•
•
•
•
•
The Heart
• The heart does not rest for more than a
fraction of a second at a time. During a
lifetime, it contracts more than 4 billion
times. To support this active state, the
coronary arteries supply more than 10
million liters of blood to the myocardium
and more than 200 million liters to the
systemic circulation. Cardiac output can
vary under physiologic conditions from 3 to
30 L/min, and regional blood flow can vary
by 200%. This wide range occurs without
any loss of efficiency in the normal state.
The major heart disease
Symptoms of cardiac disease
coronary heart disease,
hypertension,
rheumatic heart disease,
bacterial endocarditis,
congenital heart disease.
• Chest pain
• Palpitations
• Dyspnea
• Syncope
• Fatigue
• Dependent edema
• Hemoptysis
Chest pain. Questions.
•
•
•
•
•
•
•
"Where is the pain?"
"How long have you had the pain?"
"Do you have recurrent episodes of pain?"
"What is the duration of the pain?"
"How often do you get the pain?"
"What do you do to make it better?“
"What makes the pain worse? breathing? lying
flat? moving your arms or neck?"
Chest pain. Questions.
• "How would you describe the pain? burning?
pressing? crushing? dull? aching? throbbing?
knife-like? sharp? constricting? sticking?"
• "Does the pain occur at rest? with exertion?
after eating? when moving your arms? with
emotional strain? while sleeping? "
• "Is the pain associated with shortness of breath?
palpitations? nausea or vomiting? coughing?
fever? coughing up blood? leg pain?"
Angina pectoris
• Angina pectoris literally means a strangling
sensation (angina) in the chest (pectoris). It is a
gripping or crushing central chest pain (or
discomfort) that may be felt around the whole
chest or deep within the chest. The pain may
radiate into the neck or jaw and, rarely, into the
teeth, back or abdomen. It is associated with
heaviness, paraesthesia or pain in one (usually
the left) or both arms. It is typically provoked by
exercise and is promptly relieved by rest.
Angina pectoris
• Angina pectoris is the true symptom of
CHD. Angina is commonly the
consequence of hypoxia of the
myocardium resulting from an imbalance
of coronary supply and myocardial
demand.
Angina pectoris
• Angina of increasing frequency, or coming
on at rest or unpredictably is called
unstable (or crescendo) angina. A pain of
similar distribution and type also occurs at
rest in myocardial infarction. The
mechanism of the pain is myocardial
hypoxia secondary to inadequate coronary
blood flow.
Levine's sign
• Commonly, a patient may describe the
angina by clenching the fist and placing it
over the sternum. This is a pathognomonic
sign of angina commonly referred to as
Levine's sign.
Palpitations
• Palpitations are the uncomfortable
sensations in the chest associated with a
range of arrhythmias. Patients may
describe palpitations as "fluttering,"
"skipped beats," "pounding," "jumping,"
"stopping or "irregularity." The normal
heartbeat is sensed when the patient is
anxious, excited, exercising, or lying on
the left side.
Palpitations
• The most common arrhythmias felt as
palpitations are premature ectopic beats and
paroxysmal tachycardias. Determine whether
the patient has had similar episodes and what
was done to extinguish them. Palpitations are
common and do not necessarily indicate serious
heart disease. Any condition in which there is an
increased stroke volume, as in aortic
regurgitation, may be associated with a
sensation of "forceful contraction."
Palpitations
• "How long have you had palpitations?"
• "Do you have recurrent attacks?" If so,
"How frequently do they occur?"
• "When did the current attack begin?"
• "How long did it last?"
• "What did it feel like?"
• "Did any maneuvers or positions stop it?"
• "Did it stop abruptly?"
Palpitations
Palpitations
• "Could you count your pulse during the attack?"
• "Can you tap out on the table what the rhythm
was like?"
• "Have you noticed palpitations on exertion?
• while lying on your left side? after a meal? when
tired?"
• "During the palpitations, have you ever fainted?
had chest pain?"
• "Was there an associated flush, headache, or
sweating associated with the palpitations?"
