Cardiovascular Reference Guide 2022 PDF

UNIVERSITY OF OTAGO Te Whare Wānanga o Otāgo ELM OTAGO MEDICAL SCHOOL Te Kura Hauora o Otāgo EARLY LEARNING IN MEDICINE CLINICAL SKILLS MICN201 and MICN301 2022 Cardiovascular...

UNIVERSITY OF OTAGO Te Whare Wānanga o Otāgo ELM OTAGO MEDICAL SCHOOL Te Kura Hauora o Otāgo EARLY LEARNING IN MEDICINE CLINICAL SKILLS MICN201 and MICN301 2022 Cardiovascular Reference Guide The Clinical Skills Module in ELM provides opportunities to build the foundational clinical skills used in a consultation with a patient. You will learn these through hands- on learning activities, tutorial-based discussions and independent learning. Our aim is that you leave ELM Clinical Skills able to use and develop your consultation skills further with the patients you work with in ALM. ELM Clinical Skills – Cardiovascular System Reference Guide 1  TABLE OF CONTENTS History Taking in a Cardiovascular Presentation..................................................................................... 3 The Cardiovascular Examination.......................................................................................................... 10 General Observation of a Patient with a Cardiovascular Problem................................................................... 11 Vital Signs.................................................................................................................................................... 11 Peripheral Pulses.......................................................................................................................................... 12 The Jugular Venous Pulse and the Jugular Venous Pressure (JVP)................................................................... 15 The Examination of the Praecordium............................................................................................................ 18 Normal Cardiac Blood Flow and Valvular Heart Disease.................................................................................. 22 The Cardiovascular Examination................................................................................................................... 24 The Cardiorespiratory Examination............................................................................................................... 25 Cardiovascular Symptoms.................................................................................................................... 26 Common Cardiovascular Conditions..................................................................................................... 29 ELM Clinical Skills – Cardiovascular System Reference Guide 2  History Taking in a Cardiovascular Presentation There is a wide range of complaints that will prompt a patient to seek medical help. When a patient initially presents it may not be obvious what system(s) the complaint(s) relate to. You will need to use your medical knowledge to fully explore the following aspects when you take the history: History of the presenting complaint o biomedical perspective ▪ ensuring you get a clear sequence of events ▪ thoroughly analysing the presenting complaint(s) ▪ asking about and analysing relevant associated symptoms ▪ asking about and exploring relevant features of the presentation o patient’s perspective ▪ genuinely considering the patient’s views on the presenting complaint(s) including: ▫ their ideas about the presenting complaint(s) ▫ their concerns regarding the presenting complaint(s) ▫ their expectations of the consultation ▫ the impact of the presenting complaint(s) on their life allow the patient to express their feelings about anything they tell you Background information o Past medical and surgical history o Medications o Allergies o Family history o Personal and social history History of Presenting Complaint Biomedical perspective Sequence of events Gaining a full understanding of the sequence of events in a cardiovascular presentation will help you focus on the conditions that are most likely to be causing the patient’s complaint(s). If the patient currently has central crushing chest pain that started 20 minutes ago it is likely that you will consider acute coronary syndrome as a cause. If the patient has had intermittent chest pain worse on lying down and increasing in frequency over the past three months it is likely you will consider gastro-oesophageal reflux as a cause. If the patient has had aching immobilising pain in their calves intermittently for months it is likely you will consider intermittent claudication as a cause. If the patient has a swollen aching calf that began after ELM Clinical Skills – Cardiovascular System Reference Guide 3 they travelled from the United Kingdom a week ago it is likely that you will consider deep vein thrombosis as a cause. Find out about: Time of onset o The date and time it started (if applicable) o When did it start? o When they were last completely well. (This can be very useful to ask if the onset is not well defined in conditions such as worsening heart failure.) Mode of onset o How the symptoms started. Was it over seconds, minutes, hours, days, or months? The chart below lists conditions according to their onset. Precipitant o What triggered the symptoms o What brought it on? Was it related to exertion? o What was going on around the time the symptoms started? Time course Step by step what has happened from the very start until now. Duration o How long do/did the symptoms last? o If symptoms are intermittent find out how long each episode lasts Frequency o If symptoms are intermittent find out how often they occur Pattern o Is there a pattern? o Are the symptoms staying the same? Deteriorating? Recovery o If the symptoms are intermittent what is the recovery period like? The table below links the mode of onset with common cardiovascular conditions. (Further details about these conditions can be found on page 28). ELM Clinical Skills – Cardiovascular System Reference Guide 4 Condition Typical mode of onset Typical time course Angina sudden, over seconds to Stable angina is episodic and not minutes increasing in frequency, occurs with exertion and relieved by rest Unstable angina is episodic with increasing frequency of episodes, occurring without exertion Acute Coronary Syndrome sudden, over seconds to Symptoms last for 15-20 minutes Myocardial infarction minutes Acute lower limb sudden, over seconds to Symptoms of ischaemia persist until ischaemia minutes treatment is given Chronic intermittent Insidious – gradual, over days to Pain occurs with exertion (walking) and claudication months is relieved by rest. It is episodic and tends to increase in frequency over time. Pulmonary embolism sudden, over seconds to This may present as sudden death. (large) minutes Symptoms are severe from the start and persist. Pulmonary embolism sudden, over seconds to Symptoms are moderate and (small, multiple) minutes intermittent, occurring with increasing frequency over hours to days Vasovagal syncope sudden, over seconds to The collapse is typically short, lasting minutes seconds to minutes, and relieved when the patient lies flat Deep vein thrombosis rapid, over hours to days Calf pain and swelling is dependent on the size of the thrombosis. This may increase over hours to days. Atrial fibrillation variable: The patient may not be aware of the may be unrecognised problem, or they may have persistent may present suddenly over heart racing and “fluttering in chest” seconds Intermittent atrial