Clinical Cardiology OV erview

By Ragab abd elsalam ( MD) Prof. of Cardiology Clinical CardiologyOVerview

Approach to Patient with Heart Disease 1- Symptoms of Heart Disease = 2° myocardial ischemia = disturbances of the contraction system / and or relaxation of myocardium = obstruction of blood flow = disturbances of the contraction = abnormal cardiac rate 2- Symptom Relationship to Etiology - ischemia = manifest as chest pain - disturbance contraction or relaxation = weakness / fatigue Severe cyanosis, hypotension, syncope, increased intra-vascular pressure

CHEST PAIN • Two categories: • Recurrent, often paroxysmal pain, which is mild or moderate in intensity. • Prolonged & severe pain which is commonly asscoiated with clinical evidence of acute, serious illness.

(1) Recurrent chest pain: • (a) Angina pectoris: • Characteristics of anginal pain: • It is “visceral” pain: poorly localized and squeezing, oppressive, burning or heavy in quality. • Duration: brief, usually it is lasting 2 to 10 min. & it is rarely longer or shorter. • Usually it is mild or moderate in intensity. • Site: it is typicaly retrosternal, but it may occur in other locations. Even then at least a portion of the pain is commonly beneath the sternum. • The pain may be referred to precordium, neck, lower jaws, shoulders, arms, back and epigasterium. Radiation to the left shoulder and arm is especially common. • Precipitations: effort or emotional stress, after meals, exposure to cold air or wind.

N.B.: Anginal pain may be excluded under the following circumstances: • If it can be localized with one finger. • If it consistently last less than 30 sec. or longer than 30 min. • If it is sticking, jabbing or throbbing. • If it occurs exclusively at rest with twoexceptions: • Pre-infarction angina. • Variant form of angina, described by prinzmetal, vasospasm of coronaries usually is the leading cause. • If the intensity of the pain is consistently severe.

Musculoskeletal chest pain: • Characteristics: • Radicular in nature. • The pain usually occurs at night. • It is usually precipitated by fatigue, incorrect posture and movement of the involved segments but not movement of the body as a whole. • It may be intensified with coughing or sneezing. • The discomfort is usually dull and aching, and may be sharp. • The pain usually lasts for hours at time. • It is usually relieved by rest, analgesics postural exercises and local heat.

Tioetze’s syndrome: - Costochondral and chondrosternal pain, or swelling or both. - The pain is usually well localized, but may radiate across the chest and over to the arms. -Tenderness on palpation over the involved articulations. • Rib pain:may be due to trauma. Rib tumour causes pain if it is metastatic in origin. -Pain is usually described as sharp or burning and reproduced by local pressure. • Fleeting, jabbing, lancinatingor sticking pains are common in many normal individuals.

The thoracic outlet syndromes(e.g. the scalenus anterior, costoclavicular hyperabduction cervical rib-syndrome), may cause chest pain. • Symptoms depend on whether neural or vascular structures are compressed at the thoracic outlet. - Nerve compression is the common cause of pain and paresthesia. It may be associated with a demonstrable weakness. - Vascular compression is quite rare, as venous obstruction by thrombosis.

Shoulder disorders: • May cause pain that is referred to chest. • Careful analysis usually reveals that pain is aggravated by shoulder movement, not the body motion. • There is local tenderness and pain. Passive movement and limitation of motion are commonly present. • Less common causes:herpes zoster and Mondor disease (superficial phlebitis of thoracic wall and chest).

Psychogenic pain : • The discomfort of angina may be mimicked by anxiety states. • It may take various forms : • Intermittent sharp, knifelike pains. • Persistent precordial aching unrelated to effort. • Tight sensations in chest. • It is commonly associated with sighing respiration and symptoms owing to hyperventillation. • There is an important statement, that is mentioned by the patient, “ the pain is coming from the heart”

DACOSTA'S SYNDROME: - Psychogenic pain usually localized to the cardiac apex. May be associated with anxiety. - It May be also associated palpitations, hyperventilation, dyspnea, weakness, depression, or other signs of anxiety.

Pain due to pulmonary hypertension: -The cause of pain may be: -Right ventricular ischemia - Enlarged right ventricle & pulmonary artery may compress on chest &sternum.

Pain associated with valvular diseases: • (a) mitral valve prolapse: • The pain may be due to : • tension on base of the redundant leaflet. • Tension on chordae tendinae and papillary muscle. • Friction effect of redundant leaflet on myocardium. • Associated with syndrome X. • Associated with gastrointestinal cause of pain. • Coincidental chest pain.

Aortic Regurgitation: • The pain usually nocturnal. (Nocturnal Angina). • It is termed Angina of Lewis. • May be related to baradycardia occurs at night and marked decrease in the diastolic pressure.

