Lect 4 & 5 PDF - Medical Screening and Cardiovascular Disease

 SCHOOL OF MEDICAL SCIENCE Medical screening DR. ISLAM ABUEMIRA PHD Of PT Cairo University. Certified Manual Therapy ( Winston Salem Uni –America) &(Mulligan -Newzelenda)&(capri -India). Certified (schroth- Germany & SEAS – Italia) for spine deformity. Certified Manual Therapy Ce...

 SCHOOL OF MEDICAL SCIENCE Medical screening DR. ISLAM ABUEMIRA PHD Of PT Cairo University. Certified Manual Therapy ( Winston Salem Uni –America) &(Mulligan -Newzelenda)&(capri -India). Certified (schroth- Germany & SEAS – Italia) for spine deformity. Certified Manual Therapy Certified Sports Injury ER (Uk)  SCREENING FOR CARDIOVASCULAR DISEASE SCHOOL OF MEDICAL SCIENCE  The cardiovascular system consists of : the heart, arteries, veins, capillaries, and lymphatics functions : coordination with the pulmonary system to circulate oxygenated blood to all cells and to collect deoxygenated blood to be delivered to the lungs.  The cardiovascular system Signs and Symptoms of Cardiovascular Disease Chest Pain or Discomfort: chest, neck and/or arm pain or discomfort, palpitation, dyspnea, syncope (fainting), fatigue, cough, diaphoresis (sweating), cyanosis (discoloration of the skin). Edema and leg pain (claudication) are the most common symptoms of the vascular component. Review Table 6-1, Signs and Symptoms of Cardiovascular  The cardiovascular system Cardiovascular Signs and Symptoms by System. Symptoms could be general, integumentary, CNS, pulmonary, musculoskeletal and gastrointestinal. Informative websites Case  Cardiac related chest pain secondary to : Angina Myocardial infarction Pericarditis Endocarditis Mitral valve prolapse Dissecting aortic aneurysm.  Frequency, location, intensity, and duration vary according to the underlying pathologic condition.  Palpitation irregular heartbeat. May also be referred as arrhythmia or dysrhythmia which may be caused by: A relatively benign condition (mitral valve prolapse, “athlete's heart”, caffeine, anxiety, exercise), severe condition (coronary artery disease, cardiomyopathy, complete heart block, ventricular aneurysm, atrioventricular valve disease mitral or aortic stenosis). Associated symptoms: lightheadedness or syncope. Occasionally, “fluttering”sensations in the neck which may be caused by anxiety or muscle fasciculation.  Dyspnea Known as breathlessness or shortness of breath secondary to: a pulmonary pathologic condition ,but also can be cardiovascular in origin. Dyspnea with mild exertion is known as Dyspnea on exertion (DOE) is the result of the lung to be unable to empty itself due to an impaired left ventricle, leading to pulmonary congestion and shortness of breath.  Dyspnea Paroxysmal nocturnal dyspnea (PND) and sudden shortness of breath frequently accompany congestive heart failure (CHF). Dyspnea relieved by specific breathing patterns (e.g.: pursed lips) or body position (e.g.: leaning forward on the arms to lock the shoulders in sitting position) is more likely to be pulmonary than cardiac in origin.  Cardiac Syncope This condition (fainting) or more mild lightheadedness caused by: reduced oxygen delivery to the brain. Cardiac conditions resulting in syncope include arrhythmias, orthostatic hypotension, poor ventricular function, coronary artery disease, and vertebral artery insufficiency. Lightheadedness can also occur in noncardiac conditions such as anxiety and emotional stress causing a vagal syncope as a result of hyperventilation. Any unexplained syncope, especially in the presence of heart or circulatory problems, or if the client has any risk factors for heart attack or stroke, should be referred for medical evaluation.  Cardiac Syncope Fatigue Often fatigue of a cardiac nature is accompanied by associated symptoms, such as: Dyspnea, Chest Pain, Palpitations, Headache. Fatigue going beyond expectations during or after exercising should be monitored closely, especially in clients with a cardiac history. Cough Cough is usually associated with pulmonary conditions, but it may occur as a complication of a cardiovascular pathologic complex due to a left ventricular dysfunction resulting from pulmonary edema or left ventricular CHF. Cyanosis Although cyanosis may accompany hematologic or central nervous system disorders, most often visible cyanosis accompanies cardiac and pulmonary problems. Edema Edema that results in swelling of the ankles, abdomen, and hands combined with shortness of breath, fatigue, and dizziness may be red-flag symptoms of CHF. Noncardiac causes of edema may include pulmonary hypertension, kidney dysfunction, cirrhosis, burns, infection, lymphatic obstruction, use of NSAIDs, or allergic reaction.  Claudication Claudication or leg pain occurs with peripheral vascular disease (PVD), often occurring simultaneously with coronary artery disease. The presence of pitting edema is usually associated with vascular disease. Other noncardiac causes of leg pain include: sciatica, pseudoclaudication, anterior compartment syndrome,gout, and peripheral neuropathy. Intermittent claudication sudden worsening may be due to thromboembolism and must be reported to the physician immediately.  