medical student 1st spiral

1. APPROACH TO A PATIENT WITH
CARDIOVASCULAR DISEASE
PROF FARHAT BASHIR
DEPARTMENT OF MEDICINE

2. Objectives
• To be able to diagnose a patient complaining
of chest pain, shortness of breath,
palpitations, syncope, edema and intermittent
claudication.
• To be able to formulate an accurate
differential diagnosis for them.

4. CHEST PAIN
• Common presentation.
• Trivial to life-threatening causes.
• Key to diagnosis is history NOT
INVESTIGATIONS.
Negative baseline investigations DO NOT rule
out serious conditions

5. Initial Approach
• Triage
– Chest pain
– Significant abnormal pulse
– Abnormal blood pressure
– Dyspnoea
– These patients need IV, O2, Monitor, ECG

6. Initial Approach
• Evaluation:
– Airway
– Breathing
– Circulation
– Vital Signs
– Focused exam
• Cardiac, pulmonary, vascular

7. Initial Approach
• History:
– Character of pain
– Presence of associated symptoms
– Cardiopulmonary history
– Pain intensity, 0-10 pain

8. Initial Approach
• Secondary exam:
– History
• Quality, radiation/migration, severity, onset, duration,
frequency, progression and provoking or relieving
factors of pain
– Risk factors
– Physical exam
– Review old records/ECG

9. Categorizing Chest Pain
1. Chest Wall Pain
• Sharp, Precisely localized
• Reproducible: Palpation, movement
2. Pleuritic or Respiratory CP
• Somatic pain, Sharp
• Worse with breathing/coughing
3. Visceral CP
• Poorly localized, aching, heaviness

10. • there are a lot of importment data of the pain:
– localisation
– radiation
– onset of the pain
– the type (press, smart,cutting)
– dinamic of the pain (continouosly, ongoing, undulaiting)
– answer to the medical therapy
CHEST PAIN

11. Chest Pain
Non Cardiac
Cardiac
PE
PTX
Oesophageal disaster
Aortic disease
Myo/pericardium
Coronary disease
Coronary spasm
Obstructive CAD
ACS
Stable angina

12. Categorizing Chest Pain
Assessment of Risk Factors
• CAD:
– Cigarette Smoking
– Diabetes
– Hypertension
– Hypercholesterolemia
– Family History

13. Life-threatening Causes of
Chest Pain
• Myocardial infarction(ACS).
• Thoracic aortic dissection.
• Pulmonary embolus.
• Tension pneumothorax.
• Oesophageal rupture

14. Investigations
• ECG most important But history is more
important.
• 20% of patients having an MI will have a
normal ECG initially.
• Negative cardiac enzymes in A&E are not
helpful.
• CXR useful to rule out other causes like
pneumonia.

15. 26 yr old thin man with sudden onset of severe, right sided
sharp, chest pain ,dyspnoeic.

16. • Right Pneumothorax

18. Pneumothorax

19. .
65 year old man(H/O DM,HTN) presented with a 1 hour
history of severe central crushing chest pain. He is
sweaty, clammy and has vomited twice

21. 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe
central crushing chest pain. He is sweaty, clammy and has vomited twice .
• Anterior (extensive) Myocardial infarction.
Why ?
Male 65 years.
H/O DM+HTN
Crushing chest pain.
Associated sweating, clammy, vomiting.

22. • A 70 years old male with long history of
untreated HTN, nonsmoker came complaining of
chest pain migrated to interscapular region &
became severe(tearing),SBP 200,ECG mild inferior
changes
• Most likely diagnosis is
• ? AMI
• ?PE
• ?Esophageal Rupture
• ?Aortic Dissection

24. Aortic dissection

25. Aortic dissection

26. Aortic Dissection
• Severe, sharp, “tearing” posterior chest
pain or back pain (occurs in 74-90% of
patients)
• Pain may be associated with syncope, CVA, MI, or CHF
– Painless dissection relatively uncommon 15%

27. • Physical Examination
• Pulse deficit
– Weak or absent carotid, brachial, or femoral
pulses
– these patients have a higher rate of mortality
• Acute Aortic Insufficiency
– Diastolic decrescendo murmur
– Best heard along the right sternal border

28. TEE of Aortic Dissection & CT aorta

29. • 40 years old male finished cardiac evaluation last week
for insurance (every thing is normal), ate a heavy meal
with friends (celebrating), followed by severe vomiting
then chest pain. Last vomitus contains streaks of fresh
blood.
• Likely diagnosis
• ?ACS
• ?PE
• ?Aortic Dissection
• Esophageal submucosal tear(Mallory Weiss syndrome).

