Advanced Assessment of the Cardiovascular System

Mary Beerman, RN, MN, CCRN

NUR 602

Interesting facts...

The heart does not rest for more than a fraction of a second at a timeDuring a lifetime it contracts more than 4 billion timesCoronary arteries supply more than 10 million liters of blood to the myocardium in a lifetime

Interesting facts.

Cardiac output (heart rate X stroke volume) can vary under physiologic conditions from 3 to 30 liters/minuteRemember: Normal cardiac output for adults is 5-6 liters/minuteCardiac index corrects for body size (Cardiac output divided by body surface area)

Common Diseases of the Heart

Coronary artery diseaseHypertensionRheumatic heart diseaseBacterial endocarditisCongenital heart disease

OTHER VERY COMMON DISEASES OF THE HEART

CONGESTIVE HEART FAILURECARDIOMYOPATHYARRHYTHMIAS

Review Structure and Physiology of the Heart in textbook

Review of Symptoms

Chest Pain

This is the most important symptom of cardiac diseasePain could be from pulmonary, intestinal, gallbladder, or musculoskeletal sources but it may be from the heart itselfEvery complaint of chest pain must be taken very seriously!

Differential Diagnoses of Chest Pain

AnginaMyocardial InfarctionOther Ischemic C-V OriginsNon-ischemic C-V OriginsPulmonaryGastrointestinalPsychogenicNeuromusculoskeletal

Differential Diagnosis of Chest Pain - ANGINA

Usually substernalRadiation chest, shoulders, neck, jaw,armsDeep, visceral (pressure) intense, not excruciatingDuration- min., not sec. (5-15 min.)

Differential Diagnosis of Chest Pain - ANGINA

Associated with nausea, vomiting diaphoresis, pallorPrecipitated by exercise & emotionBecomes Unstable when occurs during sleep, at rest, or increases in severity/frequencyRelief with rest or NTG

Differential Diagnosis of CP Myocardial Infarction

Same type of pain as anginaDuration greater than 15 min.Occurs spontaneously, often sequela of unstable anginaRelieved with Morphine, successful reperfusion of blocked coronary artery

Differential Diagnosis of CP Other C-V Ischemic Origins

Aortic Stenosis/RegurgitationIdiopathic Hypertrophic Subaortic Stenosis (IHSS)Uncontrolled HypertensionSevere Anemia/HypoxiaTachycardia/ArrhythmiasPulmonary Hypertension

Differential Diagnosis of CP Nonischemic C-V Origins

Aortic Dissection

Sudden, excruciating pain (knife-like, tearing)

Migrating pain (depends on location of tear)

Frequently, hemodynamic instability

Appearance of shock with normal or elevated BP

Absent or unequal peripheral pulses

Differential Diagnosis of CP Nonischemic C-V Origins

Pericarditis

Sharp or dull, retrosternal or precordial pain

Radiates to trapezius ridge

Aggravated by inspiration, coughing, recumbency, & rotation of trunk

Lessened by sitting upright & leaning forward

Relief - analgesics & anti-inflammatory meds

Differential Diagnosis of CP Nonischemic C-V Origins

Mitral Valve Prolapse

Left anterior superficial, rarely visceral pain

Variable in character

Lasts minutes, not hours

Spontaneous onset with no pattern

Relieved with time

Differential Diagnosis of CP - Pulmonary

Pulmonary Embolus /InfarctPneumothoraxPneumonia with pleural involvementPleurisy

Differential Diagnosis of CP - Pulmonary

Pleuritic Pain

Visceral Pain arising from inferior portion of pleura

May be substernal and radiate to costal margins or upper abdomen

Lasts greater than 30 minutes

Often occurs spontaneously with associated dyspnea

Worsened with inspiration

Relief time, rest, bronchodilators

Differential Diagnosis of CP - Gastrointestinal

Esophageal Spasm

Substernal visceral (pressure) pain, radiates

Duration 5 to 60 minutes

Spontaneous or provoked by cold liquids,exercise

Mimics angina

Relief with NTG

Differential Diagnosis of CP - Gastrointestinal

GERD/Hiatal Hernia

Substernal & epigastric, rarely radiates

Duration is 10-60 min.

Provoked by recumbency, lack of food

Relieved by food, antacid

Peptic Ulcer Disease

Substernal & epigastric pressure/burning

Duration hours

Differential Diagnosis of CP - Gastrointestinal

PUD (Cont.)

