Cardiovascular system

Cardiovascular system

1. CARDIOVASCULAR SYSTEM (HARRISON’S) MOTE SRIKANTH CV disease is now the most common cause of death worldwide

2. What are the cardiac symptoms ?? Chest pain Palpitations Dyspnea Dizziness & Syncope Easy fatigability Oliguria Swelling of feet Loss of appetite & weight (due to congestive hepatopathy & gastropathy) Ascites Jaundice (due to cardiac cirrhosis) Recurrent respiratory tract infections (due to pulmonary congestion)

3. What do they indicate ?? SYMPTOM CAUSE/ INDICATES 1) CHEST DISCOMFORT Myocardial ischemia caused by an imbalance between the heart’s oxygen supply and demand 2) EASY FATIGABILITY PERIPHERAL EDEMA DYSPNEA (due to pulm. edema) Reduction of the pumping ability of heart 3) EDEMA (+ all other symptoms resembling those of myocardial failure) Obstruction to blood flow (eg: vascular stenosis ) 4) PALPITATIONS SYNCOPE DYSPNEA HYPOTENSION Abnormal cardiac rate or rhythm (Cardiac arrhythmias)

4. Are these symptoms restricted to only CVS ?? SYMPTOM OTHER POSSIBLE CAUSES DYSPNEA Pulmonary disease Marked obesity Anxiety, etc. CHEST DISCOMFORT Other cardiac causes (apart from myocardial ischemia) Non-cardiac causes EDEMA Primary renal disease Hepatic cirrhosis SYNCOPE Neurological conditions NOPE !!

5. How will you know if heart disease is responsible for these symptoms ?? By carrying out a careful clinical examination Supplemented by non-invasive testing (eg: electrocardiography at rest & during exercise, echocardiography) & other forms of myocardial imaging Myocardial or coronary function that may be adequate at rest but insufficient during exertion  dyspnea, chest discomfort (during activity) are characteristic of patients with heart disease

6. So now roughly you have come to know that it is cardiac pathology..then what next ?? To come to a complete cardiac diagnosis, following considerations to be made: ELEMENTS QUESTIONS UNDERLYING ETIOLOGY Congenital ? Hypertensive ? Ischemic ? Inflammatory in origin ? ANATOMIC ABNORMALITIES Chambers involved? Are they hypertrophied? dilated? both? Valves affected? Regurgitant? Stenotic? Pericardial involvement? PHYSIOLOGIC DISTURBANCES Arrhythmia present? Evidence of M.ischemia or CHF FUNCTIONAL DISABILITY How strenuous is the physical activity required to elicit symptoms? (NYHA classification)

7. 4a:

8. 4b: (grading of dyspnea) Grade 1: Dyspnea occurring during unaccustomed exertion (classical eg: running up 2 long flights of stairs) Grade 2: during accustomed exertion (classical eg: climbing up 2 long flights of stairs) Grade 3: during minimal exertion (classical eg: walking from room to room) Grade 4: at rest

9. For example, In a patient who presents with exertional chest discomfort, the identification of myocardial ischemia as the etiology is of great clinical importance. However the simple recognition of ischemia is insufficient to formulate a therapeutic strategy or prognosis until the underlying anatomic abnormalities responsible for the myocardial ischemia [eg: coronary atherosclerosis or aortic stenosis] are identified and a judgment is made about whether other physiologic disturbances that cause an imbalance between myocardial oxygen supply and demand [eg: severe anemia, thyrotoxicosis] play contributory roles. Finally the severity of the disability should govern the extent and tempo of the workup and strongly influence the therapeutic strategy that is selected

