Cardiovascular differential diagnosis Flashcards
Diagnosis
An imbalance of myocardial oxygen supply and demand resulting in ischemic chest pain
acute coronary syndrome (ACS)
When do symptoms present with acute coronary syndrome?
when lumen is at least 70% occluded
What is Levine’s sign?
patient clenching fist over their sternum
(indicative of angina)
What are the 3 types of angina?
- unstable angina (crescendo angina)
- stable angina
- variant angina (Prinzmetal’s angina)
definition
Classic angina occurring during exercise or activity; occurs at a predictable rate-pressure product (RPP) and is relieved with rest and/or nitroglycerin
RPP = (HR x BP)
stable angina
diagnosis
coronary insufficiency without any precipitating factors or exertion. Chest pain is difficult to control and increases in severity, frequency, and duration.
unstable angina
(true/false) unstable angina is responsive to treatment such as nitroglycerin
false
increased risk of MI and/or lethal arrythmia
What is variant angina?
Angina caused by vasospasm of the coronary arteries in the absence of an occlusive disease
(true/false) Variant angina is unresponsive to nitroglycerin and/or calcium channel blockers
false - it is responsive
calcium channel blockers are used long-term
diagnosis
prolonged ischemia, injury, and death of an area of the myocardium caused by occlusion of one or more coronary arteries
myocardial infarction
What are the zones of infarction? Describe them.
- Zone of infarction: consists of necrotic, noncontractile tissue - ECG showed ST segment deviation
- Zone of injury: area immediately adjacent to the central zone; tissue is noncontractile and the cells are undergoing metabolic changes; electrically unstable with elevated ST segments over the injured area
- zone of ischemia: outer area with cells undergoing metabolic changes; electrically unstable with T-wave inversion
What are the types of heart failure?
- Left-sided HF (CHF)
- right-sided HF
- biventricular failure
diagnosis
Characterized by pulmonary congestion, edema, and low cardiac input due to backup of blood from the left ventricle to the left atrium and lungs.
- cardiac arryhtmias and/or heart damage
- occurs with insult of the left ventricle from myocardial disease and excessive workload of the heart
Left-sided heart failure (CHF)
diagnosis
Characterized by increased pressure load on the right ventricle with higher pulmonary vascular pressures
- produces hallmark signs of jugular vein distention and peripheral edema
- mitral valve disease or chronic lung disease (cor pulmonale)
right-sided heart failure
diagnosis
- severe left ventricle pathology producing back up of blood into the lungs
- increased PA pressure
- Right ventricular pathology s/s
biventricular failure
What are associated symptoms to HF?
- osteoporosis
- myopathies
- muscle wasting
What is compensated heart failure?
When the heart returns to functional status with reduced cardiac output and exercise tolerance
Control achieved by:
- medical therapy
- physiological compensatory mechanisms: SNS stimulation, LV hypertrophy, anaeroic metaolism, cardiac dilation, and arterial vasoconstriction
What is decompensated heart failure?
Structural or functional change in heart leads to the heart’s inability to eject and/or accommodate blood within normal physiological levels
Does decompensated heart failure occur abruptly or gradually?
Can occur abruptly or gradually
medical emergency
What are the s/s of right-sided HF?
- dyspnea
- fatigue
- rales
- peripheral edema
What are the color zones associated with clinical manifestations of heart failure and PT recommendations?
- Green
- yellow
- red
What are the s/s associated with the green zone of heart failure? What are the PT recommendations?
- no s/s
- continue activity as tolerated
What are the s/s associated with the yellow zone of heart failure? What are the PT recommendations?
- 2 to 3 pound weight gain within 24 hours
- increased cough
- peripheral edema
- SOB
- orthopnea
- symptoms can indicate an adjustment in medications and warrants communication with physician
What are the s/s associated with the red zone of heart failure? What are the PT recommendations?
- SOB at rest
- unrelieved chest pain
- wheezing or chest tightness at rest
- paroxysmal nocturnal dyspnea
- weight gain/loss of 5+ pounds within 3 days
- confusion
- immediate medical attention is needed
- pt must sit in a chair to sleep
diagnosis
elevation of blood glucose levels and accelerated atherosclerosis
diabetic angiopathy
What is a major complication of diabetic angiopathy?
- neuropathy
- neurotropic ulcers that can lead to gangrene and amputation
What is raynaud’s phenomenon?
episodic spasm of small arteries and arterioles exacerbated by coldness and/or emotional stress
What are the s/s of Raynaud’s phenomenon?
tips of fingers develop pallor, cyanosis, numbness, and tingling
Does raynaud’s phenomenon affect males or females more?
females
What can varicose veins lead to?
varicose ulcers
definition
Formation of blood clot in a deep vein that can lead to complications including DVT, PE, or postthrombotic syndrome
venous thromboembolism (VTE)
1/3 of cases experience another VTE within 10 years
What is the mortality rate of venous thromboembolisms (VTE)?
10-30% within 1 month of diagnosis
What is the chronic form of VTE?
postthrombotic syndrome
What are the s/s of DVT?