sudden, over seconds Each episode has sudden onset, and fibrillation episodes occur over days- months Heart failure (acute) rapid over hours-days Symptoms worsen over hours- days until treatment is given Heart failure (chronic) insidious over weeks-months Symptoms slowly worsen over weeks - months ELM Clinical Skills – Cardiovascular System Reference Guide 5 Symptom analysis You will need to analyse each symptom. SOCRATES can be useful to analyse chest pain. WWQQAA (where, when, quality, quantity, aggravating and alleviating factors) can be useful for other symptoms such as shortness of breath. Where: This may help you narrow down the anatomical structures that are involved. o Is it a localised problem, or more widespread? o Which part of the body is affected? o Is it symmetrical? o Is it in a recognisable pattern? (such as retrosternal pain radiating to the left arm that can occur with cardiac ischaemia) When: Determine the onset and sequence of events o When did it start? o How long does it last? o Is it sudden, rapid, or gradual in onset? o Are the symptoms static, or deteriorating, or intermittent? Quality: Get a good description and a clear understanding of what the patient means. o What is it like? o Tell me what you mean by... Quantity: You will get an indication of severity from what the patient is able to do. o Did the pain stop you walking? (This is likely to happen with intermittent claudication and cardiac ischaemia) o Does the breathlessness stop you from getting the housework done? (This may happen with left heart failure.) o You may use the pain scale to quantify pain. Aggravating: Many cardiovascular conditions get worse exertion o What makes it worse? o What triggers the symptoms? (lying down flat will make the breathlessness of left heart failure worse) Alleviating/Relieving: Rest may relieve symptoms due to ischaemia o What makes it better? Associated symptoms Relevant associated symptoms for a cardiovascular presentation will include: Cardiovascular symptoms and General symptoms Associated symptoms for a cardiovascular presentation may include: Relevant symptoms from other body systems The common cardiovascular symptoms are: Pain Dyspnoea o Orthopnoea ELM Clinical Skills – Cardiovascular System Reference Guide 6  o Paroxysmal Nocturnal Dyspnoea (PND) Palpitations Syncope and Pre-syncope Oedema Claudication There is more information about cardiovascular symptoms on page 25. You will also ask about general symptoms. General symptoms are: fever fatigue problems sleeping mood change appetite change weight change Fatigue, sleep disturbance, and weight change are common in cardiovascular presentations. There is more information about general symptoms in the General Symptoms Reference Guide. You may also need to ask about symptoms related to other body systems. A presentation that initially appears to be cardiovascular in origin may be due to a problem in another system. For example, central chest pain may be due to gastro-oesophageal reflux. As you progress through the medical course you will learn more about this. Relevant features There may also be specific features of the presenting complaint that you can explore that may be relevant to a cardiovascular presentation. Ability to perform the usual activities of daily living can be a useful indicator of the severity of the problem. A family history of ischaemic heart disease is significant A history of smoking is significant Patient’s perspective It is essential to explore the patient’s perspective. Cardiovascular conditions can have significant short and long-term impacts on the patient, their dependants, and their support network. Make sure you have a clear appreciation of: The patient’s ideas about the presentation What the patient is concerned about What the patient is expecting from the consultation The effect that the presenting problem is having on the patient’s life Ensure that you validate the patient’s feelings by allowing them to express their feelings about anything they tell you at any stage in the interaction. ELM Clinical Skills – Cardiovascular System Reference Guide 7 Aspects to Consider in the Background Information in a Cardiovascular Presentation When you are gathering information about the patient’s background you need to use your biomedical knowledge to inform your questions. For example in a possible cardiovascular presentation you need to know if the patient has a history of heart disease or risk factors for developing heart disease. The following is a summary of what can be considered when a patient presents with a possible cardiovascular problem. This summary is not exhaustive and you will continue to add to this as your knowledge grows. Past Medical History Previous heart disease (risk factor for heart disease - congenital, infectious, ischaemic) Hypercholesterolemia (risk factor for ischaemic heart disease) Hypertension (risk factor for ischaemic heart disease) Cerebrovascular disease (risk factor for ischaemic heart disease) Peripheral vascular disease (risk factor for ischaemic heart disease) Diabetes (risk factor for ischaemic heart disease) Rheumatic fever (risk factor for heart disease) Dental decay or infection (risk factor for infective endocarditis) Thyrotoxicosis (can cause tachycardia, arrhythmia and heart failure) Chronic kidney disease (risk factor for ischaemic heart disease) Marfan’s Syndrome (aortic regurgitation) Down Syndrome (coarctation of the aorta) Chronic lung disease (right heart failure) Rheumatoid arthritis (pericarditis) Medication Non-steroidal anti-inflammatory drugs (increase cardiovascular risk and increase risk of gastrointestinal problems when prescribed with aspirin used as anti-platelet medication) Beta blockers (aggravate peripheral vascular disease increasing intermittent claudication) Thyroxine (arrhythmia and tachycardia) Cocaine and amphetamines (increased catecholamines raising heart rate and blood pressure) Complementary and alternative medicines (interactions and cardiac side effects) The triad of ABC (aspirin, beta blocker, cholesterol lowering drug) can suggest ischaemic heart disease. ELM Clinical Skills – Cardiovascular System Reference Guide 8 Family History These conditions have a hereditary component and should be considered in cardiovascular presentations: Ischaemic heart disease Thrombophilia Inherited arrhythmia Cardiomyopathy Diabetes Hypertension Hypercholesterolemia Personal and Social History Ethnicity - increased risk of cardiovascular disease in Māori, Pacific people, Indo- Asian (Indian, Fijian Indian, Sri Lankan, Afghani, Bangladeshi, Nepalese, Pakistani, Tibetan) Smoking – increases cardiovascular risk Alcohol – heavy drinking is associated with cardiovascular disease Other recreational drugs: cocaine, amphetamines, injected drugs Sedentary Lifestyle Nutrition (a low-saturated fat, high-fibre, high plant food diet can reduce the risk of developing heart disease) Occupation (solvents cause cardiomyopathy or arrhythmia, cold exposure and Raynauds or angina, a bus driver cannot work with a serious arrhythmia) Effect of disease on daily life/function/ability to care for themselves/ability to work (a person with intermittent short runs of VT cannot have a passenger licence) Physical Activity History o What does the patient do now? o What did they do in the past? o What would they like to be able to do? ELM Clinical Skills – Cardiovascular System Reference Guide 9  The Cardiovascular Examination Examination of the Cardiovascular System in ELM 