30. Oesophageal rupture: Diagnosis
• CXR: early shows
mediastinal or free
peritoneal air
–Hours to days
later: widening of
mediastinum,
pleural effusion

31. Oesophageal rupture:
• CT scan: Oesophageal
oedema, extra
oesophageal air,
perioesophageal fluid
• Oesophagram:
Extravasation of
contrast
• NO role for endoscopy
which introduces more
air into mediastinum

32. A 26 year old woman presented 1 week post delivery of
her first baby. She has sharp L sided chest pain and she
is short of breath.

33. • Pulmonary Embolism
• Why ?
• Young female
• Pregnancy hypercoagulable state
• Occurrence one week post partum

36. A 26 year old army officer had flu last week, felt chest
pain while driving his car, pain increased by deep
breathing, he has no history of DM or HTN,
nonsmoker, lipid profile LDL 94mg/dl

37. • Acute Pericarditis

38. Pericarditis: ECG:

39. 26 Old army officer had flu last week,felt
chest pain while driving his car,pain
increased by deep breath,ECG after 5 days

40. • Resolved Pericarditis.

41. Diagnostic limitations
 History:
25% have ‘atypical’ histories
 ECG:
20% of patients with Acute Myocardial
Infarction have a normal first 12-lead ECG
 Conventional Cardiac Markers:
Normal for the first 3- 4 hours

42. Take home points
•History 90%
•ECG: if ST elevated act fast
•Risk factor reduction
•Never ignore chest pain

45. Dyspnea
• Awareness of his own breathing.
– Hyperventilation
– Sighing breath
– Inability to take deep breath
• Orthopnea dyspnea on lying down
• Dyspnea of exertion (DOE)
– Exertion-induced SOB
– Grades of dyspnea
• Paroxysmal nocturnal dyspnea (PND)
– Sudden SOB after recumbent

46. 1. 73 year old female with HO IHD presents to the ED
with complaints of SOB for the last 2 days.
2. 28 year male presented with high grade fever,
cough and SOB for 5 days. On examination of chest
there is bronchial breathing.
a) Diagnosis
b) Investigation & Management

47. Dyspnea
Rapid Assessment
• ABC’s
• Mental status
• Rapid history and examination

48. Dyspnea
Initial Interventions
• IV assess
• Pulse oximetry; supplemental O2
• Cardiac monitor

49. Dyspnea
History
• Prolonged questioning can be counterproductive
– Yes/No questions if significantly dyspneic
– Unlike pain, severity of dyspnea = severity of disease
• What does patient mean by SOB?
• How long has SOB been present?
– Is it sudden or gradual
• Does anything make it better or worse?

50. Dyspnea
History
• Has there been similar episodes?
• Are there associated symptoms?
• What is the past medical Hx?
– Smoking Hx?
– Medications?

51. Minutes
• Pneumothorax
• Pulmonary oedema
• Major pulmonary
embolism
• Foreign body
• Laryngeal oedema
Hours
• Asthma
• Left heart failure
• Pneumonia
• Metabolic acidosis
• ARDS
Days
• Pneumonia
• ARDS
• Left heart failure
• Repeated pulmonary
embolism
• Metabolic acidosis
Weeks
• Pleural effusion
• Anemia
• Muscle weakness
• Tumours
ONSET OF DYSPNOEA

52. Months
• Pulmonary
fibrosis
• Thyrotoxicosis
• Muscle
weakness
Years
• Muscle
weakness
• COPD
• Chest wall
disorders

53. • GRADE 1 –Dyspnoea only with unusual
exertion.
• GRADE 2 –Dyspnoea on doing ordinary
activity
• GRADE 3 –Dyspnoea on doing less than
ordinary activity.
• GRADE 4 –Dyspnoea at rest.
NYHA SCALE

54. Dyspnea
Common Cardiac Causes
• Acute coronary syndromes
• CHF
• Arrythmias
• Valvular heart disease

55. Dyspnea
Physical Examination: Vital Signs
• BP
• Pulse
– Usually 
– Bradycardia - severe hypoxemia
• Respiratory rate
– Sensitive indicator of respiratory distress
– DANGER = > 35-40 bpm or < 8-10 bpm

56. Dyspnea
Physical Examination: Observation
• Ability to speak
• Patient position
• Cyanosis
– Central vs. peripheral (acrocyanosis)
• Mental status
– Altered MS - hypoxemia/hypercapnia

57. Cardiovascular examination
• JVP , extra heart sound (S3 gallop rhythm), and
fluid retention - congestive heart failure.
• Elevated neck veins, pulsus paradoxus, a
pericardial knock, pericardial rub, and the
Kussmaul's sign - Constrictive pericarditis and
effussion
• An irregular or fast heart beat - a tachyarrhythmia
or atrial fibrillation.
• A loud S2 -PAH
• A systolic heart murmur- acute valvular
insufficiency, mechanical valve malfunction.

