Screening for Cardiovascular Diseases PDF

Screening for Cardiovascular Diseases Goodman and Snyder’s Differential Diagnosis for Physical Therapists: Screening for Referral. 7th edition, 2022 Chapter 7 Signs and Symptoms of Cardiovascular Disease System Symptoms General...

Screening for Cardiovascular Diseases Goodman and Snyder’s Differential Diagnosis for Physical Therapists: Screening for Referral. 7th edition, 2022 Chapter 7 Signs and Symptoms of Cardiovascular Disease System Symptoms General Weakness Fatigue Weight change Poor exercise tolerance Peripheral edema Integumentary Pressure ulcers Loss of body hair Signs and Symptoms of Cardiovascular Disease System Symptoms Central nervous system Headache Impaired vision Dizziness or syncope Pulmonary Labored breathing, dyspnea Productive cough Gastrointestinal Nausea and vomiting Ascites (abdominal distention) Signs and Symptoms of Cardiovascular Disease System Symptoms Musculoskeletal Chest, shoulder, back, neck, jaw, or arm pain Myalgia Muscular fatigue Muscle atrophy Edema Claudication Urinary frequency Genitourinary Nocturia Concentrated urine Decreased urinary output Cardiac Pathophysiology In most cases, a cardiopulmonary pathologic condition can be traced to at least one of three processes:  Obstruction or restriction.  Inflammation.  Dilation or distention. Angina Pectoris Angina Pectoris: Acute pain in the chest It results from the imbalance between cardiac workload and oxygen supply to myocardial tissue. Angina is a symptom of obstructed or decreased blood supply to the heart muscle primarily from atherosclerosis. Types of Anginal Pain Chronic stable angina: it occurs at a predictable level of physical or emotional stress and responds promptly to rest or nitroglycerin. Resting angina (angina decubitus): it occurs at rest in the supine position and frequently at the same time every day. The pain is neither brought on by exercise nor relieved by rest. Unstable angina: it is an abrupt change in the intensity and frequency of symptoms or decreased threshold of stimulus, such as the onset of chest pain while at rest. The most common trigger of unstable angina is the bursting of a cholesterol-filled plaque in the lining of a coronary artery. Types of Anginal Pain Nocturnal angina: it may awaken a person from sleep with the same sensation experienced during exertion. Thiis type of angina may be associated with underlying congestive heart failure (CHF). Angina Pectoris - Clinical Signs and Symptoms Gripping, vise-like feeling of pain or pressure behind the breast bone Pain that may radiate to the neck, jaw, back, shoulder, or arms (most often the left arm in men) Toothache Burning indigestion Dyspnea (shortness of breath); exercise intolerance Nausea Belching Myocardial Infarction (MI) MI: also known as a heart attack or coronary occlusion: it is the development of ischemia and necrosis of myocardial tissue. It results from a sudden decrease in coronary perfusion or an increase in myocardial oxygen demand without adequate blood supply.  MI - Clinical Signs and Symptoms May be silent (smokers, diabetics) Angina unrelieved by rest, nitroglycerin, Sudden cardiac death or antacids Prolonged or severe substernal chest pain Pain of infarct unrelieved by rest or a or squeezing pressure change in position Pain possibly radiating down one or both Nausea arms and/or up to the throat, neck, back, Sudden dimness or loss of vision or jaw, shoulders, or arms speech Feeling of nausea or indigestion Pallor Angina lasting for 30minutes or more Diaphoresis (heavy perspiration) Shortness of breath Weakness, numbness, and feelings of faintness Pericarditis Pericarditis is an inflammation of the pericardium, the saclike covering of the heart. The inflammatory process may develop either as a primary condition or secondary to several diseases and conditions.  