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role) o explain what you want to do o explain what the examination will involve o gain permission to continue Position: o Examination couch at 45 degrees o Patient comfortably with head supported on white pillow o Yourself so you can access the anterior chest and right arm Expose the patient as appropriate for each part of the cardiovascular examination Right: o when examining the patient on the examination couch examine from the patient’s RIGHT o examining from the right is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect o examining from the right contributes to consistent and reproducible examination 2. Communicate with the patient throughout the examination as necessary keep them informed of progress check they are ok gain permission where appropriate as you move through your examination 3. Ensure the patient is comfortable with dignity preserved throughout the examination 4. Observe the patient throughout the examination to check whether the examination is causing pain or distress 5. Make a general observation throughout the examination 6. Assess the vital signs 7. Examine the patient’s hands 8. Examine the patient’s face 9. Examine the patient’s neck 10. Examine the patient’s anterior chest 11. Examine the patient’s posterior chest 12. Examine the patient’s abdomen 13. Examine the patient’s lower limbs 14. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair ELM Clinical Skills – Cardiovascular System Reference Guide 10  Wash your hands The cardiovascular examination begins with General Observation of the patient. Following this the convention is to start peripherally and move more centrally. We start with examination of the patient’s hands including assessment of the radial pulse, and then move to examine their neck, face and praecordium or anterior chest (from the Latin prae meaning “in front of” and cor meaning “heart”). We then examine the patient’s back, abdomen, and lower limbs. Auscultation of the back will be taught when we study the Respiratory System and palpation of the liver will be taught when we study the Gastrointestinal System. General Observation of a Patient with a Cardiovascular Problem General observation is the first step in all clinical examinations. It begins as soon as you see the patient. Does the patient look well? Or unwell? What is the patient doing when you first see them? o Are they walking with ease? o Are they lying flat? Is the patient’s appearance consistent with his/her stated age? Do they have a syndrome that may make a cardiovascular condition more likely? o Marfan’s Syndrome is associated with aortic regurgitation o Down Syndrome is associated with congenital heart disease o Turner’s Syndrome is associated with coarctation of the aorta Is the patient distressed or in pain? Does the patient’s breathing look comfortable or laboured? Does this vary when they are at rest or exerting themselves? What is the patient’s respiratory rate? What is the patient’s colour or complexion? (Pale, cyanosed, plethoric.) Does the patient look clammy or sweaty? What is your estimate of their weight? Are they underweight? Are they overweight? Has their weight changed? (if you have seen them before) Is the patient able to exert themselves? (Walking to the examination couch, getting on the couch, and lying down on the couch is a good test.) Can the patient lie flat? Vital Signs Refer to the Vital Signs Reference Guide on MedMoodle. ELM Clinical Skills – Cardiovascular System Reference Guide 11 Peripheral Pulses The arterial pulse is a wave generated by the contraction of the left ventricle of the heart. Pulses can be palpated at a variety of sites where an artery runs close to the skin. The normal pulse rate is 55-95 beats/minute. Bradycardia is a slower than normal pulse or heart rate. Tachycardia is a faster than normal pulse or heart rate. Causes of an absent pulse are: occlusion (thrombus, embolus, dissection, or transection) cardiac arrest Peripheral pulses are measured as part of the assessment of the peripheral circulation. They are assessed during the cardiovascular examination as part of the diagnosis of peripheral vascular disease. They are also assessed when there is a possibility of disruption to the peripheral circulation following trauma or surgery. Assessment of the Pulse When measuring the pulse note the following: Rate – count for 15 seconds and multiply by four to give the pulse rate over a minute. By convention we assess pulse rate with the radial pulse. Rhythm – note whether the pulse feels regular or irregular. As you will learn in the coming weeks, an irregular heart rhythm or arrhythmia may be irregularly irregular, or regularly irregular. It is important to be able to distinguish these two, as they have different clinical implications. Atrial fibrillation is the commonest cause of an irregularly irregular pulse. It can be helpful to tap the rhythm you are palpating to determine if it is regular or irregular. Character and Volume – carotid or brachial pulses should be used to assess character and volume as these pulses more accurately reflect the form of the aortic pressure wave. Words that can be used to describe the volume and character of a pulse are weak, strong, bounding, collapsing, thready, or full. You will learn how to assess character and volume in ALM. o A low volume pulse may be caused by low cardiac output from shock or myocardial infarct, dilated cardiomyopathy, valvular stenosis, pericardial tamponade or constrictive pericarditis. o A high volume pulse may be caused by anxiety, exercise, fever, hyperthyroidism, anaemia, patent ductus arteriosus with normal pulmonary pressures, large arterial venous fistulas or severe aortic regurgitation. The Radial Pulse The radial pulse is found at the wrist where the radial artery runs just medial to the distal radius. It should be palpated using the index and middle fingers, rather than the thumb as there can sometimes be confusion between the pulsation in the examiner's thumb and the pulse of the patient. By convention, we measure the pulse rate using the radial pulse. ELM Clinical Skills – Cardiovascular System Reference Guide 12 The Brachial Pulse The brachial artery is in the antecubital fossa medial to the biceps tendon. This is a large artery. It can be palpated using the index and middle fingers, or it can be palpated using the thumb. This artery is conventionally used to assess the blood pressure by auscultation. The brachial artery is also used to assess character and volume. The Carotid Pulse The carotid artery is located medial to the sternocleidomastoid muscle in the anterior part of the neck. In patients with low blood pressure it can be difficult to palpate the radial pulse, so on these occasions the carotid pulse should be assessed. The carotid artery is used to assess character and volume. The Femoral Pulse The femoral artery is found in the groin in an anatomical space referred to as the femoral triangle. It lies lateral to the femoral vein, and medial to the femoral nerve. NAVY is a useful aide memoire for the order of the structures in the groin. The femoral nerve N is lateral and the Y representing the groin is medial. The femoral pulse is best palpated using two hands (one on top of the other) and with the hip slightly abducted. It can be felt by pressing reasonably deeply below the inguinal ligament and approximately midway between the symphysis pubis and the anterior superior iliac spine. The Popliteal Pulse The popliteal artery