Cardiovascular

Cardiovascular Left Ventricular Failure General Features Exertional dyspneal Orthopnoea Paroxysmal nocturnal dyspneal Tachypnoea (due to raised pulmonary pressures). Central cyanosis (due to pulmonary edema). Cheyne-Stokes breathing Especially in sedated in elderly patient. Pulse related features Peripheral cyanosis (due to low cardiac output) Hypotension (due to low cardiac output). Low pulses pressure (due to low cardiac output). Pulses alternans -> alternations between weak and strong beats. Sinus tachycardia (due to increased sympathetic tone). Apex beat related features Displaced apex beat with dilation of the left ventricle -> may feel dyskinetic if the patient had anterior MI or has had dilated cardiomyopathy. Absence of this sign does not mean that there is no LVF. Auscultation related features S3: Due to increase turbulence An important sign Possibly functional mitral valve regurgitation: Secondary to valve ring dilation. Lung field related features Signs of pulmonary congestion: Basal inspiratory crackles. Pulmonary edema: Crackles and wheeze throughout lung fields. Due to increased cardiac preload -> raised venous pressure Other features Positive abdominojugular reflex -> sign of RHF Anaemia Systemic infection (aetiology) Volume overload: Aortic regurgitation Mitral regurgitation Patent ductus arteriosus Signs of MI Pressure overload: Systolic hypertension Aortic stenosis Rapid arrythmia -> e.g. AF -> possible aetiology Thyrotoxicosis -> possible aetiology Right Ventricular Failure General Features Ankle, sacral or abdominal edema/swelling. Anorexia Lethargy Nasuea Peripheral cyanosis (due to low cardiac output). Arterial Pulse Related Features Low volume: Due to low cardiac output JVP Related Features High JVP: Due to increased preload -> raised venous pressure. Kussmaul’s sign: Due to poor ventricular compliance -> e.g. when there is right ventricular MI. Large V waves: Valve ring dilation -> functional tricuspid valve regurgitation. Heaves: Precordial palpation Parasternal impulse -> right ventricular heave Auscultation Related features Right ventricular S3 Pansystolic murmur of the functional tricuspid valve regurgitation Absence of murmur does not mean that there is no tricuspid valve regurgitation. Abdomen Related Features Tender hepatomegaly: Due to increased venous pressure via the hepatic veins. Pulsatile liver: Useful sign if tricuspid valve regurgitation is present. Oedema Related Features Due to sodium and water retention plus raised venous pressure. Manifests as sacral and ankle edema, ascites or pleural effusion. Other Important Features for Aetiology COPD features (most common cause). Features of LVF Volume overload: Atrial septal defect Primary tricuspid valve regurgitation. Pulmonary stenosis Idiopathic pulmonary hypertension. Features of MI RVH Chest Pain Important Points Many represent medical or surgical emergencies. The appropriate diagnosis is often suggested by: History Physical examination ECG CXR CTPA General Features Diaphoresis Angor animi -> impending sense of doom Restlessness Pulse and Blood Pressure Related Features Tachycardia Hypotension Bradycardia JVP Related Features Increased right ventricular infraction: Kussmaul’s sign Specific and sensitive sign of RV infraction for patients with a recent inferior infarct. Apex Beat Related Features Dyskinetic in patients with large anterior infarction. Auscultation S4 S3 Decreased intensity of heart sounds Transient apical mid systolic or late systolic murmurs: 25% from mitral regurgitation secondary to papillary muscle dysfunction. Pericardial rub: Usually occurs only some days later Killip Classification Can be calculated from the examination. It gives considerable prognostic information. CLASSIFICATION DESCRIPTION CLASS I No evidence of heart failure Mild heart failure CLASS II Crackles over the lower third or less of the lungs Systolic blood pressure over 90 mmHg Pulmonary edema Crackles CLASS III More than 1/3 of the chest Systolic blood pressure over 90 mmHg Cardiogenic shock Pulmonary edema CLASS IV Crackles more than 1/3 of the chest Systolic blood pressure less than 90 mmHg. Class II: is associated with a threefold increase in mortality compared to class I. Class III or IV: associated with a fivefold increase in mortality compared to class I. Pulmonary Embolism No specific signs for this. Shortness of breath Profound dyspnoea that might cause the patient to become exhausted. Most common clinical examination finding of PE Usually resting tachycardia Signs suggestive of