Dr. J.A. Coetser
GKV 353
CoetserJA@ufs.ac.za
0833542861
A 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?
 When
evaluating symptomatic
complaints
• Site
• Onset
• Character
• Radiation
• Alleviating factors
• Timing
• Exacerbating factors
• Severity
 Determine
the cause!
 4 cardinal features
• Duration (timing)
• Location (site)
• Quality (character)
• Precipitating and aggravating factors
 Angina
• Crushing pain, heaviness, discomfort or choking
•
•
•
•
sensation in retrosternal area
Central rather than left chest
May radiate to jaw
and/or arms
Rarely below umbilicus
Typical vs. atypical angina
Typical vs. atypical angina
Typical angina
Meets all 3:
1. Characteristic restrosternal chest
discomfort – typical quality and
duration
2. Provoked by exertion or emotion
3. Relieved by rest or GTN or both
Atypical angina
Meets 2 of above
Non cardiac chest pain
Meets 1 or none of above
 Pain
from acute coronary syndromes
(myocardial infarction and unstable
angina)
• Often comes on at rest
• Pain present >30min
Angina
Acute
coronary
syndromes
• Clot dissolves
• Coronary blood flow returns
• No cardiac muscle damage
UNSTABLE ANGINA
• Clot persists
• Coronary blood flow cut off
• Cardiac muscle dies
MYOCARDIAL INFARCT
 Pleuritic
pain
• Due to movement of pleural surfaces on one
another
• Inflammation of pleura or pericardium
 Viral infection of pleura
 Pneumonia
 Pulmonary embolism
• Made worse by inspiration
• Often relieved by sitting up and leaning forward
 Dissecting
aneurysm
• 3 features
 Severe, tearing pain
 Rapid onset
 Radiates to back
• Proximal aorta dissection = anterior chest pain
• Descending aorta dissection = interscapular
pain
• Hx of HPT, or connective tissue disorder e.g.
Marfan’s syndrome
 Massive
pulmonary embolism
• Sudden onset
• May be retrosternal/angina-like
• Can be associated with dyspnoea, collapse and
cyanosis
 Spontaneous
pneumothorax
• Sharp pain and severe dyspnoea
• Localized to one part of chest
 Oesophageal
disorders
• Reflux disease can mimic angina
• Oesophageal spasm
 Especially after drinking hot or cold fluid
 Associated with dysphagia
 Relieved by nitrates
 Don’t
forget:
• Cholecystitis
• Herpes zoster
 Dyspnoea
definition: unexpected
awareness of breathing
• Sensation of increased force needed for work of
breathing
 Need
to distinguish between cardiac and
respiratory causes
 Cardiac
dyspnoea
• LV output fails to rise during exercise
• Increased LV end-diastolic pressure
• Raised pressure in LA
• Raised pressure in pulmonary venous system
• Leakage of fluid into interstitial space
• Decreased lung compliance
NYHA classification of dyspnoea
Class I
Disease is present, but no dyspnoea
OR
Dyspnoea only on heavy exertion
Class II
Dyspnoea on moderate exertion
(climbing stairs)
Class III
Dyspnoea on minimal exertion
(getting dressed, washing)
Class IV
Dyspnoea at rest
 Orthopnoea
• Dyspnoea in the supine position
• In supine position, interstitial oedema distributes
to all lung zones, decreasing overall oxygenation
• In sitting position, oedema redistributes to lower
zones, leaving upper zones free for oxygenation
• Other causes of orthopnoea
 Massive ascites
 Pregnancy
 Bilateral diaphragmatic paralysis
 Large pleural effusion
 Severe pneumonia
 Paroxysmal nocturnal dyspnoea (PND)
• Severe dyspnoea that wakes patient from sleep
• Has to sit up and gasps for breath
• Mechanism
 Sudden failure of LV
 Reabsorption of peripheral oedema at night while
supine with overload of LV
 Don’t forget anxiety as cause of dyspnoea
• Inability to take deep enough breath to fill lungs
in satisfying way
 Ankle
oedema of cardiac origin
• Usually symmetrical
• Worst in evenings, improves during night
• As failure progresses, involves legs, thighs,
genitalia and abdomen
• Find out if pt is on a calcium channel blocker, i.e.
Adalat XL® (nifedipine), amlodipine, etc., which
can also cause ankle oedema
• If oedema also involves face, think of nephrotic
syndrome
 Definition
palpitations: unexpected
awareness of the heartbeat
• Ask pt to tap out beat with finger
• Ask if palpitations are slow or fast, regular or
irregular, and what the duration is
• Any fast arrhythmia can produce angina if pt also
has ischaemic heart disease
 Atrial
fibrillation
• Completely irregular rhythm
 Atrial
or ventricular ectopic beat
• Sensation of skipped beat, followed by
particularly heavy beat
 Ventricular
tachycardia
• Rapid palpitations followed by syncope
 Syncope
= transient loss of
consciousness resulting from cerebral
anoxia, usually due to inadequate
cerebral blood flow
 Presyncope = transient sensation of
weakness without loss of consciousness
(I’m about to faint)
 NB: ask about family history of sudden
death
• Long QT syndrome / Brugada syndrome

Postural syncope
• LOC when standing for long periods or standing up
suddenly
 Ask about drugs that can cause postural hypotension

Micturition syncope
• LOC when passing urine

Vasovagal syncope
• LOC with emotional stress

Syncope due to arrhythmia
• LOC regardless of position

Exertional syncope
• Aortic stenosis
• Hypertrophic cardiomyopathy
 Claudication
= pain in one or both calves
(thighs or buttocks) on walking more than a
certain distance (claudication distance)
 6 P’s of peripheral vascular disease
•
•
•
•
•
•
Pain
Pallor
Pulselessness
Parasthesiae
Perishingly cold
Paralysed
 Lumbar
spinal stenosis (pseudo
claudication)
• Pain relieved by flexing spine
• Exacerbated by walking downhill
 Common
symptom of cardiac failure
 Remember other causes
• Lack of sleep
• Anaemia
• Depression
 Previous ischaemic heart disease
 Hypercholesterolaemia
 Smoking
 Hypertension
 Family history
• 1st degree relatives (parents of siblings)
• Especially if <60yrs
 Diabetes mellitus
• DM is a coronary heart disease equivalent
• Risk of diabetic for MI is the same as a non-diabetic
who has had an infarct
 Chronic
kidney disease
 Which
medications?
 Any side-effects?
 Previous procedures, e.g. CABG,
angioplasty
• Ask how many arteries were bypassed?
• How many stents were placed?
 Previous MI or angina?
• Increases risk for further events
 Rheumatic fever
 Hypertension
• Alcohol use
• Salt intake
• Obesity
• Lack of exercise
• Kidney disease
• NSAIDs
 Ischaemic
heart disease can interfere
with daily functioning
• Is patient still working?
• Has living arrangements changed?
 Enquire
about rehabilitation programs