10. The establishment of a correct and complete cardiac diagnosis usually commences with History Physical examination 5 types of lab tests 5 LABORATORY TESTS ECG Non-invasive imaging examinations (echocardiogram, CT imaging, MRI, etc.) Blood tests to assess risk (eg: lipid determinations, CRP) or cardiac function (eg: BNP) Occasionally specialized invasive examinations (cardiac catheterization, coronary arteriography) Genetic tests to identify monogenic cardiac diseases (eg: hypertrophic cardiomyopathy, Marfan’s syndrome, sudden death assoc. with a prolonged QT interval syndrome) In history taking of a patient with known or suspected CV disease, particular attention should be directed to family history WHY ?? Coz familial clustering is common in many forms of heart disease: hypertrophic cardiomyopathy Marfan’s syndrome sudden death assoc. with a prolonged QT interval syndrome

11. Can you prevent cad ?? How ?? Prevention begins with Risk assessment Lifestyle changes (eg: achieving optimal weight, physical activity, smoking cessation, etc.) Aggressive treatment of all abnormal risk factors (HT, hyperlipidemia, DM) YES !!

12. Management: In absence of evidence of heart disease In absence of evidence of heart disease but the patient has one or more risk factors Asymptomatic / mildly symptomatic patients with valvular heart disease (that is anatomically severe) In patients with CAD Inform the pt. clearly of this assessment and NOT BE asked to return at intervals for repeated examination Develop a plan for their reduction & pt. should be retested at intervals to assess the efficacy in risk reduction Evaluated periodically every 6-12 months by clinical & non-invasive examinations Rx: medical, percutaneous coronary intervention, surgical revascularization

13. Why scenario 3 type of patient needs to be evaluated every 6-12 months ?? Coz in case of early signs of deterioration of ventricular function signifies the need for surgical treatment before the development of disabling symptoms, irreversible myocardial damage, etc. Can we do revascularization for all scenario 4 patients?? The mere presence of angina pectoris &/ demonstration of critical coronary artery narrowing at angiography should not reflexively evoke a decision to treat patient by revascularization. Instead it must be limited to patients with CAD whose angina has not responded adequately to medical treatment or in whom revascularization has been shown to improve the natural history (eg: acute coronary syndrome or multivessel CAD with left ventricular dysfunction)

14. Something about heart murmur: (extra) Majority of heart murmurs are midsystolic and soft (grades 1-2) Do all murmurs require echocardiography ?? NOPE !!

15. Evaluation of heart murmur: (Pg 1441)

16. Now let us go in detail with examination part.. 2 parts GENERAL PHYSICAL EXAMINATION CARDIOVASCULAR EXAMINATION

17. General Physical Examination: General appearance of patient - built & nourishment - posture - dyspneic ? - diaphoretic ? - in pain / resting quietly ? - does the patient choose to avoid certain body positions to reduce/ eliminate pain ? - mental status - level of alertness - mood

18. SKIN CONDITION INDICATES 1) CENTRAL CYANOSIS Significant right-to-left shunting at the level of heart / lungs 2) PERIPHERAL CYANOSIS Reduced blood flow to extremity due to small vessel constriction (as in severe heart failure/ shock/ peripheral vascular disease) 3) DIFFERENTIAL CYANOSIS Large PDA Secondary pulmonary HT with right-to-left shunting at great vessel level 4) TELANGIECTASIAS (on face) Advance mitral stenosis Scleroderma 5) TAN/ BRONZE DISCOLORATION OF SKIN Hemochromatosis is the cause of assoc. heart failure 6) JAUNDICE Advanced right heart failure Congestive hepatomegaly (cardiac cirrhosis)

19. 7) CUTANEOUS ECCHYMOSES Patient is taking Vit K antagonists or antiplatelet agents (eg: aspirin) 8) XANTHOMAS Lipid disorders

20. HEAD & NECK: Dentition & oral hygiene Ocular examination Face FEATURE CONDITION 1) High-arched palate Marfan’s syndrome & other connective tissue disease syndromes 2) Bifid uvula Loeys-Dietz syndrome 3) Orange tonsils Tangier disease FEATURE CONDITION 1) Blue sclera Osteogenesis imperfecta Many patients with congenital heart disease have associated h ypertelorism + low-set ears + micrognathia FEATURE CONDITION 1) INFLAMMED PINNA / SADDLE NOSE DEFORMITY Relapsing polychondritis