- TTP
- dull ache
- tightness
- calf pain
- swelling
- warmth and redness
- LE discoloration
- prominent superficial veins
(true/false) Those with early DVT can be asymptomatic.
true
What is the criteria score for DVT?
Wells score
When is low molecular weight heparin contraindicated?
Those at high risk of bleeding
what medication is used for patients with a high risk of bleeding?
unfractionated heparin (UFH)
Heparin-induced thrombocytopenia is associated with an increased risk of what?
venous and arterial thrombosis
What are the s/s of PE?
- abrupt onset
- chest pain
- dyspnea
- diaphoresis
- cough
- apprehension
What percent of patient immediately die from a PE?
20%
40% die within 3 months
What diagnosis can PE lead to?
right heart dysfunction and failure
diagnosis
a combination of clinical signs and symptoms that persists after an LE DVT - thrombosis resolution is incomplete
chronic postthrombotic syndrome
What are the s/s of chronic postthrombotic syndrome?
- pain
- edema
- limb heaviness
- skin pigmentation changes
- leg ulcers
What causes venous valvular insufficiency?
Fibroelastic degneration of the valve tissue; venous dilation
What is PAD?
Chronic, occlusive arterial disease of medium and large vessels caused by atherosclerosis- pulses are absent or diminished in the affected extremities
- associated with HTN and hyperlipidemia
- may have CAD, cerebrovascular disease, DM, metabolic syndrome, Hx of smoking
What is the presentation of early PAD?
- intermittent claudication
- burnging/aching/tightness/cramping pain
- relieved by rest
What additional s/s are seen in late PAD?
- pain during rest
- muscle atrophy
- trophic changes (hair loss, skin changes, nail changes)
What s/s are seen with critical stenosis PAD?
- resting and/or nocturnal pain
- skin ulcers
- gangrene
What is the etiology of chronic arterial insufficiency?
- atherosclerosis thrombosis
- emboli
- inflammatory process
What is the etiology of chronic venous insufficiency?
- thrombophleitis
- trauma
- vein obstruction/clot
- vein incompetence
What are the s/s of acute arterial obstruction?
- distal pain
- paresthesia
- pale
- pulselessness
- sudden onset
definition
an inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs
thrombophlebitis
Where is the pain located when chronic arterial insufficiency is present?
calf, lower leg, or dorsum of foot
–> may occur in thigh, hip, and/or buttock
Where is pain located when chronic venous insufficiency is present?
muscle compartment tenderness
What vascular changes occur with chronic arterial insufficiency?
- decreased or absent pulses
- pallor of forefoot during elevation
- dependent rubor
What vascular changes occur with chronic venous insufficiency?
- venous dilation or varicosity
- moderate to severe edema
What skin changes are observed with chronic arterial insufficiency?
- pale, shiny, dry skin
- loss of hair
- nail changes
- extremity coolness
What skin changes are observed with chronic venous insufficiency?
- hemosiderin staining
- lipodermatosclerosis (fibrosing of the subcutaneous tissue)
- possible stasis dermatitis or cellulitis
Where can ulcers occur with chronic arterial insufficiency? What will the tissues look like?
- toes
- feet
- areas of trauma
- pale, yellow, or black eschar
- possible gangrene
- regular borders/shape
- “punched out” ulcer
What causes a “punched” out ulcer?
chronic arterial insufficiency
Where do ulcers occur with chronic venous insufficiency? What do the ulcers look like?
- sides of ankles along the course of the veins
- painful and shallow ulcer
- irregular borders
- exudate
- granulation tissue at base of ulcer
What are signs and symptoms of pulmonary congestion in left ventricular failure?
- dyspnea
- cough
- orthopnea
- paroxysmal nocturnal dyspnea
- pulmonary rales and/or wheezing
What are the signs and symptoms of low cardiac output with left ventricular failure?
- hypotension
- tachycardia
- lightheadedness
- cerebral hypoxia
- fatigue and weakness
- enlarged heart on CXR
- S3 sound (S4 is possible)
- murmurs of mitral or tricuspid regurgitation
What are the signs and sympotms of pulmonary congestion with right ventricular failure?
- dependent edema
- weight gain
- ascites
- hepatomegaly
What are the signs and symptoms of low cardiac output with right ventricular failure?
- anorexia
- nausea
- bloating
- cyanosis (nail beds)
- RUQ pain
- jugular vein distention
- R-sided S3 sound
- murmurs of pulmonary or tricuspid insufficiency
What kind of P wave does A-flutter have?
Saw tooth
If a pt is asymptomatic, decrease intensity
If a pt is symptomatic, stop exercise
What kind of P wave does A-fib have?
unrecognizable (looks like a squiggle)
stop exercise and refer to physician
What kind of P wave does A-tach have?
Shape of P-wave is not changed, however, it will have short duration due to tachycardia
Rank the following based on range of HR from high to low:
A-flutter
A-tach
A-fib
- A-Fib (350-400 bpm)
- A-flutter (200-400 bpm)
- A-tach (150-250 bpm)
What does the QRS complex look like when V-tach is present?
mountains
medical emergency
What does the QRS complex look like with V-fib?
scribble
unrecognizable rhythm components; medical emergency
What does the QRS complex look like with PVC?
Inverted or reverse “s” shape