Claudication Vital Signs During client's exercise, the therapist should remain alert to changes in heart rate, blood pressure (systolic and diastolic), and irregular pulse rate Cardiac Pathophysiology Three cardiac conditions related to the heart muscle, the heart valves, and the cardiac nervous system are presented (Table 6-2). It shows cardiac diseases that could affect each of it. Conditions Affecting the Heart Muscle In most cases a cardiopulmonary condition can be traced to at least one of three processes: - Obstruction or restriction - Inflammation - Dilation or distension The most common cardiovascular conditions mimicking musculoskeletal conditions are angina, myocardial infarction, pericarditis, and dissecting aortic aneurysm. Degenerative heart disease is a condition related to aging and refers to changes in the blood supply to the heart and major vessels. It is also known as atherosclerotic cardiovascular disease, coronary heart disease (CHD), and coronary artery disease (CAD).  Hyperlipidemia Refers to a group of metabolic abnormalities resulting in combinations of: elevated serum total cholesterol, elevated low-density lipoproteins (LDL) (transports cholesterol from the liver to the tissues of the body)(bad), elevated triglycerides, decreased high-density lipoproteins (HDL) (removes cholesterol from the blood)(good). Statin medications used to reduce LDL-cholesterol have been associated with some cases of rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood.), and if symptoms are detected early should be reported to the treating physician.  Hyperlipidemia Screening for Side Effects of Statins Myalgia is the most common effect associated with statins; joint pain is also reported. Muscular symptoms are more common in older individuals. Examples of Statins approved in the U.S. include: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altocor) pravastatin (Pravachol), simvastatin (Zocor), and. rosuvastatin (Crestor).  Myositis signs : Muscles aches pain, unexplained fever, nausea, vomiting, dark urine Should be referred to a physician immediately.  Myositis Other risk factors include: - Age over 80 (women more than men) - Small body frame or frail - Kidney or liver disease - Drink excessive grapefruit juice daily (more than 1 quart/day) - Use of other medications (e.g.: cyclosporine, some antibiotics, Verapamil, HIV protease inhibitors, some antidepressants) - Alcohol abuse Screening for liver impairment is an important part of assessing for rhabdomyolysis in people taking statins (See Chapter 9). Clinical Signs and Symptoms of Statin-Induced Side Effects - Myalgia - Unexplained fever - Nausea, vomiting - Dark urine  Coronary Artery Disease When a coronary artery becomes narrowed or blocked, the area of the heart muscle supplied by that artery becomes ischemic and injured, and infarction may result. The major disorders caused by insufficient blood supply to the myocardium are angina pectoris and myocardial infarction, known as coronary artery disease (CAD). Coronary artery disease includes atherosclerosis (fatty buildup), thrombus (blood clot), and spasm (intermittent constriction).  Coronary Artery Disease Atherosclerosis Also called arteriosclerosis is a progressive disease process beginning from childhood resulting in a hardening of the arteries, due to the accumulation of fatty substance, or lipids, and cholesterol which then calcify and harden (Fig. 6-2) and thrombosis may occur.  Atherosclerosis The filler, called plaque, when fully developed can cause bleeding, clot formation, and distortion or rupture of a blood vessel (Fig. 6-3). Heart attacks and strokes are the most sudden and often fatal signs of the disease. Thrombus When plaque builds up, the blood flow is slowed and a clot (thrombus) on the artery wall may form. A vessel blocked by a thrombus is known as thrombosis which when is formed in a coronary artery heart attack if it happens in the brain causes a stroke. Atherosclerosis Spasm A spasm is a temporary sudden constriction of a coronary artery that may cause mild symptoms and never return, If prolonged may cause a heart infarct. Chemicals like nicotine and cocaine may lead to coronary artery spasm; other factors are anxiety and cold air.  Risk Factors CAD Research revealed modifiable and nonmodifiable factors associated with death caused by CHD.  