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1. . . SCHOOL OF CLINICAL SCIENCES MAKENI MAKAMBO PRESENTATION MODULE: INTERNAL MEDICINE TOPIC: Approach to managing a patient with cardiovascular dfiseases (history and physical examination). Invbestigations used in cardiovascular medicine LEVEL: Year three SEMESTER: First GROUP: one (1) LECTURER: Dr Martin

2. Name ID Sylvanus L. Bangura 23007 Jarieu Sheriff Bah 23001 Rugiatu Neneh Bah 23002 Ibrahim Bangura 23004 Ishatu Bangura 23005 Unisa Ibrahim S Bangura 23008 Aminata I Barrie 23009 Sulaiman Barrie 23010 Alhaji Brima 23011 (leader) Abdulai Baimba Conteh 23013 Adama Conteh 23014 Santigie Aldo Bangura 22001

3. content Introduction Importance of CVDs Objectives of CVD Management Initial Assessment and History in a Patient with Cardiovascular Disease (CVDs ) Physical Examination in a Patient with Cardiovascular Diseases (CVDs ) Investigations in Cardiovascular Diseases (CVDs ) . General Principles of Follow-up Refrences

4. Approach to Managing a Patient with Cardiovascular Diseases (CVDs)  Introduction Cardiovascular diseases (CVDs) are a group of disorders affecting the heart and blood vessels, including conditions such as hypertension, coronary artery disease, heart failure, and stroke. They are the leading cause of morbidity and mortality worldwide. Managing a patient with CVDs requires a comprehensive, multidisciplinary approach to reduce disease progression, improve quality of life, and prevent complications . Importance of CVDs Global Burden: CVDs account for a significant number of deaths and disabilities worldwide .   Economic Impact: They contribute to high healthcare costs due to hospitalizations, medications, and interventions .   Risk Factors: Common risk factors include hypertension, diabetes, obesity, smoking, sedentary lifestyle, and unhealthy diet .   Preventability: Many CVDs can be prevented or managed effectively through lifestyle modifications and medical interventions .

5. Objectives of CVD Management 1 . Early Detection and Diagnosis Identifying risk factors through history, physical examination, and screening tests .   Using diagnostic tools such as ECG, echocardiography, and blood tests (lipid profile, cardiac markers ).   2. Risk Factor Modification Encouraging a heart-healthy diet (low salt, low saturated fat, high fiber ). Promoting regular physical activity . Smoking cessation and limiting alcohol intake Controlling comorbidities like hypertension, diabetes, and hyperlipidemia . 3. Medical Management Using antihypertensives , statins, antiplatelet agents, and anticoagulants as indicated .   Managing symptoms with appropriate medications (e.g., beta-blockers, diuretics, ACE inhibitors ).   Monitoring medication adherence and side effects .

6. Objectives of CVD Management cont …..  4. Lifestyle and Behavioral Interventions Patient education on disease progression and self-care. Stress management techniques. Weight management strategies.  5. Interventional and Surgical Management When necessary, procedures such as angioplasty, stenting, or coronary artery bypass graft (CABG) may be required. Advanced treatments like implantable cardiac devices for heart failure or arrhythmias.  6. Regular Monitoring and Follow-up Routine check-ups to assess disease progression. Adjusting treatment plans as needed. Preventing complications such as stroke, heart failure, etc.

7. Initial Assessment and History in a Patient with Cardiovascular Disease (CVDs) A thorough initial assessment is crucial for diagnosing and managing cardiovascular diseases (CVDs). This includes obtaining a detailed history, performing a physical examination, and ordering appropriate investigations .   1. Presenting Complaint and History of Presenting Complaint (HPC) Patients with CVDs often present with symptoms related to compromised cardiac function. A systematic approach to history-taking helps in identifying the underlying pathology .   Common Cardiovascular Symptoms   1. Chest Pain   Character: Sharp, dull, crushing, or burning pain .   Location: Retrosternal, left-sided, radiating to the arm, jaw, or back .   Duration: Seconds (e.g., musculoskeletal), minutes (angina), or hours (myocardial infarction ).   Exacerb ating and Relieving Factors :   Worsened by exertion (angina, myocardial infarction ). Relieved by rest or nitrates (stable angina ). Positional or pleuritic (pericarditis, pulmonary embolism ). Associated Symptoms: Sweating, nausea, vomiting, dizziness .