59. Case 1
History
• Symptoms started 2 days ago
• Onset gradual and progressive
• Exertion makes it worse
• New onset
• (+) chest pain, cough, DOE, PND
• No past medical Hx
• No medications or smoking Hx

60. Case 1
Physical Examination
• Moderate respiratory distress, talks in partial
sentences, prefers to sit in ED wheel-chair
• BP = 190/110 mmHg; HR = 118 /min; RR = 36
bpm; afebrile; SpO2 = 85%
• HEENT: no angioedema
• Lungs: rales & wheezing bilaterally
• Cardiac: (+) JVP; (+) S3
• Skin: no rashes
• Extremities: no edema

61. Case 1
• What are likely etiologies for this patient’s
dyspnea?
– Heart failure
– ? ACS

62. Dyspnea
Diagnostic Adjuncts
• What study will most patient’s with dyspnea
get?
– CXR
• Indicated in most cases of dyspnea, especially new-
onset

63. Case 1

64. Dyspnea
Diagnostic Adjuncts
• What other non-laboratory study would you
like?
– ECG
• Indicated if cardiac etiology suspected or cardiac
history

65. Case 1

66. Dyspnea
Diagnostic Adjuncts
• What lab tests might be useful in dyspnea
workup?
– ABG
• If any question about ventilatory or acid-base status
• Beware of interpretation of (A–a)O2
– Troponin
• How would it be helpful in our patient?
– B-type natriuretic protein (BNP)
– Laboratory studies based on suspected etiology of
dyspnea

67. PALPITATION
• Abnormal subjective awareness of the heart beat.
• Thumping, pounding, fluttering, jumping, racing,
skipping)
• But patient may describe palpitation as a feeling
of breathlessness, excitement, fright etc.
• Palpitation is not always = arrythmias

68. B. Causes.
• Palpitation may be due to Rapid heart beat or
Slow heart beat or
Irregular heart beat.
• Palpitation may be due to
Primary cardiac disease (Acute or Chronic) or
Secondary effect on the heart (Systemic disease or
Drugs)

69. Common causes are
(1) Anxiety, Exercise, hyperthyroidism
(2) Drugs (Sympathomimetics, Atropine)
(3) Diet (Tea, coffee, cola)
(4) Nicotine (Smoking)
(5) Abnormal rate
Sinus tachycardia(100-160)
Supraventricular tachycardia(160-220)
Ventricular tachycardia
Sinus Bradycardia

70. (6) irregular rhythms
Atrial fibrillation
Ventricular fibrillation?
(7) Extrasystole
Atrial extrasystole.
Ventricular extrasystole
(8) Wolff-Parkinson-White (WPW)
(9) Forceful heart beat
Aortic regurgitation.

71. C. Diagnosis
• Careful and thorough history is important.
• Definitive diagnosis may be obtained by doing ECG
during attacks or ambulatory ECG monitoring.

72. The evaluation of patient with palpitation.
• Continuous or intermittent?
• Regular or irregular heartbeat?
• Approximate heart rate?
• Discrete attacks or not? If yes, is the onset abrupt?
Or how do attacks terminate?
• Any associated symptoms? Eg. Chest pain,
lightheadedness, polyuria.
• Any precipitating factors? Eg. Exercise, alcohol.
• Evidence of structural heart disease? Eg. Coronary
heart disease, valvular heart disease.

73. Regular heart beat
NO
Yes
Ectopics
Atrial fibrillation Discrete attacks
NOYes
SVT Sinus tachycardia
High stroke volume
Anaemia
Anxiety
AR

74. SYNCOPE/ PRESYNCOPE
• Sudden loss of consciousness
• May be due to reduced cerebral perfusion.
• Presyncope is lightheadedness in which the
patient thinks he may black out.

75. • Cardiac syncope- arrythmia, structural heart
disease
• Neurocardiogenic syncope- situational,
vasovagal, hypersensitive carotid sinus
syndrome
• Postural hypotension
• CNS: Loss of consciousness due to seizure,
CVA, hypoglycemia.

76. Questions to be asked for syncope
• Did you lose consciousness completely? If yes for how long?
• Do you blackout or feel dizzy when you stand up quickly?
• How often have episodes occurred?
• Was the sensation more one of spinning?
• Did the episode occur during heavy exercise? Or when you got up to pass
urine during the night?
• Have you injured yourself?
• Do you get any warning?
• 9feeling of nausea while in a stuffy room suggests----; a strange smell or
feeling of deja-vu suggests an aura and therefore----)
• Have you become incontinent during an episode?
• Have you bitten your tongue?
• Has anyone witnessed an episode and seen tonic clonic jerking?
• Do you wake up feeling normal or drowsy?
• What medications are you taking?

77. Edema
• Hydrostatic and oncotic pressure imbalance
• Cardiac
• Renal, hepatic, GIT

78. Intermittent claudication
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Perishingly cold
• Paralysed

79. QUESTIONS??????