Cardiac Evaluation Zubaid

Cardiac Evaluation Mohammad Zubaid MB, ChB, FRCPC, FACC Associate Professor of Medicine Head, Division of Cardiology Mubarak Al-Kabeer Hospital Done by : Shaikha AL-Faresi -Doctor slides are written by this font. -My additional notes are written by this font. MON. 18-sept.-2006 History Symptoms of cardiovascular Disease Risk factors for CAD and other cardiac diseases Related old history Medications     A clue about their disease Side effects Smoking and Alcohol -Doctor said u have to concentrate at the symptoms of cardiovascular diseases(CVDs).The risk of medications is extremely important.  History Symptoms Symptoms of cardiovascular disease Chest pain Dyspnea (shortness of breath) Palpitation Syncope Edema  • • • • • Types of cardiac pain Type Cause Characteristics Angina Coronary stenosis (rarely aortic Precipitated by exertion, stenosis, hypertrophic eased by rest, characteristic cardiomyopathy) distribution Myocardial infarction Pericarditic pain Dissecting aneurysm Coronary occlusion Similar sites to angina, more severe, persists at rest Sharp, raw or stabbing varies with movement or breathing Severe, sudden onset, felt first in back, persists at rest Pericarditis Dissecting aneurysm -Angina comes with exertion and goes away with rest. -Myocardial Infraction(MI) is ischemia started at rest and not related to exercise -Angina & MI are similar in some characteristics such as heaviness and shaking. -Pericarditic pain is distinct sharp, knife stabbing, can be persisted and related to breathing & posture. - Dissecting aneurysm is quite different, distinct, very severe onset,back pain starts at the upper back then to the front. Cardiac dyspnea Causes Acute left heart failure Myocardial infarction Mitral valve disease Aortic stenosis Pulmonary edema Mechanism  Left atrial pressure Arrhythmia Cardiomyopathy Over transfusion Hypoxia Reflex vasoconstriction Further  LV function -The major cause of cardiac dyspnea is increasing in left atrial pressure. Whatever acute left heart failure, MI, mitral valve disease, aortic stenosis, arrhythmia, cardiomyopathy or over transfusion all lead to increase left atrial pressure. - Over transfusion happens in post operative patient when they give him fluid overdose and over transfuses him causing increase in the left atrial pressure and concequensely pulmonary edema and hypoxia which makes patient feeling dyspnea.This large atrial pressure will reach the pulmonary vein and then to the pulmonary bronchioles and capillaries leading to accumulation of the fluid in the alveoli and as a result pulmonary edema occures. - -Right side heart failure does not cause dyspnea. However, it is presented with congestion, swelling of legs and abdominal pain due to congested liver which is very painful. Usually, the cause of right heart failure is related to hypooxygenation. for ex. Somebody has severe pulmonary hypertension because of pulmonary emboli or COPD lung disease causing right heart failure, he will suffer from dyspnea not because of right heart failure, well it is due to pulmonary hypertension and COPD disease. -It is not common and rare in case of pure tricuspid valve regurgitation to have right heart failure symptoms like jugular venous pulsation, abdominal pain and leg swelling, we shouldn’t have dyspnea. Dyspnea Exertional dyspnea – what distance?  Orthopnea Paroxysmal nocturnal dyspnea (PND)     Cough Pulmonary edema -Exertional dyspnea is related to distance so we ask the patient whether he feels dyspnea when he walks for example for 10 or 100 meters. - Orthopnea is feeling of shortness of breath when u lie down.- -In (PND) patient wakes up suddenly feeling shortness of breath and he tells u I go to bed fine and suddenly I wake up feeling shortness of breath then he goes for example to open the window, usually it takes 10-15 min then he gets back to bed. Usually patients wake up at night due to prostate enlargement, night mare or due to snoring which causes sleep apnea, major problem in which patients wake up suddenly and get sleep again ‫ انمزيض يصذً و يزد يناو مايزوح يذىس و يفتخ انذرايش ويتهىي‬sleep apnea ‫يعني بـ‬ ‫ انمزيض يصذً و يقىو مه انفزاش يفتخ انذرايش يذور هىا ياخذ تقزيبا01-51دقيقت‬PND ‫ نكه بـ‬‫بعذيه يزجع انفزاش يناو. بهيز ال تتخزبطىن بيه انذانتيه‬ -Cough is extremely important because most patients come to casualty coughing and it worsens at night, the dr gives them anti-cough medications because they don’t feel shortness of breath!!.They sleep at up right position on the chair if they lie down they will cough because they actually have heart failure. - pulmonary edema is due to impairment of LVF(left ventricular function),fluid in alveoli patient looks very sick having acute shortness of breath. Descriptions of palpitation Arrhythmia Ventricular or atrial extrasystoles Patient’s description “Heart misses a beat “ Heart “jumps” or “flutters” Atrial fibrillation Supraventricular tachycardia Heart “jumping about” or “racing” May be unnoticed Heart racing or fluttering Asystole, complete heart block and ventricular tachycardia often present as syncope rather than as palpitation -Palpitation is extremely common symptom. -In ventricular or atrial extrasystoles, the patient feels his heart beats and this is very annoying!! this doesn’t mean they are abnormal. !!