Precipitated by lack of food or acidic food

Relief with antacids & food

Biliary Disease

Colicky or continuous, visceral epigastric & RUQ abdominal pain

Radiates to back & right shoulder

Occurs spontaneous & after heavy meal

Relief analgesics & time

Differential Diagnosis of CP - Psychogenic

Nonradiating, variable pain over chestDuration 2-3 minutesMay be associated with numbness/tingling of hands & mouthPrecipitated by stress, emotional tachypneaRelief by removal of stimulus, relaxationCauses depression, anxiety, self gain

Differential Diagnosis of CP - Neuromusculoskeletal

Thoracic Outlet SyndromeDegenerative Joint Disease of cervical/thoracic spine

Superficial pain in arms & neck

Duration variable, gradually subsides

Precipitated by head & neck movement, palpation

Relief time, analgesia

Differential Diagnosis of CP - Neuromusculoskeletal

Herpes Zoster (Shingles)

Pain follows dermatomal distribution of nerve

Costochondritis (Tietzes syndrome)

Superficial pain, reproducible with movement & palpation

May be localized or in multiple locations

Duration variable

Relief time, analgesia, anti-inflammatory meds

Ask These Questions about Chest Pain

Description of characterLocationDuration/RecurrencePrecipitating factorsAssociated symptomsRelieving factorsHistory of similar symptoms

Angina

Angina Pectoris is the true symptom of coronary artery disease.It is caused by hypoxia to the myocardium which leads to anaerobic metabolism and the production of lactic acid. The acid irritates the actual heart muscle and makes it hurt

Angina, cont

Angina is due to an imbalance of oxygen delivery TO the heart and the oxygen needs OF the heartLevines Sign---Patients will describe angina by clenching their first and placing it over the sternum.

PALPITATIONS

Palpitations

The uncomfortable sensations in the chest associated with a range of arrhythmias. Patients may describe palpitations as fluttering, skipped beats, pounding, jumping, stopping, or irregularity

EXTRASYSTOLES

Premature atrial contractions (PACs)Premature ventricular contractions (PVCs)

TACHYARRHYTHMIAS

Sinus Tachycardia

Usually gradual onset and offset

Paroxysmal Supraventricular Tachycardia (PSVT)

Sudden, abrupt onset and offset

Atrial FibrillationVentricular Tachycardia

CAUSES of ATRIAL FIBRILLATION

HypertensionHyperthyroidismAcute MIPericarditisCoronary Artery DiseaseCongestive Heart FailureValvular Heart DiseaseAcute or Chronic ETOH abusePost-operative state

ATRIAL FIBRILLATION

Major complication

Peripheral embolization

CVA

May present as CVA, Transient ischemic attack, Amaurosis fugax, ischemic limb, ischemic bowel or other viscera

VENTRICULAR TACHYCARDIA

Causes include:

Acute myocardial ischemia/infarct

Chronic Coronary artery disease

Cardiomyopathy

Prolonged QT interval (Congenital, drug-induced, acquired)

VENTRICULAR TACHYCARDIA

May present as:

Sudden cardiac death

VT degenerated into VF

Syncope

Wide complex tachycardia

Often hemodynamically well tolerated

BRADY - ARRHYTHMIAS

Heart BlockSinus Arrest

Common Causes of Palpitations - DRUGS

Bronchodilators

tachycardia

Beta Blockers, Calcium Channel Blockers

bradycardia

Digitalis

bradycardia, toxicity causes brady-dysrhythmias

Common Causes of Palpitations More DRUGS

Antidepressants

Prolong QT interval

OTC medications Antihistamines, Decongestants, Weight Loss preparations

Extrasystoles, Tachy-dysrhythmias

Common Causes of Palpitations OTHER

TobaccoCaffeineThyroid disorders

Paroxysmal Nocturnal Dyspnea (PND)

Occurs at night or when patient is supine. Patient awakens after being asleep about 2 hours and is smothering. Runs to window to get more airThis is a specific sign of congestive heart failure

Orthopnea

Dyspnea when lying downAsk all patients: How many pillows do you use in order to sleep?To quantify the orthopnea, record 3-pillow orthopnea for the past month

Dyspnea on Exertion (DOE)

This is usually due to chronic CHF or severe pulmonary diseaseQuantify the severity by asking, How many level blocks can you walk before you get short of breath? How many could you walk six months ago?

How to Chart about Dyspnea

The patient has had 1-block dyspnea on exertion for the past six months. Before 6 months ago, the patient was able to walk 4 blocks without shortness of breath. In addition, during the past month the patient has noted 4-pillow orthopnea. Previously he was able to sleep with just two pillows.