In addition to primary cardiovascular causes
• thyrotoxicosis,
• hypoglycemia,
• fever,
• anemia,
• pheochromocytoma,
• and anxiety states are commonly
associated with palpitations.
Dyspnea
• Dyspnea is an abnormal awareness of
breathlessness, and can be due to cardiac
or respiratory causes.
• Patients report that they have "shortness
of breath" or that they "can't get enough
air." It occurs on exertion or may be
present at rest.
Example
"The patient has had 1-block DOE
(Dyspnea on exertion) for the past 6
months. Before 6 months ago, the patient
was able to walk 4 blocks without
becoming short of breath.”
Dyspnea
• Left ventricular failure causes dyspnea
because of a rise of pressure in the left
atrium and pulmonary capillaries leading
to interstitial and alveolar edema. This
makes the lungs stiff (less compliant),
which increases the amount of respiratory
effort necessary to breathe. Usually a fast
breathing rate (tachypnoea) is also
present owing to stimulation of the
pulmonary stretch receptors.
Orthopnea
Orthopnea is a form of breathlessness that
occurs when the patient lies flat, and
occurs because lying flat results in
redistribution of blood, leading to an
increased central and pulmonary blood
volume.
Orthopnea
• Patients usually cope with orthopnea by
propping themselves up with pillows.
Inquire of all patients, "How many pillows
do you need in order to sleep?" To help
quantify the orthopnea, you can state, for
example, "3-pillow orthopnea for the past 4
months."
Paroxysmal nocturnal dyspnea
• Paroxysmal nocturnal dyspnea (PND)
occurs when there is an accumulation of
fluid in the lungs (pulmonary edema) at
night.
• The patient is woken from sleep fighting
for breath, a dramatic and frightening
experience.
Paroxysmal nocturnal dyspnea
Syncope
• Sitting on the side of the bed or getting up
may relieve the breathlessness.
Sometimes the patient will get up and
open a window to gasp for fresh air.
Wheezing, due to bronchial endothelial
edema, is common (cardiac asthma), and
a cough, often productive of frothy or
blood-tinged sputum, usually occurs.
Initially these episodes terminate
spontaneously.
• Fainting, or syncope, is the transient loss
of consciousness that is due to inadequate
cerebral perfusion. Ask patients what they
mean by "fainting" or "dizziness." Syncope
may be related to cardiac as well as
noncardiac causes.
Syncope
• "What were you doing just before you
fainted?"
• "Have you had recurrent fainting spells?" If
so, "How often do you have these
attacks?"
• "Was there an abrupt onset to the
fainting?"
• "Did you lose consciousness?"
Syncope
• "In what position were you when you
fainted?"
• "Was the fainting preceded by any other
symptom? nausea? chest pain?
palpitations? confusion? hunger?"
• "Did you have any warning that you were
going to faint?"
• "Did you have any black, tarry bowel
movements after the faint?"
Syncope
Syncope
• The activity that preceded the syncope is
important because some cardiac causes are
associated with syncope during exercise (e.g.,
valvular aortic stenosis, idiopathic hypertrophic
subaortic stenosis, and primary pulmonary
hypertension). If a patient describes palpitations
before the syncope, an arrhythmogenic cause
may be present. Cardiac output may be reduced
by arrhythmias or obstructive lesions.
• The position of the patient just before fainting is
important because this information may help
determine the cause of the syncope. For
example, if a patient fainted after rising suddenly
from bed in the middle of the night to run to
answer the telephone, orthostatic hypotension
may be the cause. Orthostatic hypotension is a
common form of postural syncope and is the
result of a peripheral autonomic limitation.
Syncope
Micturition syncope
• There is a sudden fall in systemic blood
pressure resulting from a failure of adaptive
reflexes to compensate for an erect posture.
Symptoms due to orthostatic hypotension
include dizziness, blurring of vision, profound
weakness, and syncope. Many drugs can cause
orthostatic hypotension by leading to changes in
intravascular volume or tone. The geriatric
patient is most prone to orthostatic hypotension.
• Micturition syncope usually occurs in men
during straining with nocturnal urination. It
may occur after considerable alcohol
consumption.