Pericarditis - Clinical Signs and Symptoms Substernal pain that may radiate to the Pain aggravated by trunk neck, upper back, upper trapezius movements (side-bending or muscle, left supraclavicular area, down rotation) and by lying down the left arm to the costal margins History of fever, chills, weakness, or Difficulty in swallowing heart disease (a recent MI Pain relieved by leaning forward or accompanying the pattern of sitting upright symptoms may alert the therapist to the need for medical referral to Pain relieved or reduced by holding the rule out cardiac involvement) breath Cough Pain aggravated by movement associated with deep breathing Lower extremity edema (feet, (laughing, coughing, deep inspiration) ankles, legs)  Pericarditis - Clinical Signs and Symptoms Pain aggravated by trunk movements (sidebending or rotation) and by lying down History of fever, chills, weakness, or heart disease Cough Lower extremity edema (feet, ankles, legs) Guidelines for Immediate Medical Attention Sudden worsening of intermittent claudication may be as a result of thromboembolism. Anginal pain is not relieved in 20 minutes after rest or taking the nitroglycerin, or the client has nausea, vomiting, or profuse sweating. Symptoms of TIAs Changes in the pattern of angina, such as increased intensity, decreased threshold of stimulus, or longer duration of pain  Guidelines for Physician Referral Client has any combination of systemic signs or symptoms. Women with chest or breast pain who have a positive family history of breast cancer or heart disease. Palpitation in any person with a history of unexplained sudden death in the family. Anyone who cannot climb a single flight of stairs without feeling moderately to severely winded. Anyone who awakens at night or experiences shortness of breath when lying down. Fainting without any warning period of lightheadedness, dizziness, or nausea may be a sign of heart valve or arrhythmia problems.  Guidelines for Physician Referral Cardiac clients should be sent back to their physician under the following conditions:  Nitroglycerin tablets do not relieve anginal pain.  Pattern of angina changes is noted.  Client has abnormally severe chest pain with nausea and vomiting.  Anginal pain radiates to the jaw or to the left arm.  Anginal pain is not relieved by rest.  Upper back feels abnormally cool, sweaty, or moist to touch.  Client develops progressively worse dyspnea.  Individual with coronary artery stent experiencing chest pain.  Client demonstrates a difference of more than 40mm Hg in pulse pressure.  Client has any doubt about his or her present condition  Clues to Screening for Cardiovascular Signs and Symptoms Whenever assessing chest, breast, neck, jaw, back, or shoulder pain for cardiac origins, look for the following clues:  Personal or family history of heart disease including hypertension.  Age (postmenopausal woman; anyone over 65 years).  Ethnicity (African-American women).  Other signs and symptoms such as pallor, unexplained profuse perspiration, inability to talk, nausea, vomiting, sense of impending doom, or extreme anxiety.  Angina is activated by physical exertion, emotional reactions, a large meal, or exposure to cold and has a lag time of 5 to 10 minutes. Angina does not occur immediately after physical activity.  Clues to Screening for Cardiovascular Signs and Symptoms Whenever assessing chest, breast, neck, jaw, back, or shoulder pain for cardiac origins, look for the following clues:  Watch for the three Ps:  Pleuritic pain: have the client hold his or her breath and reassess symptoms—any reduction or elimination of symptoms with breathholding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms.  Pain on palpation (musculoskeletal origin).  Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and improves when sitting up or leaning forward is often pleuritic in origin).  If two of the three P’s are present, an Myocardial Infarction (MI) is very unlikely  Clues to Screening for Cardiovascular Signs and Symptoms Whenever assessing chest, breast, neck, jaw, back, or shoulder pain for cardiac origins, look for the following clues:  Chest pain, shoulder pain, neck pain, or TMJ pain occurring in the presence of CAD or previous history of MI.  Upper quadrant pain that can be induced or reproduced by lower quadrant activity.  Insidious onset of joint or muscle pain in the older client who has had a previously diagnosed heart murmur may be caused by bacterial endocarditis.  Throbbing pain at the base of the neck and/or along the back into the interscapular areas that increases with exertion. 