Symptoms and Signs of Cardiovascular Disease

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Symptoms and Signs of Cardiovascular Disease

• Wole Adebiyi
• Cardiology Unit
• Department of Medicine
• College of Medicine
• University of Ibadan
• Ibadan Nigeria

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Importance of the history

• The richest source of information concerning the
  patients illness
• Establishes a bond with the patient
• Allows evaluation of the impact of the disease

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Breathlessness(dyspnoea)

• abnormally uncomfortable awareness of breathing
• regarded as abnormal only when it occurs
• at rest or
• at level of physical activity not expected to
  cause it
• associated with diseases of
• heart
• lungs
• chest wall
• respiratory muscles
• also associated with anxiety

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Breathlessness(dyspnoea)

• Exertional dyspnoea
• Comes on during exertion and subsides with rest
• Commonly due to HF or lung disease
• Orthopnoea
• breathlessness on lying flat
• A symptom of left ventricular failure
• due to redistribution of fluid from the lower
  extremities to the lungs

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Breathlessness(dyspnoea)

• Paroxysmal Nocturnal dyspnoea
• a variant of orthopnoea
• patient awakes from sleep
• severely breathless
• persistent cough, may have white frothy sputum
• a manifestation of left ventricular failure

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Chest Pain or Discomfort

• history is very important
• although a cardinal manifestation of heart
  disease, also originates from
• Non-cardiac intrathoracic structures
• aorta, pulmonary artery, bronchopulmonary tree,
  pleura, mediastinum, oesophagus and diaphragm
• tissues of the neck and thoracic wall
• skin, thoracic muscles, cervicodorsal spine,
  costochondral junctions, breasts, sensory nerves
  and spinal cord
• subdiaphragmatic organs
• stomach, duodenum, pancreas and gallbladder
• Functional or factitious

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Chest Pain

• Points to note in the history
• location
• radiation
• character
• aggravating factors
• relieving factors
• time relationships
• duration, frequency and pattern of occurrence
• setting in which it occurs
• associated factors

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Differential diagnosis of chest pain according to
location
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Oedema

• Peripheral Oedema
• a feature of chronic heart failure
• due to excessive salt and water retention
• In ambulant patients
• found in the ankles, legs, thighs and lower
  abdomen
• In patients who are recumbent
• over the sacrum
• associated with other features of heart failure
• Usually pitting except if it has been long
  standing

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Oedema

• Causes of peripheral oedema
• cardiac failure
• Chronic venous insufficiency
• Hypoalbuminaemia nephrotic syndrome, liver
  disease, protein losing enteropathy
• Drugs
• retaining sodium (fludrocortisone, NSAID)
• increasing capillary permeability (nifedipine)

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Palpitations

• definition
• unpleasant awareness of forceful or rapid beating
  of the heart
• caused by disorders of cardiac rhythm and rate
• history in palpitation
• isolated jump or skips
• extrasystoles
• attacks with abrupt beginning, rapid heart rate
  with regular or irregular rhythm
• paroxysmal tachycardias
• independent of exercise or excitement to account
  for the symptom
• atrial fibrillation, atrial flutter,
  thyrotoxicosis, anaemia, anxiety states

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Palpitations

• associated with drug use
• tobacco, coffee, tea, alcohol epinephrine,
  aminophylline, MAOI
• on standing
• postural hypotension
• middle aged women, associated flushes and sweats
• menopausal syndrome
• associated with normal rate and rhythm
• anxiety state

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Syncope

• definition
• sudden temporary loss of consciousness
• associated with loss of postural tone
• with spontaneous recovery
• not requiring electrical or chemical
  cardioversion
• due to sudden vasodilation or sudden fall in
  cardiac output or both simultaneously

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Cough

• defined as explosive expiration for clearing the
  tracheobronchial tree of secretions and foreign
  bodies
• cardiovascular causes include those that lead to
• pulmonary venous hypertension
• interstitial and alveolar oedema
• pulmonary infarction
• compression of the tracheobronchial tree