8. Initial Assessment and History in a Patient with Cardiovascular Disease (CVDs) 2. Dyspnea (Shortness of Breath )   Types : Exertional dyspnea: Suggestive of heart failure or ischemic heart disease . Orthopnea: Worsens when lying flat, relieved by sitting up (suggestive of left heart failure ). Paroxysmal nocturnal dyspnea (PND): Waking up at night gasping for air (left ventricular failure ) Associated Symptoms: Cough, wheezing, leg swelling . 3. Palpitations Nature: Fast, slow, irregular, or skipped beats . Onset and Duration: Sudden or gradual onset, lasting seconds to hours . Triggers: Stress, caffeine, exertion, medications . Associated Symptoms: Dizziness, chest discomfort, syncope .

9. Initial Assessment and History in a Patient with Cardiovascular Disease (CVDs) 4. Edema (Swelling of the Limbs/Body)  Location: Lower limbs (common in heart failure), generalized ( anasarca ), periorbital (renal causes). Timing: Worse in the evening, progressive over days to weeks. Associated Symptoms: Weight gain, dyspnea, ascites (if severe heart failure). 5. Syncope (Fainting or Loss of Consciousness) Preceding Symptoms: Dizziness, lightheadedness, palpitations. Triggers: Standing up (orthostatic hypotension), exertion (aortic stenosis), emotional stress (vasovagal). Duration and Recovery: Brief loss of consciousness with spontaneous recovery (suggests cardiac syncope if sudden). 6. Fatigue and Weakness Common in heart failure due to reduced cardiac output. Can be associated with anemia, electrolyte imbalances, or medication side effects. 7. Claudication (Pain in the Limbs with Walking)  Suggests peripheral artery disease (PAD). Relieved with rest (intermittent claudication)

10. 2 . Past Medical History History of hypertension, diabetes, dyslipidemia, previous heart disease, stroke . Prior surgeries, especially cardiac procedures (stents, bypass ). Rheumatic fever history (risk for valvular heart disease ). History of thromboembolic events ( DVT, PE). 3 . Family History Sudden cardiac death, myocardial infarction, or stroke at a young age . History of genetic cardiovascular conditions (hypertrophic cardiomyopathy, arrhythmias ).

11. 4. Social History Smoking, alcohol use, recreational drugs (e.g., cocaine in young patients with MI). Physical activity level and dietary habits. Occupational stress and lifestyle factors. 5. Medication History Current medications, including antihypertensives , anticoagulants, statins. Compliance with prescribed treatment. Use of herbal or over-the-counter medications that may interact with cardiovascular drugs.

12. c 1. Vital Signs 1.1 Blood Pressure (BP ) Measure in both arms (significant difference >20 mmHg may indicate aortic dissection or subclavian stenosis ). Assess for hypertension, hypotension, or orthostatic changes . 1.2 Heart Rate (HR) and Rhythm Normal: 60 – 100 bpm ; tachycardia (>100 bpm ) or bradycardia (<60 bpm ) may indicate arrhythmias . Check for irregular rhythm (suggests atrial fibrillation ) 1.3 Respiratory Rate (RR ) Tachypnea (>20 breaths per minute) may indicate heart failure, pulmonary edema, or respiratory distress . 1.4 Temperatur Fever may suggest infective endocarditis or pericarditis . 1.5 Oxygen Saturation ( SpO ₂ )   Low oxygen levels (<90%) may indicate heart failure, pulmonary embolism, or chronic lung disease.

13. 2. General Examination A full-body assessment helps detect signs of systemic involvement in CVD .   2.1 Appearance Pale or cyanotic (poor perfusion, heart failure ). Sweating and anxious (acute coronary syndrome ). Cachexia (chronic heart failure or malignancy ). 2.2 Skin and Nails Cyanosis: Peripheral (cold hands/feet, poor circulation) or central (heart failure, congenital heart disease ). Pallor: Suggests anemia or poor perfusion . Clubbing: Seen in congenital heart disease, infective endocarditis . Splinter hemorrhages: Small red streaks in nails (infective endocarditis ). Janeway lesions, Osler nodes: Painless/painful lesions on hands and feet (infective endocarditis ).

