Approach To The Cardiac Patient

Howard Sacher D.O.Chief, Division of Cardiology, New York

College of Osteopathic Medicine.

Adjunct Clinical Associate Professor of Medicine, New York College of Osteopathic Medicine

Signs and Symptoms

Most Common are non-specificDyspneaChest PainPalpations Presyncope/ SyncopeFatigue

DyspneaMore often than not is a results of either:

Elevated left atrial pressure LV dysfunction valvular obstruction

Elevated pulmonic venous pressuresPulmonary Edema secondary to acute LA HTN

Hypoxemia Pulmonary Edema Intracardiac shunting

Paroxysmal Nocturnal Dyspnea Most specific for cardiac diseaseOccurs acutely with 30min to 2hrs of going

to bedRelieved by sitting or standing up

Chest PainMost commonly associated with angina pectoris

Not always associated with acute myocardial infarction (AMI)

Patients usually complain not of pain but rather Pressure Tightness Squeezing Gassy/Bloated feeling

Ischemic Chest Pain

Usually subsides within 30min (depends)Precipitated by

ColdExertion MealsStress

Usually pain > 30min is indicative of an AMIUsually associated with

Anxiety and uneasiness SSCP that may radiate

Other causes of cardiac chest pain

Ventricular hypertrophy

Valvular heart disease

Myocarditis

Endocarditis

Pericarditis

Cardiomyopathies

Aortic Dissection

PalpitationsThe “awareness of one’s heart beat”Usually normal

Pathologies include:Cardiac abnormalities that increase Stroke VolumeRegurgitant diseases

BradycardiaVentricular or Atrial Premature beatsSupraventricular TachycardiaVentricular Tachycardia

These pathologies can cause a significant decline in CO leading to impaired cerebral blood flow, causing Dizziness Blurring of visionSyncope

Cardiogenic Syncope

Most commonly a result of Sinus node arrest Exit block Atrioventricular block Ventricular

tachycardia Ventricular fibrillation

Other significant causes: Aortic valve disease Idiopathic

hypertrophic subaortic stenosis

Hyperstimulation of the vagus nerve

Edema

Right heart failure most commonly presents with dependent edemaOther causesPericardial diseasesTricuspid and pulmonic Valve diseasesCor Pulmonale Should also look for a “nutmeg liver” as a

possible etiology

4 Functional Classes of Heart Disease

(Very Important)

Class INo limitation of physical activityOrdinary activity does not induce

symptomology

Class IISlight limitation on physical activity in

which the patient becomes symptomatic

Class IIIMarked limitation on physical activity;

comfortable only at rest. With ordinary activities the patient becomes symptomatic

Class IVPt is symptomatic at rest and is unable to

engage in any limited activities without discomfort and pain

Look at your patient:Appearance:

Diaphoretic? – Think hypotension, cardiac tamponade, tachyarrhythmias, or an acute MI

Cachectic? – Think CHF, low cardiac output states Cyanotic? – Ask is it central or peripheral?

Central – think arterial desaturation states Peripheral – think impaired tissue delivery

Check Vital Signs: HR BP – check bilaterally as well as sitting and standing RR Temp

PulsesPeripheral Central

Check carotid pulse for evidence of delayed carotid upstroke and/or a “bisferiens” pulse

Pulsus Paradoxus – decrease in blood pressure > 10 mmHg with inspiration

Pulsus Alternans – amplitude of the the pulse alternates with each beat during normal sinus rhythm (most commonly seen in patients with pericardial effussions)

Jugular venous pulsations – helps in evaluating right atrial pressure

Cannon A waves suggest 3rd degree heart block

Pulmonary ExamCrackles (aka Rales) – CHFWheezing – COPD (COLD)Rhonchi – COPD (COLD)Pleural effusion on CXR – CHF is cause most

commonly

Precordial PulsationsParasternal lift – think RVH, LAH, PHTNDisplaced or Exaggerated PMI – think LVH

Heart Sounds

S1 – First heart sound – closing of the MV and TV; occurs during isovolumetric systole

Ej – Second heart sound as the contraction begins to take place and the blood is ejected

S2 – Third heart sound as diastole begins with isovolumetric relaxation forcing the AoV and PV closed (on inspiration S2 has a normal physiologic splitting)

OS - The fourth heart sound during the tailend of isovolumetric relaxation – a point in which the ventricular pressure falls below atrial pressure and one can hear the opening snap of the MV/TV (this usually silent but accentuated with MVS)

S3 – normal in young adults, peds and pregnancy. A Sound made by the deceleration of the blood as it hits the ventricular wall. Pathologic in all other patients – sign of a stiff ventricle

S4 – abnormal in all patients if heard, this last heart sound of the cardiac cycle is indicative of an atrium that is trying to pump blood into a very stiff ventricle

Please review heart sounds in Harrison’s textbook

MurmursInnocent murmurs – vary with inspiration most commonly in adolescence and diminishes in the upright position – located along the lower left sternal border

Most murmurs are diagnostic for valvular diseaseSystolic Murmurs Holosystolic – start with S1 ending with S2Ejection – start with S1 and end before S2

Diastolic MurmursAssociated with a palpable vibration - Thrills