Cardiovascular Semiology PDF

Dr. Ahmadou M. Jingi Professor Gloria Ashuntantang. Department of Clinical Sciences Faculty of Health Sciences The University of Bamenda OBJECTIVES 1. List the characteristics of Chest pain 2. Describe the stages of Dyspnea according to the NYHA classification 3. Explain the difference...

Dr. Ahmadou M. Jingi Professor Gloria Ashuntantang. Department of Clinical Sciences Faculty of Health Sciences The University of Bamenda OBJECTIVES 1. List the characteristics of Chest pain 2. Describe the stages of Dyspnea according to the NYHA classification 3. Explain the differences Syncope and lipothymia 4. Illustrate the 4 main areas of heart asculatation 5. Enumerate the characteristics of a Heart murmur 6. Explain the difference between Systolic and Diastolic Heart Murmurs 06/12/2023 Clinical methods: Dr Jingi 2 Plan 1. Risk factors of CVD Classic CVD risk factors   Other risk factors 2. Symptoms of CVD: History 3. Signs of CVD: Physical examination 4. Investigations of CVD:  Biochemistry  Chest X-ray  ECG  Ultrasound 06/12/2023 Clinical methods: Dr Jingi 3  APPROACH TO PATIENTS WITH CVD 1. History  Identification  PC: symptoms of CVD  HPC: description of symptoms  Past Medical history: Risk factors of CVD 2. Physical examination: Signs of CVD  Cardiac  Peripheral 06/12/2023 Clinical methods: Dr Jingi 4 HISTORY  Identification  Age  Sex  Profession  Geographical origin  Residence  Religion 06/12/2023 Clinical methods: Dr Jingi 5  RISK FACTORS FOR HEART DISEASES 1. Classic CVD risk factors Non modifiable CVRF Modifiable CVRF Age and sex Diabetes > 50 years in males FBG > 1.26g/L >60 years in females OGTT > 2 g/L after 2 hours of 75 g of oral glu RBG > 2 g/L with symptoms Family history of MI or sudden death in a 1° Hypertension relative SBP ≥ 140 mmHg < 55 years in father/brother DBP≥90 mmHg 94/80cm) Tobacco (Pack-years) Sedentarity 06/12/2023 Clinical methods: Dr Jingi Alcohol (g/day) 6  RISK FACTORS FOR HEART DISEASES 2. Non-Classic CVD risk factors Non vascular Risk factor Heart disease condition Recurrent sore throat/Rheumatic fever Valvular heart disease HIV infection HIV cardiomyopathy, Pericarditis Cancer Carcinoid heart disease Anti-cancer chemotherapy Toxic cardiomyopathy Illicit IV drug use Infectious endocarditis Auto-immune disease (SLE, RA) Carditis (Endo-Myo-Pericarditis) Other organ diseases (CKD, Liver disease, Sleep apnea Sd) Cardiorenal Sd. Hepatorenal Sd 06/12/2023 Clinical methods: Dr Jingi 7  SYMPTOMS 06/12/2023 Clinical methods: Dr Jingi 8 SYMPTOMS: Cardiovascular diseases 1-Cardiac symptoms 1. Chest pain 2. Palpitations 3. Dyspnea or Shortness of Breath (SOB) 4. Syncope/Lipothymia 5. Cough 6. Exertional hepatalgia 06/12/2023 Clinical methods: Dr Jingi 9 SYMPTOMS: Cardiovascular diseases 2-Peripheral vessels 1. Lower limb pain 2. Claudication of the lower limbs 3. Redness and swellings 4. Trophic changes 06/12/2023 Clinical methods: Dr Jingi 10 SYMPTOMS (1): Chest pain (Characteristics)  Chest pain: MISTIDRATS 1. Mode of onset 2. Intensity 3. Site 4. Type (constrictive, burning), 5. Irradiation, 6. Duration, 7. Relieving factors 8. Associated symptoms 9. Time 10. Sensitivity to trinitrine Levine’s sign 06/12/2023 Clinical methods: Dr Jingi 11 SYMPTOMS (1): Chest pain (Causes) 1. Cardiovascular causes (PIED):  Angina pectoris (I)  Myocardial infarction (I)  Pericarditis (P)  Aortic disection (D)  Pulmonary Embolism (E)  Pulmonary hypertension (E) 2. Non Cardiovascular causes:  Pneumothorax  Pneumopathy  Oesophagus Sd(esophagitis/GERD, Spasm)  Chest wall (Intercostal Neuralgia, Tietze Syndrome, Cyriac) 06/12/2023 Clinical methods: Dr Jingi 12  SYMPTOMS (1): Chest pain (CV Causes) 1-Stable angina pectoris 1. Mode: Chronic, intermittent crises 2. Intensity: Variable (Canadian heart association scale) 3. Site: Diffuse, retrosternal, left mediothoracic, epigastric, interscapular, left scapular 4. Type: Constrictive, oppresion, tightness (blockpnea), horizontal bar 5. Irradiation: Neck, mandibules, shoulders, arm, fore arm, wrist. 