‫ عهً قىنت انذكتىر ادش قهبي يطمز فجاة و ينزل في بطني‬extrasystoles -Most important thing for u as a doctor when u see a patient with palpitations is to recognize whether patient feels his normal or abnormal beats so he asks him if they are fast or strong beats? History Symptoms Syncope – most difficult to investigate  • Nuerologic – seizures, stroke, bleed • Arrhythmia • Hypotension • Vasovagal – common faint -Syncope is loss of consciousness and its very difficult to investigate. -Vasovagal syncope is the commonest type and it occurs due to sudden bad or god news causes vasodilation of periphery.It can happen also in people who stand for very long time for ex. police,army,and security where all blood pulled to veins of legs causing vasovagal syncope. - Neurological syncope is distinct like tongue biting in tonic clonic seizure and so on, however, it is important to know whether the patient lost control of urine or feces during syncope so u ask him did u wet ur self?if yes a lot of times it indicates true deep syncope. It is better to find a wetness to describe for u what happened. Most patients who tell that they had syncope, they actually had dizziness or vertigo not syncope because syncope is complete loss of consciousness and it is brief in most cases. -Most elderly lose conscious in bathroom due to constipation or enlarged prostate. -In arrhythmia,u will be lucky if a patient tells u I feel my heart racing then I lost consciousness.They don’t always say that. - History Symptoms Edema Peripheral edema Generalized edema Possible causes -Peripheral edema is like leg swelling & Generalized edema is severe heart failure either in left or right side. Possible causes of edema could be cardiac,renal and hepatic.  • • • History Symptoms of cardiovascular Disease  Risk factors for CAD and other cardiac diseases Related old history   Medications A clue about their disease Side effects Smoking and Alcohol   History Risk factors – depends on the disease Risk factors for CAD Risk factors for valve disease Risk factors for cardiomyopathy Dilated cardiomyopathy (DCM) Hypertrophic obstructive cardiomyopathy (HOCM)  • • • • • • • Risk factors for Syncope Risk factors for pericardial disease -Risk factors for coronary artery disease(CAD)are traditional hypertension, diabetes, smoking, hyperlipidemia, male gender and family history of premature CAD. -Risk factor for valve disease: rheumatic fever as child. -Rik factor of cardiomyopathy is family history of DCM. -Risk factors of DCM is previous MI or known history of valve disease. -Main risk factor of HOCM is family history. - Risk factor for cardiac syncope is presence of old MI because these people are prone to arrhythmias. -Risk factor for pericardial disease is TB which causes pericardial calcification usually seen in young bangaladishi and indian people.Viral infections may lead to the disease. - - Cardiovascular diseases in which several genes may interact Ischemic heart disease  Hypertension Rheumatic heart disease Abdominal aortic aneurysm  - Family history in CVDs is not mandalian relationship but it is gene interaction. History Symptoms of cardiovascular Disease  Risk factors for CAD and other cardiac diseases  Related old history Medications A clue about their disease Side effects Smoking and Alcohol    History Related old history – very important Congestive heart failure  • Syncope • Ischemia • -For ex. Hypertension, diabetes and heart attack are important old history for congestive heart failure. History Symptoms of cardiovascular Disease  Risk factors for CAD and other cardiac diseases Related old history   Medications A clue about their disease Side effects Smoking and Alcohol   History Medications A clue about their disease Side effects Aspirin – bleeding Betablockers – fatigue, nightmares, impotence, syncope Calcium blockers – leg edema, constipation, syncope Nitrates – headaches Statins – muscle aches, raised liver function tests ACE inhibitors – renal impairment, hyperkalemi  • • • • • • • • -It is extremely important to know all the medications that patient use, even in casualty tell to his family to go back to home and get all the patient medications. History Symptoms of cardiovascular Disease  Risk factors for CAD and other cardiac diseases Related old history   Medications A clue about their disease Side effects  Smoking and Alcohol  History Smoking and Alcohol – don’t be deceived by looks Smoking – need a whole week to talk about  • Dilated cardiomyopathy, with or without AF • Atrial fibrillation (binge drinking) -When u see a man with unexplained dilated cardiomyopathy u have to wonder about chronic alcohol consumption.It can happen with or without atrial fibrillation. It is not nice or logical to ask for ex. 70 years old kuwaiti lady whether • Alcohol • -  she drinks or not!!! She could be smoker ‫عهً قىنت انذكتىر ممكه تكىن شاربت قذوو مال قبم‬