CV and chest pain Flashcards
what is ankle oedema a sign of and give some characteristics?
R ventricular/congestive cardiac failure
pitting, symmetrical, worse in evenings
what is intermittent claudication and what is it a symptom of?
pain in thighs, calves, buttocks after walking and relieved by rest
peripheral vascular disease
is fatigue a symptom of cardiac failure?
Y
what past conditions neeed to be asked about in CV hx and why?
previous angina or MI: risk of further CV and cerebrovascular events
htn, hypercholesterolemia and dm rf for ihd
rheumatic fever predisposes to valvular disease
strokes: could be due to ischaemic event
asthma: contra-indicates use of BB
what fhx is important in cv hx?
MI/stroke of relative under 65
what is the typical character of chest pain with a cardiac cause?
central and crushing
however in angina may describe discomfort not pain
MI usually severe pain
where does cardiac pain typically radiate to?
left arm, neck, jaw,
occassionally: teeth, back or abdomen
why is the duration of the pain important?
over 30 mins is likely to be associated with damage to the heart muscle
why are exacerbating and relieving factors important in cardiac chest pain?
stable angina bought on by exercise and relived by rest. nitrates tend to relieve the pain
why is leg swelling important in cardiac history?
usually bilateral
with hf may report ankle swelling that is worse in evenings
what are some associated symptoms with an MI?
dyspnoea, sweating, anxiety, nausea, faintness, chest pain
which RF should be asked about for an MI?
fhx, htn, diabetes, smoking, hypercholesterolaemia
describe the basic management of an MI.
bed rest, oxygen, opiate, monitor, anticoagulate, reeduce clot size
why is the onset of palpitations important?
cardiac arrhythmias=sudden
sinus tachycardia=insidious
what are some triggers for palpitations/
anxiety
ectopic beats more noticeable if background rate slow e.g. at rest
paroxysmal tachycardia: exercise, specific movements
coffee, tea, alcohol
what may relieve palpitations?
coughing or swallowing
Valsalva manoevre may terminate supraventricular tachycardia
why is the medical hx important in palpitations?
can caused by MI, valvular disease cardiomyopathy, myocarditis, aberrant conduction pathways
htn risk of AF
why is it important to ask about wt loss, heat intolerance, increased stool frequency and irritability in palpitations?
can be caused by thyrotoxicosis
why is medication important in the history of palpitations?
many drugs can cause arrhythmias, particularly in overdose
why is it important to ask which part of the leg is affected in intermittent claudication?
calf pain=disease in superficial femoral artery
thigh pain=external iliac
buttock pain=lower aorta or common iliac
why would you ask whether bending forward relieved the pain in suspected intermittent claudication?
more likely to be spinal canal stenosis in the lumbar region
what skin changes are seen in intermittent claudication/
hairless, dry, ulcers
what causes Raynauds disease?
blood disorders, arterial (atherosclerosis), drugs (BB), connective tissue disorders (SLE, RA), traumatic (vibration injury)
what general clues can you get from a patient regarding CV disease/
colour and resp pattern any oxygen or GTN spray present Cachexia: malignancy or severe cardiac failure Marfans syndrome: aortic regurgitation Downs syndrome: congenital heart disease Turners syndrome: coarction of aorta
what hand and nail changes can be seen in CV disease?
clubbing: cyanotic congenital heart disease, subacute infective endocarditis spinter hemorrhages: infective endocarditis koilonychia: iron deficiency anaemia oslers nodes (painful): infective endocardiits janeway lesions (not painful): infective endocardiits tendon xanthomata (yellow lipid in tendon): type II hyperlipidaemia
what causes a collapsing pulse/
aortic regurgitation, patent ductus arteriosus, hyperdynamic circulation
what does radio-radial delay suggest?
large arterial occlusion
what does radio-femoral delay suggest/
coarction of aorta
what signs in the face indicate CV diseas?
jaundice: prosthetic heart valve induced haemolysis
pallor: anaemia
petechal hemorrhages in conjunctiva: embolic phenomena
xanthelasma: hyperlipidaemia
malar flush: pulmonary htn, low cardiac output (severe mitral stenosis)
what signs in the tongue and lips indicate cv disease/
cyanosis
mucosal petechiae: infective endocarditis
high arched palate: marfans
what can cause and increased JVP?
