Cardiac signs and symptoms Flashcards
Which events come under the category of acute coronary syndrome (ACS)?
- STEMI
- NSTEMI
- Unstable angina
What is the difference between a STEMI vs NSTEMI?
STEMI = blocked off artery completely NSTEMI = Partial blockage, but not complete occlusion of the coronary artery and raised troponin
What are the cardinal symptoms of ACS events?
- Chest pain
- Crushing ischaemic pain
- Radiates to left arm and jaw - Breathlessness
- Palpitations
- Syncope
- Haemoptysis
- Nausea
- Oedema
- Cough
- Fatigue
Haemoptysis can be seen with which diseases?
- Pulmonary oedema
- Mitral stenosis
- Pulmonary infarction
- Lung carcinoma
Give some different causes of fatigue?
- Excessive diuresis
- Diuretic induced hypokalaemia
- Reduced cardiac output
- Drugs e.g. beta-blockers
- Heart failure
- Hypertension
Different ways that sputum can present and what this signifies: ‘pink frothy’
Pulmonary oedema
Different ways that sputum can present and what this signifies: clear, white, mucoid sputum
Viral infection or longstanding bronchial irritation
Different ways that sputum can present and what this signifies: thick, yellowish sputum
Infection
Different ways that sputum can present and what this signifies: rusty sputum
Pneumococcal pneumonia
Different ways that sputum can present and what this signifies: blood-streaked sputum
Tuberculosis
Bronchiectasis
Lung cancer
Pulmonary infarction
Ischaemic cardiac chest pain is which two processes?
MI
Angina
Explain the site, character, pattern, severity and radiation of ischaemic cardiac chest pain
Site: chest
Character: tightness/crushing/heavy/squeezing
Pattern: Always there in MI and comes with stress or exertion in angina
Severity: extreme
Radiation: shoulder (L) or jaw
Chest pain is not likely to be ischaemic if…
- It is continuous/very prolonged
- Unrelated to activity
- Brought on by breathing in
Give differential diagnoses for retrosternal pain
- Myocardial ischaemic pain
- Pericardial pain
- Oesophageal pain
- Aortic dissection
- Mediastinal lesions
- PE
Give differential diagnoses for shoulder pain
- Myocardial ischaemic pain
- Pericarditis
- Subdiaphragmatic abscess
- Diaphragmatic pleurisy
- Cervical spine disease
- Acute musculoskeletal pain
- Thoracic outlet syndrome
Give differential diagnoses for arm pain
- Myocardial ischaemic pain
- Cervical/dorsal spine pain
- Thoracic outlet syndrome
Give differential diagnoses for epigastric pain
- Myocardial ischaemic pain
- Pericardial pain
- Oesophageal pain
- Duodenal pain
- Pancreatic pain
- Gallbladder pain
- Distention of the liver
- Diaphragmatic pleurisy
- Pneumonia
Give differential diagnoses for RIGHT lower anterior chest pain
- Gall bladder pain
- Distention of the liver
- Subdiaphragmatic abscess
- Pneumonia/pleurisy
- Gastric or duodenal penetrating ulcer
- Pulmonary embolisation
- Acute myositis
- Injuries
Give differential diagnoses for LEFT lower anterior chest pain
- Intercostal neuralgia
- PE
- Myositis
- Pneumonia/pleurisy
- Splenic infarction
- Splenic flexure syndrome
- Subdiaphragmatic abscess
- Precordial catch syndrome
- Injuries
Which features may make a diagnosis of stable angina unlikely?
- Continuous or prolonged pain
- Unrelated to activity
- Brought on by breathing
- Associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing
Typical angina meets which characteristics? Compare this with atypical angina and non-cardiac chest pain
- Substernal chest discomfort of characteristic quality and duration
- Provoked by exertion or emotional stress
- Relieved by rest and/or GTN
- Atypical angina meets 2/3 of these characteristics
- Non-cardiac chest pain meets 1/3 or 0/3 of these characteristics
Compare signs and symptoms of angina vs MI
- Angina due to exertion whereas MI is at rest
- Angina due to emotional stress whereas MI builds up over a few minutes
- Angina is worse in the cold
- Angina is relieved by rest or GTN (2-10 mins) whereas MI has no relief from rest/GTN and lasts 30mins+
- MI is associated with autonomic symptoms such as breathlessness, sweating and nausea
Explain what the HPC of a patient with pericarditis would be
- Sharp, stabbing chest pain
- Worse with inspiration
- Worse lying flat
- Eased by sitting up and NSAIDs
- Hours to days
Causes of pericarditis
- Infection
2. Pericardial infusion - with infection, malignancy, lymphoma
Explain what the HPC of a patient with aortic dissection would be
- Sudden onset
- Tearing, knife-like pain
- Excruciating
- Radiating to back
- Abdominal pain - may require opiate analgesia
- Often seen in ELDERLY population with HYPERTENSION
- Seen in people with stressful jobs with hypertension at a young age
Explain what the HPC of a patient with PE would be
- Pain over infarcted area
- Pleuritic pain (on inspiration)
- Associated with SOB
- Tachycardia/AF
- Tachypnoea
Breathlessness can be which processes?