Common Causes of Congestive Heart Failure

Uncontrolled HypertensionMyocardial ischemia/infarctArrhythmiasLack of compliance

Diet

Drugs

Fluid overload

More Common Causes of Congestive Heart Failure

Blood loss, AnemiaPulmonary embolismSystemic infectionValvular heart diseaseNonischemic Dilated CardiomyopathyRenal Artery Stenosis

SYNCOPE

Syncope

Fainting or syncope is the transient loss of consciousness that is due to inadequate cerebral perfusionSyncope can be from cardiac or non-cardiac causes

Common Causes of Syncope

CardiacNeurocardiogenicOrthostatic HypotensionMetabolicNeurologicPsychogenic

Common Causes of Syncope - CARDIAC

Obstruction to Blood Flow

Valvular stenosis

Hypertrophic cardiomyopathy

Prosthetic valve dysfunction

Atrial myxoma

Common Causes of Syncope - CARDIAC

Obstruction to Blood Flow (cont)

Pericardial tamponade

Pulmonary hypertension

Pulmonary emboli

Congenital heart disease

Pump failure (MI or ischemia)

Common Causes of Syncope - CARDIAC

Arrhythmias

Brady-arrhythmias

Sinus bradycardia

Sick sinus syndrome

Atrioventricular block (AVB)

Pacemaker malfunction

Drug-induced bradycardia

Tachy-dysrhythmias

VTach, SVT

Common Causes of Syncope - NEUROCARDIOGENIC

Vasovagal

Vasodepressor

Carotid sinus hypersensitivity

Situational Cough, Micturition, Defecation, Deglutition

Vasovagal Syncope

This is the most common type of fainting and is one of the most difficult to manage.It has been estimated that 40% of all syncopal events are vasovagal in natureThis occurs during periods of sudden, stressful, or painful experiences such as getting bad news, trauma, blood loss, sight of blood

Vasovagal Syncope, cont

There is warning that the fainting is about to occurpallor, nausea, weakness, blurred vision, lightheadedness, perspiration, yawning, diaphoresis, hyperventilation, or a sinking feeling

Carotid Sinus Syncope

This may occur in the elderly who may have a hypersensitive carotid sinusIf they are wearing a tight shirt or collar or turn their neck in a certain way, there is increased stimulation of the carotid sinus, a sudden fall in systolic blood pressure, and a decrease in heart rate.

Common Causes of Syncope Orthostatic Hypotension

Volume depletionAntihypertensive medicationsAntidepressant medications

Common Causes of Syncope METABOLIC

HypoglycemiaHyperventilationHypoxia

Common Causes of Syncope

NEUROLOGIC

Epilepsy

Cerebrovascular disease

PSYCHOGENIC

Ask These Questions about Syncope

What were you doing just before you fainted?Have you had recurrent fainting spells? How often do they happen?Was there an abrupt onset to the fainting, or did you feel it coming?Did you totally lose consciousness?

Syncope Questions, cont

In what position were you in when you fainted? (possible orthostatic hypotension?)Was the fainting preceded by other symptoms like nausea, chest pain, palpitations, confusion, numbness, or hunger?

more syncope questions...

Was fainting episode witnessed by anyone? Who?Did you have warning that you were going to faint?Did you have any black, tarry BMs before or after the fainting episode?Did you experience any loss of urine or stool during the fainting episode?

And Just One More

On regaining consciousness, did you know where you were and who people were around you?

Fatigue

This is a common symptom of decreased cardiac output. A common complaint from people with CHF and mitral valve disorderFatigue may be the presenting symptom of a woman having an MINot at all specific to heart disease, but you must consider it always

Common Causes of Fatique

CardiacAnxiety/DepressionAnemiaChronic Diseases

Dependent Edema

When peripheral venous pressure is high, fluid leaks out from the veins into tissuesThis is often the presenting symptom of right ventricular failureEdema will begin in legs and gets worse as the day progresses. Least evident in the a.m. after sleeping with the legs flat, worse as gravity pulls fluid to legs.

More about Dependent Edema

This indicates that there is excess fluid volume and 3rd spacing of fluids.People on bedrest will have edema of their sacral areaIn severe right or bi-ventricular heart failure, people often have abdominal distension, liver engorgement, constipation, and anorexiaAnasarca may develop. Gross generalized edema

Ask These Questions about Dependent Edema

When did you first notice the swelling?Do both legs swell equally?Did the swelling appear suddenly?What time of the day is it worse?Does it disappear after sleeping?Does propping your legs up make it go away?

More Questions about Edema...

What medicines do you take now?Do you have any kidney, heart, or liver disease?Do you have shortness of breath? Pain in your legs? Ulcers on your legs?

And, More Questions about Edema

Have you noticed a difference in how your clothes fit, especially around the waist?Have you noticed recent problems with constipation?How is your appetite?

More and More

Do you add salt to food at mealtime and/or when cookingDo you eat out in restaurants or get take-out food frequently?Do you read labels on food before purchasing?