14. 2.3 Head and Neck Eyes: Xanthelasma (cholesterol deposits) – hyperlipidemia. Retinal hemorrhages, cotton wool spots (hypertensive retinopathy, endocarditis). Mouth: Poor dentition – risk of infective endocarditis. High-arched palate – Marfan syndrome (risk of aortic dissection). 2.4 Jugular Venous Pressure (JVP) Elevated JVP suggests right heart failure, fluid overload. Positive hepatojugular reflux – right-sided heart failure. 2.5 Chest Inspection Scars (previous surgery: CABG, pacemaker, valve replacement) Visible pulsations (aneurysm, heart failure). 2.6 Abdominal Examination Hepatomegaly: Congestive heart failure. Ascites: Right heart failure. Pulsatile mass: Abdominal aortic aneurysm (AAA).

15. 3. Peripheral Vascular Examination 3.1 Pulse Examination   Radial Pulse: Rate , rhythm, volume . Irregular pulse – atrial fibrillation Brachial/Femoral Delay : Delayed femoral pulse – coarctation of the aorta . Carotid Pulse : Bounding (aortic regurgitation ). Weak (heart failure, aortic stenosis ). 3.2 Blood Vessels and Circulation Capillary Refill Time (CRT): Delayed (>2 sec) – poor perfusion . Peripheral Cyanosis: Cold, dusky extremities – poor cardiac output . Edema: Pitting in heart failure, non-pitting in lymphatic disorders 3.3 Signs of Peripheral Vascular Disease (PVD ) Intermittent Claudication: Pain in legs while walking (PAD ). Absent/Diminished Pulses: Suggests arterial insufficiency . Buerger ’ s Test: Pale foot when raised, red when lowered (severe ischemia ). Venous Insufficiency: Varicose veins, ulcers, hemosiderin staining etc

16. Investigations in Cardiovascular Diseases (CVDs) The evaluation of cardiovascular diseases (CVDs) involves a combination of laboratory tests, imaging studies, and functional assessments to diagnose, assess severity, and guide treatment   1. Laboratory Investigations 1.1 Cardiac Biomarkers Troponin I & T: Elevated in acute coronary syndrome (ACS), myocardial infarction (MI ). Creatine Kinase-MB (CK-MB): Rises in MI but less specific than troponin . Brain Natriuretic Peptide (BNP) / NT- proBNP : Increased in heart failure (HF ). 1.2 Blood Tests for Risk Factors and General Health Complete Blood Count (CBC): Detects anemia (affecting oxygen delivery), infection . Lipid Profile: Total cholesterol, LDL, HDL, triglycerides (assesses cardiovascular risk ). Blood Glucose & HbA1c: Checks for diabetes, a major CVD risk factor . Renal Function Tests (Urea, Creatinine , Electrolytes): Evaluates kidney function, electrolyte imbalances affecting the heart . Liver Function Tests (LFTs): Assesses hepatic congestion in right heart failure . C-reactive Protein (CRP) & High-Sensitivity CRP ( hs -CRP): Markers of inflammation linked to atherosclerosis . Thyroid Function Tests (TFTs): Hyperthyroidism can cause arrhythmias; hypothyroidism can contribute to heart failure . D-dimer: Elevated in pulmonary embolism (PE) and deep vein thrombosis (DVT).

17. 2. Electrocardiography (ECG) A primary tool for diagnosing heart conditions . ST-segment changes → Myocardial infarction (ST-elevation or depression ). Arrhythmias → Atrial fibrillation, ventricular tachycardia . Heart Blocks → First-degree, second-degree, complete heart block . Signs of Left/Right Ventricular Hypertrophy .

18. 3. Imaging Studies 3.1 Chest X-ray (CXR) Cardiomegaly → Suggests heart failure, pericardial effusion. Pulmonary Congestion → Pulmonary edema in left heart failure. Aortic Dilatation or Calcifications → Aneurysm, atherosclerosis. 3.2 Echocardiography (ECHO) Transthoracic Echocardiogram (TTE): Assesses heart structure, ejection fraction (EF), valve abnormalities, pericardial effusion. Transesophageal Echocardiogram (TEE): More detailed for endocarditis, aortic dissection. 3.3 Stress Testing Exercise Stress Test: Evaluates ischemia (ST changes on ECG during exercise). Dobutamine Stress Echocardiography: For patients unable to exercise.   3.4 Coronary Angiography Gold standard for diagnosing coronary artery disease (CAD). Identifies stenosis requiring stenting or bypass surgery. 3.5 Cardiac CT & MRI CT Coronary Angiography: Non-invasive imaging for coronary artery disease. Cardiac MRI: Useful in myocarditis, cardiomyopathy, congenital heart diseases.