21. CHEST: FEATURES INDICATES 1) Scars ? 2) Prominent venous collateral pattern Subclavian / vena caval obstruction 3) Thoracic cage abnormalities Pectus carinatum (pigeon chest ) Pectus excavatum (funnel chest) Barrel chest Connective tissue disease syndromes Obstructive Lung disease 4) Severe kyphosis Auscultate for murmur of AR 5) Straight back syndrome Mitral valve prolapse 6) Asymmetric chest wall with anterior displacement of left hemithorax Cyanotic congenital heart disease

22. ABDOMEN FEATURE INDICATES 1) Point of maximum cardiac impulse in epigastrium Advanced obstructive lung disease 2) Enlarged & tender liver Chronic heart failure 3) Systolic pulsations over liver Tricuspid regurgitation 4) Splenomegaly Infective endocarditis 5) Ascites Chronic right heart failure Constrictive pericarditis Hepatic cirrhosis Intraperitoneal malignancy 6) Arterial bruit over abdomen High grade atherosclerotic disease

23. EXTREMITIES: FEATURE INDICATES 1) Temperature ? 2) Color ? 3) Clubbing Central right-to-left shunting 4) Fingerized thumb Holt- Oram syndrome 5) - Arachnodactyly - Positive “wrist” sign (overlapping of thumb & 5 th finger around the wrist) / - Positive “thumb” sign (protrusion of the thumb beyond the ulnar aspect of hand when the fingers are clenched over the thumb in a fist) Marfan’s syndrome

24. 6) - Janeway lesions (non tender, slightly raised hemorrhages on palms & soles) - Osler’s nodes (tender, raised nodules on the pads of the fingers or toes) - Splinter hemorrhages Endocarditis 7) Lower extremity or pre-sacral edema (+increased JVP) (-increased JVP) (-increased JVP + varicosities/ venous ulcers –medial / brownish cutaneous discoloration from hemosiderin discoloration –EBURNATION) Chronic heart failure Constrictive pericarditis Lymphatic/venous obstruction Venous insufficiency (MC) 8) Muscular atrophy / absence of hair along an extremity Severe arterial insufficiency Primary neuromuscular disorder

25. Cardiovascular Examination: Jugular venous pressure & waveform BP Arterial pulse Inspection & palpation of heart Cardiac auscultation

26. JVP: AIM: to estimate the volume status Which vein is used to measure JVP? Internal jugular vein is preferred. External Jugular vein is less reliable coz of: Does not directly drain into SVC & Rt. atrium Has valves How do you measure JVP ? Traditionally has been measured as vertical distance between the top of the jugular venous pulsation & Angle of Louis. A distance > 4.5cm at 30 degree elevation is considered abnormal Finding of an elevated JVP implies a cardiovascular pathology

27. Why clavicle is preferred over Angle of Louis as a reference point? Coz the actual distance between the mid-right atrium and the angle of Louis varies considerably as a function of both body size & the patient angle at which assessment is made (30/45/60 degree) Venous pulsations above clavicle in the sitting position (with the legs dangling below the bedside) are clearly abnormal as the distance between the clavicle & the right atrium is at least 10 cm

28. Differentiation btw venous & arterial pulsation ? VENOUS PULSATION ARTERIAL PULSATION Lateral to SCM Medial to SCM 2) Waves disappear when pressure given at root of neck Not easily obliterated with palpation 3) Usually biphasic Monophasic 4) Easily seen than felt Easily felt than seen 5) Change with changes in posture or inspiration

29. Waves ?? ‘ WAVES MECHANISM ‘a' wave [MOST DOMINANT WAVE] + Right atrial contraction ‘c’ wave + Closure & bulging of tricuspid valve ‘x’ descent - Atrial relaxation with downward descent of tricuspid valve ‘v’ wave + Passive right atrial filling during ventricular systole ‘y’ descent - Right ventricular filling with atrial emptying