Prolonged chest pain • Prolonged, severe, protracted chest pain may be the result of serious underlying disease, such as myocardial infarction, therefore, immediate hospitalization of patients for proper diagnosis and therapy is mandatory.

(a) Acute myocardial infarction: • (b) Pain due to Aortic Dissection: • (c) Acute pericarditis: • Three types of pain may occur in acute pericarditis: • Pleuritic pain is the most common type. • Steady, severe retrosternal pain of sudden onset, simulating pain of acute myocardial infarction. • The rarest type is pain at the cardiac apex felt synchronously with each heart beat. • Characteristics: • The pain is commonly sharp increased by breathing deeply, swallowing and lying supine. It is sometimes relieved by sitting-up and leaning forward. • The pain is most commonly located in the precordial region and may radiate to the neck or left shoulder

Mediastinal Emphysema: Free air in the mediastinum produces chest tightness and dyspnea. ** Hamman's Sign: Crunching, rasping sound heard synchronous with the heartbeat, indicative of mediastinal emphysema.

Reminders • Angina pectoris: angina is a discomfort in chest or adjacent area that is associated with myocardial ischemia without necrosis. It is due to an imbalance in myocardial oxygen supply and demand. • Stable (Typical) Angina: Angina upon effort, or angina induced by increased blood pressure or increased heart-rate. Angina is relieved by nitroglycerin, although nitroglycerin is not specific to this type of angina.

* Levine's Sign: Patient makes fist and holds it up to his chest, to describe the pain. • Second-wind Phenomenon: If patient repeats same activity after the attack, he may not feel the attack again the second time. • Walk-through Angina: The pain subsides as patient continues the activity.

Atypical Angina: Atypical presentation of typical angina. • Atypical Symptoms: Sharp or stabbing pain, rather than crushing pain. • Atypical Causes: Angina with change in position, for example, rather than angina strictly upon effort. • Angina Equivalents: Other symptoms that are caused by myocardial ischemia. > Exertional dyspnea. > Nausea, indigestion. > Dizziness, sweating.

Unstable Angina: Angina even at rest, or angina that has recently gotten worse. It is associated with sharply increased risk for myocardial infarct within 4 months. • Angina Decubitusis a specific term for angina occurring at rest. • Variant Angina (Prinzmetal Angina): Paradoxic angina occurring during rest but usually not during exercise. It is caused by coronary artery spasm. It can be hard to spot because it can coexist with typical angina.

Clinical presentation of patients with chest pain: It can be divided into three subsets: • Typical angina pectoris. • Atypical angina pectoris. • Non-anginal chest pain.

Dyspnea • Definitions : It is the patient complaint of: - shortness of breath. or - he can’t get enough breath. or - awareness of respiration. • It is subjective distress complaint of difficult breathing. • It is one of the most common distressing symptom in cardiovascular disease.

Types: - Dyspnea on effort (exertional dyspnea). - Orthopnea. - Paroxysmal nocturnal dyspnea. - Acute pulmonary edema. - Cheyne-Stokes Breathing. - Dry non-productive cough.

* According to the cause, dyspnea may be: • Cardiac causes of dyspnea. • Non-cardiac causes of dyspnea. Lung diseases. Anxiety. Anemia. Thyrotoxicosis. False-dyspneas in: Pregnancy  “huff and puff” Compansatory hyperpnea associated with metabolic acidosis due to diabetes mellitus and uremia.

Dyspnea on effort: • it is a common complaint. It is usually due to congestive heart failure or chronic pulmonary disease. • * It is necessary to establish the degree of activity requiring to produce dyspnea. - What is about the daily activity of the patient? - When the patient began to notice increasing dyspnea? *When dyspnea is associated with wheezing: • If the patient is an adult especially over 40 years old, heart failure is the foremost in the mind of the physician. • If there is a history of periodic wheezing and dyspnea since childhood, bronchial asthma and lung disease is more likely to be the cause of dyspnea. • It is important to remember that long standing pulmonary disease may develop heart disease and heart failure. Also heart failure may precipitate more bronchial asthma.

Orthopnea: It implies that the patient has more dyspnea when he is lying down. • The patient relates that he must use two or three pillows in order to have a restful night. • Orthopnea is often associated with congestive heart failure, but may also be associated with severe lung disease. The fatigue associated with the exertion of breathing seems to be less when dyspnea is due to pulmonary disease than when it is due to heart failure.

Ask the patient: • Does the dyspnea occur whether the patient lies on back, left or right side?. • Is it improved with digitalis & diuretic?. • Does it being within a half minute of lying flat? • Is the patient not completely free of dyspnea at any chest elevation (severe mitral stenosis). • Is the dyspnea developed rapidly and for less than one minute in supine position and then feels no dyspnea? (suggest pulmonary hypertension).