Risk Factors CAD Additional risk factors include: - Exposure to bacteria such as Chlamydia Pneumoniae - Excess level of homocysteine (amino-acids) - High levels of LDL (transport fat throughout the body) - High levels of fibrinogen(binds platelet cells in blood clot) - Large amounts of C-reactive protein (repair of tissue injury) - The presence of troponin T (protein helps heart muscle to contract) - The presence of diagonal earlobe creases (called “Frank's sign”) Women and Heart Disease Whenever screening chest pain, keep in mind the demographics: older men and women, menopausal women, and black women are at greatest risk. Women with diabetes are seven times more likely to have cardiovascular complications and about half of them will die of CAD. Women experience symptoms of CAD, which are more subtle and “atypical”compared with traditional symptoms such as angina and chest pain. Women and Heart Disease The classic pain is usually: Substernal chest pain characterized by a crushing, heavy squeezing sensation commonly occuring during emotion or exertion. One of the most important primary signs of CAD in women is unexplained, severe episodic fatigue and weakness associated with decreased ability to carry out normal activities of daily living (ADL's). CLINICAL SIGNS AND SYMPTOMS Atherosclerosis by itself, does not necessarily produce symptoms.For manifestations to develop there must be a critical deficit in blood supply to the heart. Often, CAD symptoms do not appear until the lumen of the coronary artery narrows by 75%. When a blood clot obstructs entirely the blood flow, a heart attack or even sudden death may result. When extensive damage to the heart tissue disrupts the electrical impulses for the heart to contract, heart failure, chronic arrhythmias, and conduction problems may develop. CLINICAL SIGNS AND SYMPTOMS Angina Angina pectoris is an acute pain in the chest due to oxygen deficit to the myocardial tissue. Angina primarily a symptom of atherosclerosis which decreases or impedes the normal supply of blood to the heart tissue (imbalance between cardiac workload and oxygen supply).  Angina A growing mass of plaque collects platelets, fibrin, and cellular debris. Platelet aggregations release prostaglandin capable of causing vessel spasm, which in turn promotes platelet aggregation resulting in a vicious spasm/pain cycle. It is theorized that the heart pain is the result of the rapid accumulation of metabolites within an ischemic segment of the myocardial muscle. TYPES OF ANGINAL PAIN There are a number of types of angina: chronic stable angina (walk-through angina), resting angina (angina decubitus), unstable angina, nocturnal angina, atypical angina, new-onset angina, and Prinzmetal's angina or “variant”angina.  CLINICAL SIGNS AND SYMPTOMS The client may indicate the location of the symptoms by placing a clenched fist against the sternum. It radiates most commonly to the left shoulder and down the inside of the arm to the fingers (Fig. 6-8), but also can radiate to other parts (see Fig. 6-4).  CLINICAL SIGNS AND SYMPTOMS The sensation of angina is described as squeezing, burning, pressing, choking, aching, or bursting and is often confused with heartburn or indigestion, hiatal hernia, esophageal spasm, or gallbladder disease. Clinical Signs and Symptoms of Heartburn - Frequent attacks - Burning sensation in the chest - Frequent use of antacids - Discomfort after eating spicy foods - Heartburn wakes client at night - Abdominal bloating and gas - Acid or bitter taste in the mouth - Difficulty in swallowing Clinical Signs and Symptoms of Angina Pectoris - Gripping, viselike feeling of pressure behind the sternum - Pain that may radiate to the neck, jaw, back, shoulder, or arms (most often to the left) - Toothache - Burning indigestion - Dyspnea; exercise intolerance - Nausea - Belching Myocardial Infarct (MI) Myocardial infarct is the development of ischemia and necrosis of heart tissue. Also known as "heart attack”, coronary occlusion, or a "coronary”. Occlusion of one of the two large arteries or any of their branches, is one of the major causes of MI.  Clinical Signs and Symptoms There are some well-known pain patterns specific to the heart and cardiac system. The onset of an infarct may be characterized by severe fatigue for several days before the infarct. Persons who have MIs may not experience any pain and may be unaware of a damaged heart muscle.  Cardiac Arrest Signs of sudden cardiac arrest include: Sudden loss of responsiveness. No response to gentle shaking No normal breathing. No signs of circulation. No movement or coughing Classical Warning Signs of Myocardial Infarction A severe unrelenting chest pain described as "crushing pain” lasting 30 minutes that is not alleviated by rest or by nitroglycerin. It may radiate to the arms, throat, and back, persisting for hours (see Fig. 6-9). Heart attack  Clinical Signs and Symptoms of Myocardial Infarction May be silent (smokers, diabetics, reduced sensitivity to pain) Pallor Prolonged or severe substernal chest pain or Nausea squeezing pressure Diaphoresis Radiating Pain down one or both arms and/or Shortness of up the throat, neck, back, jaw,shoulders breath Angina lasting for 30 minutes or more Sudden Angina unrelieved by rest, nitroglycerin or cardiac death antacids Feeling of Pain unrelieved by change of position indigestion Sudden dimness or loss of vision or speech Weakness, numbness, and feelings of faintness Warning Signs of Myocardial Infarction in Women For women symptoms may be more subtle or “atypical”. They