When u see a man with unexplained dilated cardiomyopathy u have

to wonder about chronic alcohol consumption.It can happen with or without atrial fibrillation.

-It is not nice or logical to ask for ex. 70 years old kuwaiti lady whether

قبل مال قدوو شاربة تكون ممكن الدكتور قولة she drinks or not!!! Sheعلىcould be smoker

History