- Dyspnoea
- Abnormal uncomfortable awareness of breathing - Tachypnoea
- Faster breathing than normal (>24 breaths per min)
Give different cardiac-related diseases associated with breathlessness
- Pulmonary oedema
- Paroxysmal nocturnal dyspnoea
- Chronic heart failure
Explain what the HPC of a patient with pulmonary oedema would be
- Abrupt - over several minutes
- Pink, frothy sputum
- Orthopnoea - breathlessness when laying flat, due to re-accumulation of fluid within the alveolar spaces in the lungs
- Cold, clammy
What are causes of pulmonary oedema
- MI
- LV dysfunction
- Renal artery stenosis
What would the CXR look like in pulmonary oedema?
- Cardiomegaly
- Bats-wing appearance (fluid and congestion)
- Fluid in interstitial spaces (kerley B lines)
Explain what the HPC of a patient with PND would be
- Wake from sleep (2-4hrs)
- Cough, wheeze
- Have to sit up whilst sleeping (ask how many pillows they sleep with)
- Frightening
- Lasts 15-20 minutes (the frightening symptoms)
Explain what the HPC of a patient with chronic heart failure would be
- Exertional breathlessness, relieved by rest
- Orthopnoea
- Swollen abdomen - ascites caused by severe LV dysfunction, R heart failure
- Nocturnal cough
- Episodes of PND
- Ankle oedema
Sensitivity vs specificity of a test?
Sensitivity = ability to correctly identify people WITH the disease
Specificity = ability to correctly identify people WITHOUT the disease
What are palpitations?
Unpleasant awareness of one’s own heart beat
When a patient presents with palpitations, what sort of questions would you ask surrounding this?
- Regular/irregular
- Rate
- Duration
- Frequency
- Precipitants, relief
- Associated symptoms
What is syncope?
Transient loss of consciousness (fainting) and postural control (collapse) due to cerebral hypoperfusion - rapid spontaneous recovery
Exertional syncope is worrying in which demographic and why?
Young people
- may be due to an underlying structural heart disease such as hypertrophic cardiomyopathy
What sort of questions do you ask when a patient presents with an event of syncope?
- Questions about circumstances just prior to attack
- Position (supine, sitting or standing)
- Activity (supine, during or after exercise)
- Situation (urination, defecation, cough, swallowing)
- Predisposing factors (crowded or warm places, prolonged standing, post-prandial period)
- Precipitating events (fear, intense pain, neck movements) - Questions about onset of attack
- Nausea, vomiting, feeling cold, sweating, aura, pain in neck or shoulders - Questions about attack (eye witness)
- Skin colour (pallor, cyanotic)
- Duration of loss of consciousness
- Movements (tonic-clonic etc)
- Tongue biting - Questions about end of attack
- Nausea, vomiting, diaphoresis, feeling cold, confusion, muscle aches, skin colour, wounds - Questions about background
- Number and duration of syncopes
- FHx of arrhythmogenic disease
- Presence of cardiac disease
- Neurological history (Parkinsonism, epilepsy, narcolepsy)
- Internal history (diabetes etc…)
- Medication (hypotensive and antidepressant agents)
Different causes for lack of consciousness
- Cardiac (syncope)
- sudden onset
- no aura
- no jerks/incontinence
- injury common
- very pale
- immediate recovery - Neurological (epilepsy)
- prodrome/aura
- convulsive moments
- incontinence
- self-harm (tongue)
- post-ictal confusion - Vasodepressor syncope
- after prolonged standing
- response to stress
- gradual developing faintness
- greying out of vision - Carotid sinus hypersensitivity
- rubbing neck causes syncope (carotid artery rubbing)
Differential causes of peripheral oedema other than CHF?
- Nephrotic syndrome
- Low albumin
- Cirrhosis
- Drugs e.g. amlodipine
- Pregnancy
What are you looking for in a CV exam general inspection?
- Breathlessness at rest/sat up
- Hands/nails
- Clubbing
- Splinter haemorrhages
- Palmar erythema
- Peripheral cyanosis
- Capillary refill <2-3secs - Face
- Arcus senilis/xanthelasma
- Central cyanosis
- Anaemia
- Poor oral hygiene
- High arched palate
- Malar flush = mitral stenosis
Causes of clubbing?
- PDA - causes toe clubbing
- Infective endocarditis
- Congenital heart disease
- Atrial myxoma
Causes of splinter haemorrhages (small emboli in finger nails)?
- Infective endocarditis
2. Vascular disease
Causes of palmar erythema?
- High oestrogen
2. Liver disease
Causes of xanthelasma?
Hypercholesterolaemia
Cause of a high arched palate?
Marfan’s syndrome
If a patient presents with SoB and clubbing, what should you suspect?
Lung cancer
What do the 1st and 2nd heart sounds represent?
