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Cardiovascular Symptomatology Based on Physiopathology. نشانه شناسي بيماريهاي قلب و عروق بر اساس فيزيوپاتولژي (رفتارشناسي سيستم قلبي عروقي ). By: Amir F.Z.Parsa , M.D. Director Division of Cardiology Tehran University of Medical Sciences .

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cardiovascular symptomatology based on physiopathology

Cardiovascular Symptomatology Based on Physiopathology

نشانه شناسي بيماريهاي قلب و عروق بر اساس فيزيوپاتولژي (رفتارشناسي سيستم قلبي عروقي )

By:

Amir F.Z.Parsa, M.D. Director Division of Cardiology

Tehran University of Medical Sciences

questions that we confronted with and must be answered
Questions that we confronted with and must be answered

What is symptomatology?

What is difference between symptom and sign?

What is difference between symptomatology and etiology?

What is difference between etiology and pathophysiology?

Why should we know cardiac symptomatology?

What is presenting symptom?

What is chief complain?

How can we matched chief complain with the diagnosis?

Why should we be logical?

What is difference between knowledge and judgment?

cardiac cardinal symptoms
Cardiac Cardinal Symptoms
  • Chest pain or discomfort
  • Dyspnea
  • Palpitation
  • Syncope
  • Cyanosis & clubbing
  • Edema
slide5

Chest Pain

What is pain?

slide6

Origin of Chest Pain

Supradiaphragmatic organs (intra-thoracic organs)

Subdiaphragmatic organs

Chest wall & Dorsal lumbar

slide7

Mechanism of Cardiac Pain

  • Biochemical substances
      • P.substance (Th.Lewis)
      • Bradykinin, Serotonin, Adensin & et cet….
  • Mechanical factors (Wenckebach)
slide12

Perception of Chest Pain

Specificity theory (simple neural transmission)

Gate control theory (Melzac & collegues)

slide13

Pathogenesis of Cardiac Pain

  • Myocardial ischemia
  • Myocardial injury
    • Decreased blood supply (infarction)
    • Inflammation (myocarditis)
  • Myocardial dilatation
slide14

Physiology of Cardiac

Circulation & Metabolysm

slide17

Factors Influencing Cardiac Oxygen Consumption

Heart rate

Myocardial contractility

Afterload & preload

slide19

Etiology of Myocardial Ischemia or Injury

  • Factors that influence supply (coronary)
    • Atherosclerotic
    • Vasculitis
    • Spasm
    • Increased resistance (arteriolar)
  • Factors that influence demand (myocardial)
    • Heart rate, pre-load and after-load (e.g. tachycardia myocardial hypertrophy; HCM- AS- Hypertension…)
slide20

Behavior of Cardiac & Non-Cardiac Chest Pain

Onset of pain

Duration of pain

Quality of pain

Locations & distributions of pain

Accompanying symptoms

slide21

Symptoms of Myocardial Ischemia

  • Angina pectoris
      • Location
      • Duration
      • Quality
      • Behavioral manner
  • Alternatives of angina pectoris
slide25

Alternatives of Angina Pectoris

Dyspnea or suffocation (chest tightness)

Fatigue or exhaustion

slide26

Characteristics of Chest Pain

  • Angina pectoris
      • Typical
      • Atypical
  • Non-anginal chest pain
slide27

Clinical Presentation of CHD

Stable angina pectoris

Unstable angina pectoris

Prolonged chest pain

slide28

Causes of Prolonged Chest Pain

Myocardial infarction

Aortic dissection

Systemic & pulmonary hypertension

Pericardial and/or pleural inflammation

Gasterointestinal origin

Musculoskeletal & Neural (chest wall) origin

slide29

GasterointestinalCauses of Chest Pain

Esophageal spasm

Esophageal reflux

Peptic ulcer & gastritis

Cholecystitis

Pancreatitis

Splenic flexure syndrome

Cafe coronary

slide30

Musculoskeletal Causes of Chest Pain

Costocondritis and/or myositis(tietze’s syndrome)