6. Duration: Few mins and disappears 5 mins after end of trigger 7. Rythme/Trigger factors: Effort+++, post prandial, cold, anemia, awakening 8. Relieving factor: End of trigger (generally 2-3 mins), Trinitrine+++ 06/12/2023 Clinical methods: Dr Jingi 13  SYMPTOMS (1): Chest pain (CV Causes) 1-Stable angina pectoris: Functional Intensity Functional class Functional description Class I Angina occurs with intense and prolong effort Class II Angina occurs with sustained daily effort: climb stairs, hill Class III Angina occurs with normal daily activities: walking, climb a flat of stairs Class IV Anginar occurs with minimal effort: toilette, dressing, at rest 06/12/2023 Clinical methods: Dr Jingi 14  SYMPTOMS (1): Chest pain (CV Causes) 2-Un-Stable angina pectoris (ACS) 1. Angina at rest lasting > 20 mins 2. Severe: Class III and IV. 3. Worsening angina pectoris: Class and duration of pain. Carries a poor short term prognosis: Evolves towards an Acute MI (SCA) 06/12/2023 Clinical methods: Dr Jingi 15  SYMPTOMS (1): Chest pain (CV Causes) 3- Prinzmetal angina 1. Unstable angina pectoris in relatively young patients 2. Spontanous angina at rest 3. Second half of the night 4. Due to coronary spasm on an atheromatous coronary artery. 06/12/2023 Clinical methods: Dr Jingi 16  SYMPTOMS (1): Chest pain (CV Causes) 4- Myocardial infarction (ACS) Classical angina pectoris with particularities: 1. Lasts > 20 mins 2. Very intense 3. Associated symptoms/Findings:  Malaise  Vomiting  Epigastric pain  Typical ECG changes: S-T segment elevation  Raised cardiac enzymes: Troponin I, CPK, CPK-MB, LDH 06/12/2023 Clinical methods: Dr Jingi 17  SYMPTOMS (1): Chest pain (CV Causes) 4- Pericarditis 1. Mode: acute onset 2. Intensity: Variable 3. Site: Precordial, medithoracic 4. Type: Burning 5. Irradiation: Rarely, left shoulder, tip of scapular 6. Duration: Prolonged and continuous 7. Rythme/Trigger: None 8. Aggravating factors: Cough, deep inspiration, dorsal decubitus 9. Relieving factor: Leaning forward 10. Associated symptoms: Prior common cold. 06/12/2023 Clinical methods: Dr Jingi 18  SYMPTOMS (1): Chest pain (CV Causes) 5- Aortic dissection (Acute Aortic Syndrome) 1. Mode: acute onset, Continuous. 2. Intensity: Violent and prolonged 3. Site: Retrosternal 4. Type: Tearing 5. Irradiation: Dorsal, interscapular, migratory to the loins 6. Duration: Prolonged and continuous 7. Rythme/Trigger: None 8. Aggravating factors: None 9. Relieving factor: None 10. Associated symptoms: Neurologic deficits (Stroke/Paraplegia), Pulse asymmetry. 06/12/2023 Clinical methods: Dr Jingi 19  SYMPTOMS (1): Chest pain (CV Causes) 6- Pulmonary Embolism 1. Mode: acute onset, Continuous. 2. Intensity: Variable 3. Site: Basitoracic (lung infarction/pleurisy), medithoracique (pulm HTN) 4. Type: Blow to the chest, Constrictive (mediothorax) 5. Irradiation: Rare 6. Duration: Prolonged and continuous 7. Rythme/Trigger: None 8. Aggravating factors: Inspiration, Cough. 9. Relieving factor: None 10. Associated symptoms: Cough, Tachycardia, Syncope (massive PE). 06/12/2023 Clinical methods: Dr Jingi 20  SYMPTOMS (1): Chest pain 6- Non CV Causes 1. Pleuropulmonary:  Pneumopathy  Pleurisy 2. Chest wall:  Traumatic  Non traumatic: TIETZE Sd, CYRIAX Sd 3. Digestive tract:  Esophagitis (GERD, Candida)  Esophageal spasm (relieve with Trinitrine) 06/12/2023 Clinical methods: Dr Jingi 21  SYMPTOMS (2): Palpitations 1. Definition: Abnormal perception of the heart beat (uncomfortable); 2. Charcteristics:  Continuous (permanent tachycardia),  Sporadiques (extrasystoles),  Paroxystiques (crises)  Trigger: Spontanous (No trigger) Effort Emotions Meal 06/12/2023 Clinical methods: Dr Jingi 22  SYMPTOMS (2): Palpitations (Causes) 1. Atrial fibrillation (Afib)  Rapid onset, irregular  Ends progressively 2. Extra-systoles or Premature contractions  Violent heart beat  Intermittent 3. Jonctional Tachycardia  Rapid and unconfortable  Vagal Manœuvres terminates crises  Associated with sudden polyuria 4. Ventricular tachycardia  Associated Lipothymia/Syncope  Stops spontanously or with Cardiovesrion (electric chock). 