is found in the popliteal fossa behind the knee. The popliteal pulse can be palpated by placing the index middle and ring fingers of each hand deep in the popliteal fossa. The Pedal Pulses The pedal (foot) pulses are the most distal pulses. There are two pulses palpable in each foot – in the posterior tibialis and the dorsalis pedis arteries. These pulses are indicators of the state of the peripheral arterial circulation. We examine these pulses if we are assessing for peripheral vascular disease or if there is a possibility of vascular trauma or other impairment of vascular supply. The posterior tibial artery is located approximately 2cm behind the medial malleolus of the ankle. It is common practice to use two or three fingers to palpate the pulse, placing the index finger of the right hand against the posterior border of the medial malleolus. The pulse will commonly be found under one of the fingers. You are likely to need to move your fingers to find the pulse. The dorsalis pedis artery runs on the dorsum of the tarsal bones and disappears to supply the plantar aspect of the foot by passing through the proximal end of the 1st metatarsal space. It is best palpated by placing two or three fingers along this first space. Take your time, you are likely to need to check several positions before you palpate the pulse. ELM Clinical Skills – Cardiovascular System Reference Guide 13 The following images from Talley and O’Connor1 demonstrate how and where to palpate the pedal pulses. a) Palpating the posterior tibial pulse: b) Palpating the dorsalis pedis pulse: Capillary Refill The capillary refill test assesses peripheral perfusion. This can be affected by conditions such as peripheral vascular disease, hypovolemic shock, or direct trauma to the affected limb. To test capillary refill: Press on a fingertip (with the arm at the level of the heart) or toe (with the leg horizontal) for 5 seconds. The fingertip or toe will blanch. Release the pressure and colour should return to the fingertip or toe in less than 2 seconds (this is approximately the time it takes to say “poor capillary refill”). If the capillary refill is longer than 2 seconds the patient has poor peripheral perfusion. 1 [Figures from: Talley and O'Connor's "Clinical Examination", (6th edition) and "Macleod’s Clinical Examination" (12th edition) ELM Clinical Skills – Cardiovascular System Reference Guide 14  Reporting findings on palpation of peripheral pulses (including general observation and capillary refill) “Today I examined Ted Thomas a 67 year old retired builder who presents with pain in his right leg when walking. He has history of hypertension and is a smoker who has smoked 20 cigarettes a day since he was 16. Mr Thomas is a lean man who looks older than his stated age. He tells his story in a relaxed way and shows no sign of pain. He is able to walk easily from the chair to the examination couch and lies down flat on this with no difficulty. The radial pulse was 72 beats per minute and regular. Both radial and brachial pulses were easily palpable bilaterally. The carotid pulse was palpable bilaterally. It was regular, and of normal character and volume. I could not palpate his dorsalis pedis, or posterior tibial pulses on the right. On the left I could palpate his popliteal pulse and posterior tibial pulse but I was unable to palpate his dorsalis pedis pulse. The capillary refill time was prolonged on each side with the right being 6 seconds and the left being 4 seconds.” The Jugular Venous Pulse and the Jugular Venous Pressure (JVP) The jugular veins take venous blood from the head to the right atrium. The internal jugular vein has no valves and drains directly into the Superior Vena Cava and from there to the Right Atrium. This means that the pressure in the Internal Jugular Vein reflects the pressure in the Right Atrium. The External Jugular Vein drains into the Innominate Vein and then into the Superior Vena Cava and Right Atrium. It is not as reliable to use for Jugular Venous Pressure measurement as it does have valves and the vein may be obstructed as it passes through fascia and muscle layers. The Jugular Venous Pulse is a venous pulse that can be seen in the jugular vein. This pulse is made of two waves caused by two events which increase pressure in the right atrium - the "a" wave which is due to increased pressure in atrial systole and the "v" wave which occurs during ventricular systole when atrium continues to fill while the tricuspid valve is closed during ventricular systole. We are interested in the height of the Jugular Venous Pulse as it reflects the Jugular Venous Pressure, or JVP. The right atrium communicates with the right internal jugular vein. The height of the Jugular Venous Pulse gives an accurate indication of right atrial pressure. When pressure is elevated in the right atrium this is reflected in the jugular veins which become distended and the ELM Clinical Skills – Cardiovascular System Reference Guide 15 height of Jugular Venous Pulse increases. Assessment of the height of the Jugular Venous Pulse is the assessment of the Jugular Venous Pressure (JVP). If the patient lies down sufficiently the Jugular Venous Pulse can be seen. The flatter the patient lies the more likely it is that you will see the Jugular Venous Pulse. In a healthy person lying on an examination couch with the head at 45 degrees the Jugular Venous Pulse may not be seen above the level of the clavicle because the Jugular Venous Pressure is less than 3cmH2O. The Right Internal Jugular Vein is used to get the most accurate indicator of pressure in the right heart. The right internal and external jugular veins are visible in the neck above the clavicle, running in a line directly towards the ear. The internal jugular lies deep to the medial aspect of the sternocleidomastoid muscle, and the external jugular vein lies laterally and superficially to it. Inspiration makes the Jugular Venous Pressure fall (because the volume of the thorax increases) and the height of the Jugular Venous Pulse will reduce with inspiration. Pressure over the abdomen causes the Jugular Venous Pulse to rise. This is called abdomino-jugular reflux and is a useful manoeuvre to identify the Jugular Venous Pulse. Persistent elevation of the Jugular Venous Pressure is a reliable sign of right heart failure. Anything that causes an increase in pressure in the right atrium raises the Jugular Venous Pressure. This increase in pressure can be due to abnormalities in the heart, abnormalities in the pulmonary system, or an increase in circulating blood volume. Common causes for a raised JVP include right ventricular failure, tricuspid stenosis, an Atrio- septal defect (ASD) with Mitral Valve disease, pericardial compression (pericarditis or tamponade), Superior Vena Cava obstruction, pulmonary embolism affecting a large pulmonary artery, lung conditions that cause pulmonary hypertension such as emphysema or pulmonary fibrosis, renal failure, excessive intravenous fluid administration, an Atrio- septal defect (ASD) with Mitral Valve disease. ELM Clinical Skills – Cardiovascular System Reference Guide 16 Measuring the jugular venous pressure When the patient is lying at 45°, the manubriosternal angle is horizontal with the base of the neck and is taken to be the zero point from which to measure the venous column. (Note that the sternal angle is about 5cm above the right atrium). In a "normal" subject the JVP will sit at or just below the level of the clavicle, which is