30. Prominent ‘a’ wave?? Tricuspid stenosis/atresia Mitral stenosis Pulmonary stenosis Pulmonary HT ‘a’ wave absent in?? Atrial fibrillation Cannon ‘a’ wave?? Very large ‘a’ wave is known as cannon wave. Seen in AV dissociation Right atrial contraction against a closed tricuspid valve

31. Kussmaul’s sign/ Venous pulsus paradoxus ? In normally healthy persons, the venous pressure should fall by at least 3 mmHg with inspiration (due to sucking of blood into right atrium) Kussmaul’s sign – Either a rise or a lack of fall of JVP with inspiration Classically associated with constrictive pericarditis Also seen in patients with - restrictive cardiomyopathy - massive pulmonary embolism - right ventricular infarction - advanced left ventricular systolic heart failure

32. Other methods of eliciting venous HT? Abdomino-jugular reflex Passive leg elevation Abdomino-jugular reflex? Elicited with firm & consistent pressure over the upper portion of the abdomen, preferably over the right upper quadrant, for at least 10 sec. + : Sustained rise of > 3 cm in JVP for at least 15 sec after release of the hand (as hepatic venous reservoir gets compressed) Useful in predicting pulmonary artery wedge pressure in excess of 15 mmHg in patients with heart failure

33. BP: How to measure BP? Best measured in seated position with the arm at the level of the heart, using an appropriately sized cuff, after 5-10 mins of relaxation When measured in supine position, arm must be raised to bring it to the level of mid-right atrium Cuff should be inflated to 30 mmHg above the expected systolic pressure and the pressure released at a rate of 2-3 mmHg /sec Systolic & diastolic pressures are defined by? 1 st & 5 th K orotkoff sounds respectively

34. BP measured at? Best assessed at brachial artery level (though it can be measured at radial, popliteal or pedal pulse level) BP should be measured in both arms and the difference should be less than 10 mmHg. >10 mmHg indicates ? Atherosclerotic/ Inflammatory subclavian artery disease Supravalvular aortic stenosis (right sided higher BP) Pre-ductal coarctation of aorta (right sided higher BP) Unilateral occlusive disease of arteries

35. Systolic leg pressures are usually as much as 20 mmHg higher than systolic arm pressures. Greater leg-arm pressure differences are seen in? Chronic severe AR Extensive & calcified lower extremity peripheral arterial disease White coat HT? Defined by at least 3 separate clinic-based measurements >140/90 mmHg & a t least 2 non-clinic based measurements <140/90 mmHg in the absence of any evidence of target organ damage May not benefit from drug therapy

36. Masked HT? Suspected when normal or even low BPs are recorded in patients with advanced atherosclerotic disease, especially when evidence of target organ damage is present or bruits are audible. Orthostatic hypotension? Fall in systolic pressure > 20 mmHg or in diastolic pressure > 10 mmHg in response to assumption of the upright posture from a supine posture within 3 mins Common cause of postural lightheadedness/ syncope CAUSES: advanced age, DM, hypovolaemia (blood or fluid loss), certain medications (centrally acting anti HT)

37. ARTERIAL PULSE: Can aortic pulse be felt? Yes. Best appreciated in the epigastrium just above the level of umbilicus Peripheral arterial pulses to be assessed? Subclavian Brachial Radial Ulnar Femoral Popliteal Dorsalis pedis Posterior tibial

38. Pulses to be examined for? Symmetry Volume Timing Contour Amplitude Duration Radio-femoral delay? HT Suspected aortic coarctation Character of pulse is best appreciated at? Carotid level

39. PULSE SEEN IN 1) PULSUS PARVUS ET TARDUS (Parvus – low in volume & amplitude; Tardus – slow rising pulse with a late systolic peak) AS 2) CORRIGAN’S / WATER-HAMMER Pul . High volume pulse, sharp rise, ill sustained & sharp fall AR 3) ANACROTIC PULSE Slow rising pulse (notched, or interrupted upstroke ) with 2 systolic peaks AS (some) 4) PULSUS BISFERIENS Rapid rising pulse with 2 systolic peaks AS + AR Hypertrophic obstructive cardiomyopathy (HOCM) 5) PULSUS ALTERNANS Alternating small & large volume pulse in regular rhythm Severe LV systolic dysfunction 6) Fall in systolic pressure > 10 mmHg with inspiration (PULSUS PARADOXUS) CARDIAC: Pericardial effusion, Constrictive pericarditis, Restrictive cardiomyopathies RS: Acute severe asthma, COPD SVC obstruction Why normally fall occurs ? – PJM 41

