Chest pain or discomfort Common presenting symptom of cardiovascular disease May be cardiac or noncardiac in origin. Cardiac – angina, MI, pericarditis, mitral valve prolapse, dissecting aortic aneurysm Non cardiac – anemia (physical exertion), cervical disc disease, anxiety, trigger points etc Follows pattern of ulnar nerve distribution (heart supplied by C3-T4 spinal segments) Radiating pain to neck, jaw, upper trapezius, upper back, shoulder or arms (commonly left

1. Screening for cardiovascular disease

2. Lecture objectives
In this lecture we will:
 Review the cardiac anatomy
 Differentiate between the types of cardiac diseases
and their characteristics
 Learn about various cardiovascular disorders
 Discuss the common signs and symptoms of cardiac
disease

4. Signs and symptoms of
cardiovascular disease
CHEST PAIN OR DISCOMFORT
 Common presenting symptom of cardiovascular disease
 May be cardiac or noncardiac in origin.
 Cardiac – angina, MI, pericarditis, mitral valve prolapse, dissecting aortic
aneurysm
 Non cardiac – anemia (physical exertion), cervical disc disease, anxiety,
trigger points etc
 Follows pattern of ulnar nerve distribution (heart supplied by C3-T4
spinal segments)
 Radiating pain to neck, jaw, upper trapezius, upper back, shoulder or
arms (commonly left)

5. PALPITATION
presence of an irregular heart beat – arrythmia or
dysrhythmia. Benign such as mitral valve prolapse,
caffeine, anxiety, exercise
Severe such as over active thyroid, coronary artery
disease, complete heart block etc
 Considered physiologic when < 6 per minute
 Lasting for hours with pain, shortness of breath, light
headedness or history of sudden death in family
needs medical referral
 Described by patients as skipped beat, bump, flutter ,
racing etc

6. DYSPNEA
Breathlessness or shortness of breath
 Cardiovascular or pulmonary in origin. More severe
disease, severe dyspnea
 DOE – dyspnea on exertion (shortness of breath with
mild exertion)
PND - Proximal nocturnal dyspnea. Dyspnea in sleeping
recumbent patient. Common in CHF
Orthopnea – breathlessness relieved by sitting upright
 Dyspnea relieved by specific breathing patterns and
or body positions is likely pulmonary in origin
 Anyone unable to climb flight of stairs, waking at night
or progressively worse dyspnea in cardiac patient
needs evaluation

7. CARDIAC SYNCOPE fainting or mild light headedness
caused by reduced oxygen delivery to brain.
 Orthostatic hypotension – sudden drop in BP due to
quick change in prolonged posture and deconditioning
 Hyperventilation in non cardiac conditions – vasovagal
syncope. Initiation and regulation of cardiac medications
such as vasodilators
 Syncope without warning period of lightheadedness is a
sign of heart valve or arrythmia problems
FATIGUE fatigue of cardiac origin accompanied by
associated symptoms. Chest pain, dyspnea etc
 In patients with fatigue without prior diagnosis of heart
disease, monitoring BP may indicate a failure of BP to
rise with increasing workloads. Do further tests such as
ETT to check if cardiac - induced
 Betablockers cause unusual fatigue symptoms

8. COUGH usually associated with pulmonary conditions but
may occur as pulmonary complication of cardiovascular
complex eg. Left ventricular dysfunction, mitral valve
dysfunction, pulmonary edema. Cough can also be
aggravated by exercise, metabolic stress, supine, PND.
CYANOSIS bluish discoloration of lips, nail beds of fingers
and toes. Usually in CNS or hematologic disorders
CLAUDICATIONleg pain with peripheral vascular disease.
Vascular when pitting edema with leg pain, skin
discoloration and trophic changes – cool skin; trophic
changes, warm skin; inflammation
differentiate from sciatica, back pain, gout, peripheral
neuropathy
Emergency due to thromboembolism if sudden
worsening of intermittent claudication or abrupt
ischemic rest pain!!