288 SECTION II Viscerogenic Causes of Neuromusculoskeletal Pain and Dysfunction Other signs and symptoms such as pallor, unexplained Upper quadrant pain that can be induced or reproduced by profuse perspiration, inability to talk, nausea, vomiting, lower quadrant activity, such as biking, stair climbing, or sense of impending doom, or extreme anxiety walking without using the arms, is usually cardiac in origin. Watch for the three Ps. Recent history of pericarditis in the presence of a new onset 1. Pleuritic pain (exacerbated by respiratory movement of chest, neck, or le shoulder pain; observe for additional involving the diaphragm, such as sighing, deep breath- symptoms of dyspnea, increased pulse rate, elevated body ing, coughing, sneezing, laughing, or the hiccups; this temperature, malaise, and myalgia(s). may be cardiac if pericarditis or it may be pulmonary); If an individual with known risk factors for congestive have the client hold his or her breath and reassess heart disease, especially a history of angina, becomes weak symptoms—any reduction or elimination of symptoms or short of breath while working with the arms extended with breathholding or the Valsalva maneuver suggests a over the head, ischemia or infarction is a likely cause of the pulmonary or cardiac source of symptoms. pain and associated symptoms. 2. Pain on palpation (musculoskeletal origin). Insidious onset of joint or muscle pain in the older client 3. Pain with changes in position (musculoskeletal or pul- who has had a previously diagnosed heart murmur may be monary origin; pain that is worse when lying down and caused by bacterial endocarditis. Usually, there is no morn- improves when sitting up or leaning forward is oen ing stiness to dierentiate it from rheumatoid arthritis. pleuritic in origin). Back pain similar to that associated with a herniated lum- If two of the three P’s are present, an MI is very unlikely. bar disk, but without neurologic decits, especially in the An MI or anginal pain occurs in approximately 5% to 7% presence of a diagnosed heart murmur, may be caused by of clients whose pain is reproducible by palpation. If the bacterial endocarditis. symptoms are altered by a change in position, this percent- Watch for arrhythmias in neurologically unstable clients age drops to 2%, and if the chest pain is reproducible by (e.g., spinal cord, new CVAs, or new traumatic brain inju- respiratory movements, the likelihood of a coronary event ries); check pulse and ask about/observe for dizziness. is only 1%.73 Anyone with chest pain must be evaluated for trigger Chest pain may occur from intercostal muscle or periosteal points. If palpation of the chest reproduces symptoms, trauma with protracted or vigorous coughing. Palpation especially symptoms of radiating pain, deactivation of of local chest wall will reproduce tenderness. However, a the trigger points must be carried out and followed by a client can have both a pulmonary/cardiac condition with reevaluation as a part of the screening process for pain of a subsequent musculoskeletal trauma from coughing. Look cardiac origin (see Fig. 18.7 and Table 18.4). for associated signs and symptoms (e.g., fever, sweats, Symptoms of vascular occlusive disease include exertional blood in sputum). calf pain that is relieved by rest (intermittent claudication), Angina is activated by physical exertion, emotional nocturnal aching of the foot and forefoot (rest pain), and reactions, a large meal, or exposure to cold and has a lag classic skin changes, especially hair loss on the ankle and time of 5 to 10 minutes. Angina does not occur imme- foot. Ischemic rest pain is relieved by placing the limb in a diately after physical activity. Immediate pain with dependent position. activity is more likely musculoskeletal, thoracic outlet robbing pain at the base of the neck and/or along the syndrome, or psychologic (e.g., “I do not want to shovel back into the interscapular areas that increases with exertion today”). requires monitoring of vital signs and palpation of periph- Chest pain, shoulder pain, neck pain, or TMJ pain occur- eral pulses to screen for aneurysm. Check for a palpable ring in the presence of CAD or previous history of MI, abdominal heartbeat that increases in the supine position. especially if accompanied by associated signs and symp- See also section on clues to dierentiating chest pain in toms, may be cardiac. Chapter 18 C A R DIAC C H E S T PA I N PAT T E R N S ANGINA (FIG. 7.8) Location: Substernal/retrosternal (beneath the sternum) Le chest pain in the absence of substernal chest pain (women) Isolated midthoracic back pain (women) Aching in one or both upper arm (biceps) Referral: Neck, jaw, back, shoulder, or arms (most commonly the le arm) May have only a toothache Occasionally to the abdomen  CHAPTER 7 Screening for Cardiovascular Disease 289 C A R DIAC C H E S T PA I N PAT T E R N S cont’d Fig. 7.8 Pain patterns associated with