- 1st = closure of the mitral and tricuspid valves
- 2nd = closure of the aortic and pulmonary valves
What are Osler nodes?
Painful lesions on the pulps of fingers and thenar eminences, caused by deposition of immune complexes in fingers
What are Janeway lesions?
Black spots on the hypothenar eminences of hands and feet, septic emboli within the dermis of skin
What is a Roth’s spot? Found in which patients?
Retinal haemorrhage, often found in patients with infective endocarditis?
What are the two things to consider with the JVP?
Height
- Measure from the angle of Louis at 45degrees, usually should be 2-3cm, if >4cm it is elevated
Waveform
What do the different waveforms of a JVP represent?
- A - produced by atrial systole
- X descent - occurs when atrial contraction finishes
- C wave - caused by rapid increase in RV pressure before tricuspid valve closure
- V wave - develops as venous return fills the RA during ventricular systole
- Y descent - follows the V wave when the tricuspid valve opens
Give examples of JVP abnormalities and their causes
- Elevated JVP
- Heart failure
- Constrictive pericarditis
- Cardiac temponade
- Renal disease
- SVC obstruction - Large A waves
- Pulmonary hypertension
- Tricuspid stenosis - No A wave
- Atrial fibrillation - Giant V waves
- Complete heart block
- VT (atria contracts onto closed tricuspid valve)
- Tricuspid regurgitation - Steep Y descent
- Constrictive pericarditis (Friedreich’s sign - rapid fall and rise in JVP)
- Cardiac temponade
What is cardiac temponade?
Cardiac tamponade happens when extra fluid builds up in the space around the heart (pericardial effusion). This fluid puts pressure on the heart and prevents it from pumping well
The fluid prevents friction between the layers when they move as the heart beats. In some cases, extra fluid can build up abnormally between these 2 layers. If too much fluid builds up, the extra fluid can make it hard for the heart to expand normally. Because of the extra pressure, less blood enters the heart from the body. This can reduce the amount of oxygen-rich blood going out to the body.
Causes of cardiac temponade?
- Infection of the pericardial sac such as during a viral or bacterial illness
- Cancer
- Inflammation of the pericardial sac from a heart attack
- Trauma from procedures done to the heart.
- Autoimmune disease
- Reactions to certain medicines
- Radiation treatment to the chest area
- Metabolic causes, such as chronic kidney failure, with a buildup of fluid and toxins in the body.
- After open heart surgery
Signs and symptoms of cardiac temponade
Classical signs = Beck’s triad
- Hypotension
- Distention of jugular veins
- Muffled heart sounds
- Chest pain radiating to shoulders or back which is relieved by sitting forward
- Dyspnoea/SoB
- Tachycardia
- Tachypnoea
- Fainting/dizziness/loss of consciousness
- Oedema (arms and legs)
- RUQ pain
Signs and symptoms of cardiomyopathy
Fatigue SoB with activity or even at rest Bloating of the abdomen due to fluid buildup Peripheral oedema (legs, ankles, feet or abdomen) Cough while lying down Chest pain or discomfort Fast, fluttering or pounding heartbeat Chest discomfort or pressure Dizziness, lightheadedness and fainting
Causes of cardiomyopathy
- Long term hypertension
- Heart tissue damage from MI
- Long term tachycardia
- Heart valve problems
- Certain infections which cause inflammation of the heart
- Metabolic disorders, such as obesity, thyroid disease or diabetes
- Lack of essential vitamins or minerals in the diet, such as thiamin (vit B-1)
- Pregnancy complications
- Iron buildup in heart muscle (haemochromatosis)
- Granulomas incl. heart and lungs (sarcoidosis)
- Amyloidosis
- Xs alcohol
- Cocaine use, amphetamines, anabolic steroids
- Chemotherapy drugs
What is cardiomyopathy?
Disease of the heart muscle that makes it harder for the heart to pump blood, this can lead to heart failure
What are the main types of cardiomyopathy?
- Dilated: LV becomes enlarged.
- Hypertrophic: abnormal thickening of heart muscle, mostly affects LV
- Restrictive: heart becomes stiff and less flexible so it can’t expand and fill with blood between heartbeats
Most common cause of dilated cardiomyopathy
CAD or MI
Most common cause of hypertrophic cardiomyopathy
FHx
- More severe if it occurs in childhood
Risk factors for cardiomyopathy
- FHx of cardiomyopathy, heart failure and sudden cardiac arrest
- Long term hypertension
- Prev. heart attack, CAD, or heart infectin (ischaemic cardiomyopathy)
- Obesity
- Long-term alcohol misuse
- Illicit drug use, cocaine, amphetamines, anabolic steroids
- Chemo treatment
Diagnosis of cardiomyopathy
- CXR
- Echo
- ECG
- Cardiac MRI
- Cardiac CT
- Blood tests - BNP (rise during heart failure)
Treatment for cardiomyopathy
- ACEi
- ARB
- Beta blockers
- Calcium channel blockers