describe heaviness, squeezing, or pain in the left side of the chest, abdomen, mid back, shoulder, or arm. Clinical Signs and Symptoms of Myocardial Ischemia in Women - Heart pain not always follows classic patterns - Many women do experience classic chest pain - Mental status change or confusion may be common in older women - Dyspnea at rest or with exertion Warning Signs of Myocardial Infarction in Women - Weakness and lethargy - Anxiety or depression - Indigestion, heartburn, or stomach pain mistakenly diagnosed as GERD - Sleep disturbance - Sensation similar to inhaling cold air: unable to talk or breath - Isolated continuous mid-thoracic or interscapular back pain: right biceps aching - Symptoms may be relieved by antacids  Pericarditis The inflammation of the pericardium is called pericarditis, specifically affecting the parietal pericardium (Fig. 6-5). The inflammatory process may develop as a primary condition or secondary to another disease (e.g: influenza, HIV infection, TBC, cancer, etc.). Pericarditis may be acute or chronic; chronic or recurring pericarditis is accompanied by a pericardium that is rigid, thickened and scarred.  Pericarditis Clinical Signs and Symptoms At first, it may have no external signs or symptoms. The symptoms usually include chest pain and dyspnea, an increase in pulse rate, and a rise of temperature. Malaise and myalgia may occur. The inflamed pericardium may cause pain when it rubs against the heart. Chest pain from pericarditis closely mimics that of a MI (see Fig. 6-10).  characteristics of cardiac chest pain Table 6-5 Clinical Signs and Symptoms of Pericarditis Substernal pain that may radiate to the neck, upper back, upper trapezius muscle, left supraclavicular area, down the left arm to the costal margin Cough Pain relieved by leaning forward or sitting upright Pain relieved or reduced by holding the breath Pain aggravated by deep breathing (laughing, coughing, deep inspiration) Difficulty in swallowing Pain aggravated by trunk movements (side bending or rotation) and by lying down History of fever, chills, weakness, or heart disease Lower extremities edema (feet, ankles, legs) characteristics of cardiac chest pain  Congestive Heart Failure Also called cardiac decompensation or cardiac insufficiency can be defined as the inability of the heart to pump enough blood to meet the metabolic needs of oxygen consumption of the body at rest or during exercise. When the heart fails to propel blood forward normally, congestion occurs in the pulmonary circulation, as blood accumulates in the lungs. The immediate result is shortness of breath and, if the process continues, it leads to pulmonary congestion or pulmonary edema. Clinical Signs and Symptoms Left Ventricular Failure This causes either pulmonary congestion or a respiratory distress. Breathlessness, exhaustion, and lower extremity edema are the most common signs and symptoms of CHF.  Dyspnea Subjective and not always correlates with the extent of heart failure. Paroxysmal nocturnal dyspnea (PND) resembles the sensation of suffocation, suddenly awakening the client with a severe frightening feeling of suffocation, forcing him to sit upright. Orthopnea is a more advanced stage of dyspnea, and corresponds to a "three-point position” when the clients sits up with both hands in the knees and leans forward. Orthopnea develops because the supine position increases the amount of blood returning from the lower extremities.  Dyspnea Cough is a common symptom of left ventricular failure an is often hacking, due to a large amount of fluid trapped in the pulmonary tree, irritating the lung mucosa. Pulmonary edema may develop when the rising capillary pressure causes fluid to move into the alveoli, resulting in extreme breathlessness, anxiety, frothy sputum, nasal flaring, use of accessory breathing muscles, tachypnea, noisy and wet breathing, and diaphoresis.  Cerebral hypoxia Result of a decrease in cardiac output, causing inadequate brain perfusion. Anxiety, irritability, restlessness, confusion, impaired memory, bad dreams, and insomnia may happen. Fatigue and muscular cramping or weakness is often associated with left ventricular failure (refer to Case Example 6-3 Congestive Heart Failure - Muscle Cramping and Headache). Disturbances in sleep and rest pattern may aggravate fatigue. Nocturia develops as a result of renal changes in both right- and left-sided heart failure, since at night urine formation increases as the blood flow to the kidneys improve. Nocturia may interfere with effective sleep patterns contributing to the fatigue associated with CHF. CHF – MS cramp & headache Clinical Signs &Symptoms of Lt Sided Heart failure Fatigue and dyspnea after mild physical exertion or exercise Persistent spasmodic cough, especially when lying down (blood returning from LE's) Paroxysmal nocturnal dyspnea Orthopnea Tachycardia Fatigue and muscle weakness Edema especially of legs and ankles, and weight gain Irritability/restlessness Decreased renal function or frequent