RV failure, tricuspid stenosis or regurgitation, pericardial effusion, constrictive pericarditis,, SVC obstruction, fluid overload
what changes in the carotid pulse indicate cv disease?
slow rising=aortic stenosis
collapsing=aortic regurgitation, hyperdynamic circulation, patent ductus arteriosus
small vol=aortic stenosis, pericardial effusion
pulsus alternans: diseased LV
what lung sounds may be heard in heart failure?
pan-inspiratory crackles, pleural effusion
give some features of ischaemic legs.
pulseless, pale, painful, paralysed, perishingly cold, ulcerated/gangrenous
what is Becks triad?
for cardiac tamponade
distant heart sounds
distended jugular veins
decreased arterial pressure
why is it important to check for scars on the chest?
CABG or valvel replacement
pacemakers
where is the apex beat/
5th L intercostal space, 1cm medial to midclavicular line
what causes changes in the apex beat/
displaced due to marfans
thrusting quality: vol overload e.g. mitral or aortic regurgitation
heaving: pressure overload e.g. aortic stenosis
impalpable: COPD, obesity, pleural or pericardial effusion, dextrocardia
what are parasternal heaves and thrills:
heaves=heel of hand: RV or LA enlargement
thrills=flat hand: palpable murmurs
when are murmurs loudest?
R=inspiration
L=expiration
where are each of the 4 areas to listen?
aortic: listen in R sternal edge 2nd IC space
pulmonary: L 2nd IC space
tricuspid: 4th IC space L sternal border
mitral=5th IC space L midclavicular
what is exacerbating turning a patient onto L and leaning forward?
mitral regurgitation
aortic regurgitation
where can murmurs radiate to?
aortic ejection murmur->carotids
aortic incompetence murmur->L sternal edge
mitral incompetence-> mid-axillary line
what is characteristic of mitral stenosis?
opening snap (after s2), low pitched rumbling mid-diastolic murmur
give the features of mitral regurgitation.
soft s1, pan-systolic murmur, loudest at apex and radiating to axilla, may be s3
what is charatceristic of aortic stenosis?
ejection click followed by ejection sytolic murmur, loudest in aortic area and radiates to carotids
give teh features of aortic regurgitation.
high pitched early diastolic murmur, best heard at L sternal edge, ejection systolic murmur
how do you describe a murmur/
intensity, location, pitch, quality, radiation, shape, timing
what are the causes of pericarditis?
collagen vascular disease, aortic aneurysm, radiation, drugs, infections, acute renal failure, cardiac infarction,, rheumatic fever, injury, neoplasms, dresslers syndrome
what do you inspect for in a peripheral vascular examination/
trauma/scarring, erythema, symmetry, skin changes/hairloss, colour, pigmentation, oedema, varicose veins, muscle wasting, ulcers
describe the allens test.
make fist for 30 s, occlude arteries, open one, colour should return within 7s
what is noral capillary refill time?
2s
describe the location of each pulse: dorsalis pedis, posterior tibial, popliteal, femoral
dorsal foot, between 1st and 2nd metatarsals
posterior to medial malleolus
between heads of gastrocnemius
halfway between pubic symphysis and asis
what is the abpi?
ankle brachial pressure index
assesses pvd, <8=pvd
what is burgers sign?
raise legs at 45 degrees for 2 min, swing over bed, white soles indicates ischaemia (blue then red)
what is trendelenburg test?
assesses varicose veins
supine, empty superficial veins, press down on saphofemoral junction with thumb (2cm below and 2cm lateral to pubic tubercle), maintain pressure when stands. if refills then incompetence is below junction
give the differentials for chest pain.
