The cardiovascular History Flashcards
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Dyspnoea
Dyspnoea can be defined as Shortness of Breath/ unexpexted awareness of breathing.
Occurs whenever the work of breathing is excessive, but the mechanism is uncertain.
Probably due to a sensation of increased force required of the respiratory muscle to produce a volume of change change in the lungs, because of a reduction in compliance of the lungs or increased resistance to air flow
Types of Dyspnoea’s
- Cardiac
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
Cardiac Dyspnoea
Cardiac dyspnoea is typically chronic and occurs with
exertion because of failure of the left ventricular output
to rise with exercise; this in turn leads to an acute rise
in left ventricular end-diastolic pressure, raised
pulmonary venous pressure, interstitial fluid leakage
and thus reduced lung compliance. However, the
dyspnoea of chronic cardiac failure does not correlate
well with measurements of pulmonary artery pressures,
and clearly the origin of the symptom of cardiac
dyspnoea is complicated Left ventricular function may
be impaired because of ischaemia (temporary or
permanent reduction in myocardial blood supply),
previous infarction (damage) or hypertrophy (often
related to hypertension). As it becomes more severe,
cardiac dyspnoea occurs at rest. Cardiac dyspnoea may
begin suddenly as a result of myocardial infarction,
GOOD SYMPTOMS G
Paroxysmal Nocturnal Dyspnoea
Chest wall pain is usually localised to a small area
of the chest wall, is sharp and is associated with
respiration or movement of the shoulders rather than
with exertion. It may last only a few seconds or be
present for prolonged periods. Disease of the cervical
or upper thoracic spine may also cause pain associated
with movement. This pain tends to radiate around from
the back towards the front of the chest.
Pain due to a dissecting aneurysm of the aorta is
usually very severe and may be described as tearing.
This pain is often greatest at the moment of onset and
radiates to the back. These three features—quality, rapid
onset and radiation—are very specific for aortic
dissection. A proximal dissection causes anterior chest
pain and involvement of the descending aorta causes
interscapular pain. A history of hypertension or of a
connective tissue disorder such as Marfan’s syndrome
or Ehlers–Danlos syndrome puts the patient at increased
risk of this condition.
Massive pulmonary embolism causes pain of very
sudden onset, which may be retrosternal and associated
with collapse, dyspnoea and cyanosis (p 199). It is often
64 SECTION 2 The cardiovascular system
b Paroxysmal symptoms or signs occur suddenly and intermittently.
CAUSES OF ORTHOPNOEA
Cardiac failure
Uncommon causes
Massive ascites
Pregnancy
Bilateral diaphragmatic paralysis
Large pleural effusion
Severe pneumonia
LIST 4.2
pulmonary oedema or sudden mitral regurgitation due
to rupture of a chorda tendineae or papillary muscle
infarction.
Orthopnoea (from the Greek ortho ‘straight’; see
List 4.2), or dyspnoea that develops when a patient
is supine, occurs because in an upright position the
patient’s interstitial oedema is redistributed; the lower
zones of the lungs become worse and the upper zones
better. This allows improved overall blood oxygenation.
Patients with severe orthopnoea spend the night sitting
up in a chair or propped up on numerous pillows in bed.
The absence of orthopnoea suggests that left ventricular
failure is unlikely to be the cause of a patient’s dyspnoea
(negative likelihood ratio [LR]=0.047
).
Paroxysmalb nocturnal dyspnoea (PND) is severe
dyspnoea that wakes the patient from sleep so that he
or she is forced to get up gasping for breath. This occurs
because of a sudden failure of left ventricular output
with an acute rise in pulmonary venous and capillary
pressures; this leads to transudation of fluid into the
interstitial tissues, which increases the work of breathing.
The sequence may be precipitated by resorption of
peripheral oedema at night while supine. Acute cardiac
dyspnoea may also occur with acute pulmonary oedema
or a pulmonary embolus
Ankle Swelling
Presence of oedema is porrly correlated with heart failure however some patients present with bilateral ankle swelling due to oedema.
Area is not painful/red as seen in inflammatory oedema
Ankle oedema of cardiac origin is usually symmetrical and worse in evenings with improvement during the night-Symptom of Biventricular/ Right Heart Failure.
As failure progresses oedema ascends to involve the legs, thighs, genitals and abdomen-Usually other signs/symptoms of Heart Disease.
NB to find the cause: Pt taking a vasodilating drug-Calcium channel blocker-which causes peripheral oedema)
Oedema that affects the face is more likelyto be related to Kidney disease-from the nephrotic syndrome
Palpitaions
An unexpected awareness of the heartbeat.
Missed haarrtbeat followed by a heavy one indicates Atrial/Ventricular ectopic beat.
If patient complains of a rapid heartbeat, It is important to find out whether the palpitations are of sudden or gradual.
Cardiac arrhythmias are usually instantaneous in onset and offset.
Sinus tachycarida are more gradual in onset and offset
Completely irregular rhythm is suggestive of Atrial Fibrilation particulary if its rapid.
Awareness of rapid palpitations followed by syncope suggest ventricular tachycardia-these pts usually have a past hx of significant heart disease.
Any rapid rhythmcmay precipitate angina in a pt with Ischaemic heart disease.
Pts have learned Manoeuvers that will return the rhythm to normal:
SVT attacks may be suddenly terminated by increasing vagal tone with Valsalva Manouver by carotid massage, coughing or swallowing cold water or ice cubes.
Syncope, Presyncope and Dizziness
Syncope: A transient loss of conciousness resulting from cerebral anoxia, usually due to inadequate blood flow.
Presyncope: A transient sensation of weakness without the loss of consciousness.
Syncope may represent a simple faint or be a symptom of cardiac or neurological disease-One must establish whether the patient actually loses consciousness and under what circumstances:
- Postural syncope-Prolonged periods or standing up suddenly- enquire the use of antihypertensives/antianginal drugs or other medications which may induce postural hypertension
- Micturation Syncope-While passing urine
- Tussive Syncope-Coughing
- Vasovagal syncope-Emotional stress-could be from something unpleasant such as the sight of blood or occur in a crowded,hot room-pts often sigh and yawn and feel nauseated and sweaty before fainting and may have previously had simialr episodes during adolenscens and young adulthoods.