less than 3 cm above the manubriosternal angle. If you see the JVP at the level of the clavicle with the patient at 45° this is normal. If the pulsation is higher in the neck the JVP is elevated by that amount. Lying the patient down flat may make the vein fill and make it easier to see. It can also be seen more easily if you gently occlude the top of the column with your fingers will cause the vein to back-fill above the occlusion. This is a useful way of trying to identify where the vein lies. An alternative is to ask the patient to perform a gentle Valsalva manoeuvre, or to exhale as completely as possible. (Note that these manoeuvres may make the vein more visible but are not helpful for assessing the actual pressure in the right atrium.) The assessment of the Jugular Venous Pressure is often a difficult task and it is frequently not visualised. In Clinical Skills (Second Edition) edited by T.A. Roper this skill is given a 9/10 Difficulty Factor which means it is a skill requiring much practice. We do not expect you to be able to reliably assess the Jugular Venous Pressure at this stage of your learning. However, we do expect that you become familiar with the location of the jugular veins, and that you understand the relevance of the Jugular Venous Pressure as a marker of cardiovascular disease. The Jugular Venous Pulse: Is visible but not palpable – pressure obliterates it. Is characterised by a complex waveform, often seen as two flickers in each cardiac cycle. Varies with respiration, decreasing with inspiration. Is abolished by gently placing the ulna border of the hand against the base of the neck. Any visible pulsation will therefore be arterial and likely to be the carotid pulse. Can often be enhanced by the abdomino-jugular reflux sign. The abdomino-jugular reflux sign is elicited by applying firm pressure to the right upper quadrant of the abdomen using the palm of the hand. This will cause a transient increase in the Jugular Venous Pressure which in healthy people will rapidly return to normal. In patients with right heart disease it will take a few moments to fall. ELM Clinical Skills – Cardiovascular System Reference Guide 17 The Examination of the Praecordium The examination of the praecordium includes: 1. Inspection 2. Palpation 3. Auscultation Inspection The examination will begin with inspection. You will inspect for: Scars – especially the median sternotomy scar from cardiac surgery Skeletal abnormalities such as pectus excavatum (pigeon chest) or kyphoscoliosis (curvature of the vertebral column) that can alter the position of the Apex Beat and interfere with pulmonary function leading to pulmonary hypertension Pacemaker or cardioverter/defibrillator box Apex Beat – normally in the 5th left intercostal space in the midclavicular line Palpation The position of the Apex Beat is defined as the most lateral and inferior point on the anterior chest wall where you are able to detect a cardiac impulse. This cardiac impulse is the result of the heart rotating, moving forward and striking against the chest wall during systole. The Apex Beat is palpable in only about 50% of adults. Pathological causes for being unable to palpate the beat include obesity, emphysema, pericardial effusion, and dextrocardia. The normal position for the apex beat is in the fifth, left intercostal space, just medial to the midclavicular line. If the Apex Beat is displaced laterally or inferiorly (or both) the most common cause for this is that the heart is enlarged. ELM Clinical Skills – Cardiovascular System Reference Guide 18 Steps for palpation of the praecordium Ask the patient to lie on their back at a 45°angle with their anterior chest exposed. Use a gown open at the front or use a modesty cloth Locate the Apex Beat by palpation of the praecordium: o Place your hand on the patient’s chest with the extended fingers applied reasonably firmly in each of the 4th, 5th, 6th and 7th intercostal spaces and the tips of the fingers in the mid-axillary line. o Move the palpating hand progressively medially until the apex is located. o Determine the position of the apex beat with respect to adjacent landmarks: ▪ Locate the manubriosternal angle, which is just above the second intercostal space. ▪ Palpate the manubriosternal angle then palpate laterally to the second intercostal space. ▪ Count down the intercostal spaces until you reach the fifth space. (You may place each of the fingers of the right hand in adjacent spaces the little finger will be in the correct space). ▪ Carefully determine the midpoint of the clavicle and draw an imaginary line down to the 5th intercostal space. ▪ Palpate at this point where you may feel the normally placed apex beat. Tips for palpating and recognising the apex beat The apex beat is best palpated gently, using the tips of the fingers with the hand laid flat on the chest Normally the apex beat is felt in an area about the size of a NZ $2 coin. The normal apex will gently lift the palpating fingers. Auscultation Auscultation (the art of listening with a stethoscope) is a basic but very important part of any clinical examination. This is especially so with respect to the Cardiovascular examination. We auscultate heart sounds and assess whether these are normal. We auscultate for heart murmurs. ELM Clinical Skills – Cardiovascular System Reference Guide 19 Normal Heart Sounds Heart sounds are heard with closure of the heart valves. There are normally two heart sounds, S1 and S2, traditionally described as sounding like “lubb – dup”. The first heart sound (S1) is the audible representation of the closure of the mitral and tricuspid (atrioventricular) valves. The mitral valve closes fractionally before the tricuspid, but generally only one sound is heard. S1 marks the beginning of ventricular systole. The second heart sound (S2) represents closure of the aortic and pulmonary valves. It marks the end of systole. To determine which sound is which, it is sometimes necessary to 'time' the heart sounds with the carotid pulse. The pulsation of the carotid pulse corresponds with systole. There are four auscultation areas relating to heart sounds: The Aortic area 2nd intercostal space, right sternal border The Pulmonary area 2nd intercostal space, left sternal border The Tricuspid area 4th to 5th intercostal space, left sternal border The Mitral area 5th intercostal space towards the apex These are the areas where it is generally easiest to hear changes related to the individual valves. Please note that these areas do not represent the exact location of the valves. 