06/12/2023 Clinical methods: Dr Jingi 23 SYMPTOMS (3): Shortness of breath (SOB) or Dyspnea Subjective feeling of respiratory discomfort or SOB Classification of Dyspnea according to NYHA (Severity) 1. Stage I : No limitation of physical activity 2. Stage II : SOB with normal daily activities (Stairs, Slope) 3. Stage III : SOB with mild effort 4. Stage IV : SOB at rest 06/12/2023 Clinical methods: Dr Jingi 24  SYMPTOMS (3): Dyspnea (SOB) Other forms of SOB: 1. Orthopnea: SOB occurs with decubitus and relief with sitting. 2. Paroxysmal Dyspnea (Worsening orthopnea). Paroxysmal nocturnal dyspnea: SOB at night in a patient who has been lieing for hours, obliging them to sit up for relief of symptoms Acute pulmonary edema: Sudden onset SOB associated with cough, productive of pink and frothy sputum obliging them to sit up and search for air by the window. 3. Cardiac asthma: SOB associated with expiratory bradypnea and Wheezing 4. Cheyne Stokes respiration: 06/12/2023 Clinical methods: Dr Jingi 25  SYMPTOMS (3): Dyspnea (SOB) Causes of SOB: Cardiac and Non-Cardiac Chronology Worsen Relief Chest Auscultation Heart failure Progressive or Sudden Decubitus Sitting Wheezing onset (OAP), then cough Coarse crackles COPD Chronic cough then SOB Effort, respiratory tract Ronchi infection Wheeze Acute onset Allergens Suppression of allergens Wheeze Asthma Episodes aigus Stress Breath in a plastic bag Normal Spasmophilia Pulmonary embolism Sudden onset Normal Chest pain Anemia 06/12/2023 Clinical methods: Dr Jingi 26 SYMPTOMS (4): Syncope and Lipothymia (Dizziness) Definition 1. Syncope:  Sudden and complete loss of consciouness.  Often brief (few minutes)  Due to cerebral anoxia, secondary to sudden drop in blood flow to the brain. 2. Lipothymia or Dizziness:  Altered vigilance  Pseudo vertigo  No loss of consciousness  Due to brief cerebral anoxia 06/12/2023 Clinical methods: Dr Jingi 27 SYMPTOMS (4): Causes of Syncope and Lipothymia Causes of Syncope/Lipothymia 1. Vascular causes:  Vaso-vagal  Orthostatic Hypotension  Carotid artery stenosis 2. Cardiac causes:  Arrhythmia eg: Ventricular tachycardia  Conduction defects eg: Complete heart block, Adams Stoke  Aortic valve stenosis  Hypertrophic Obstructive Cardiomyopathy (HOCM) 3. Other causes:  Hypoglycemia  Panic attacks 06/12/2023 Clinical methods: Dr Jingi 28 SYMPTOMS (4): Causes of Syncope and Lipothymia Trigger Postural Prodromes Recovery Associations Vasovagal syncope Emotion, None (20%) Standing Rapid Postprandial Nervousness, pallor, Fatigue, Hunger Sweat, Yawning Orthostatic Orthostatism None Shortly after standing Rapid Medicines Light headedness, Hypotension Palpitations Arrhythmia None None None Rapid Panic attacts Anxiety Dyspnea, None Slow After Hyperventilation Palpitation, Chest pain Aortic Stenosis Effort SOB on effort Standing Variable Hypoglycemia Fasting Sweating, None Varies with the severity tremors, Palpitation, hunger 06/12/2023 Clinical methods: Dr Jingi 29 SYMPTOMS (5): Intermittent Claudication of the Lower Limbs Characteristics: Descriptive form (Peripheral Artery Disease) 1. Onset of lower limb (Calf) pain or dyscomfort with effort  Striction  Tightness  Cramp 2. Reproducible with similar effort. 3. Relief with rest or Standing. 4. Bilateral or Unilateral. Other forms: Venous insufficiency. Stenosis of the lumbar canal. 06/12/2023 Clinical methods: Dr Jingi 30 SYMPTOMS (5): Intermittent Claudication of the Lower Limbs Peripheral Artery Disease (PAD): Leriche and Fontaine Stage Description Stage 1 Asymtomatic. Absent pulse Stage 2 (2a and 2b) Intermittent claudication (2a > 250 m and 2b