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Cough

• the nature of the sputum is often helpful
• pink frothy sputum - pulmonary oedema
• clear white mucoid sputum viral infection or
  longstanding bronchial irritation
• thick, yellowish sputum infection
• rusty sputum pneumococcal pneumonia
• blood streaked sputum tuberculosis,
  bronchiectasis, Ca lung or pulmonary infarction

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fatigue

• non-specific
• common in patients with impaired cardiovascular
  function
• consequent to a reduced cardiac output
• associated with muscular weakness
• may be caused by drugs e.g. ß-blockers
• may also result for excessive blood pressure
  reduction in patients with hypertension or heart
  failure
• caused by excessive diuresis or diuretic induced
  hypokalaemia

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Other symptoms

• Nocturia
• common in early heart failure
• Anorexia
• Abdominal fullness
• right upper quadrant abdominal discomfort
• weight loss
• cachexia

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Physical Examination

• General examination
• pallor indicate anaemia
• cyanosis bluish discolouration of the mucous
  mucosa and skin due to arterial hypoxaemia
• central cyanosis
• poor gaseous exchange in the lungs pulmonary
  disease or pulmonary oedema
• right to left shunt in congenital heart disease
• peripheral cyanosis
• obesity
• associated with hyperlipidaemia and diabetes
• features of hyperlipidaemia
• corneal arcus
• xanthelasma

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Physical Examination

• facial abnormalities
• ptosis and frontal baldness dystonia
  myotonica(cardiomyopathy and conduction defects)
• high arched palate and ocular lens abnormalities
  Marfans syndrome(Aortic aneurysm)
• unusual facial features(congenital heart
  diseases)
• finger clubbing
• cyanotic congenital heart diseases
• infective endocarditis(advanced)
• Splinter haemorrhages
• trauma
• infective endocarditis
• Moist palms
• cold anxiety
• warm thyrotoxicosis

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CVS examination

• Pulse
• Rate
• bradycardia
• tachycardia
• Rhythm
• regular
• irregular
• regular with dropped beats
• completely irregular
• sinus arrhythmia (speeds up in inspiration and
  slows with expiration)
• Volume
• depend on the cardiac stroke volume and the
  compliance of the arterial system
• State of the arterial wall
• Synchronicity
• radio-femoral delay
• Other pulses
• brachial, carotid, femoral, popliteal, posterior
  tibial and dorsalis pedis

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Blood pressure

• use of a sphygmomanometer
• inflatable cuff connected to mercury or aneroid
  manometer
• stethoscope over the branchial artery
• inflate cuff above the POP
• reduce the pressure in the cuff slowly
• reappearance of Korotkov sound systolic
  pressure
• disappearance of Korotkov sounds diastolic
  pressure

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Blood pressure

• Pitfalls in BP measurement
• apparatus
• small cuff overestimation of the BP by 20 - 30
  mmHg
• large cuff underestimation of the blood
  pressure
• calibration of the sphygmomanometer
• Patient
• emotional state of the patient
• anxiety(white coat hypertension)
• posture and the position of the sphyg
• observer
• auscultatory gap

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Jugular venous pulse

• observed from the right internal jugular vein
• usually examined with patient at 45
• 2 major pulsations can be observed a and v
  waves
• measurement of the JVP
• height above the sternal angle usually lt 4cm
• Abdomino-jugular reflux
• seen in right heart failure
• Causes of raised JVP
• Rt heart failure
• Tricuspid incompetence
• Pericardial effusion
• SVC obstruction
• Constrictive pericarditis
• Tricuspid stenosis

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Praecordium

• Inspection
• evidence of respiratory difficulty
• visible veins obstruction of SVC
• praecordial bulge or prominence long standing
  cardiac enlargement before puberty
• abnormalities of the chest wall
• Praecordial hyperactivity suggests severe
  valvular abnormality
• Apex beat