Physical Exam for Edema

Press fingers into the dependent areas for 2-3 seconds.If pitting is present, the fingers will sink into the tissue and when fingers are removed, the impression of the fingers will remainEdema is quantified from 1+ to 4+ depending on how deep the indentation is

The Physical Examination

Inspection

General Appearance

Is the patient in acute distress?Is breathing labored or easy?Is there use of accessory muscles?Is there cyanosis? Pallor?Are xanthomata present (stony hard, yellowish masses on extensor tendons of the fingers. Due to hypercholesterolemia

Inspection...

Inspect nails. Splinter hemorrhages are associated with infective endocarditisInspect the face. People with supravalvular aortic stenosis have wide-set eyes, stabismus, low-set ears, upturned nose, hypoplasia of the mandibleMoon face suggests pulmonic stenosis

More inspection...

Expressionless face with puffy eyelids and loss of the outer 1/3 of the eyebrow is seen in hypothyroidismInspect eyes. Yellow plaques on eyelids (xanthelasma) may be due to hyperlipoproteinemiaOpacities of the cornea may be sarcoidosis

and more inspection...

Conjunctival hemorrhage is commonly seen with infective endocarditisPetechiae on the palate may be seen with infectious endocarditisHigh arched palate may be seen with Marfans SyndromeArm Breadth greater that body height is also seen in Marfans

Inspection of the Chest Wall

The heart and chest develop at the same time in embryo, so anything that interferes with development of the chest may interfere with the heart Pectus Excavatum (caved-in chest) is seen in Marfans syndrome and sometimes MVPPectus Carinatum (pigeon breast) also seen in Marfans syndrome

Inspection of the chest, cont

Are there any visible cardiac motions?

Inspection of the extremities

Look for edema (pitting and non-pitting)Observe colorBabies with atrial septal defects may have an extra finger or toe.Long, slender fingers suggest Marfans with possible aortic valve deformity

Inspection of Extremities Continued

Loss of hair may indicate hypothyroidism or PVD

Assessment of Blood Pressure

Always measure in both arms sitting Then take BP standing

Orthostatic Hypotension

Have the patient lie down for 5 minutes and measure BP and pulseHave patient stand and repeat reading immediately. Allow 90 seconds for maximum orthostatic changesA drop in systolic BP of 20 mmHg or more when standing is orthostaticThere is usually an increase in HR

Rule out Supravalvular Aortic Stenosis

If there is hypertension in the right arm, take BP in the left arm as wellIn supravalvular aortic stenosis, there will be hypertension in the right arm and hypotension in the left arm

Rule out Coarctation of the Aorta

If the patient is hypertensive in both arms, have patient lie on abdomen, put cuff around lower thigh, listen to BP at the popliteal arteryA leg blood pressure lower than the arm BP suggests coarctationNormally BP higher in leg arteries than arm

Rule out Cardiac Tamponade

An exageration of the normal inspiratory fall in systolic BP (it should normally fall about 5 mmHg during inspirationYou should check for a paradoxical pulse any time there is low arterial BP and a rapid, feeble pulse

Checking for Paradoxical Pulse

Have the patient breathe normally, inflate BP cuff until no sounds are heard. Gradually deflate cuff until sounds are heard on expiration only and note this numberContinue to deflate the cuff until sounds are heard during inspiration as well. Note this number

A Positive Paradoxical Pulse

If the difference in BP exceeds 10 mmHg, this is abnormal and indicates possible cardiac tamponade

Assessment of the Arterial Pulse

Grasp both radial arteries, count for 30 seconds, and multiply by 2Determine rhythm. The slower the rate, the longer you should palpate. If the rhythm is irregular, is there a pattern to the irregularity?

Arterial Pulse, cont

Premature beats are isolated extra beats in a regular rhythmA grossly irregular rhythm is most likely atrial fibrillationPalpate the carotid artery by standing at the patients right side with him resting on his back. Listen first for possible bruit and do not palpate if you hear one

Arterial Pulse, cont

Never palpate both carotids at the same time

Jugular Venous Pulse

Remember that the internal jugular vein provides information about right atrial pressureThe pulsation of the internal jugular vein are beneath the sternocleidomastoid muscle and are visible as they are transmitted through surrounding tissueThe vein itself cannot be seen

Jugular Venous Pressure, cont

Because the right internal jugular vein is straighter than the left, only the right IJV is evaluatedTo determine jugular waveform, have patient lie without pillow at about 25 degree angle. Turn head slight to the right and slightly down to relax the right sternocleidomastoid muscle

Jugular Venous Pulse, cont

Standing on the right side of the patient, place your right hand holding a pinlight on the patients sternum and shine the light tangentially across the right side of the patients neck.Shadows of the pulsation will be cast on the sheet.Chart: JV pulsation seen at 25 degrees

Jugular Venous Distension

Hepatojugular Reflex

A useful test for assessing high jugular venous pressure (also called abdominal compression)By applying pressure over the liver, you can grossly assess RV function. People with RV failure have dilated sinusoids in the liver. Pressure over right upper quadrant pushes blood out and increases JV pressure

How to Check for Hepatojugular Reflex

Have patient lie in bed, mouth open, breathe normally to prevent valsalva maneuver.Place right hand over RUQ and apply firm pressure for 10 secondsNormally there will be a short increase in venous dilation followed by fall to baseline

How to Check for Hepatojugular Reflex Cont.