2 Splitting of S2 2(Adapted from:www.radiationoncology.ca / ascm / Physical_Examination / ascm1 / Precordial / images / chest landmarks precordial title.jpg) ELM Clinical Skills – Cardiovascular System Reference Guide 20 Because each sound is made up of the combined closure of two valves you will sometimes hear reference to the “splitting of S2”. This occurs because the pulmonary valve closes later than the aortic valve. This is because the lower pressure in the pulmonary circulation compared with the aorta means that flow continues in to the pulmonary artery after the end of right ventricular systole. A split S2 is a normal finding when a patient is asked to breathe in. Inspiration causes a decrease in intrathoracic pressure and this pressure decrease leads to an increase in venous return. There is delay in the closure of the pulmonary valve producing a distinct double sound as represented in the following figure. This is often represented phonetically as “LUBB TaDUB”, and is best heard in the pulmonary region and along the left sternal border. Abnormal Heart Sounds Abnormal heart sounds include extra heart sounds (S3 and S4), and additional sounds. You will learn more about these and what causes them in future years. Murmurs Heart murmurs are caused by pathology at the different heart valves. Different pathological changes generate different murmurs and in future years you learn how to auscultate these. Steps for auscultation of the praecordium Ensure that the environment is as quiet as possible Ensure that the patient is comfortable and aware of what will be done Position the patient correctly - lying on the bed at 45° Apply the stethoscope to bare skin using the diaphragm Auscultate (listening for heart sounds, murmurs, and added sounds) in four areas on the Praecordium Palpate the carotid while auscultating in order to determine which heart sound is S1 (which occurs during systole and will be synchronous with the carotid pulse) Reporting findings on examination of the praecordium “Today I examined Alan Huang who presented for a medical examination before going to Outward Bound. Alan is a 22 year old junior accountant with no past medical history of note. On inspection of the praecordium I noted Alan was slim. There were no scars. There was no deformity of the chest wall. A pulsation was visible on the left side of his chest, that I presume to be the apex beat. On palpation the apex beat was palpable in the area of pulsation. The apex beat was sited in the left mid-clavicular line, in the 5th intercostal space. ELM Clinical Skills – Cardiovascular System Reference Guide 21  I auscultated the heart sounds in each of the four valvular areas – the aortic, the pulmonary, the tricuspid, and the mitral. The heart sounds were dual, S1 S2, with no added sounds or murmurs.” Normal Cardiac Blood Flow and Valvular Heart Disease In order to understand cardiac valve disease which can significantly disrupt blood flow through the heart, it will be helpful to know about normal cardiac blood flow. Normally blood flows unidirectionally through the heart. Deoxygenated blood enters the heart through the Right Atrium, then passes through the Tricuspid Valve to the Right Ventricle, and from there passes through the Pulmonary Valve to the lungs. Oxygenated blood from the lungs enters the Left Atrium and passes through the Mitral Valve to the Left Ventricle and is then pumped through the Aortic Valve to the rest of the body. As the pressure blood builds in the Atria, the Mitral and Tricuspid Valves open to allow blood to flow into the Ventricles. As the ventricles contract, ventricular pressure increases and when it exceeds arterial pressure the Aortic and Pulmonary Valves open to pump blood in to Pulmonary Artery and Aorta. Regurgitation and Stenosis are the two main problems that can occur when heart valves are diseased or damaged. Regurgitation occurs when the valve doesn’t completely close. As a result, blood can flow backwards rather than being pumped out of the heart. A regurgitant lesion causes dilatation due to volume overload. Stenosis happens when the tissue of the valve thickens or becomes very stiff. This can block or limit blood flow through the heart and to the rest of the body. With stenosis, the myocardium will hypertrophy over time. Initially, this is a helpful situation as the muscle builds more strength and retains function. But over time the heart fails as the blood supply is not sufficient to sustain the hypertrophied muscle. You will learn more about this in other parts of the course. ELM Clinical Skills – Cardiovascular System Reference Guide 22 Valvular Heart Disease Cardiac valve disease has many causes. These include congenital causes, rheumatic fever, atherosclerosis, infarction, hypertension or aging, endocarditis and myocardial disease. Aortic stenosis: The patient can present with breathlessness, chest pain or tightness with exertion, palpitations, pre-syncope (a feeling of near blackout) or syncope (blackout). Mitral stenosis: The patient can present with breathlessness and can have paroxysmal nocturnal dyspnoea making them wake at night breathless. They may have palpitations and may present with ankle swelling. Aortic regurgitation: The patient can present with breathlessness especially on exertion, chest pain on exertion, feeling tired, feeling faint, palpitations and symptoms of heart failure. Mitral regurgitation: The patient can present with shortness of breath (due to the increased left atrial pressure), fatigue, orthopnoea (shortness of breath lying flat) and ankle swelling. Mitral regurgitation causes increased volume in the Left Atrium and can lead to pulmonary oedema. ELM Clinical Skills – Cardiovascular System Reference Guide 23 The Cardiovascular Examination As we noted earlier the Cardiovascular examination begins with General Observation of the patient. By convention we then continue the cardiovascular examination by starting peripherally and moving more centrally. We start with examination of the patient’s hands including taking their radial pulse, and then move to examine their neck, face and praecordium. We then examine the patient’s back, abdomen, and lower limbs. A complete cardiovascular examination includes skills that we have not covered in Clinical Skills as we have chosen to teach you fundamental skills that you can build on in future years. What follows is a summary of a modified complete cardiovascular examination: 1. Wash hands 2. Introduce yourself 3. Ensure patient comfort (acceptable position, dignity and modesty preserved) 4. Lie the patient on the bed at 45° with their chest exposed appropriately draped/covered with a cloth or gown if necessary 5. Look at the patient, observing them in particular for signs of distress 6. Pick up and look at the patient's hands. (At this stage we do not expect you to be expert at identifying signs of disease which are apparent in the hands but these include splinter haemorrhages in the nail beds and clubbing3.) 7. Palpate the radial pulse noting rate and rhythm 8. Check the respiratory rate 9. Check the temperature 10. Check the blood pressure 11. Look at the patient's face paying attention to their colour (specifically cyanosis 4and pallor) 12. Assess the jugular venous pulse and measure JVP 13. Inspect the praecordium for scars, deformity, apex beat, or pacemaker box 14. Palpate for the position of the apex beat 15. Auscultate the heart sounds 16. Move to the lower limbs and palpate the peripheral pulses 17. Check for oedema of the lower legs by inspection 18. Thank the patient 19. Wash hands You will note that we have not included examination of the lungs. This is as essential part of the Cardiovascular examination but we will be learning about this when we learn how to examine the lungs as part of the examination of the Respiratory System. 3 Clubbing is the term for the loss of the nail bed angle and thickening of the distal finger which occurs in cardiac and respiratory disease. The cause is unknown but a favoured theory is that megakaryocytes which enter the systemic circulation due to damage in the pulmonary capillaries are trapped in the capillaries of the fingers where they release growth factors in to the surrounding tissue. 