(c) paroxysmal Nocturnal Dyspnea: • Characteristically, the patient goes to bed and has little difficulty going to sleep in the recumbent position. • One or two hours later he is awakened from sleep with acute shortness of breath. • He seeks relief by sitting upright, perhaps on the side of the bed, or he even sits in a chair. • He occasionally goes to the open window searching for air. After a time he becomes comfortable and returns to bed. • He may then sleep comfortably the remainder of the night.

 It is almost specific for left side heart failure. •  The only other causes for this unusual sequence of events are: • - Hyperventillation syndrome due to anxiety. - Pulmonary emboli. • (1) For pulmonary emboli: it would be most unusual for pulmonary emboli to occur for very many nights at the same hour. • (2) For hyperventilation syndrome due to anxiety:It is not so clearly relieved by sitting-up and is associated with other signs suggesting this syndrome, such as tingling of arms and hands and other evidence of anxiety.

ASK about: • How long after sleeping does it occur? (Redistribution of fluid takes 2-4 hours to raise left atrial pressure). • Does the patient angle legs to get relief?. • Duration? (10-30 minutes). • Is it associated with cough, wheezing or frothy, pink sputum? • Obstructive sleep apnea? History of heavy snoring? • Paroxysmol nocturnal dyspnea usually occure in patients who are suffering also from exertional dyspnea and orthopnea. • The precipitating factors of the attack is uncertain and probably variable. Cough, bad dreams, slipping position, turning to side on which he is ordinary dyspneic and abdominal distension are among those suggested factors.

(d) Acute Pulmonary Edema: The patient experiences the sudden development of dyspnea and cough and he may produce frothy blood-tinged sputum. This symptom may occur without previous warning as in myocardial infarction, or its may be preceded by cardiac asthma or dyspnea on effort.

(e) Cheyne-Stokes breathing: Periods of hyperpnea which alternate with periods of apnea. This type of breathing occurs in: • Older patients with heart failure, hypertension or cerebrovascular accident • It is associated with: Hypoventillation syndrome of obesity (pickwickian syndrome)  the breathing is periodic in nature, but it is not typical as chyne-stoke breathing. • Rarely occurs in children or in patients with core pulmonale.

(f) Dry non-productive cough: • Cough may on occasion the earliest symptom, the most prominent symptom or the only apparent symptom of left ventricular failure. • * Cough is an important symptom in certain forms of cardiovascular diseases, even in absence of heart failure : • Aortic aneurysm with compression on bronchus or trachea. • Mitral stenosis with aneurysmally dilated left atrium. • Markedly dilated pulmonary artery. • Congenital double aortic arch forming a vascular compression ring around the trachea.

Trepopnea: Dyspnea that occurs in only one of several recombent positions not due to congestive heart failure: (a) Cardiomegally. (b) Musculoskeletal.

Platypnea: It is the dyspnea provoked by sitting-up. • Left atrial myxoma. • Ball-valve thrombus of left atrium. • Orthostatic hypotension. • N.B.: • Some patient with angina pectoris, may complaint of dyspnea rather than chest pain. This is termed (Angina equavelent).

Clinical significance of orthopnea: • It is usually the result of heart disease (as many as 95% cases). It reflects, a severe lung congestion on lying supine in patients with left sided heart disease. • In about 5% of causes, are related to lung diseases: • Chronic obstructive lung disease (COLD) with apical bullae, where the sitting position, not only improves the gas exchange but also, lung mechanics. • N.B.: • patients with COLD, usually have a sitting-up and either clasping the side of the bed or pushing over their thighs, producing the formation of two patches of hyperpigmented callus immediately above the knees (Dahl’s sign.). • Orthopnea in asthmatic patient is usually a sign of severity. If it is observed at time of emergency, it is a good predictor of poor outcome.

Paroxysmal Nocturnal dyspnea (PND). • It is sought to be specific for Left sided heart disease and failure, but: • Patient with chronic obstructive lung disease (COLD) may have PND due to excessive secretion upon lying down. • Asthmatic patients also may have PND due to night worsening bronchospasm. Orthopnea: • Occurs in patients with heart failure, but also may occur in patients with COLD due to partial loss of diaphragmatic and accessory muscle function when supine.

Palpitation • It is a disagreable awarness of the heart beat. The patient may use some other terms and report as “pounding”, ‘stopping”, “jumping”, or “racing” in the chest. The patient may complain when the heart beat is slow, fast or irregular.