urination at night  Right Ventricular Failure It may occur in response to left-sided CHF or as a result of pulmonary embolism, resulting in peripheral edema and venous congestion of the organs. Dependent edema is one of the early signs of right ventricular failure and usually is symmetric. In ambulatory individuals, edema begins in the feet and ankles, and ascends the lower legs. It is most noticeable at the end of the day and decreases after night's rest. (Case Example 6-4) Cyanosis of the nail beds appears as venous congestion reduces peripheral blood flow. Congestive Heart Failure-Bil Pitting Edema Clinical Signs and Symptoms of Right-Sided HF Increased fatigue Dependent edema (usually beginning in the ankles) Pitting edema (after 5 to 10 pounds of edema accumulate) Edema in the sacral area or the back of the thighs Right upper quadrant pain Cyanosis of nail beds Aneurysm This is an abnormal dilation in the wall of an artery, a vein, or the heart. (See section Peripheral Vascular Disease also). Thoracic aneurysms usually involve the ascending, transverse, or descending portion of the aorta; abdominal aneurysms involve the abdominal aorta, and peripheral aneurysms affect the femoral and popliteal arteries. THORACIC AND PERIPHERAL ARTERIAL ANEURYSMS Thoracic aneurysms occur most frequently in hypertensive men between the ages of 40 and 70 years. Elevated blood pressure may facilitate the final rupture of the aortic wall when a small tear in the intima has occurred. The most common site for peripheral arterial aneurysms is the popliteal space, causing ischemic symptoms in the lower legs and an easily palpable large amplitude popliteal pulse. ABDOMINAL AORTIC ANEURYSMS (AAA's) The most common places are the aorta and the cerebral arterial vessels. Abdominal aortic aneurysms occur about four times more often than thoracic aneurysms. The most common is just below the kidneys, with referred pain to the thoraco-lumbar junction (see Fig. 6-11). Aneurysms causes : - Trauma/weight lifting (aging athletes) - Congenital vascular disease - Infection - Atherosclerosis  AAA's RISK FACTORS A history of known congenital heart disease, recent infection, or coronary artery disease (CAD; atherosclerosis) are among the risk factors. Senior keeping active and fit may be at risk while lifting weight (Case Example 6-5). AAA's can be exacerbated by anticoagulant therapy. Clinical Signs and Symptoms Most AAA's are asymptomatic. The most common symptom is awareness of a pulsating mass in the abdomen with or without pain (Case Example 6-6).  AAA's Back pain may be the only presenting feature, eventually radiating to the groin and flank. The pain is described as sharp, intense, knifelike in the abdomen, chest, or anywhere in the back (including the sacrum). Pain may also radiate to the chest, between the scapulae, and posterior thighs. Systolic blood pressure below 100 mm Hg and pulse rate over 100 bpm may indicate signs of shock. Other symptoms; severe and sudden pain in abdomen, paravertebral area, or flank; lightheadedness and nausea with sudden hypotension. Clinical Signs and Symptoms of Aneurysm Chest pain with any of the following: - Palpable, pulsating mass (abdomen, popliteal space) - Abdominal "heartbeat”felt by the client when lying down - Dull ache in the midabdominal left flank or low back - Groin and/or leg pain - Ruptured aneurysm - Weakness or transient paralysis of legs - Sudden, severe chest pain with tearing sensation (Fig.6-11) Clinical Signs and Symptoms of Aneurysm - Pain may extend to neck, shoulders, between scapulae, lower back, abdomen: pain radiating to posterior thighs help distinguish it from MI - Pain is not relieved by change of position - Pain may be described as "tearing” or "riping” - Pulsating abdominal mass - Pulse rate more than 100 bpm and systolic pressure under 100 mm Hg - Ecchymoses in the flank and perianal area - Lightheadedness and nausea  Conditions Affecting the Heart Valves Three types of valve deformities may affect the tricuspid, mitral or pulmonic valves:stenosis, insufficiency and prolapse. Stenosis is a restriction that prevents the valve from opening fully. Insufficiency (or regurgitation) occurs when the valve does not close properly and blood flows back into the heart chamber. Prolapse only affects the mitral valve and occurs when enlarged valve leaflets bulge backwards into the atrium. Clinical Signs and Symptoms of Cardiac Valve Disease Easy fatigue Dyspnea Palpitation (subjective sensation of throbbing, skipping, rapid or forcible pulsation of the heart) Clinical Signs and Symptoms of Cardiac Valvular Disease (cont'd) Pitting edema Orthopnea or paroxysmal dyspnea Dizziness and syncope (episodes of fainting or loss of consciousness) Rheumatic Fever This is an infection caused by streptococcal bacteria that leading to scarring and deformity of the heart valves, and eventually may be fatal. Two of the most common symptoms are fever and joint pain. The infection generally starts with strep throat in children between 5 and 15 years