Podcast
Questions and Answers
Which of the following are considered major cardiac symptoms? (Select all that apply)
Which of the following are considered major cardiac symptoms? (Select all that apply)
Angina Pectoris is characterized by an O₂ imbalance due to decreased demand for oxygen.
Angina Pectoris is characterized by an O₂ imbalance due to decreased demand for oxygen.
False
What is the primary mechanism for Angina Pectoris?
What is the primary mechanism for Angina Pectoris?
myocardial ischemia
The typical pain associated with Angina is described as _______ and can radiate to the left shoulder or arm.
The typical pain associated with Angina is described as _______ and can radiate to the left shoulder or arm.
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Match the types of angina with their criteria:
Match the types of angina with their criteria:
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Which of the following factors can provoke Angina Pectoris?
Which of the following factors can provoke Angina Pectoris?
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Shortness of breath (Dyspnea) is not a symptom associated with cardiovascular issues.
Shortness of breath (Dyspnea) is not a symptom associated with cardiovascular issues.
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The duration of angina can be classified as acute, ________, or chronic.
The duration of angina can be classified as acute, ________, or chronic.
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Which of the following conditions is NOT associated with chest pain?
Which of the following conditions is NOT associated with chest pain?
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New onset angina is a feature of unstable angina pectoris.
New onset angina is a feature of unstable angina pectoris.
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What are the typical features of chest pain?
What are the typical features of chest pain?
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Shortness of breath that occurs when lying down is known as _____?
Shortness of breath that occurs when lying down is known as _____?
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Match the type of chest pain with its associated trigger:
Match the type of chest pain with its associated trigger:
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Which symptom is associated with pulmonary congestion?
Which symptom is associated with pulmonary congestion?
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All types of dyspnea indicate a serious medical condition.
All types of dyspnea indicate a serious medical condition.
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Name at least two risk factors for coronary artery disease.
Name at least two risk factors for coronary artery disease.
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What condition is characterized by the inability to lay down due to dyspnea?
What condition is characterized by the inability to lay down due to dyspnea?
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Paroxysmal nocturnal dyspnea occurs immediately upon falling asleep.
Paroxysmal nocturnal dyspnea occurs immediately upon falling asleep.
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What is the minimum amount of excess fluid needed to cause edema?
What is the minimum amount of excess fluid needed to cause edema?
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In right heart failure, edema is primarily seen in the ______.
In right heart failure, edema is primarily seen in the ______.
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Which of the following is NOT a cause of low cardiac output leading to syncope?
Which of the following is NOT a cause of low cardiac output leading to syncope?
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Match the following symptoms with their related conditions:
Match the following symptoms with their related conditions:
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Dyspnea can be associated with pulmonary congestion in left heart failure.
Dyspnea can be associated with pulmonary congestion in left heart failure.
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List two risk factors for coronary artery disease.
List two risk factors for coronary artery disease.
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Study Notes
History and Physical Examination of Cardiovascular System
- The presentation covers the history and physical examination of the cardiovascular system.
- This includes learning goals, cardiac history, cardiovascular examination, auscultation, and specific symptoms like angina pectoris or dyspnea.
- It also covers causes of chest pain which vary considerably.
Learning Goals
- The presentation details learning objectives related to cardiac history including factors like major symptoms, past medical history, and family history.
- Cardiovascular examination techniques are outlined which include cardiac exam, vascular exam (arteries, veins), and auscultation (heart sounds, pathological sounds, murmurs).
Cardiac History
- Patient history begins with personal details such as date of examination, name, age, sex, ethnicity, and occupation.
- Major complaints (symptoms) and a complete medical history (past & family history) are crucial for cardiac assessment.
Major Cardiac Symptoms
- Chest pain (angina), shortness of breath (dyspnea), palpitations, edema, syncope, and claudication are presented as major symptoms to consider.
Angina = Myocardial Ischemia
- Angina is a type of chest pain, pressure, or discomfort.
- It results from inadequate blood flow to the heart muscle due to coronary artery narrowing.
- Myocardial oxygen imbalance is a key contributor to angina, relating to increased oxygen demand versus decreased supply.
Angina Pectoris
- This is the most common symptom of myocardial ischemia linked to CAD or other ischemic conditions.
- Localization is often retrosternal.
- Character is often squeezing, burning, or pressure.
- Pain may radiate to the left shoulder, arm (left arm, both), back, or epigastric region.
- Provocation often relates to exercise, stress, or cold; relief often from resting or nitrates.
- Duration can range from acute to chronic.
- Criteria for classifying angina are also presented, including 1, 2, and 3 criteria for assessing typical or atypical angina.
Typical Angina
- Retrosternal pain/pressure/burning/squeezing.
- Increased pain with exercise/stress.
- Decreased pain with rest or nitrate.
Atypical Angina
- This refers to exhibiting 1-2 of the 3 criteria of typical angina;
Non-cardiac Chest Pain.
- This corresponds to 0 out of 3 criteria of typical angina.
Causes of Chest Pain
- Causes of chest pain are detailed:
- Coronary Artery Disease/ MI.