shock: Hypotension Cyanosis -> indicates a very large and life-threatening embolus. DVT signs in the leg. Absence does NOT exclude the diagnosis Acute Aortic Dissection General Features from History Chest pain: Severe pain -> maximum intensity Radiates to the back Stroke Syncope -> associated with tamponade Symptom of LV failure Rarely limp pain (due to ischemia). Paraplegia -> spinal cord compression (rare). Mesenteric ischemia -> abdominal pain (rare). Physical Findings from Examination Signs of body habitus ->features of Marfan’s or Ehlers-Danlos Syndrome Diminished radial pulse on one side A blood pressure difference of 20 mmHg or greater between the upper limbs. Examine the patient for signs of cardiac tamponade. Occurs when the aorta ruptures into the pericardial sac. Examine for signs of aortic regurgitation. Due to a disruption of the aortic valve annulus. Neurological examination: Mary reveals signs of hemiplegia due to dissection of one of the carotid arteries. Rare findings that have been found: Recurrent laryngeal nerve compression -> voice hoarseness. Oesophageal compression -> dysphagia Tracheal tug if there is an already present aneurysm of the aortic arch. Pericardial Disease Acute Pericarditis General Features Dyspnoea Fever Pericardial rub: Ask the patient to sit up and hold their breath. High pitched scratching on auscultations -> indicates friction between the visceral and partial pericardial tissue. Best heard over the left sternal boarder during expiration while the patient is sitting up and leaning forwards. Chronic Constrictive Pericarditis General features Cachexia Pulse and Blood Pressure Related Features Pulses paradoxus: More than 10 mmHg fall in the arterial pulse pressure on inspiration, because the increased right ventricular filling compresses the left ventricle. Low blood pressure JVP Related Features Elevated JVP. Kussmaul sign: Lack of fall or even increase distension inspiration. Prominent x and y descents -> brick collapse during systole. Apex Beat Related Features Not palpable Auscultation Related Features Distant heart sounds Early S3 Early pericardial knock -> rapid ventricular fulling abruptly halted. Abdomen Related Features Hepatomegaly Splenomegaly Ascites All are due to raised venous pressure. Other Important Manifestations Peripheral edema Acute Cardiac Tamponade General features Tachypnoea Anxiety Restlessness Syncope Patients look very ill Cardiovascular Related Features Pulse and blood pressure: Rapid pulse rate Pulses paradoxus Hypotension JVP Raised Prominent x wave, but absent y wave Apex beat Not palpable Auscultation Soft and muffled heart sounds Respiratory Related Features Dullness Bronchial breathing at the left base Due to lung compression by the distended pericardial sac. Infective Endocarditis General Features Fever Weight loss Pallor – anaemia Upper Limb Related Features Splinter haemorrhages Clubbing Within 6 weeks of onset Osler nodes (rare). Janeway lesions (very rare). Evidence of intravenous drug use: Right and left cardiac endocarditis Eye Related Features Pale conjunctivae -> anaemia Retinal or conjunctival haemorrhages -> Roth Spots Fundal vasculitic lesions with yellow centre surrounded by a red ring. Heart Related Features Acquired: Mitral valve regurgitation Mitral stenosis Aortic stenosis Aortic regurgitations Congenital: Patent ductus arteriosus Ventricular septal defect Contraction of the aorta Other Important Features Splenomegaly Peripheral evidence of embolism to limbs or nervous system. This may manifest as: Mycotic aneurysm Erythematous nodules on the skin ->nose, ankle and buttocks. Large emboli may cause an ischemic limb or stroke. Urinalysis: Dysmorphic RBCs RBC casts on microscopy Systemic Hypertension General inspection The rare signs of secondary hypertension much be sought after. Cushing’s syndrome Acromegaly Polycythaemia CKD Blood Pressure A rise in diastolic blood pressure on standing occurs in essential hypertension. A fall on standing may suggest a secondary cause. Usually a side effect of anti-hypertensives. Palpate for radio-femoral delay: Check the BP in the legs if coaction of the aorta is suspected or if severe hypertension is suspected before 30 years of age. Fundi Examination Check for retinal changes of hypertension. Graded from 1 to 4. Grade Description Silver wiring of the arteries only GRADE I Sclerosis of the vessel wall reduced it transparency, so the central light streak becomes broader and shinier. Grade I AND GRADE II Arteriovenous nipping or nicking Indentation or deflection