cardiac: stable angina, unstable angina, NSTEMI, STEMI, pericarditis
resp: PE, pneumothorax, pneumonia
vascular: aortic dissection
MSK: chest wall trauma, rib fracture, costochondritis
GI: GORD, peptic ulcer disease, oesophageal spasm
how does stable angina present?
dull heavy pain, onset with exertion, relief with rest +/- GTN, moderate pain
how does ACS present?
ongoing rest pain, autonomic sx, severe
how does pericarditis present?
sharp, stabbing, sudden onset, relief sat forwards
how does aortic dissection present?
tearing pain, radiates between shoulder blades
+/- syncope, +/-neuro deficit
what are the cardiac rf?
smoking, diabetes, htn, hypercholesterolaemia, fhx, male
how does pneumothorax present?
tall, thin patient
sudden onset unilateral pleuritic chest pain, associated sob
how does pneumonia present?
gradual onset and progressive, associated fever and productive cough, pleuritic chest pain
how does PE present?
rf, pleuritic chest pain, associated sob, associaetd calf swelling/heat/pain +/- haemoptysis, peripheral odema
what are the rf for vte?
immobility, cancer, pregnancy, previous dvt/pe, oestrogen, obesity, hypercoagulability disorders
how does GORD present?
burning retrosternal pain, related to meals and position, relief with antacids
how does peptic ulcer disease present?
epigastric pain, can radiate to back, association with meals
how does oesophageal spasm present?
very similar to ischaemic pain, brought on by extreme temp, relief with gtn but more prolonged than ischaemic pain
what investigations are done for chest pain?
bloods: FBC, U and E, clotting screen, TFTs, lipid profile, cardiac enzymes
CXR
serial ECGs
how is ACS managed?
morphine 1-10mg IV and antiemetic
oxygen if needed
nitrates
aspirin 300mg
clopidogrel 300mg
LMWH (enoxaparin)
give some Symptoms of cardiovascular disease.
Chest pain • Dyspnoea (shortness of breath) • Orthopnoea (SOB on lying flat that is relieved by sitting upright) • Paroxysmal nocturnal dyspnoea (acute dyspnoea that wakes the patient from sleep) • Ankle oedema • Cough, sputum & haemoptysis • Dizziness • Light-headedness • Presyncope & syncope • Palpitations • Nausea & sweating • Claudication • Systemic symptoms e.g. fatigue, weight loss, anorexia, fever
what are some RF for IHD?
Male sex • Age • Smoking • Hypertension • Diabetes mellitus • Family history of IHD • Hypercholesterolaemia • Physical inactivity and obesity
how does cardiac chest pain present (socrates)
site: Central substernal,
across mid-thorax anteriorly,
in both arms/shoulders,
in the neck/cheeks/teeth,
in the forearms/ fingers,
in the interscapular region
Onset: Acute
Character: Crushing, tight, constricting, squeezing, burning,
‘heaviness’
Radiation: Neck, jaw, left arm
Associated symptoms: Sweating, nausea, shortness of breath, palpitations
Timing: On exertion? At rest?
Exacerbating factors: Exercise, excitement, stress, cold weather, after meals,
smoking,
lying flat (decubitus angina 2° to left heart failure)
Alleviating factors: Rest, medication, oxygen
Severity: Pain scale (1 – 10)
how do cardaic causes dyspnea present (socreates)
Onset: Acute, chronic, acute-on-chronic
Associated symptoms: Sweating, nausea (due to hepatic/gastric congestion),
pain, cough, sputum (watery/frothy? Blood-tinged?),
swollen ankles, palpitations, nocturnal micturition, rapid
weight gain (could be due to oedema)
Timing: On exertion? At rest? Constant? At night (paroxysmal
nocturnal dyspnoea)?
Exacerbating factors: Position (number of pillows – orthopnoea)?