angina. Left, Area of substernal discomfort projected to the left shoulder and arm over the distribution of the ulnar nerve. Referred pain may be present only in the left shoulder or in the shoulder and along the arm only to the elbow. Right, Occasionally, anginal pain may be referred to the back in the area of the left scapula or the interscapular region. Women can have the same patterns as shown for men in this gure or they may present as shown in Fig. 7.4. There may be no pain but rather a presenting symptom of extreme fatigue, weakness, or breathlessness. Description: Vise-like pressure, squeezing, heaviness, burning indigestion Intensitya: Mild to moderate Builds up gradually or may be sudden Duration: Usually less than 10 minutes Never more than 30 minutes Average: 3–5 minutes Associated signs and Extreme fatigue, lethargy, weakness (women) symptoms: Shortness of breath (dyspnea) Nausea Diaphoresis (heavy perspiration) Anxiety or apprehension Belching (eructation) “Heartburn” (unrelieved by antacids) (women) Sensation similar to inhaling cold air (women) Prolonged and repeated palpitations without chest pain (women) Relieving factors: Rest or nitroglycerin Antacids (women) Aggravating factors: Exercise or physical exertion Cold weather or wind Heavy meals Emotional stress a For each pattern reviewed, intensity is related directly to the degree of noxious stimuli. MYOCARDIAL INFARCTION (FIG. 7.9) Location: Substernal, anterior chest Referral: May radiate like angina, frequently down both arms Description: Burning, stabbing, vise-like pressure, squeezing, heaviness Intensity: Severe Duration: Usually at least 30 minutes; may last 1–2 hours Residual soreness 1–3 days 290 SECTION II Viscerogenic Causes of Neuromusculoskeletal Pain and Dysfunction C A R DIAC C H E S T PA I N PAT T E R N S cont’d Localized just Mid-chest under breastbone; Common and inside arms. Upper abdomen– or in larger area combination: Left arm and where most often of mid-chest; or mid-chest, shoulder more mistaken for entire upper chest neck, and jaw frequent than right indigestion Larger area Lower center Inside right arm Between of chest, neck, to both from armpit to shoulder blades neck, jaw, sides of upper neck; below elbow; and inside arms and jaw from ear to ear inside left arm to waist. Left arm and shoulder more frequent than right Most common warning signs of heart attack Atypical, less common warning signs (especially women)  Uncomfortable pressure, fullness, squeezing  Unusual chest pain (quality, location, e.g., burning, or pain in the center of the chest (prolonged) heaviness; left chest), stomach or abdominal pain  Pain that spreads to the throat, neck, back,  Continuous midthoracic or interscapular pain jaw, shoulders, or arms  Continuous neck or shoulder pain (not shown in  Chest discomfort with light-headedness, dizziness, Fig. 7.9) sweating, pallor, nausea, or shortness of breath  Pain relieved by antacids; pain unrelieved by rest or  Prolonged symptoms unrelieved by antacids, nitroglycerin nitroglycerin, or rest  Nausea and vomiting; flu-like manifestation without chest pain/discomfort  Unexplained intense anxiety, weakness, or fatigue  Breathlessness, dizziness Fig. 7.9 Early warning signs of a heart attack. Multiple segmental nerve innervations shown in Fig. 3.3 account for varied pain patterns possible. A woman can experience any of the various patterns described but is just as likely to develop atypical symptoms of pain as depicted here. (From Goodman CC, Fuller K: Pathology: implications for the physical therapist, ed 3, Philadelphia, 2009, WB Saunders.) Associated signs and None with a silent MI symptoms: Dizziness, feeling faint Nausea, vomiting Pallor Diaphoresis (heavy perspiration) Apprehension, severe anxiety Fatigue, sudden weakness Dyspnea May be followed by painful shoulder-hand syndrome (see text) Relieving factors: None; unrelieved by rest or nitroglycerin taken every 5 minutes for 20 minutes Aggravating factors: Not necessarily anything; may occur at rest or may follow emotional stress or physical exertion  CHAPTER 7 Screening for Cardiovascular Disease 291 C A R DIAC C H E S T PA I N PAT T E R N S cont’d Fig. 7.10 Substernal pain associated with pericarditis (dark red) may radiate anteriorly (light red) to the costal margins, neck, upper back, upper trapezius muscle, and left supraclavicular area or down the left arm. PERICARDITIS (FIG. 7.10) Location: Substernal or over the sternum, sometimes