If there is RV failure, neck veins will stay elevated during entire time of compression

Percussion

Not helpful in CV assessmentCXR shows heart size and borders very accurately

Palpation

Point of Maximal Impulse (PMI)

Stand on the right side of the patient with him sitting. Place fingertips at 5th ICS, MCL and you should feel PMIPMI is usually within 10 cm of the midsternal line and no larger than 2-3 cm diameterPMI that is lateral or displaced suggests cardiomegaly

PMI, cont

About 70% of the time you will be able to feel PMI with patient sitting. If you cant, turn patient to his left side, lying down.A PMI that is over 3 cm diameter indicates left ventricular hypertrophy and is 86% predictive of increased left ventricular end diastolic pressure

General Motion

After palpating with the fingertips for PMI, use palm of your hand to palpate any large areas of sustained outward motion (heave or lift)Palpate all 4 cardiac areasAny condition that increases the rate of ventricular filling can produce a palpable impulse

Have you ever felt a thrill?

Thrills are superficial vibratory sensations felt on the skin overlying an area of turbulenceThe presence of a thrill indicates that you will hear a loud murmur (grade 4-6)Simply an indication of what you will hear when you listen.

Auscultation

General Principles of Auscultation

Close your eyes when listeningNever listen through any kind of clothingListen at all 4 cardiac areas: Aortic --2nd ICS, RSB Pulmonic---2nd ICS, LSB Mitral--cardiac apex, 5th ICS, MCL Tricuspid---left lower sternal border

Principles of Auscultation, cont

Normally only the closing of valves can be heard.Closure of the tricuspid and mitral valves (AV valves) produce the 1st heart sound.Closure of the aortic and pulmonic valves produce the 2nd heart sound.Opening of valves can only be heard if they are very damaged (opening snap click)

Third Heart Sound

When AV valves open, the period of rapid filling of ventricles occurs. 80% of ventricular filling occurs now. At the END of rapid filling, a 3rd heart sound may be heardS-3 is normal in children and young adults, but not in people over age 30. It means there is volume overload of ventricle

What an S3 Sounds Like...

SLOSH-ing-in, Slosh-ing-in, Slosh-ing-inOr Ken-tuck-y

Fourth Heart Sound

At the end of diastole, atrial contraction contributes to the additional 20% filling of the ventricleIf the left ventricle is stiff and non-compliant, you will hear an S4.It sounds like this: a-STIFF-wall, a-STIFF-wall, a-STIFF-wallOr sounds like TEN-ne-see

Gallop Rhythms

The presence of an S3 and an S4 creates a cadence resembling the gallop of a horse. Hence the term gallop rhythm

Auscultation Procedure

Stand at the patients right side while he is flat on his back.Listen to all 4 valve areas, inching the stethoscope along from area to areaWhile listening at the apex and left lower sternal border with the bell, youll be able to determine if an S3 or S4 are present

Procedures, cont

Next have the patient turn to his left side and listen to the apex for low-pitched diastolic murmurs with bellHave patient sit upright and listen everywhere with diaphragm.Have patient sit and lean forward, exhale, and hold breath while you listen with diaphragm to hear high diastolic murmur

Procedure, cont

To interpret heart sounds correctly, you must clearly identify what sound is S1. To do this, palpate the carotid artery while you listen. The sound that you hear when you feel the carotid pulse is S1.S2 will follow the pulse

Procedure, cont

Please see pictures on pages 255-256 of your textbook for approach to auscultation

Murmurs

They are produced when there is turbulent blood flow within the heartTurbulence may be due to a narrowed opening of a valve (stenosis) or a valve that does not close completely, allowing blood to slosh backwards (regurgitation or insufficiency)

Describing Murmurs

When in the cardiac cycle do you hear the murmur? Systole? Diastole? Pan-systolic?Location (in which of the 4 cardiac areas do you hear it the loudest?)Radiation (does the sound travel throughout the chest?)Duration of the murmur

The Intensity of Murmurs

Grade I = lowest intensity, not heard by inexperienced listenerGrade II = low intensity, usually audible to everyoneGrade III = medium intensity but no palpable thrillGrade IV = medium intensity with a thrill

Intensity of murmurs, cont

Grade V = loudest murmur audible when stethoscope is on the chest. Has a thrillGrade VI = loudest intensity, audible when stethoscope is removed from the chest. Has a thrill

Other Ways to Describe Murmurs

Pitch (high? Low?)Quality (rumbling? blowing? harsh? musical? scratchy?)Is there any relationship to the respiratory cycle?

