Notions of cardio-vascular semiology 6 Flashcards
Symptoms
Chest pain
Can have different origins
Angor pectoris
Cause: myocardial anoxia
Location: retrosternal, precordial
Irradiation:
typically – in the left shoulder and upper limb
atypically – in the right shoulder and upper limb, the lower maxillary, epigastrium, the back (the inter-scapular space)
Duration
2-30 minutes (frequently 5-20 minutes)
It is described as a profound constriction sensation of the thorax; this constrictive character can be encountered in the arms and wrists
It is caused by effort and it ceases together with the effort
Pain can also occur during rest
It is trinitro-sensible
Symptoms
Myocardial infarction
The pain caused by angina pectoris, with a few differences:
Longer duration > 30 minutes
Non responsive to nitroglycerine
Associated with pallor, anxiety, sweat
pericardial pain – cause by an acute inflammation of the pericardial serous membrane
It is anterior, median or left parasternal
Independent from effort
Variable intensity
Accentuated by deep inhaling or cough
Attenuated or calmed by certain postures: forward bending of the thorax
Retrosternal pain caused by the dissection of the thoracic aorta wall
Dyspnoea
cardiac dyspnoea is:
Predominantly inspiratory
Progressive
Present in cardiac failure, mitral stenosis
types of cardiac dyspnoea
progressive effort dyspnoea– for sustained efforts, then more and more moderate, with increased respiratory frequency and the decrease in amplitude of the thorax movements
Deubitus dyspnoea– when patient is in dorsal decubitus and is forced to adopt a semi-sitting, orthopneic posture paroxismal dyspnoea (PD) – appears: during effort or in decubitus posture, more frequently during the night (nocturnal PD) cardiac asthma – PD with associated bronchial spasm (dyspnoea is predominantly expiratory +/- wheezing)
Asthenia and fatigability
caused by the decrease of cardiac debit
Palpitations
The perception of heart beats felt by the patient sometimes in a painful and anxious manner
Can be significant in cardiac rhythm disorders, but can also have neurotonic origin
Classification of functional signs acording to the New York Heart Association (NYHA
Class 1: without the limitation of physical activity
Class 2: moderate discomfort, appears during significant effort (without rest discomfort)
Class 3: dyspnoea and fatigue following regular daily activities
Class 4: incapacity for any physical activity, even basic ones (getting up, getting dressed
Objective exam
Palpation
Done with the right hand on the patient’s thorax, or the tip of the three middle fingers, that allow a more localized palpation
5th left inter-costal space, on the mid-clavicular line – location of apexian shock: synchronous with arterial pulse and cardiac systole, shows the left ventricle contraction
The movement of apexian shock outside the mamelon line or in the 6th left inter-costal space is due to the left ventricle dilatation
Objective exam
Cardiac auscultation
Done with a stethoscope
Must be systematic:
Aortic valvular orifice in the parasternal 2 ICD space
Pulmonary valvular orifice in the parasternal 2 ICS space
Tricuspid orifice of the xiphoid appendix
Mitral centre at the tip of the heart
Normal cardiac sound
The first sound is due the shutting of the mitral and tricuspid valves; its intensity is maximal at the tip of the heart; it is the start of the cardiac systole (ventricle contraction)
The second sound is due to the shutting of aortic and pulmonary sigmoid valves; it is the end of the systole and the start of the diastole; it is maximal in the aortic and pulmonary centers
The third sound is due to the fast ventricular refilling; occurs after the second noise
The fourth sound is due to the atrial contraction; perceived in tele-diastole.
Sound 3 and 4 (physiological) can be heard in children and teenagers; in adults they are always pathological
Cardiac murmur
Are perceived in the auscultation of the pre-cordial area, are due to the acoustic vibrations; their physical-pathological mechanism is explained through the laws of fluid flow through tubular pipes
We distinguish:
Anorganic murmur – alterations of blood flow through the heart cavities, without anatomical lesions (hyperthyroidism, anemia, etc.)
Organic murmur – appear when permanent anatomic lesions occur, which involve the atrio-ventricular and sigmoid valves
The ejections murmurs are due to the presence of an obstacle in the blood flow
Aortic stenosis systolic murmur
Mitral failure diastolic murmur
Regurgitation murmurs are due to the blood flow against the normal flow, through a valvular orifice (mitral, tricuspid) or arterial one (aortic, pulmonary) when the orifice is dilated and/or when the valves are incontinent
Aortic failure diastolic murmur
Organic mitral failure systolic murmur
Pericardial sound
pericardial friction rub; due to the inflammation of pericardial serous membrane
Complementary exams
Electrocardiography
recording of the electrical action potentials of the heart. The electrodes are placed on the body in specific location, two by two; they define the derivations. Usually and ECG includes 12 derivations.
Limbs bipolar derivations: D1, D2, D3
Limbs unipolar derivations: AVR, AVL, AVF
Precordial derivations: V1-V6
V1: explores the right ventricle
V2-V4: explores the anterior wall of the right ventricle
D1, AVL, V5-V6: explores the lateral wall of the right ventricle
D2, D3, AVF: explores the inferior wall of the right ventricle
Analytical description of a normal ECG
P wave – atrial depolarization
PR interval – measures the atrial-ventricular conduction time
QRS complex – ventricular depolarization
ST segment – total depolarization of the ventricular muscle
T wave – ventricular re-polarization
Echocardiography
Principles: the ultrasounds are vibrating waves whose high frequency allows them to be transmitted through the biological tissues; they can appear in the interface between two connected structures due to different acoustic properties, generating a reflection wave (echo); this is recorded to obtain a cardiac image.
Modes
Bi-dimensional echocardiography
Echography in TM (Time Motion) mode
Cardiac Eco-Doppler – consists of combining the bi-dimensional echocardiography with the Doppler effect
This technique allows the measurement of the:
trans-valvular blood flow speed
Valvular orifice surface
Radiological exam
Cardiomegalia (increased heart size)
valvular, pericardial, aortic calcifications
Lung alterations due to LV failure (interstitial edema, alveolar edema, etc)
Coronarography
The opaque rendering of coronary vessels through selective catheterization of the right and left coronary is a reference exam in the diagnosis of coronary diseases.