Alleviating factors: Rest, medication, oxygen, sitting up straight
Severity: How debilitating? Effect on activities of daily life?
Exercise tolerance (see below)
what are important qs about exercsie tolerance?
‘How far can you walk on the flat before you need to stop and rest?’
• ‘What is it that limits how far you can walk?’
• ‘Do you feel short of breath when you walk, such as walking up hills or stairs?’
• ‘Do you have any discomfort or tightness in your chest when you walk?’
• ‘How long ago did you notice a problem when you are walking…did it get worse suddenly
or gradually…. how far were you able to walk a year/month ago?’
what are important qs about palpitations?
Have you had any palpitations or awareness of your heart racing?’
• ‘Does anything seem to provoke this?’
• ‘Does it start suddenly or build up gradually?’ ‘Does it stop suddenly or gradually?’ ‘How
long does it last?’
• ‘Do you have any other symptoms with the palpitations?’
• ‘Can you can tap the rhythm?’ (Is it regular, irregular or regularly irregular? Is it fast or
slow?
what past medical hx is important in cardiac hx
Similar episodes, previous diagnoses, treatments and responses to treatment. • Previous cardiac surgery • Hypertension • Hypercholesterolaemia • Anaemia • Diabetes • Angina • Myocardial infarction • Cerebrovascular accident / Transient ischaemic attack • Peripheral vascular disease e.g. intermittent claudication • Cardiac failure • Rheumatic fever
what drugs are relevant in cardiac hx?
Antihypertensive drugs
All cardiac drugs
Other drugs with cardiac side effects e.g. corticosteroids (hypertension and fluid retention),
and drugs that can cause sinus tachycardia (e.g. salbutamol, theophylline, nifedipine,
thyroxine)
Over-the-counter drugs e.g. aspirin, NSAIDs
what social hx is important in cardiac hx?
Occupation, smoking (number of pack years), alcohol (can cause atrial fibrillation,
cardiomyopathy, hypertension and tachycardia), diet, stress
what fhx is important in cardiac hx?
Family history of ischaemic heart disease or cerebrovascular accident before the age of 65
what cardaic signs may be present in the hands?
Tar staining o Vasodilatation/constriction, temperature o Sweating (suggests increased sympathetic drive) o Pallor of palmar creases o Peripheral cyanosis o Clubbing o Splinter haemorrhages o Osler’s nodes and Janeway lesions o Tendon xanthomas
how do you assess for mitral stenosis?
auscultate the apex with the patient rolled 45° to the left
how do you assess for aortic regurgitation
auscultate at the 4th/5th
intercostal space to the left of the sternum on held expiration
what should you state you will do in the OSCE but not actually do?
femoral pulses
12 lead ECG
BP
what is intermittent claudication?
A reproducible discomfort of a defined group of muscles that is
induced by exercise and relieved with rest. This disorder results from an imbalance between
supply and demand of blood flow that fails to satisfy ongoing metabolic requirements.
what are the features of intermittent claudication?
Site Depends on the site of arterial occlusion, e.g. occlusion of the
superficial femoral artery often causes pain in the calf
muscles
Onset Acute e.g. after acute thrombosis
Chronic e.g. atherosclerotic stenosis/occlusion
Character Gripping, cramping, burning, tightness
Radiation -
Associated symptoms (For example, chest pain) May suggest atherosclerotic
vascular disease elsewhere e.g. ischaemic heart disease,
cerebrovascular disease, erectile dysfunction
Timing Intermittent?
Exacerbating factors Exercise (“How far can you walk?”, “Does the pain limit your
walking, or something else e.g. shortness of breath?”)
Rest (“How long before the pain subsides?”) – Usually
minutes
Severity Pain scale (1-10).
what are the features of rest pain caused by PVD
Site Foot/toes
Onset Usually progresses from intermittent Claudication to rest pain
Character Sharp, burning, usually severe
Radiation -
Associated symptoms (For example, chest pain) May suggest atherosclerotic
vascular disease elsewhere e.g. ischaemic heart disease,
cerebrovascular disease, erectile dysfunction
Timing At rest (Worse at night)
Exacerbating factors Elevation of leg
Relieving Factors Lowering legs
what are the sx acute ischaemia?