of the veins where they are crossed by the arteries. Image Grade II AND GRADE III GRADE IV Haemorrhage (flame-shaped) and exudates (soft-cottonwool spots due to ischemia or hard-liquid residues from leaking vessel). Grade III AND Papilledema Examine the rest of the cardiovascular system Examine the Abdomen with a Focus on: Palpate for renal or adrenal masses and for possible presence of an abdominal aortic aneurysm (a possible complication). Examine for signs or renal artery stenosis Indicated by: A loud systolic-diastolic bruit that is prominent in the epigastrium. Examine the central nervous system Look for sings of previous cerebrovascular accidents Palpate and auscultate for carotid artery bruits. Pulmonary Hypertension Important Points Mena pulmonary pressures higher than 35 mmHg and systolic pressures of more than 50 mmHg are abnormal and constitute pulmonary hypertension. General Features Exertional dyspnoea Fatigue Chest pain Possibly due to right ventricular ischemia in upton 50% of patients. Tachypnoea Peripheral cyanosis Cold extremities Due to low cardiac output Hoarseness Very rare -> due to pulmonary artery compression of the left recurrent laryngeal nerve. Pulse Related Features Mainly small volume Due to low cardiac output Only in severe disease JVP Related Features Prominent a wave Due forceful right atrial contraction. Cardiac Related Features Right ventricular heave Palpable P2. Auscultation: Systolic ejection click -> due to dilation of the pulmonary artery Loud P2 -> due to forceful valve closure because of high pulmonary pressures. S4 Pulmonary ejection murmur -> due to dilation of the pulmonary artery resulting in turbulent blood flow Murmur of the pulmonary valve regurgitation if dilation of the pulmonary artery occurs. Mitral Stenosis Important Notes The normal area of the mitral valve is 4 to 6 cm 2 . Reduction of the valve area to half normal or less causes significant obstruction to the left ventricular filling and blood flow from the left atrium to the left ventricle only if the left atrial pressure is raised. General Features Dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea Increased led atrial pressure Tachypnoea Peripheral cyanosis Haemoptysis Ruptured bronchial veins Ascites Oedema Fatigue Due to pulmonary hypertension Vascular Related Features Pulse and blood pressure: Normal or reduced in volume Due to reduced cardiac output, AF may be present dye to left atrial enlargement. JVP: Normal Prominent a wave if pulmonary hypertension is present Loss of a wave if AF is present Cardiac Related Features Palpation: Tapping quality of the apex beat -> palpable S1 Right ventricular heave (parasternal impulse) Palpable P2 if pulmonary hypertension is present Diastolic thrill -> rare Lay the patient on the left side to check for this. Auscultation: Loud S1 -> valve cusps widely apart at the systole onset. Palpable P2 if pulmonary hypertension is present. Opening snap -> high left atrial pressure forces the valve cusps apparent, but the valve cone halts abruptly. Low pitched diastolic murmur: Best heard with the bell Lay the patient in left lateral position Exercise increases the murmur intensity -> ask the patient to sit up and down the head really quickly Signs that indicate severe mitral valve stenosis This is when the valvular area is less than 1 cm 2 Small pulse pressure Soft first heart sound Early opening snap: Due to increased left atrial pressures Long diastolic murmur Persists as long as there is a gradient Diastolic thrill at the apex Signs of pulmonary hypertension Mitral Valve Regurgitation General Features Dyspnoea: Increased left atrial pressure Fatigue: Decreased cardiac output Tachypnoea Pulse Related Features Normal or sharp upstroke due to rapid left ventricular decompensation. AF is common Cardiac Related Features Palpation: Displaced apex beat Diffuse and hyperdynamic beat Pansystolic thrill at apex Parasternal impulse Due to left atrial enlargement behind the right ventricle – the left atrium is often larger in mitral regurgitation than in mitral stenosis is massive. Auscultation Soft or absent S1 Left ventricular S3 -> due to rapid ventricular filling in early diastole Pansystolic murmur maximal at the apex and usually radiates to the axilla. Severe signs indicating chronic mitral regurgitation: Small volume pulse Enlarged soft LV Loud S3 Soft S1 A2 is early -> due to rapid left ventricular decompression into the LA causes the aortic valve to close early. Early diastolic rumble Signs of pulmonary hypertension Signs of LVF