and damages the heart in approximately 50% of cases. It is treated with aggressive antibiotic therapy. CLINICAL SIGNS AND SYMPTOMS Initial cold or sore throat followed by sudden or gradual onset of painful migratory joint symptoms 2 or 3 weeks later. Fever, palpitations, and fatigue are also present. Malaise, weakness, weight loss, and anorexia. The arthralgias may last only 24 hours, or they may persist for several weeks, and resolve completely. The most characteristic and potentially dangerous is the inflammatory reaction affecting the heart valves. Rheumatic chorea (St. Vitus’ dance) may occur 1 to 3 months after the strep infection and always is noted after polyarthritis. The person develops rapid, purposeless, non repetitive movements that involve all muscles except the eyes. Clinical Signs and Symptoms of Rheumatic Fever Migratory arthralgias Subcutaneous nodules on extensor surfaces Fever and sore throat Flat, painless skin rash (short duration) Carditis Chorea Weakness, malaise, weight loss, and anorexia Acquired valvular disease  Endocarditis Bacterial endocarditis is another common heart infection causing inflammation of the cardiac endothelium and damaging the tricuspid, aortic, and mitral valves. Endocarditis may be caused by bacteria entering the bloodstream from a remote part of the body (e.gr.: skin infection, oral cavity), or it may be the result of abnormal growths (vegetations) of collagen fibers in the closure lines of previously damaged valves; causing infarction of the myocardium, kidney, brain, spleen, abdomen, or extremities.  Endocarditis Risk Factors In addition to previous valvular damage, injection drug users and postcardiac surgical clients are at high risk for developing endocarditis. CLINICAL SIGNS AND SYMPTOMS Up to 45% of clients with bacterial endocarditis have musculoskeletal symptoms, including arthralgias, arthritis, low back pain, being the most common symptom arthralgia of the proximal joints.  Endocarditis Osteoarticular infections are infrequent and the more commonly affected sites include vertebrae, the wrist, the sternoclavicular joints, and the sacroiliac joints. Sacroiliac joint destructive changes occur probably as the result of a septic emboli. Endocarditis-induced low back pain may be differentiated from a herniated disk because there is no neurological component, although symptoms mimic a lumbar disk herniation.  Endocarditis Clinical Signs and Symptoms of Endocarditis Arthralgias, arthritis Musculoskeletal symptoms, myalgias Low back/sacroiliac pain Dyspnea, chest pain Cold and painful extremities Conditions Affecting the Cardiac Nervous System The third component of cardiac disease is the failure of the heart's nervous system to conduct normal electrical impulses. Arrhythmias, also called dysrhythmias, are disorders of the heart rate and rhythm caused by a dysfunctional conduction system. Arrhythmias may cause the heart to beat too fast (tachycardia), too slow (bradycardia), or with extra beats and fibrillations, and can lead to hypotension, heart failure, and shock.  Fibrillation The sinoatrial (SA) node - pacemaker - is responsible to initiate the heart contractions. During a MI, damaged heart cells can release small electrical impulses that may disrupt the normal conduction pathway, resulting in fibrillation of the atria or the ventricles. Ventricular fibrillation usually requires resuscitation and emergency electrical countershock (defibrillation) as life saving measures, while atrial fibrillation is not an immediate lethal arrhythmia, but a series of unsynchronized pattern of contractions, causing the atrium to quiver. Blood tends to pool, which allows for clots to form that can break loose, and travel to the brain causing a stroke.  Fibrillation RISK FACTORS Persons at risk for fibrillation include those who have had a previous heart attack, high blood pressure, CHF, digitalis toxicity, pericarditis, or rheumatic mitral stenosis. Clinical Signs and Symptoms of Fibrillation Subjective report of palpitations Sensation of fluttering, skipping, irregular beating or pounding Dyspnea Clinical Signs and Symptoms of Fibrillation Chest pain Anxiety Pallor Nervousness Cyanosis Sinus Tachycardia It is an abnormally rapid heart rate, usually more than 100 beats per minute. Usually it is of no physiologic significance; however, in clients with organic myocardial disease it may result in reduced cardiac output, CHF, or arrhythmias. Clinical Signs and Symptoms of Sinus Tachycardia Palpitation (the most common symptom) Restlessness Clinical Signs and Symptoms of Sinus Tachycardia Chest discomfort or pain Agitation Anxiety and apprehension Sinus Bradycardia The sinus node discharges at a rate less than 60 bpm, however, the impulses travel down the same pathway as sinus rhythm. It may be normal in athletes or young adults and therefore is asymptomatic. Syncope may be preceded by sudden onset of weakness, sweating, nausea, pallor, vomiting, and distortion or dimming of vision. Clinical Signs and Symptoms of Bradycardia Reduced pulse rate Syncope  Cardiovascular Disorders Hypertension It is a major cardiovascular risk factor when associated with elevated risk factors of MI, stroke, PVD, and cardiovascular death (Case Example 6-9). Pulse Pressure It is the difference between the systolic and diastolic pressure. A widened pulse pressure often results from stiffening of the aorta secondary to atherosclerosis and is linked to a significantly higher risk of stroke and heart failure after the sixth decade.  