If there is a history of palpitations: • (a) Orientation: • When did they begin? • Ask about: shortest, and longest duration and the length of time between attacks. • (b) Types and rate: ask about. • Regular or irregular. • Sustained or occasionally, strong beats. • Onset and offset. •  gradual  sinus tachycardia. •  sudden  ectopic tachycardia. • Rest or exercise. • Associated symptoms. • Maneuvers or medications that stop it.

Hemoptysis • Definition : • It means coughing-up blood. • Brisk bleeding: is commonly associated with specific focal ulceration of the bronchus, such as” (bronchogenic carcinoma, foreign body, or bronchiectasis). • Slow bleeding: Strongly suggest venous bleeding and is more likely to be the result of increased pulmonary vascular resistance, with secondary increase in flow through the bronchial venous system such as may occur as a result of mitral stenosis or bronchiectasis. • It is also helpful to notice whether the expectorated blood is admixed with sputum or pus. This is valuable, as the site of origin of the bleeding could be determined. Intimate admixture of blood and pus are signs pointing to a deep-seated site of pulmonary suppuration such as pyogenic lung abscess.

Three conditions must never be overlooked as causes of hemoptysis: • (1) Mitral stenosis: • It is frequently induced by physical exercise, sexual intercourse, or marked excitement. • It may be the first symptom, and may occur during pregnancy. • The blood comes from a break in the pulmonary veins, which rupture under high pressure. • Apoplexy: occurs in 10% of cases with reversible pulmonary hypertension due to rupture of broncho-pulmonary venous varicosities. This type tend to subside as the vein adapt to high pressure and as pulmonary arteriolar disease develops.

2) Pulmonary infarction: • Frank hemoptysis occurs in the minority of instances. • When hemoptysis occurs in a patient with heart failure, pulmonary infarction is likely. • The bloody sputum usually appears from a few hours to a day after the embolus.

(3) Eisenmenger physiology: Patients with severe pulmonary hypertension associated with atrial septal defect, or patent ductus arteriosus, may have hemoptysis, secondary to rupture of pulmonary capillaries. • Four additional rare causes of hemoptysis: • Rupture of a pulmonary arteriovenous fistula. • Rupture of aortic aneurysm into the trachea or bronchus. • Pulmonary hemosiderosis. • Bronchial ulceration due to foreign body.

Cyanosis • Definition : • Bluish coloration of skin and mucous membrane. • Cyanosis cannot occur when the hemoglobin is less than 33 percent of normal since reduced hemoglobin cannot be produced in an amount sufficient to cause the bluish color (Five grams of reduced hemoglobin is needed for cyanosis to occur). When the hemoglobin is normal, about one-third of it must be in the reduced form for the bluish color to appear.

* Clinical significance of history of cyanosis: • If cyanosis is present only during the neonatal period the possibility of an atrial septal defect with temporarily reversed flow (right-to-left shunt) during the neonatal period is suggested. • However, the most common causes of neonatal cyanosis are, atelectasis, pneumonia, or even occasionally from cerebral damage.

Persistent and severe neonatal cyanosis suggests a right-to-left shunt often with marked impairment of pulmonary blood flow: • Tetralogy of Fallot with pulmonary atresia. • The hypoplastic left ventricular syndrome. • Tricuspid atresia. • Sometimes transposition of great vessels.

Cyanosis that develops after a few years of life suggests a less severe form of tetralogy of Fallot, in about of 75% or more. Cyanosis often appeas following delayed closure of a patent ductus arteriosus, or when child begins to walk. • Cyanosis occuring later in life of childhood is suggestive of Eisenmenger complex (N.B. Occasionally cyanosis may be present early in life with this disorder, but not common). • Patients with trialogy of Fallot (atrial septal defect and pulmonary stenosis), usually describe history of cyanosis, late in (childhood or adolescence).

A history of squatting with severe cyanosis (Hypoxic spells), are most suggestive of: • Tetralogy of Fallot. • Trialogy of Fallot. - tricuspid atresia. • N.B. • Squatting seldom occur in Eisenmenger syndrome. • The squatting usually occur to relieve dyspnea and spells of unconsciousness, with severe cyanosis. • In adults cyanosis and digital clubbing may be caused by right-to-left- shunting. Such shunting is most often the result of the Eisenmenger syndrome and occasionally of tetralogy or trialogy of fallot or Ebstein’s anomally, or partial transposition of the great vessels. • Adult cyanosis also may result from chronic or acute pulmonary disease.

Adult cyanosis also may result from chronic or acute pulmonary disease. • Chronic disease as: • Chronic obstructive lung disease. • Hypoventillation syndromes. • Pulmonary infiltrative diseases as Hamman-Rich syndrome, sarcoidosis, metastatic cancer or severe bronchiectasis. • Acute disease:  Pneumonia.  Pulmonary embolism.  But the patient seldom complains of cyanosis in these problems.

Clinical Cardiology OV erview