Pain • Pallor • Pulselessness • Paralysis (loss of function) • Paraesthesia (loss of sensation) • Perishing cold
how does AAA present?
Asymptomatic – majority of AAA’s are identified incidentally
Symptomatic – In this situation patients may complain of back pain
Ruptured – These present as an emergency with back pain and collapse
what are the features of virchows triad?
Stasis e.g. prolonged immobility, post-operative state, intra-abdominal/ pelvic mass
compressing the venous system
• Hypercoagulability e.g. high-dose oestrogens, malignancy, sepsis, thrombophilia’s
• Intimal damage – trauma
what past medical hx is important in PVD
Previous vascular problems
• Previous vascular surgery/intervention
• Diseases caused by atheroma elsewhere e.g. coronary artery atheroma (angina and
myocardial infarction), carotid artery atheroma (stroke, transient ischaemic attack,
amaurosis fugax)
• Major Risk factors:
o Smoking
o Hypercholesterolaemia
o Diabetes mellitus
o Hypertension
what drug hx is relevant in PVD?
Drugs of relevance include anticoagulants, antiplatelet agents, lipid/cholesterol lowering
drugs, cardiac medication, anti-hypertensives, oral contraceptive.
what social hx is relevant in PVD
Occupation, smoking (number of pack years), alcohol, diet, exercise, recent travel etc
what fhx is relevant in PVD/
Some prothrombotic conditions are hereditary e.g. Factor V Leiden mutation
Family history is also a risk factor for atherosclerosis
describe buergers test for PVD?
this assesses critical ischaemia)
o With the patient supine, elevate both legs to an angle of 45° and hold for one
to two minutes. Pallor of the feet indicates ischemia. The poorer the arterial
supply, the less the angle to which the legs have to be raised for them to
become pale (Buerger’s Angle)
o Then sit the patient up and ask them to hang their legs down over the side of
the bed at an angle of 90°. Gravity aids blood flow and colour returns in the
ischemic leg. The skin at first becomes blue, as blood is deoxygenated in its
passage through the ischemic tissue, and then red, due to reactive hyperaemia
from post-hypoxic vasodilatation. Both legs should be examined
simultaneously as the changes are most obvious when one leg has a normal
circulation, (the time it takes to become pink/red relates to the severity or
ischemia – Buerger’s time)
how is ABPI calculated?
dividing the highest systolic
blood pressure in the arteries at the ankle by the higher of the two systolic blood
pressures in the arms. Significant arterial disease is indicated by an ABPI of <0.8.
what is the cough test for chronic venous insufficiency
finger on the SFJ and asking the patient to
cough. Palpate for thrills at the SFJ
what is the tap test for chronic venous insufficiency?
finger on the SFJ and putting a finger of your
other hand on any varicosities in the long saphenous vein distribution. Tap on the
SFJ and if it is incompetent, you will feel the transmitted percussion wave in the
varicosities further down the leg.
describe the trendelenburg/tourniquet test?
Ask the patient to lie flat. Raise
the leg and keep it raised for a few minutes to exsanguinate as much blood as
possible. Apply a tourniquet high around the thigh. Ask the patient to stand up and
inspect to see whether the varicose veins refill. If not, the problem originates at the
SFJ. If the veins do refill, repeat the test at the mid-thigh perforators, the
saphenopopliteal junction and the mid-calf perforators
describe perthes test?
assess the patency of the deep veins. Ask the patient to
lie down. Without exsanguinating the leg, apply a tourniquet around the thigh. Ask
the patient to stand and rock up and down onto his tiptoes ten times. If the
superficial veins empty, the deep veins must be patent.