Vasovagal syncope
Vasovagal syncope
• Vasovagal syncope is the most common
type of fainting and is one of the most
difficult to manage. It has been estimated
that 40% of all syncopal events are
vasovagal in nature. Vasovagal syncope
occurs during periods of sudden, stressful
or painful experiences, such as receiving
bad news, surgical manipulation, trauma,
the loss of blood, or even the sight of
blood.
• It is often preceded by pallor, nausea,
weakness, blurred vision, lightheadedness,
perspiration, yawning, diaphoresis,
hyperventilation, epigastric discomfort, or a
"sinking feeling." There is a sudden fall in
systemic vascular resistance without a
compensatory increase in cardiac output as a
result of an increased vagotonia. If the patient
sits or lies down promptly, frank syncope can be
aborted.
Carotid sinus syncope
Post-tussive syncope
• Carotid sinus syncope is associated with a
hypersensitive carotid sinus and is seen more
commonly in the aged population. Whenever a
patient with carotid sinus syncope wears a tight
shirt collar or turns the neck in a certain way,
there is an increased stimulation of the carotid
sinus. This causes a sudden fall in systemic
pressure, and syncope results. Two types of
carotid sinus hypersensitivity exist: a
cardioinhibitory (bradycardia) type and a
vasodepressor (hypotension without
bradycardia) type.
• Post-tussive syncope generally occurs in
patients with chronic obstructive lung disease.
Several mechanisms have been postulated to
explain its occurrence. It is generally accepted
that coughing produces an increase in
intrathoracic pressure, which decreases venous
return and decreases cardiac output. There may
also be a rise in cerebrospinal fluid pressure,
producing a decreased perfusion to the brain.
Fatigue
• Fatigue is a common symptom of decreased
cardiac output. Patients with congestive heart
failure and mitral valvular disease frequently
complain of fatigue. Fatigue, however, is not
specific for cardiac problems. The most common
causes of fatigue are anxiety and depression.
Other conditions associated with fatigue include
anemia and chronic diseases. The examiner
must attempt to differentiate organic from
psychogenic fatigue.
• "How long have you been tired?"
• "Was the onset abrupt?"
• "Do you feel tired all day? in the morning?
in the evening?"
• "When do you feel least tired?"
• "Do you feel more tired at home than at
work?"
• "Is the fatigue relieved by rest?"
Dependent Edema
• Swelling of the legs, a form of dependent
edema, is a frequent complaint of patients. Heart
failure results in salt and water retention.
Retained fluid accumulates in the feet and
ankles of ambulant patients and over the sacrum
of bed-bound patients. The edema associated
with heart failure becomes progressively worse
during the day and is often absent on initial
rising as the fluid is reabsorbed on lying down.
When severe, the calf and thigh may become
edematous and ascites or pleural effusion may
develop.
Dependent Edema
• "What kind of medications are you
taking?"
• "Is there a history of kidney, heart, or liver
disease?"
• "Do you have shortness of breath?" If so,
"Which came first, the edema or the
shortness of breath?"
• "Do you have pain in the legs?"
• "Do you have any ulcers on your legs?"
Hemoptysis
• In addition to the pulmonary causes, mitral
stenosis should not be forgotten as an
important cause of hemoptysis. Rupture of
the bronchial veins, which are under high
back pressure in mitral stenosis, produces
the hemoptysis.
Dependent Edema
•
•
•
•
"When was the swelling first noted?"
"Are both legs swollen equally?"
"Did the swelling appear suddenly?"
"Is the swelling worse at any time of the
day?"
• "Does it disappear after a night's sleep?"
• "Does elevation of your feet reduce the
swelling?"
Dependent Edema
• The patient with congestive heart failure has
symmetric edema of the lower extremities that
worsens as the day progresses. It is least in the
morning after sleeping with elevation of the legs
in bed. If the patient also complains of dyspnea,
it is helpful to determine which symptom came
first. In patients with dyspnea and edema
secondary to cardiac causes, the dyspnea
usually precedes the edema. Bedridden patients
may have dependent edema in the sacral area.