Systolic Murmurs

These are ejection murmursMay be caused by turbulence across the aortic or pulmonic valves if they are stenosedMay be caused by turbulence across the mitral or tricuspid valves if they are incompetent (regurgitant)

Systolic Murmurs, cont

The murmur falls between S1 and S2Sounds like, LUB-shhh-dub

Diastolic Murmurs

Mitral and tricuspid stenosis can cause a diastolic murmurAortic or pulmonic regurgitation can cause a diastolic murmurSounds like this: Lub-dub-shhh

Pericardial Friction Rub

These are extra-cardiac sounds of short duration that have a sound like scratching on sandpaperMay result from irritation of the pericardium from infection, inflammation, or after open heart surgeryBest heard when patient sits and holds breath

Friction Rub, cont

A rub that disappears when the patient holds his breath does NOT come from the heart. This is probably a pleural friction rubThere are three components to a friction rubone systolic (during ejection) and two diastolic (during rapid filling of the heart and again during atrial contraction)

Refer to excellent charts regarding Extra Cardiac Sounds and Murmurs on pages 258-259 in textbook.

Assessment of the Peripheral Vascular System

Introduction

Peripheral vascular disease - very common, may involve arteries or veins.Arterial diseases include cerebrovascular, aortoiliac, femoropopliteal, renal, and aortic occlusive or aneurysmal diseaseNarrowing of vessels causes a decreased blood supply, resulting in ischemia.

Abdominal Aortic Aneurysms

The abdominal aorta is the artery most frequently involved in the development of an aneurysmUsually occur below the renal arteriesFew symptoms until it ruptures. You may discover a pulsatile mass in the abdomenUsually first sign is catastrophic rupture

Microvascular Disease

Diabetes is the most common cause of microvascular diseaseNew recommendations - blood sugar should be covered with insulin in hospitalized patients for BG over 150Peripheral venous disease often progresses to venous stasis and thrombotic disorders (we fear pulmonary emboli the most)

Review of Symptoms

Pain

This is the principal symptom of atherosclerosis. Pain is often in calf, arch of foot, thighs, hips, or buttocks while walking (intermittent claudication)Leriches Syndromechronic aorto-iliac obstruction. Pain in buttocks and thigh, as well as erectile dysfunction

Skin Changes

Color changes are common with vascular diseaseChronic arterial insufficiency produces a cool, pale extremityChronic VENOUS insufficiency produces a warmer-than-normal extremity (leg becomes red, erosions develop, increased pigmentation, swelling, aching, heaviness

Deep Vein Thrombosis

People with DVT have secondary inflammation of the tissue around the vein.This produces warmth, redness, and feverSwelling of one leg more than 2 cm at the ankle or mid-calf should be considered significant

Edema

Lymphedema results from obstruction to flow in which there is stasis of lymph fluid in the tissuesThis produces firm, non-pitting edemaSeen in women post-mastectomy with lymph node removal

Ulceration

Persistent ischemia of a limb is associated with ischemic ulceration and gangreneUlceration is almost inevitable once the skin has thickened and circulation is compromisedUlceration can occur with just the slightest trauma

Ulceration, cont

Rapidly developing ulcers are commonly caused by arterial insufficiency, whereas slowly developing ulcerations are usually the result of venous insufficiency

Emboli

Thrombi form from stasis or hypercoagulabilityBedrest, CHF, obesity, pregnancy, recent extended travel on planes, and oral contraceptives have been associated with thrombus formation and emboliSymptoms depend on where clot lodges

The Physical Examination

Points to Consider in Exam

Inspect for symmetry of extremitiesExamine arterial pulsesAuscultate carotid artery with diaphragm (slightly elevate head on pillow and turn slightly away from the side being auscultated) If a bruit is noted, do NOT palpate!Should not be able to palpate abdominal pulse unless very thin. Err on side of caution. Get abdominal ultrasound to R/O aneurysm. Often too late when bulging mass felt.

Exam, cont

Palpate abdomen deeply but gently for a mass with laterally expansive pulsation (surgical mortality for a non-ruptured abdominal aneurysm is only 5%, but rupture increases mortality to over 90%)Listen for bruits over major arteries with patient lying flat. Listen 2 inches above umbilicus for presence of aortic bruit

Exam, cont

Renal artery bruits may be heard about 2 inches above umbilicus and 1-2 inches laterally from mid-linePalpate femoral pulse. The lateral corners of the pubic hair triangle is where you will find the pulse. Feel both femorals so you can judge equality

more of the exam...