to the le of midline toward the cardiac apex Referral: Neck, upper back, upper trapezius muscle, le supraclavicular area, down the le arm, costal margins Description: More localized than pain of MI Sharp, stabbing, knife-like Intensity: Moderate-to-severe Duration: Continuous; may last hours or days followed by residual soreness Associated signs and Usually medically determined associated symptoms (e.g., by chest auscultation using a stethoscope); symptoms: cough Relieving factors: Sitting upright or leaning forward Aggravating factors: Muscle movement associated with deep breathing (e.g., laughter, inspiration, coughing) Le lateral (side) bending of the upper trunk Trunk rotation (either to the right or to the le) Supine position DISSECTING AORTIC ANEURYSM (FIG. 7.11) Left renal Right renal artery artery Kidney Abdominal aortic aneurysm Fig. 7.11 Most aortic aneurysms (more than 95%) are located just below the renal arteries and extend to the umbilicus, causing low back pain. Chest pain (dark red) associated with thoracic aneurysms may radiate (arrows) to the neck, interscapular area, shoulders, low back, or abdomen. Early warning signs of an impending rupture may include an abdominal heartbeat when lying down (not shown) or a dull ache in the midabdominal left ank or low back (light red) 292 SECTION II Viscerogenic Causes of Neuromusculoskeletal Pain and Dysfunction C A R DIAC C H E S T PA I N PAT T E R N S cont’d Location: Anterior chest (thoracic aneurysm) Abdomen (abdominal aneurysm) oracic area of back Referral: Pain may move in the chest as dissection progresses Pain may extend to the neck, shoulders, interscapular area, or lower back Description: Knife-like, tearing (thoracic aneurysm) Dull ache in the lower back or midabdominal le ank (abdominal aneurysm) Intensity: Severe, excruciating Duration: Hours Associated signs and Pulses absent symptoms: Person senses “heartbeat” when lying down Palpable, pulsating abdominal mass Lower BP in one arm Other medically determined symptoms Relieving factors: None Aggravating factors: Supine position accentuates symptoms NONCARDIAC CHEST PAIN PATTERNS Gastrointestinal disorders; see Chapter 9 Musculoskeletal disorders; see Chapters 15 to 19 Breast diseases; see Chapter 18 Neurologic disorders; see Chapters 15 to 19 Anxiety states; see Chapter 3 Pleuropulmonary disorders; see Chapter 8 Key Points to Remember 1. Fatigue beyond expectation during or aer exercise is achieve a target heart rate (THR) above 90 bpm. To a red-ag symptom. determine a safe rate of exercise, the heart rate should 2. Be on the alert for cardiac risk factors in older adults, return to the resting level 2 minutes aer stopping especially women, and begin a conditioning program exercise. before an exercise program. 8. Make sure that a client with cardiac compromise 3. e client with stable angina typically has a normal has not smoked a cigarette or eaten a large meal just BP; it may be low, depending on medications. BP may before exercise. be elevated when anxiety accompanies chest pain or 9. A 3-pound or greater weight gain, or a gradual, con- during acute coronary insuciency; systolic BP may tinuous gain over several days resulting in swelling be low if there is HF. of the ankles, abdomen, and hands, combined with 4. Cervical disk disease and arthritic change can mimic shortness of breath, fatigue, and dizziness that persists atypical chest pain of angina pectoris, requiring despite rest, may be red-ag symptoms of CHF. screening through questions and musculoskeletal 10.e pericardium (sac around the entire heart) is evaluation. adjacent to the diaphragm. Pain of cardiac and dia- 5. If a client uses nitroglycerin, make sure that he or she phragmatic origin is oen experienced in the shoul- has a fresh supply, and check that the physical therapy der because the heart and the diaphragm are supplied department has a fresh supply in a readily accessible by the C5-C6 spinal segment. e visceral pain is location. referred to the corresponding somatic area. 6. Anyone being treated with both NSAIDs and ACE 11.Watch for muscle pain, cramps, stiness, spasms, inhibitors must be monitored closely during exercise and weakness that cannot be explained by arthritis, for elevated BP. recent strenuous exercise, a fever, a recent fall, or 7. A person taking medications, such as beta-blockers other common causes in clients taking statins to lower or calcium channel blockers, may not be able to cholesterol.