Herpes zoster

Scalenusanticus

Radicular pain (radiculopathy)

Shoulders osteoarthropathy

slide31

Dyspnea

What is dyspnea?

slide32

Dyspnea

Unpleasant awareness of breathing and respiratory distress , disproportionate to the degree of activity

slide33

Dyspnea

Exhilarating Unpleasant

Breathlessness

slide37

Respiratory Dysfunction

Increased airway resistance

Decreased lung compliance

Respiratory muscle weakness

slide38

Ventilatory Drives

Intrapulmonary receptors stimuli (congestion or inflammation)

Abnormal blood gases (Hypercapnea-hypoxia)

Central nervous system stimuli (Anxiety)

slide42

Mechanism of Dyspnea

Respiratory muscle tension-length misalignment

Increased respiratory center activity (Tachypnea)

slide43

Pathogenesis of Dyspnea

Pulmonary congestion

Increased pulmonary arterial pressure

Abnormal blood gases

slide44

Clinical Presentation of Cardiac Dyspnea

Exertionaldyspnea (fatique)

Orthopnea

Paroxismalnucturnaldyspnea (PND)

Acute pulmonary edema (cardiac asthma)

slide48

Differential Diagnosis of Dyspnea

Lung diseases (acute & chronic)

Pulmonary hypertension & emboli

Massive pleural effusion

Overweight or pregnancy

Hyperventilation & acidosis

slide50

Palpitation

What is palpitation?

slide51

Palpitation

Definition :

Unpleasant awareness of heart beating

slide52

Mechanism of Palpitation

Acute Changes in :

  • Heart rate & rhythm
  • Contractility & stroke volume
slide53

Diagnosis of Palpitation

Electrocardiography is the only tool for definitive diagnosis of heart rate & rhythm that could be achieved either by resting ECG or by holter monitoring or event recorder.

slide54

Syncope

What is syncope?

slide55

Syncope

Definition :

Transient & reversible loss of consciousness due to one or more abnormal phenomena in cardiovascular & circulatory system that leads to reduction in cerebral blood flow .

slide56

Classification of Syncope

Cardiac

Neurocardiovascular

Vascular

slide57

Neurocardiovascular Syncope

(Vasomotor instability)

  • Neurocardiogenic
  • Carotid sinus hypersensitivity
  • Situational
      • Micturation & defecation
      • Cough & swallowing
slide58

Vascular Syncope

  • Orthostatic hypotension & pregnancy
  • Cerebrovascular
      • Migraine or TIA
      • Vascular (subclavian steal syndrome)
slide59

Causes of Orthostatic Hypotension

Prolonged inactivity

Volume depletion

Aging

Peripheral and autonomic neuropathy

Central nervous system disorders

Drugs

Familial hyperbradykininism

slide60

Causes of Cardiac Syncope

Anatomical disorders

  • Aortic stenosis
  • Hypertrophic cardiomyopathy
  • Mitral valve prolapse
  • Aortic dissection
  • Myocardial ischemia or infarction
  • Pulmonary embolism (massive)
  • Pulmonary hypertension, or sever stenosis
  • Cardiac tamponade

Electrical disorders

  • AV block (high grade)
  • Sick sinus syndrome
  • Long QT syndrome (malignant arrhythmias)
  • Pre-excitation (WPW syndrome)
  • Pacemaker syndrome
  • Severe tacky or brady arrhythmias
syncope evaluation and differential diagnosis
Syncope Evaluation and Differential Diagnosis
  • Complete Description
    • From patient and observers
  • Type of Onset
  • Duration of Attacks
  • Posture
  • Associated Symptoms
  • Sequelae

History – What to Look for?