Palpate popliteal pulseoften hard to feel. Place thumbs on patella and press remaining fingers of both hands in popliteal fossa. Have legs in mid-flexed positionPalpate dorsalis pedis (top of foot) and posterior-tibial pulse (inside ankle bone)

Grading Pulses

0 = absent pulse (check with doppler!)1+ = diminished2+ = normal3+ = increased4+ = bounding

Capillary Refill

Evaluate capillary refill by compressing the toe or fingernail tufts until they blanche. Color should return in 3-5 secondsProlonged time for color to return is a sign of arterial vascular insufficiency

Allens Test:
Evaluating arterial supply in arms

Occlude the radial artery by firm pressure. Ask patient to clinch his fist, then open the fist and observe the color of the palmThen compress ulnar artery, clinch fist, and observe color of palmPallor of the palm during compression of one artery indicates occlusion of the OTHER artery!

Acute Arterial Occlusion:
The Five Ps

PainPallorParesthesiaParalysisPulselessness

Raynauds Disease

Poor peripheral circulation to distal fingers and toesYou may see three distinct color changes: white (pallor) due to decreased blood supply, blue (cyanosis) due to increased peripheral extraction of oxygen, and then red (rubor) due to the return of blood flow

Diagnostic Tests

Venous doppler flow studiesArterial doppler flow studies

CARDIAC LABORATORY TESTS

COMPLETE BLOOD COUNT
(CBC)

WBC

Increases with inflammation & phagocytosis

MI

Large hematoma

Pericarditis

Increases with use of steroids

Treatment of Pericarditis

Treatment of allergic reactions to IV contrast

RBC, HG, HCT, INDICES

Evaluate for anemia as cause of chest pain, dyspneaEvaluate safety for initiation and continued use of anticoagulant and antiplatelet therapy

PLATELETS

Evaluate safety for initiation of & continued use of anticoagulant and antiplatelet therapyDecreases may be due to adverse drug effect

Heparin-induced Thrombocytopenia (HIT)

H-2 blockers (Pepcid, Tagamet, Zantac)

Aspirin, Plavix

COMPLETE METABOLIC PROFILE (CMP)

SODIUM (Na)

Increases

Dehydration

Increases Na intake

Decreases

Volume overload

Decreased Na intake

Diuretics

POTASSIUM (K)

MUST keep in tight rangeDecreases due to:

Diuresis

Decreased potassium intake

Diarrhea

Nausea & Vomiting

Gastric Suctioning

Hypoglycemia

Alkalosis

POTASSIUM (K)

Increases due to:

Renal failure

Dehydration

Acidosis

Hyperglycemia

Increased potassium intake

ACE inhibitors

Hemolysis

HYPOKALEMIA

Often presents as:

PVCs

Atrial tachycardia

Ventricular tachycardia

Ventricular fibrillation

Leg Cramps

HYPERKALEMIA

Often presents as:

Bradycardia

Heart block

Idioventricular rhythms

VTach

VFib

Ventricular arrest

Muscle weakness

Tetany

POTASSIUM

Potassium level should be maintained 4.0 to 5.0 in cardiac patients, especially with acute MI, Cardiomyopathy, history of Ventricular arrhythmias, and diuretic therapy (as long as normal renal function).

CARBON DIOXIDE

Measures bicarbonate level of bloodMeasures metabolic state

BLOOD UREA NITROGEN
(BUN)

Increased level (azotemia) with impaired renal function caused by:

CHF, Dehydration, Shock, Stress, Acute MI

Increased levels also with renal disease and GI bleed

CREATININE (CR)

Increased level indicates worsening renal function

GLUCOSE (BG)

May elevate with stress such as with MI

LIVER FUNCTION TESTS

AST, ALT, Alkaline PhosphataseMay elevate in CHF due to hepatic congestionWill elevate in low perfusion states causing shock liver due to ischemia. Common with cardiac arrest S/P resuscitation, prolonged hypotension, shock states, embolic event.

Liver Function Tests

May elevate due to anti-lipidemic drugs. Usually not a problem unless 2X normal range.