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Praecordium palpation

• apex beat
• lowermost and outermost point of cardiac impulse
• normally in the 5LICS at the mid-clavicular line
• when displaced suggests cardiac enlargement
• heaving apex LVH
• tapping apex beat (palpable 1st heart sound)
  mitral stenosis

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Praecordium palpation

• Right ventricle
• left parasternal heave indicate RVH
• Palpable sounds
• Palpable 2nd heart sound loud P2 or A2
• Thrills
• palpable murmurs with low frequency components

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Cardiac auscultation

• Areas for auscultation
• cardiac apex
• right and left sternal borders interspace by
  interspace

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Heart sounds

• 4 basic heart sounds
• other sounds i.e. clicks, prosthetic valve
  sounds
• time the sounds with palpation of the carotid
  artery

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Heart sound

• 1st heart sound
• two major components
• due to closure of the atrio-ventricular valves
• loud in
• tachycardia
• short PR interval
• short circle lengths in AF
• mitral stenosis with a pliable leaflet
• 2nd heart sound
• due to closure of the semi-lunar valves
• normally two components A2 and P2
• splitting of the 2nd heart sound in inspiration

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2nd Heart sound abnormal splitting

• single 2nd heart sound
• inaudible pulm. component
• pulmonary atresia
• due to emphysema
• severe pulm. stenosis
• inaudible aortic component
• severe calcific aortic stenosis
• aortic atresia
• persistent synchrony of the two components
• Eisenmengers complex

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2nd Heart sound abnormal splitting

• Persistent splitting
• delay in the pulm. component
• complete RBBB
• early timing of the first component
• mitral regurgitation
• Fixed splitting
• ostium secundum atrial septal defect
• Paradoxical splitting
• complete LBBB
• right ventricular pacemaker
• severe aortic outflow obstruction
• a large aorta-to-pulmonary artery shunt

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2nd Heart sound abnormal intensity

• Increased A2
• systemic hypertension
• increased P2
• pulmonary hypertension

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3rd heart sound

• due to sudden limitation of ventricular expansion
  during early diastolic filling
• heard normally in children
• and in patients with high cardiac output
• in patients over 40 years old
• an S3 usually indicates
• impairment of ventricular function
• AV valve regurgitation
• other conditions that increase the rate or volume
  of ventricular filling

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4th heart sound

• a low-pitched, presystolic sound produced in the
  ventricle during ventricular filling
• it is associated with an effective atrial
  contraction and is best heard with the bell piece
  of the stethoscope
• absent atrial fibrillation
• occurs when diminished ventricular compliance
  increases the resistance to ventricular filling
• seen in
• patients with systemic hypertension
• aortic stenosis
• hypertrophic cardiomyopathy
• ischemic heart disease
• acute mitral regurgitation

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Murmurs

• result from vibrations set up
• in the blood stream
• and the surrounding heart and great vessels
• as a result of
• turbulent blood flow,
• formation of eddies,
• cavitation (bubble formation as a result of
  sudden decrease in pressure)
• graded I VI
• grade I faint, heard only with special effort
• grade II soft
• grade III loud
• grade IV loud with thrill
• grade V audible with stethoscope barely touching
  the chest
• grade VI murmur is audible with the stethoscope
  removed from contact with the chest

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Murmurs

• for a murmur, determine its
• timing
• intensity
• pitch
• site of maximal intensity
• radiation
• configuration
• relationship with posture and respiration
• three major categories of murmurs
• systolic, diastolic and continuous

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Sites for heart sounds

• http//www.bioscience.org/sound
• http//members.aol.com/kjbleu/
• http//www.medlib.com/spi/coolstuff2.htm

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other cardiac sounds

• Pericardial rubs
• the hallmark of acute pericarditis
• generated by the parietal and visceral pleura
  rubbing against each other

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Other relevant examination

• lung bases
• crepitations in left heart failure
• abdomen
• hepatomegaly in right heart failure