slide62

Syncope

History

After sudden unexpected pain, or unpleasant sight, etc…

During or immediately after micturition,defecation, cough, or swallowing, etc…

Upon standing

With changing position

With or after exertion

With head rotation, shaving tight collars, or neck tumors

With diplopia, dysarthria, or vertigo, etc…

With arm exercise

Confusion after episode

In suppine position

Diagnosis

Neurocardiogenic

Situational

Orthostatic

Atrialmyxoma, or thrombus

AS,IHSS, CAD, PH, or PS (severe)

Carotid sinus hypersensitivity

TIA (basilar artery), or migraine

Subclavin steal

Seizure

Cardiac asystole, or arrest, hyperventilation or hysterical, seizure

causes of syncope like states
Causes of Syncope-like States
  • Migraine*
  • Acute hypoxemia*
  • Hyperventilation*
  • Somatization disorder (psychogenic)
  • Acute Intoxication (e.g., alcohol)
  • Seizures
  • Hypoglycemia
  • Sleep disorders

* may cause ‘true’ syncope

cyanosis
Cyanosis

What is cyanosis?

slide65

Cyanosis

Definition:

Bluish discolaration of skin and mucous membranes resulting from an increased amount of deoxygenated hemoglobin ≥4gr/dlor hemoglobin derivatives (methemoglobin-sulfhemoglobin…) in the blood perfusing these areas

slide66

Causes of Blue Skin Color

Genetic causes

Metabolic causes

Nutritional causes

Chemical causes

Neoplastic causes

Circulatory causes (cyanosis)

slide67

Factors that Influence Appearance of Cyanosis

Total hemoglobin concentration

Body temperature & pH

Intracellular concentration of 2, 3, DPG

slide68

Types of Cyanosis

Central cyanosis

Peripheral cyanosis

slide69

Causes of Central Cyanosis

Cardiac right to left shunts

Pulmonary right to left shunts (AV fistulae)

Abnormal hemoglobin derivatives

Respiratory dysfunction

High altitude (decrease inspired oxygen tension)

slide70

Causes of Peripheral Cyanosis

Cold exposure

Low cardiac output

Arterial obstruction or spasm

Venous obstruction

slide71

Edema

What is edema?

slide72

Edema

Definition :

Increased extravascular compartment of extracellular (interstitial) fluid volume.

slide73

Mechanism of Edema

Edema occurs as a result of imbalance in the starling forces or capillary damage.

slide74

Starling Forces

Vascular hydrostatic pressure

Vascular colloid oncotic pressure

Interstitial hydrostatic pressure (tissue tension)

slide75

Pathogenesis of Edema

Increased capillary hydrostatic pressure

Decreased plasma colloid oncotic pressure

Capillary endothelial injury

slide77

Causes of local Edema

Venous obstruction

Lymphatic obstruction

Angioedema(biochemical capillary damage)

Mechanical injury

slide78

Causes of Diffuse Edema

Cardiac (hydrostatic pressure ↑)

Noncardiac (plasma colloid oncotic pressure↓ and/endothelial injury )

slide79

Causes of Noncardiac Diffuse Edema

Renal

Hepatic

Malnutrition

Endocrine

Hypersensitivity

slide80

Causes of Cardiac Edema

Congestive heart failure

Tricuspid stenosis

Constrictive pericarditis

slide81

Mechanism of Cardiac Edema

Decreased cardiac output

Increased reabsorption of sodium and water by kidney

Increased cardiac filling pressure

Increased mean circulatory filling pressure

Increased capillary hydrostatic pressure

Fluid transudation

Edema

slide86

Coronary Heart Disease (CHD)

Atherosclerotic

Non-atherosclerotic

slide89

Clubbing of Fingers

Definition :

Increased finger’s distal phalanxes and nail-bed soft tissue accompany with arteriolo-venoul fistula. And in the more severe forms with hypertrophic osteoarthropathy.

slide90

Causes of Clubbing

Cardiac (with/without cyanosis)

Pulmonary (with/without cyanosis)

Gastrointestinal

Occupational

slide91

Causes of Cyanotic Clubbing

Cyanotic heart disease

Pulmonary AV fistula