9. VITAL SIGNS look for abnormal response - too high or too
low heart rate, irregular pulse rate, systolic BP not rising
progressively or falling in response to exercise, change
in diastolic BP 15 – 20 mmHg.
 Monitor HR as a gauge or heart work load but use RPE
rating of perceived exertion in patients using BP lowering
medications as some will not allow HR to be > 90 bpm
EDEMA non cardiac origin: pulmonary hypertension, kidney
dysfunction, cirrhosis, burns, infection, lymphatic
obstruction, using NSAIDs or allergic reaction
 Cardiac origin – right heart failure, 2ndry to cardiac
surgery, CAD, venous valve incompetence
 Edema in form of 3 pound or greater weight gain or
gradual continuous weight gain with ankle, hand
swelling, SOB, fatigue and dizziness – red flag for CHF
 Can be accompanied by jugular venous distention and
cyanosis of lips

10. Cardiac diseases
Heart muscle Heart valves Cardiac nervous
system
Coronary artery disease Rheumatic fever Arrythmias
Myocardial infarct Endocarditis Tachcardia
Pericarditis Mitral valve prolapse Bradycardia
Congestive heart failure Congenital deformities
aneurysms

11. Conditions affecting heart
muscle
 Obstruction or restriction
 Inflammation
 Dilation or distention
Can occur in combination. Underlying obstruction such
as pulmonary embolus leads to congestion and
subsequent dilation of vessels blocked by embolus.

12. Hyperlipidemia
Metabolic abnormality
 Elevated serum total cholesterol
 Elevated triglycerides
 Elevated low density lipoproteins
 Decreased high density lipoproteins
STATIN INDUCED MUSCULAR SYMPTOMS
 Myalgia common in elderly especially females, small body
frame, kidney or liver disease, drinking excessive grape fruit
juice. Normal creatinekinase levels
 Myositis – muscle pain, fever, nausea, vomiting. Increased CK
levels
 Rhabdomyoliysis – marked CK elevation

13. Coronary artery disease
When coronary artery becomes narrow or blocked, the
area of heart muscle supplied by the artery becomes
ischemic and injured resulting in infarction
Coronary artery disease CAD or Ischemic heart
disease IHD includes:
 atherosclerosis (fatty buildup) hardening of medium
sized arteries. Heart attacks and strokes most common
fatal sign of disease
 thrombus (blood clot) – coronary thrombosis; clot
formation in coronary artery
 spasm (intermittent constriction) –brief such as nicotine
intake, anxiety, cold air and healthy persons. Prolonged
can cause heart damage

14. Modifiable risk
factors
Physical inactivity
Cigarette smoking
Elevated serum
cholestrol
High blood
pressure
Nonmodifiable
risk factors
Age
Male gender
Family history
Race
Postmenopausal (
female)
Contributing
factors
Obesity
Response to stress
Personality
Peripheral vascular
disease
Hormonal status
Alcohol
consumption
Risk factors for coronary artery disease

15. Angina
 Acute pain in chest – angina pectoris
 Symptom of reduced blood supply to heart muscle,
results from imbalance between cardiac workload and
oxygen supply to myocardial tissue
 SYMPTOMS
 Pain radiating to back, neck, jaw, arm
 Gripping feeling
 Toothache
 Dyspnea
 Belching
 Nausea

16. Angina
Chronic
stable
Predictable
level of
stress,
relieved by
rest and NG
Resting
At rest,
supine. Not
relieved by
rest, NG
Unstable
Abrupt change in
frequency and intensity
of stimulus. 1-5 mins, not
linger than 20 mins.
Require immediate
medical attention. Not
relieved by NG
Nocturnal
During sleep.
CHF common
Atypical
Unusual symptoms
toothache earache.
Related to physical
exertion
New
onse
t
Developed
first time in
60 days
Prinzmetal’s
Due to spasm.
Cyclic and early
morning, at rest and
postmenaupausal
women

18. Coronary circulation

19. Cardiac arrest OR myocardial
infarction?
 Sudden death can be the first sign of heart disease
 The onset of an infarct may be characterized by severe
fatigue for several days before the infarct – prodromal
symptom
 Chances of heart attack 40% higher in the morning
 Cardiac arrest strikes without warning.
 Sudden loss of responsiveness
 No normal breathing
 No signs of circulation
Call for help and begin CPR immediately!