- Other cardiovascular causes (ischemic and non-ischemic).
- Gastrointestinal : esophageal spasm, reflux, peptic ulcer
- Psychogenic: anxiety, depression.
- Neurogenic / Locomotor: Thoracic outlet syndrome, cervical degenerative arthrosis, costochondritis, herpes zoster, and trauma.
- Pulmonary: pulmonary embolism, pulmonary infarction, pneumothorax, pneumonia, and pleural effusion.
History of a Patient with Chest Pain
- A patient's history includes details on age, gender, history of coronary artery disease, risk factors (diabetes, hypertension, high cholesterol, smoking, family), & details of chest pain (typical or atypical).
- Localization (retrosternal), characteristics (burning, pressure, squeezing), radiation (left arm, shoulder, jaw, back), trigger or provocation (exercise, stress, cold), relief (rest, nitrates), and duration (acute/chronic) are considered.
Unstable Angina Pectoris
- This presents as new-onset angina, or rest pain/minimal effort, progressive angina or post-MI angina.
- Possible associated symptoms include anxiety, fear, nausea, dyspnea, or sweating.
Shortness of Breath (Dyspnea)
- Dyspnea is a subjective feeling of inadequate breathing.
- A cardiac mechanism leading to dyspnea is pulmonary congestion.
- Types of dyspnea discussed include exercise dyspnea, orthopnea, paroxysmal nocturnal dyspnea, rest dyspnea, and acute pulmonary edema.
Orthopnea
- Orthopnea is difficulty breathing when lying down.
- This issue is due to pulmonary congestion; fluid redistribution occurring when lying down.
- It is often associated with congestive heart failure.
- Patients might need props (pillows) to sleep in a semi-upright position.
Paroxysmal Nocturnal Dyspnea
- A sudden episode of breathlessness (dyspnea) usually occurring at night.
- It's caused by fluid redistribution in the pulmonary circulation (due to lying down) with an excess of fluid returning to the heart.
- Symptoms include waking up with a feeling of struggling to breathe (hunger for air), coughing, and shortness of breath.
Cardiac Edema
- Edema arises from increased total body fluid and increased hydrostatic pressure leading to leakage from blood vessels into tissue spaces.
- Pretibial edema is common.
- At least 5 liters of excess fluid causes noticeable edema.
- Edema locations vary, and for example right heart failure shows edema in legs, sacrum, or abdomen. Edema with left heart failure is associated with pulmonary congestion/pulmonary edema.
Palpitation
- Palpitation is a subjective feeling of awareness of heartbeats.
- Heart beats can feel fast, slow, irregular, strong and paused.
- Symptoms can be associated with heart rhythm disturbances like tachycardia, bradycardia, extra-systoles (VES/AES) or pauses.
Syncope (Fainting)
- Syncope results from cerebral hypo-perfusion due to low cardiac output.
- Patients experience a sudden loss of body posture and consciousness.
- Loss of consciousness resolves spontaneously.
- Causes of low cardiac output comprise mechanical problems (e.g., aortic stenosis, hypertrophic cardiomyopathy) or arrhythmias (e.g., ventricular tachycardia).
Past Medical History
- Risk factors for coronary artery disease (CAD) are mentioned.
- This includes age (male over 45, female over 55), gender, diabetes mellitus, hypertension, dyslipidemia, smoking, family history, relevant habits (smoking, alcohol, drug use), history of rheumatic fever, and medication usage.
- Chronic illnesses and previous operations/trauma/allergy are also important.
Family History
- Family history is significant for assessment of cardiovascular issues.
- Relevant are coronary artery disease, congenital heart disease (ASD, VSD, PDA), genetic disorders, and conditions like hypertrophic cardiomyopathy, mitral valve prolapse, dilated cardiomyopathy, Marfan syndrome, and Long QT syndrome.
Physical Examination
- The physical examination involves:
- Inspection
- Palpation
- Percussion
- Auscultation
Cardiovascular Examination
- Cardiac exam includes inspection, palpation, and percussion.
- Auscultation is critical for listening to heart sounds and detecting murmurs.
- Vascular exam entails checking blood pressure and assessing arterial and venous pulses (temporal, carotid, axillary, brachial, radial, femoral, popliteal, tibialis posterior, dorsalis pedis, jugular venous pressure).
Cardiac Exam (Inspection)
- Physical attributes are noted including general appearance (tachypnea, anxiety, depression, confusion)
- Body type (Down, Turner, Marfan)
- Signs such as sweating, cyanosis and anemia are considered.
- Obesity (using BMI), abdominal obesity, and cachexia are significant observations.
- Assessing for venous distention and central venous pressure
Jugular Veins
- The jugular venous pressure is important, indicating right heart function.
- Different methods for measuring the pressure are included.
Cardiac Exam (Palpation)
- Chest palpation includes determining apical beat characteristics (localization, strength), and detecting right ventricular beat and any palpable thrills (pulsations caused by increased blood flow).
- Palpating arteries are critical; peripheral pulses (detailed with locations such as temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial) and their quality (tempo and strength).