4 Cyanosis is the term for a bluish tinge to the skin caused by hypoxia (among other things). The cardiovascular examination also includes listening to the patient’s lungs which we will also cover in the coming Respiratory Module. ELM Clinical Skills – Cardiovascular System Reference Guide 24 The Cardiorespiratory Examination The cardiovascular examination can be combined with the skills used in the respiratory examination (see the Respiratory Reference Guide). In the cardiovascular setting it is posteriorly where signs are most likely to be found with percussion and auscultation. Generally, this is done after listening to the heart sounds. What follows is a summary of a cardiorespiratory examination: 1. Wash your hands 2. Introduce yourself, confirm name, explain that you want to examine them with a focus on the heart and lungs, gain permission to proceed 3. Lie the patient on the bed at 45° with their chest exposed (patients should be appropriately draped/covered with a cloth and offered a gown) 4. Ensure the patient is comfortable 5. Look at the patient, observing them in particular for signs of distress 6. Listen to the patient. Can you hear anything unusual in their breathing? Is there wheeze? 7. Pick up and look at the patient's hands. (You may find signs that include clubbing, splinter haemorrhages, peripheral cyanosis, and nicotine staining). 8. Assess peripheral perfusion in the hands. 9. Palpate the radial pulse noting rate and rhythm 10. Assess the respiratory rate 11. Take the blood pressure 12. Look at the patient's face paying attention to their colour (especially pallor and cyanosis) 13. Assess the JVP 14. Check the carotid pulse for character and volume 15. Assess the position of the trachea 16. Move to the chest and inspect for scars, deformity (including pacemaker), signs of respiratory distress, and any other abnormality 17. Palpate the apex beat and determine its position using anatomical landmarks 18. Auscultate the heart sounds 19. Ask the patient to sit forward so that you can access their back 20. Make sure they are comfortable and well supported (you can use a pillow) 21. Assess chest expansion 22. Percuss the lung fields as you have learned to do when examining the respiratory system. (It is not uncommon to find pleural effusion with severe left heart failure) 23. Auscultate the lung fields, paying particular attention to the lung bases posteriorly where you can hear fine crackles if left heart failure is present) 24. Palpate the peripheral pulses 25. Assess peripheral perfusion in the feet 26. Check for oedema of the lower legs 27. Thank the patient and advise they can get dressed 28. Wash hands ELM Clinical Skills – Cardiovascular System Reference Guide 25  Cardiovascular Symptoms The symptoms of a patient with a cardiovascular presentation tend to arise from problems in the heart, lungs, or blood vessels. Pain Pain is the most common presentation of ischaemic heart disease. The classical description of chest pain due to acute coronary syndrome (that may lead to myocardial infarction) is of severe, central, retrosternal, crushing or heavy pain that comes on over minutes at rest. It can radiate to the arms, throat, jaw or teeth. It is associated with dyspnoea (breathlessness), sweating, anxiety (a “sense of impending doom”), nausea, or vomiting. It is not relieved by sublingual glyceryl trinitrate. Angina pain is classically precipitated by exercise, and is a dull discomfort, like a pressing tight band or heavy weight. It is relieved by rest. It is rapidly relieved by sublingual glyceryl trinitrate. It can be felt in the anterior chest, and can radiate to the arms, throat, jaw or teeth. Severity can vary widely between patients for a number of reasons – because of this, asking about “chest discomfort” is considered to be more sensitive than asking about “chest pain”. As individual experience of cardiac pain can vary widely chest discomfort which is “atypical” should be assessed carefully before discounting cardiac ischaemia as a cause. Dyspnoea Dyspnoea, put simply, means shortness of breath. Dyspnoea is sometimes also described as “an unexpected awareness of breathing” or “air hunger”. There are many causes of dyspnoea but it is commonly associated with the cardiovascular presentation. Assessment of a patient’s exercise tolerance is important; a commonly useful question is to ask your patient how well they cope with climbing a flight of stairs. If they get breathless a cardiovascular cause should be considered. There are two particular patterns of dyspnoea to be aware of, which are highly suggestive of cardiac disease: Orthopnoea refers to shortness of breath on lying flat. This occurs with left ventricular failure. It is considered to be due to redistribution of the collected fluid in the lungs causing more widespread lung stiffness, particularly in the upper lobes. Patients affected by orthopnoea may report needing to be propped up on a number of pillows to be able to sleep without getting breathless. Paroxysmal Nocturnal Dyspnoea (PND) refers to nightly (nocturnal) attacks (paroxysms) of breathlessness (dyspnoea). Patients may report episodes of waking up from sleep gasping for breath. ELM Clinical Skills – Cardiovascular System Reference Guide 26 Palpitations Palpitations are an unexpected or unpleasant awareness of the heartbeat, which may be reported variably by patients, using terms such as “feeling my heart thumping” or “butterflies in my chest”. Reports of palpitations raise suspicions of an arrhythmia such as atrial fibrillation, ventricular tachycardia, or supraventricular tachycardia. It can be useful to assess the rate and rhythm of the palpitations by asking the patient to tap the rhythm out with their finger. Palpitations associated with cardiac arrhythmia usually have a sudden onset. They may be precipitated by exercise, anxiety, caffeine, or alcohol. Palpitations may be associated with chest pain, dyspnoea or syncope if cardiac output is compromised due to arrhythmia. Syncope and Pre-syncope Syncope is the presentation commonly known as “fainting”. It is a transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate blood flow. Presyncope is decreased cerebral perfusion that does not reach the stage of syncope. The patient feels light-headed and “about to faint”. Common underlying causes include arrhythmia or sudden emotional stress (“vasovagal syncope” – a collapse due to a specific trigger such as an exposure to blood or needles). A number of medications also interfere with blood pressure homeostasis, which can increase susceptibility to syncope. It is important to enquire about the circumstances of onset; preceding symptoms (such as pain or palpitations), duration of the syncopal event, and the nature of the recovery. Oedema Oedema is the collection of fluid in the interstitial space. Peripheral oedema in right ventricular or biventricular failure is usually bilateral. It will most commonly be noticed in the ankles, or at the sacrum in a patient who is lying in bed. Ankle swelling due to cardiac failure is usually worse at the end of the day, and improves overnight. Pulmonary oedema due to left ventricular failure presents with dyspnoea, orthopnoea, or paroxysmal nocturnal dyspnoea. The oedema of cardiac failure can be associated with other symptoms of fluid overload such as including dyspnoea, orthopnoea and abdominal distension. Other causes of bilateral oedema include chronic venous disease due to varicose veins, vasodilating calcium channel antagonists (such as amlodipine) and hypoalbuminaemia (low albumin). Unilateral lower limb oedema can occur in deep vein thrombosis. The thrombosis, or clot, in the venous system causes oedema and swelling in the affected