Cardiovascular Disorders Blood Pressure Classification Primary, essential, or idiopathic hypertension accounts for 90% to 95% of all hypertensive clients. Secondary hypertension results from an identifiable cause such as renal artery stenosis, oral contraceptive use, hyperthyroidism, adrenal tumors, and medication. Risk Factors There are modifiable factors and nonmodifiable factors. (Table 6-6) Modifiable factors such as smoking, obesity, sedentary life, stress, diet, high cholesterol, and alcohole use. Clinical Signs and Symptoms of Hypertension Occipital headache Vertigo (dizziness) Flushed face Spontaneous epistaxis (nose bleeding) Vision changes Nocturnal urinary frequency Transient Ischemic Attack (TIA) When blood supply to parts of the brain has been temporarily disrupted. TIAs are important warning signs that an obstruction exists in an artery leading to the brain. Immediate medical referral is advised.  Clinical Signs and Symptoms of Transient Ischemic Attack Slurredspeech, sudden difficulty understanding others Sudden confusion, loss of memory, even loss of consciousness Temporary blindness or other dramatic visual changes Dizziness Sudden, severe headache Paralysis or extreme weakness, usually affecting one side of the body Difficulty walking, loss of balance or coordination Symptoms are usually brief, lasting only a few minutes but can persist up to 24 hours  Clinical Signs and Symptoms of Transient Ischemic Attack Orthostatic Hypotension This is an excessive fall in blood pressure of 20 mm Hg or more in systolic pressure or a drop of 10 mm Hg or more of both systolic and diastolic blood pressure on assumption of the erect position with a 10% to 20% increase in pulse rate. P.T. should measure the vital signs before treatment. Peripheral Vascular Disease (PVDs) Impaired circulation may be caused by a number of acute or chronic medical conditions affecting the arterial, venous, or lymphatic circulatory system. Arterial (Occlusive) Disease Arterial diseases include acute and chronic arterial occlusion. (Table 6-7). Acute arterial occlusion usually associated with 6 P’s symptoms (pain, pallor, pulselessness, paresthesia, coldness, paralysis) RISK FACTORS Diabetes mellitus, smoking, hypertension, hyperlipidemia, and older age are known risk factors. Clinical Signs and Symptoms of Arterial Disease Intermittent claudication Burning, ischemic pain at rest Rest pain aggravated by elevating extremities; relieved by hanging the foot down Color, temperature, skin, nail bed changes. Decreased skin temperature. Dry, scaly, or shiny skin. Poor nail and hair growth Possible ulcerations and gangrene on weight bearing surfaces (e.g.: toes, heels) Vision changes (diabetic atherosclerosis) Fatigue on exertion (diabetic atherosclerosis) Raynaud's Phenomenon and Disease It refers to intermittent episodes of constriction of small arteries in extremities, causing temporary pallor and cyanosis of the digits and changes in skin temperature. Secondary Raynaud's Phenomenon and Disease It is often associated with connective tissue or collagen vascular disease as polymyosistis, SLE or RA.  Clinical Signs and Symptoms of Raynaud's Phenomenon and Disease Pallorin the digits Cyanotic, blue digits Cold, numbness, pain of digits Intense redness of digits Venous Disorders They can be divided into acute and chronic conditions. Chronic venous disorders can be separated into varicose vein formation and chronic vein insufficiency.  ACUTE VENOUS DISORDERS They are due to formation of thrombi (clots) which obstruct the venous flow. Pulmonary emboli are an acute and potentially lethal complication of deep venous thrombosis of the legs. Risk Factors for Pulmonary Embolism (PE) and Deep Venous Thrombosis (DVT) and Case- Example 6- 11). P.T. should pay attention to the symptoms of DVT. Review table 412 for Well’s Clinical decision Rule for DVT. P.T. uses it for screening. Clinical Signs and Symptoms Superficial thrombophlebitis appears as a visible subcutaneous venous distention, while deep venous thrombosis are less distinctive (Case Example 6-12,). Clinical Signs and Symptoms of Superficial Venous Thrombosis Subcutaneous venous distention Palpable cord Warmth, redness Indurated (hard)  Clinical Signs and Symptoms of Deep Venous Thrombosis Unilateral tenderness or leg pain Unilateral swelling Warmth and discoloration Pain with blood pressure cuff around calf inflated to 160 mm to 180 mm Hg  Lymphedema It is an excessive accumulation of fluid in tissue spaces. Clinical Signs and Symptoms of Lymphedema Edema of the dorsum of the foot or hand Decreased range of motion, flexibility, and function Usually unilateral Worse after prolonged dependency No discomfort or a dull, heavy sensation; sense of fullness Screening for the Effects of Cardiovascular Medications Table 6-8,. physical therapist should pay attention to the signs and symptoms develpoed from the side effects of the drugs used for cardiac conditions. Box 6-3 shows the Potential Side Effects of Cardiovascular Medications provides a list of conditions and symptoms that may need immediate referral or notification to the physician such as abdominal pain, asthmatic attack, bradycardia, dehudration…. etc.  