19. 4. Functional and Hemodynamic Tests 4.1 Ambulatory ECG ( Holter Monitoring )   Continuous ECG monitoring for arrhythmias in palpitations or syncope .   4.2 Tilt Table Test   Assesses syncope related to autonomic dysfunction .   4.3 Ankle-Brachial Index (ABI )   Evaluates peripheral artery disease (PAD ).   4.4 Right Heart Catheterization

20. . General Principles of Follow-up Assess disease progression and treatment effectiveness .   Monitor for complications (e.g., heart failure worsening, arrhythmias). Ensure adherence to medications and lifestyle modifications . Adjust treatment as needed based on clinical status and investigations .

21. 2. Follow-up Plan Based on CVD Type 2.1 Hypertension Frequency: Every 3 – 6 months if stable, 1 – 2 months if uncontrolled . Monitoring : Blood pressure (home BP monitoring may be advised ). Renal function and electrolytes (especially if on diuretics, ACE inhibitors ). Lipid profile (annually) and glucose levels . Lifestyle adherence (diet, exercise, smoking cessation )   2.2 Coronary Artery Disease (CAD) / Post-Myocardial Infarction (MI ) Frequency :   Initial follow-up: 2 – 4 weeks after an MI or stenting . Long-term: Every 3 – 6 months for stable CAD . Monitoring Symptom assessment (angina, dyspnea, fatigue ). ECG (if symptoms recur or for rhythm monitoring ). Lipid profile, blood pressure, HbA1c (if diabetic ). Adherence to dual antiplatelet therapy (aspirin, clopidogrel ). Stress testing or echocardiography (if new symptoms or suspected ischemia ).  

22. 2. Follow-up Plan Based on CVD Type cont … 2.3 Heart Failure (HF) Frequency: Severe or decompensated HF: Every 1 – 2 weeks. Stable HF: Every 3 – 6 months. Monitoring: Weight monitoring (daily at home to detect fluid retention). BNP/NT- proBNP (if worsening symptoms). Echocardiography (every 6 – 12 months to assess ejection fraction). Renal function and electrolytes (especially with diuretics, ACE inhibitors)  Medication adherence and dose adjustments. 2.4 Atrial Fibrillation (AF) and Arrhythmias Frequency: Every 3 – 6 months if stable, sooner if symptomatic Monitoring: ECG or Holter monitoring (to assess rhythm control). INR monitoring (if on warfarin). Echocardiography (if structural heart disease is suspected). Stroke risk assessment (CHA ₂ DS ₂ - VASc score).

23. 2. Follow-up Plan Based on CVD Type cont.. 2.5 Peripheral Artery Disease (PAD) Frequency: Every 3 – 6 months for symptomatic patients, annually if stable. Monitoring: Ankle-Brachial Index (ABI) (to assess disease progression). Symptoms of claudication or rest pain. Lifestyle adherence (smoking cessation, exercise). 2.6 Post-Cardiac Surgery (CABG, Valve Surgery, Pacemaker, ICD) Frequency: First visit: 4 – 6 weeks after surgery Long-term: Every 6 – 12 months. Monitoring: ECG and echocardiography (to assess heart function post-surgery). Pacemaker/ICD interrogation (device function check every 6 – 12 months). Lipid profile, renal function, BP. Incision site healing and infection signs post-surgery.

24. 3. Home Monitoring and Patient Education Daily weight monitoring (heart failure patients ). BP self-monitoring (hypertension patients ). Recognizing warning signs (chest pain, palpitations, sudden dyspnea, swelling ). Adherence to medications and lifestyle (diet, exercise, smoking cessation). 4 . When to Seek Urgent Medical Attention Patients should be educated to seek immediate medical care for Severe chest pain (possible MI ) Sudden shortness of breath or leg swelling (heart failure exacerbation ). Syncope or dizziness (arrhythmia, severe valvular diease ). Worsening leg pain or ulcers (critical limb ischemia ).

25. references