20. Myocardial infarction
 Heart attack, coronary occlusion – development of
ischemia and necrosis of myocardial tissue
 Results from sudden decrease in coronary perfusion
or increase in myocardial oxygen demand without
adequate blood supply.
 Usually preceded by occlusion of major cardiac artery
due to a clot or sclerosed artery with thrombosis
 cause with interrelated factors such as coronary artery
spasm, platelet aggregation, embolism, thrombus
secondary to rheumatic heart disease, cold, exercise,
spasm of arteries etc

22. Clinical signs and symptoms of MI
May be silent – smokers, diabetics, reduced sensitivity
to pain
Sudden cardiac death
Prolonged sub sternal chest pain/ squeezing pressure
Pain down one or both arms, jaw, throat, neck, back
Feeling of indigestion
Angina lasting 30 minutes or more
Angina unrelieved by rest, nitroglycerin, or antacids
Pain of infarct unrelieved by rest or change in position
nausea
pallor
Diaphoresis (heavy perspiration)
Shortness of breath
Weakness, numbness, feeling of faintness
Sudden dimness, loss of vision or speech
Isolated biceps aching

23. Pericarditis
 Inflammation of the pericardium, sac like covering of the
heart
 May develop as a primary condition or secondary to
conditions such as influenza, TB, HIV, kidney failure,
autoimmune disorders, cancer or idiopathic
 Acute or chronic and recurring with scarred and
thickened pericardium
 Can occur in any age group therefore a history of recent
pericarditis with new onset of chest, neck or L arm pain
is important .
 Post infection onset can be 1-3 weeks later

24. •No signs symptoms initially
•Accumulation of fluid in
pericardium causes pain with
breathing
•Closely mimics MI pain
pattern
•BUT MI pain unaffected by
position breathing or
movement
•PERICARDITIS PAIN
relieved by kneeling on all
fours, forward or sitting
upright
•Worse pain with breathing,
swallowing, neck movements
•Pain diminishes if the breath
is held
•History of recent fever, chills
and infection
•Sharp pain with intermittent
bursts

25. Congestive heart failure or Heart
failure
Also called cardiac decompensation or cardiac insufficiency
 Physiologic state in which the heart is unable to pump enough blood to
meet the metabolic needs of the body at rest or during exercise even
though filling pressures are adequate
 Not a disease itself, inadequate pump performance from cardiac valves
or myocardium

28. Aneurysm
 Abnormal dilatation (saclike formation) in wall of artery, vein or
heart.
 Occurs when vessel or heart wall become weakened from
trauma, congenital vascular disease, infection or
atherosclerosis
 Named according to artery or vein and the region.
 DISSECTING ANEURYSM – spits and penetrates the arterial
wall creating a false vessel.
 Thoracic aneurysms most common among men 40 – 70 years
 Most common site for peripheral arterial aneurysms –
popliteal space. May have an enlarged area behind knee
without discomfort

29. Abdominal aortic aneurysms
AAA
 Most common places for aneurysm are aorta and cerebral
arteries
 Progression of AAA – expansion and rupture
 Most common aortic aneurysm site just below kidney
 Can be caused by trauma, weight lifting in aging athletes,
congenital vascular disease, infection, atherosclerosis, clients
having anterior spinal procedures of any kind
 Exacerbated by anticoagulant therapy
 Therapist should be careful in prescribing resisted exercises,
monitor vital signs, instruct patients to avoid Valsalva maneuver
 Now recommendation of ultrasonographic screening for
abdominal aortic aneurysm for men aged 65 to 75 who smoke or
have history of smoking

30. Aortic aneurysm signs and
symptoms
•Mostly asymptomatic
•Pulsating mass in abdomen with or without pain
•Distended abdomen
•Change in blood pressure
•Changes in stool
•Possible back or shoulder pain
•Symptoms not relieved by change in position
RUPTURED
• SBP below 100 mmHg
•Pulse rate over 100
•Severe sudden abdominal pain
•Cold pulse less lower extremities

31. Conditions affecting the
valves
 Stenosis – is a narrowing or constriction that prevents the valve from
opening fully caused by growths, scars or abnormal growths on leaflets
 Insufficiency – (regurgitation) when valve does not close properly and
blood flows back into the heart chamber
 Prolapse – enlarged valve leaflets bulge back into the left atrium, only
in the mitral valve
 Require heart to work harder to pump blood. Complications might occur
secondary to bacterial infections (endocarditis)
 Pericarditis common in systemic lupus erythematosus – multi system
illness associated with release of autoantibodies in the blood stream
 Persons may be asymptommatic. Fatigue is an early sign followed by
dyspnea.