Arterial Pulse
- The presentation describes the arterial system and associated pulse examination from a mechanistic standpoint.
Peripheral Pulses
- Different locations for artery palpation are identified including temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial.
Intermittent Claudication
- Intermittent claudication presents as pain in the legs/feet during exercise that resolves with rest.
- This relates to peripheral arterial disease (PAD).
Cardiac Exam (Percussion)
- Cardiac size assessment and identifying presence/absence of pleural or pericardial fluid are two elements of percussion.
Cardiac Exam (Auscultation)
- Techniques of auscultation are described, including use of stethoscope (diaphragm/bell) in a silent environment, direct contact with skin and using appropriate auscultation positions and points.
Auscultation Positions
- Sitting, supine, left lateral recumbent, and leaning forward positions for auscultation.
Auscultation Points
- Specific auscultation points for different heart valves are included. Different heart valve acoustic focus areas are mentioned (aortic, pulmonary, tricuspid and mitral), and for the mesocardiac (Erb point) which is linked to conditions such as ventricular septal defect and aortic/pulmonary regurgitation.
What do we listen to?
-
Techniques and elements for listening to heart sounds are provided including:
- Heart rate (bradycardic, normocardic, or tachycardic)
- Rhythm (regular or irregular ?)
- Heart sounds (physiologic (S1, S2, rarely S3, and S4) and pathological (S3 and S4)).
- Additional sounds (systolic clicks, opening snap, pericardial knock, pericardial friction rub, and prosthetic valve clicks))
- Murmurs.
Heart Sounds
- Basic heart sounds (S1, S2) are the result of heart valve closures.
- The S1 sound is associated with mitral and tricuspid valve closure while S2 with aortic and pulmonary valve closure.
- Specific time intervals exist between sounds relating to systole and diastole. (S1-S2 = systole; S2-S1 = diastole).
First Heart Sound (S1)
- Result of mitral and tricuspid valve closure. (Components= M1 and T1).
- Commonly found during the start of systole.
Second Heart Sound (S2)
- The result of aortic and pulmonary valve closure. (Components= A2 and P2).
- Typically found at the end of systole
Third Heart Sound (S3)
- Physiologic or pathological; heard in 25-50% of healthy young individuals.
- Early diastolic heart sounds caused by rapid filling of ventricles post valve opening.
Fourth Heart Sound (S4)
- Late diastolic; heard in 25% of healthy individuals.
- The consequence of atrial contraction filling part of ventricular space.
Pathological S3 and S4
- Pathological S3 arises from conditions such as volume overload, systolic dysfunction, and congestive heart failure.
- Pathological S4 is a result of pressure overload, diastolic dysfunction, and systemic hypertension.
Additional Sounds
- Systolic clicks, opening snap, pericardial knock, pericardial friction rub, and prosthetic heart valves are extra heart sounds to note.
Systolic Clicks
- These sounds are found between S1 and S2.
- Mitral valve prolapse or conditions like aortic and pulmonary valve stenosis or aneurisms can result in different types of systolic clicks.
Opening Snap
- Opening snap follows S2 during early diastole.
- It arises from conditions such as mitral valve stenosis or tricuspid valve stenosis.
Pericardial Knock
- Associated with constrictive pericarditis.
- A sound indicating hitting of the ventricle against a calcified pericardium during early diastole.
Pericardial Friction Rub
- This sound arises from friction between the pericardium layers during acute pericarditis.
Cardiac Murmurs
- Cardiac murmurs are turbulent blood flow generated from valve stenosis, regurgitation, high blood flow across normal valves or intracardiac shunts.
Features of a Murmur
- Features to note with murmurs include timing (systolic or diastolic?), and severity (grading of 1/6 to 6/6).
- Also, auscultation locations and perceived radiation.
Classification of Murmurs
- Murmurs are categorised into systolic, diastolic, and continuous. Each type includes subtypes such as: (1) Systolic (midsystolic, pansystolic, early systolic, late systolic) (2) Diastolic (early, mid, late diastolic). (3) Continuous.
Intensity of Murmurs
- Different intensity gradings (ranging from 1/6 to 6/6) for murmurs are detailed.
Systolic Murmurs
- Mid systolic murmurs can arise from aortic or pulmonary stenosis.
- Late systolic from mitral valve prolapse.
- Pansystolic: mitral or tricuspid regurgitation, or ventricular septal defect.
Diastolic Murmurs
- Early diastolic: Aortic or pulmonary regurgitation.
- Mid-late diastolic: Mitral valve stenosis, Tricuspid valve stenosis, atrial myxoma.
Continuous Murmurs
- Continuous murmurs are heard throughout systole and diastole.
- Examples include patent ductus arteriosus, sinus valsalva aneurysm rupture, pregnancy or lactation, or arteriovenous fistulae.
PDA (Patent Ductus Arteriosus)
- A persistent connection between the aorta and pulmonary artery in the developing heart.
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Description
Test your knowledge on major cardiac symptoms and angina pectoris. This quiz covers various aspects, including the primary mechanisms of angina, its symptoms, and classification. Challenge yourself to identify the features and triggers associated with chest pain and dyspnea.