Physician Referral It is not the therapist's responsibility to differentiate diagnostically among the various causes of cardiovascular disorders, but rather recognize the systemic origin of signs and symptoms that may mimic musculoskeletal disorders.  Guidelines for Immediate Medical Attention: Sudden worsening of intermittent claudications If anginal pain is not relieved in 20 minutes within administration of nitroglycerin Nausea, vomiting, or profuse sweating Pain does not relieve by rest, increased intensity, or longer duration of pain Guidelines for Physician Referral: Systemic signs or symptoms Positive family history of breast cancer or heart disease Palpitation associated with pain, SOB, fainting, light headedness Cannot climb a single flight or stairs without feeling severely winded Awakening at night because of SOB when lying down Fainting without any warning periods of dizziness, nausea, or light headedness Neurologically unstable as a result of CVA, head trauma, spinal cord injury, or other CNS insult often exhibits new arrhythmias Demonstrate a difference between SBP and DBP of > 40 mm Hg (pulse pressure).  Clues for Screening for cardiovascular Signs and Symptoms Watch for the three Ps * Pleuritic pain (exacerbated by respiratory movement involving the diaghragm)(pain is worse on lying down and improves on sitting up or leaning forward) * pain on palpitation * pain with changing positions (musculoskeletal or pulmonary) If two of the three Ps are present, a myocardial infarction is very unlikely.  KEY POINTS TO REMEMBER 1. / Fatigue beyond expectations during or after exercise is a red-flag symptom. 2. / Be on the alert for cardiac risk factors in older adults, especially women, an begin a conditioning program before an exercise program. 3. / The client with stable angina typically has a normal blood pressure; it may below, depending on medications. Blood pressure may be elevated when anxiety accompanies chest pain or during acute coronary insufficiency; systolic blood pressure may be low if there is heart failure.  KEY POINTS TO REMEMBER 1. / Fatigue beyond expectations during or after exercise is a red-flag symptom. 2. / Be on the alert for cardiac risk factors in older adults, especially women, an begin a conditioning program before an exercise program. 3. / The client with stable angina typically has a normal blood pressure; it may below, depending on medications. Blood pressure may be elevated when anxiety accompanies chest pain or during acute coronary insufficiency; systolic blood pressure may be low if there is heart failure.  KEY POINTS TO REMEMBER 4. / Cervical disk disease and arthritic changes can mimic atypical chest pain of angina pectoris, requiring screening through questions and musculoskeletal evaluation. 5. / If a client uses nitroglycerin, make sure that he or she has a fresh supply, and check that the physical therapy department has a fresh supply in a readily accessible location. 6. / Anyone being treated with both NSAIDs and ACE inhibitors must be monitored closely during exercise for elevated blood pressure.  KEY POINTS TO REMEMBER 7. / A person taking medications, such as beta-blockers or calcium channel blockers, may not be able to achieve a target heart rate (THR) above 90 beats per minute. To determine a safe rate of exercise, the heart rate should return to the resting level 2 minutes after stopping exercise. 8. / Make sure that a client with cardiac compromise has not smoked a cigarette or eaten a large meal just before exercise.  KEY POINTS TO REMEMBER 9. / A 3-pound or greater weight gain or gradual, continuous gain over several days, resulting in swelling of the ankles, abdomen, and hands, combined with shortness of breath, fatigue, and dizziness that persist despite rest, may be red-flag symptoms of CHF. 10. / The pericardium (sac around the entire heart) is adjacent to the diaphragm. Pain of cardiac and diaphragmatic origin is often experienced in the shoulder because the heart and the diaphragm are supplied by the C5-6 spinal segment. The visceral pain is referred to the corresponding somatic area.  KEY POINTS TO REMEMBER 11. / Watch for muscle pain, cramps, stiffness, spasms, and weakness that cannot be explained by arthritis, recent strenuous exercise, a fever, a recent fall, or other common causes in clients taking statins to lower cholesterol.