leg. ELM Clinical Skills – Cardiovascular System Reference Guide 27 Claudication Claudication refers to ischaemic pain in the muscles of the legs. The classic presentation is a complaint of crushing, vice-like pain in one or both calves after walking a certain distance. It is typically relieved by rest. Claudication is due to inadequate vascular supply to the muscles of the leg, generally due to peripheral vascular disease, and is commonly associated with other vascular disease such as ischaemic heart disease or cerebrovascular disease. ELM Clinical Skills – Cardiovascular System Reference Guide 28  Common Cardiovascular Conditions Angina: The patient typically presents with heavy, tight, gripping central chest pain or discomfort that occurs with exercise or emotional stress and eases rapidly with rest. It can be associated with feeling lightheaded and shortness of breath. Angina is reproducible with exertion, as opposed to the unstable presentations of acute coronary syndromes. Angina is caused by atheroma or spasm in the coronary arteries. Acute Coronary Syndrome: The patient typically presents as unwell and in distress with new onset chest pain or deterioration of pre-existing angina. The pain is described as central retrosternal chest pain that is “crushing”, and often radiating to the left arm or the neck. It is associated with shortness of breath, anxiety, sweating, and restlessness. It is due to atherosclerosis in the coronary arteries. The artery becomes occluded when a coronary artery plaque ruptures or erodes and this leads to severe ischemia. Myocardial infarction: This can occur when acute coronary syndrome is not recognised and treated. Myocardial infarction occurs when cardiac myocytes die due to myocardial ischemia. If a patient with acute coronary syndrome presents in a timely fashion and they have successful treatment with reperfusion therapy with either percutaneous coronary intervention (PCI) or fibrinolysis then infarction can be prevented or reduced. Myocardial infarction can lead to heart failure. Peripheral vascular disease: This can cause intermittent claudication or acute lower limb ischemia. It is caused by atherosclerosis affecting the aorto-iliac or infra-inguinal arteries. A patient with intermittent claudication typically presents with aching immobilising pain in the calves that comes on with exertion and gets better with rest. A patient with an acutely ischemic limb presents with an unbearably painful white, cold, leg that has reduced sensation and movement. Hypertension: The patient typically has no symptoms. Hypertension is diagnosed when the blood pressure is consistently elevated on examination. Hypertension can cause vascular disease, arrhythmias, and heart failure and a patient with hypertension may also present with these complications of hypertension. Please refer to “Vital Signs: T, P, R, BP” that follows after Cardiovascular Symptoms for more information about blood pressure and hypertension. Heart failure: This is a common presentation. It is due to a reduction in cardiac function to the extent that blood flow is compromised, leading to the signs and symptoms of heart failure. Right heart failure: The patient typically presents with ankle, sacral, or abdominal swelling, weight gain, increased urination, anorexia, and nausea. Left heart failure: The patient typically presents with shortness of breath on exertion, orthopnoea (shortness of breath lying flat), and paroxysmal nocturnal dyspnoea (severe shortness of breath that wakes the patient from sleep). They may have a cough. They may have fatigue. This can be caused by myocardial disease (such as ischemic heart disease, or cardiomyopathy), volume overload due to aortic ELM Clinical Skills – Cardiovascular System Reference Guide 29  regurgitation, mitral regurgitation, or patent ductus arteriosus, or pressure overload due to hypertension or aortic stenosis. It may also occur in patients with thyrotoxicosis, rapid arrhythmia such as atrial fibrillation, or anaemia. Biventricular heart failure: The patient typically presents with symptoms of both right and left sided heart failure as both ventricles are failing to pump adequately. Atrial fibrillation: The patient can present with shortness of breath on exertion, reduced exercise tolerance, and fatigue. They may present with an unusual feeling in their chest and they may also be aware of palpitations, noticing their heart beating out of rhythm. They may present symptoms of a cerebrovascular accident (stoke) due to an embolus from the atrium. Sometimes they can be asymptomatic. Neurocardiogenic syncope or vasovagal syncope (simple faint): Patient typically presents with temporary loss of consciousness after being exposed to a specific trigger such as standing or emotion. It may be preceded by nausea, sweating, light-headedness, blurred vision, headaches, palpitations, paraesthesiae (abnormal sensations), and pallor. It usually occurs when the patient is in in the upright position and resolves almost immediately when the patient lies down. After recovery patients with neurocardiogenic syncope may complain of a “washed out” and tired feeling. Valvular heart disease: Cardiac valve disease has many causes. These include congenital causes, rheumatic fever, atherosclerosis, infarction, hypertension, aging, endocarditis, and myocardial disease. The symptomatic patient typically presents with symptoms of cardiac pump failure. Some conditions such as aortic stenosis can present with chest pain similar to angina or pre-syncope on exertion. Aortic stenosis: The patient can present with breathlessness, chest pain or tightness with exertion, palpitations, pre-syncope (a feeling of near blackout) or syncope (blackout). Mitral stenosis: The patient can present with breathlessness and can have paroxysmal nocturnal dyspnoea making them wake at night breathless. They may have palpitations and may present with ankle swelling. Aortic regurgitation: The patient can present with breathlessness especially on exertion, chest pain on exertion, feeling tired, feeling faint, palpitations and symptoms of heart failure. Mitral regurgitation: The patient can present with shortness of breath (due to the increased left atrial pressure), fatigue, orthopnoea (shortness of breath lying flat) and ankle swelling. Mitral regurgitation causes increased volume in the left atrium and can lead to pulmonary oedema. Deep vein thrombosis (DVT): Patient typically presents with a painful swollen calf, usually after a period of inactivity due to surgery, injury or travel. It is caused by a clot in the venous system. The patient typically has calf pain, swelling and redness and has engorged superficial veins. The patient may be asymptomatic and the DVT is only diagnosed when the patient presents with a pulmonary embolism. ELM Clinical Skills – Cardiovascular System Reference Guide 30 Pulmonary embolism: Patient typically presents with sudden unexplained shortness of breath (dyspnoea). If lung infarction occurs the patient can have chest pain that gets worse with breathing (pleuritic chest pain) and cough up blood (haemoptysis). It can present as sudden collapse with severe central chest pain, shock, pallor and sweatiness with syncope and sudden death. A pulmonary embolism is caused by an embolus from a thrombus in the venous system, most often the leg veins. The patient may have an associated swollen painful calf due to a deep vein thrombosis. ELM Clinical Skills – Cardiovascular System Reference Guide 31