40. Causes of arterial bruit? Vascular obstruction AV fistula with enhanced flow Auscultation of carotid, subclavian, abdominal aortic and femoral artery bruits should be routine

41. INSPECTION OF HEART: Apex beat? Visible in left 5 th ICS, ½ inch medial to mid clavicular line in thin-chested adults Abnormal visible pulsations? Anywhere other than this expected location Visible right upper parasternal pulsation is suggestive of? Ascending aortic aneurysm disease In thin, tall patients and patients with advanced obstructive lung disease and flattened diaphragms; the cardiac impulse may be visible in the epigastrium and should be distinguished from a pulsatile liver edge

42. PALPATION OF HEART: Begins with the patient in the supine position at 30 degree and can be enhanced by placing the patient in the left lateral decubitus position Normal LV impulse? < 2cm in diameter Moves quickly away from the fingers Better appreciated at end expiration With the heart closer to ant. chest wall Characteristics such as size, amplitude & rate of force development should be noted

43. Right ventricular pressure or volume overload  sternal lift APEX BEAT INDICATES 1) Leftward & downward displacement of an enlarged apex beat Enlargement of LV cavity 2) Sustained apex beat Pressure overload AS Chronic HT

44. CARDIAC AUSCULTATION: S1 indicates? Mitral & tricuspid valve closure S2 indicates? Aortic & pulmonary valve closure Ventricular systole? Interval between S1 & S2 S2 consists of? A2 + P2 A loud single or palpable P2 is suggestive of? Pulmonary arterial HT

45. When is P2 considered to be loud? When its intensity exceeds that of A2 at the base/ When it can be palpated in the area of proximal main pulmonary artery (2 nd left ICS)/ When both components of S2 can be appreciated at lower left sternal border or apex Intensity of A2 decreases with? Aortic stenosis Intensity of P2 decreases with? Pulmonary stenosis

46. CARDIAC MURMURS: Result from audible vibrations that are caused by increased turbulence Intensity of a heart murmur is graded on a scale of 1-6 Thrill is present with murmurs of >/= grade 4 Types of systolic murmurs based on timing? Early Mid – begins after S1 & ends before S2 Late Holosystolic

47. MURMUR CONDITION 1) Early systolic murmur MR 2) Early systolic murmur (increases in intensity with inspiration) heard at left lower sternal border TR 3) Midsystolic murmur AS (most common) Pulmonary valve stenosis HOCM Left-to-right shunting Several states associated with accelerated blood flow in the absence of structural heart disease - fever - thyrotoxicosis - pregnancy - anemia 4) Late systolic murmur (heard best at apex) MVP 5) Holosystolic VSD

48. MURMUR OF BEST HEARD 1) AS 2 nd right ICS with radiation into carotids 2) HOCM Between lower left sternal border & apex 3) PS 2 nd left ICS 4) MR Over cardiac apex 5) VSD Mid-left sternal border (+thrill) 6) TR Lower left sternal border (increases in intensity with inspiration – Carvallo’s sign )

49. Diastolic heart murmurs always signify? Structural heart disease Classic cause of mid- to late diastolic murmurs? MS Classic example of continuous murmur? That assoc. with PDA 2 types of benign continuous murmurs? Cervical venous hum – heard in children or adolescents in supraclavicular fossa Mammary souffle of pregnancy – due to enhanced arterial blood flow through engorged breasts

50. How can diagnostic accuracy be enhanced? Right sided events increase (except for pulmonic ejection sound) in intensity with inspiration & decrease with expiration Left sided events behave oppositely

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