MISCELLANEOUS LABS

Amylase & Lipase

Increases with pancreatitis or GB disease

May order if suspect GI source of chest pain

Magnesium

Decreased levels cause arrhythmias

Always check in atrial & ventricular arrhythmias and QT prolongation

MISCELLANEOUS

Thyroid Function Tests

Thyroid abnormalities can cause:

Arrhythmias

Fatique

Anemia

Usually start by checking TSH. If abnormal, check full thyroid panel

CARDIAC ISOENZYMES

Total CK (Creatine Kinase)

Enzyme found in heart, skeletal, and brain muscle cells. Enzyme is released with injury to cells

Increases with acute MI, myocarditis, post-CABG, cardioversion(defibrillation)

Can also elevate with rhabdomyolysis. May see with cocaine intoxication & adverse effect from statin drugs for hypercholestolemia

CARDIAC ISOENZYMES

CK-MB

Specific to myocardium

Increases with acute MI, myocarditis , post-CABG, cardioversion

May also elevate with chronic renal failure

With acute MI, MB occurs in serum in 6-12 hrs. & remains for 18-32 hrs.

Presence is diagnostic of MI

CARDIAC ISOENZYMES

MB Index

Percentage of MB in comparison with total CK

*** Three sets of cardiac isoenzymes should be ordered 8 hrs. apart to diagnose/confirm acute MI.

TROPONIN I and T

Troponin I more specificUnique to heart muscleReleased with very small amounts of damage as early as 1-3 hrs. after injuryPeaks in 12-48 hrs.Levels return to normal in 7-10 days.Useful in delayed diagnosis of MI also

TROPONIN T

May also elevate in unstable angina, myocarditis, chronic renal failure, acute muscle trauma, rhabdomyolysis, polymyositis, and dermatomyosis.

MYOGLOBIN

Oxygen-binding protein of striated muscle. Released with injury to muscle.Used as early marker of muscle damage in MIElevates in 2-4 hrs.Peaks in 8-10 hrs.Returns to normal in 24 hrs.

B-type NATRIURETIC PEPTIDE
(BNP)

Hormone produced by ventricles of the heart that increases in response to ventricular volume expansion and pressure overload.Marker of ventricular systolic and diastolic dysfunctionUseful in diagnosing CHFNormal is less than 100 ng/L

CARDIAC DIAGNOSTIC TESTS

ELECTROCARDIOGRAM
(EKG or ECG)

Cardiac rhythmChamber enlargementConduction abnormalitiesElectrolyte and toxic disorders

Peaked T-waves = Hyperkalemia

U waves = Hypokalemia

QT prolongation = toxic drug effects

EKG cont.

Acute MI

T wave inversion = ischemia

ST elevation = acute injury

Q waves = Transmural MI

CAN HAVE AN MI WITH NORMAL EKG!!

Cannot read with Left Bundle Branch Block

CHEST X-RAY (CXR)

Heart sizeCalcification on valves and arteriesEvidence of CHF

Pulmonary vascular congestion

Pleural effusions

Masses

ECHOCARDIOGRAM
(ECHO)

Structural Abnormalities

Anatomical

Presence of thrombi, vegetations,

Presence of pericardial effusion/tamponade

Chamber sizesValvular functionLeft ventricular function

Wall motion, Ejection Fraction (EF)

TYPES OF ECHOCARDIOGRAM

TRANSTHORACIC (TTE)

Most common

Transesophageal (TEE)

Usually ordered to evaluate for vegetations, valvular disorders, and thrombi.

STRESS TESTING

Exercise Treadmill testingMyocardial Perfusion Imaging (MPI)

Often called misnomer, Thallium scan

Types Exercise, Persantine, Adenosine, Dobutamine

Stress Echocardiogram

Types Exercise, Dobutamine

All done to evaluate for myocardial ischemia

RADIONUCLIDE ANGIOGRAPHY

Often called MUGA scan stands for multiple gated angiographyDetermines ejection fractionAlmost always automatically done with MPI now

COMPUTED TOMOGRAPHY
(CT)

Helical CT

Uses IV Contrast

Used to diagnose Aortic dissection, Pulmonary emboli

Plain CT

Abnormal masses (with or without contrast)

Hematoma or retroperitoneal bleed better with IV contrast

CT cont.

Ultrafast CT

No contrast used

Detection of coronary artery calcification as indicator of atherosclerosis

The higher the score, the more calcium detected

CARDIAC CATHETERIZATION

Uses IV contrastReveals:

Pressures in chambers/Aorta

LV wall motion and ejection fraction

Visualization of coronary anatomy

Valvular function

ARRHYTHMIA MONITORING

TelemetryHolter monitor continuous recording of heart rhythm, usually for 24 hrs.Event recorder records specific events to correlate symptoms with possible arrhythmia, worn for several weeksLoop recorder implanted in chest wall, continuous recording, then explanted.

ELECTROPHYSIOLOGY STUDY
(EPS)

Evaluation of conduction systemInducibility of arrhythmiasEffectiveness of Antiarrythmic therapies

Ventilation-Perfusion Scan
(VQ Scan)

Used to diagnose Pulmonary embolismWill read as high, moderate, or low probability for PE