32. Endocarditis
 Inflammation of cardiac endothelium
 Infection may be caused by bacteria entering the blood
stream by remote part of the body eg. Skin, oral cavity or
growths on previously damaged or artificial valves. Risk
of embolization of these growths or vegetations
 Injection drug users and post cardiac surgical clients at
high risk of developing endocarditis
 Musculoskeletal symptoms :
 Arthralgias
 Arthritis
 Low back/sacroiliac pain
 Myalgias
 Constitutional symptoms
 Neurologic deficits absent, morning stiffness absent

33. Rheumatic fever
 Infection caused by streptococcal bacteria. Can be fatal. Called
such because fever and joint pain are two most common
symptoms
 Infection generally starts with strep throat in children 5 – 15
years followed 2-3 weeks later by sudden or gradual migratory
joint symptoms in knees, shoulders, feet, ankles, elbows, fingers
or neck. Palpitations, fatigue, weakness, weight loss may also be
present
 All layers of heart and the heart valves are affected
 Rheumatic Chorea – chorea in child 1-3 months after fever and
poly arthritis almost always a manifestation of rheumatic fever
 Recurrences common after 5 years of good health

34. Mitral valve prolapse
Mitral leaflet thickness, decrease stiffness and
strength due to connective tissue or left
ventricular cavity geometry abnormalities.
• benign or in combination with conditions
such as endocarditis, systemic lupus
erythematosus, fibromyalgia
• No symptoms in 2/3rd persons with MVP
•dysautonomia – imbalance of autonomic
nervous system
• SYMPTOMS
•Profound fatigue
•Dyspnea
•Palpitations
•TMJ syndrome
•Myalgia
•migraine

35. Conditions affecting
cardiac nervous system
Failure of heart’s nervous system to
conduct normal electrical impulses
 Neurologically impaired patients
susceptible such as CVA, head trauma,
spinal cord injury
 Monitor pulse before, during and after
exercise when working with stroke
patients
Arrythmia /
Dysrhythmia
bradycardia tachycardia

36. Sinus Tachycardia
 Heart rate >100 beats per minute
 Physiologic to stressors such as fever, anxiety,
exertion, thyrotoxicosis, MI, CHF, shock
 In patients with cardiac disease means reduced
cardiac output, CHF or arrythmia when persistent
 SYMPTOMS
 Palpitation
 Restlessness
 Chest discomfort/pain
 Agitation and anxiety

37. Sinus bradycardia
 Heart rate < 60 beats per minute
 Asymptomatic in athletes and youngster
 Benign arrhythmia might be beneficial by increasing
longer diastole period and increased ventricular filling
 Might occur after eye surgery, MI, jaundice
 SYMPTOMS
 Reduced pulse rate
 Syncope
 Weakness
 Sweating
 Nausea and vomiting
 Dimming of vision
Signs and symptoms immediately resolved by placing patient
in horizontal position

38. Fibrillation
 Small electrical impulses by damaged atrial or ventricular muscles felt
as irregular pulses on palpation
 VENTRICULAR FIBRILLATION can result in sudden death and
requires immediate CPR with defibrillation
 ATRIAL FIBRILLATION can cause stroke by clot formation in the atria
SYMPTOMS RISK FACTORS
Palpitation
Restlessness
Fluttering, skipping,
pounding
Dyspnea
Chest pain
anxiety
Previous heart attack
H Pylori
High BP
Digitalis toxicity
CHF
Pericarditis
Rheumatic mitral
stenosis

40. hypertension
• Primary /
essential
• Secondary
• borderline
Transient
ischemic
attack
Orthostatic
hypotentsion
Peripheral
vascular
disorders
• Arterial occlusive
disease
• Raynaud’s
phenomenon
• lymphedema
Cardiovascular
disorders

41. Classification of blood pressure
For adults Systolic blood
pressure
Diastolic blood
pressure
Normal <120 mmHg <80mmHg
Prehypertensive 120-139 mmHg 80-89 mmHg
Stage I hypertension 140-159 mmHg 90-99 mmHg
Stage II hypertension ≥ 160 mmHg ≥ 100 mmHg
From the seventh report of the Joint National committee on prevention,
detection, evaluation and treatment of high blood pressure, NIH publication
no. 03-5233, May 2003. National Heart Lung and Blood Institute (NHLBI)

42. Risk factors for hypertension
• Smoking/ tobacco
• High cholesterol
• Obesity
• Sedentary lifestyle
• Stress
• Diet, nutritional status/ potassium deficiency
modifiable
• Age (60 or older)
• Family history of cardiovascular disease
(women younger than 65, men younger
than 55)
• Postmenopausal status ( including
surgically induced)
Non
modifiable