CARDIOVASCULAR

EXAMINATION
Chest pain and discomfort
Dyspnoea (breathlessness
Palpitation
Presyncope and syncope
) Lower limb edema
 Chest pain
Chest pain and discomfort are crucial •
symptoms because of their association
with major pathology such as coronary
artery disease and aortic dissection
 Causes of chest pain

Non-central •
Pleural • Infection: pneumonia, •
bronchiectasis, tuberculosis • Malignancy:
lung cancer, mesothelioma, metastatic •
Pneumothorax • Pulmonary infarction •
Connective tissue disease: rheumatoid
arthritis, SL
 Chest wall • Malignancy: lung cancer, •
mesothelioma, bony metastases •
Persistent cough/ breathlessness • Muscle
sprains/tears • Bornholm’s disease
(Coxsackie B infection) • Tietze’s
syndrome (costochondritis) • Rib fracture •
Intercostal nerve compression • Thoracic
shingles (herpes
Tracheal • Infection • Irritant dusts Cardiac •
• Massive pulmonary thromboembolism •
Acute myocardial infarction/ ischaemia
Oesophageal • Oesophagitis • Rupture
Great vessels • Aortic dissection
Mediastinal • Lung cancer • Thymoma •
Lymphadenopathy • Metastases •
Mediastinitis
 :Angina symptoms include

Chest pain or discomfort, possibly described as •

pressure, squeezing, burning or fullness
Pain in your arms, neck, jaw, shoulder or back •
accompanying chest pain
Nausea •
Fatigue •
Shortness of breath •
Sweating •
Dizziness •
 Definition
Generally described as •
retrosternal heavy or
gripping sensation with
radiation to left arm or
neck, provoked by exertion
and eased with rest or
nitrates
 Angina pectoris
Angina pectoris Angina pectoris is the most •
common cardiac pain. It is usually due to
myocardial ischaemia from obstructed
flow in an epicardial coronary vessel, but can •
occur in conditions such as aortic stenosis or
hypertrophic cardiomyopathy when there is
increased myocardial oxygen demand due to
increased left ventricular afterload
Characteristically angina is an ache or dull •
discomfort, felt diffusely in the centre of
the anterior chest, lasting less than
10mints
Patients describe a tight or pressing ‘band- •
like’ sensation, similar to a heavy weight,
which can be confused with indigestion
 CHEST PAIN
SOCRATES •
Site – Where is the pain? Or the maximal •
site of the pain
Onset – When did the pain start, and was •
it sudden or gradual? Include also whether
.it is progressive or regressive
  •
 :Angina can be
Stable •

Unstable caused by •
unstable plaque, occurs
at rest, unpredictable,
pain can increase for no
obvious reason

Prinzmetal’s occurs •
without provocation,
usually at rest, as a result
of coronary artery spasm
Character – What is the pain like?? •
Stabbing PRESURE HEAVINESS
Radiation – Does the pain radiate •
? ?anywhere
Associations – Any other signs or  •
?symptoms associated with the pain
Time course – Does the pain follow any •
?pattern
Exacerbating/relieving factors – Does •
anything change the pain
?Severity – How bad is the pain •
? •
 Stable angina pectoris
Provoked by physical •
exertion, especially in cold
weather, after meals and
commonly aggravated by
anger or excitement
The pain fades quickly •
with rest
In some patients pain •
occurs predictably at a
certain level of exertion
 Clinical symptoms
˝Patient history is a˝golden standard •
Retrosternal pain •
Dyspnea •
Nausea •
Arrhythmia •
Restlessness •
Levine sign •
Pain eased after taking nitrates •
Physical examination
Hypertension •
Obesity •
Hyperglycemia •
Hyperlipidemia •
Auscultation •
 Dyspnoea (breathlessness)
This is an awareness of increased drive to •
breathe and is normal on exercise
It is pathological if it occurs at a •
significantly lower threshold than
expected. Breathlessness is a non-specific
symptom and may be caused by cardiac,
respiratory, neuromuscular and metabolic
conditions, or by toxins or anxiety
 Causes of dypnea
•
Causes of breathlessness •
Non-cardiorespiratory •
Anaemia • Metabolic acidosis • Obesity • •
Psychogenic • Neurogenic
 Cardiac
Left ventricular failure • Mitral valve •
disease • Cardiomyopathy • Constrictive
pericarditis • Pericardial effusion
respiratory
 Dyspnoea may be caused by myocardial •
ischaemia and is known as ‘angina
equivalent’. It may occur instead of, or
with, chest discomfort, especially in elderly
and diabetic patients
Platypnoea is breathlessness on sitting •
upright. It is much rarer than orthopnoea
and is usually associated with
deoxygenation (platypnoea–orthodeoxia
syndrome
Causes can be broadly categorized into 4  •
groups: intracardiac shunting, pulmonary
shunting, ventilation-perfusion mismatch,
.or a combination of these
Platypnea-orthodeoxia syndrome should •
be suspected when normal arterial oxygen
saturations are recorded while an
individual is supine, followed by abrupt
declines in those saturations when upright
 palpitation
Palpitation is an unexpected awareness of •
the heart beating in the chest. It may be
rapid, forceful or irregular, and described
as thumping, pounding, fluttering, jumping,
racing or skipping. The patient may be
able to mimic the rhythm by tapping it out
 syncope
Syncope is a loss of consciousness due to •
cerebral hypoperfusion.or lightheadedness
.Vertigo is rarely caused by heart disease •
Lightheadedness, syncope or a feeling of •
impending loss of consciousness
(presyncope) may be cardiovascular in
origin
 Causes of syncope
• postural hypotension • •
neurocardiogenic syncope •
• arrhythmias • •
mechanical obstruction to cardiac output •
 Postural hypotension is a fall of >20 •
mmHg in systolic BP on standing. It can
be caused by hypovolaemia,
antihypertensive drug therapy, especially
diuretics and vasodilators
 autonomic neuropathy. Postural •
hypotension is common in the elderly,
affecting up to 30% of individuals aged
.>65 years
Neurocardiogenic syncope
is a group of conditions caused by •
abnormal autonomic reflexes
Frequent fainting caused by minor stimuli •
may be due to malignant vasovagal
syndrome or hypersensitive
carotid sinus syndrome (HCSS •
 Oedema
Excess fluid in the interstitial space causes •
oedema (tissue swelling
It is usually gravity-dependent and so •
especially seen around the ankles, or over
) the sacrum in patients lying in bed
Causes of edema
Uniltareal •
Bilateral •
Pitting and nonpitting oedema •
Causes of unilateral and bilateral
leg oedema
Unilateral • Deep vein thrombosis • Soft- •
tissue infection • Trauma • Immobility, e.g.
hemiplegia • Lymphoedema
 bilateral
Heart failure • Chronic venous insufficiency • •
Hypoproteinaemia, e.g. nephrotic syndrome,
kwashiorkor, cirrhosis • Lymphatic obstruction,
e.g. pelvic tumour, filariasis • Drugs, e.g.
NSAIDs, nifedipine, amlodipine, fludrocortisone •
Inferior vena caval obstruction • Thiamine
(vitamin B1) deficiency (wet beriberi) • Milroy’s
disease (unexplained lymphoedema which
appears at puberty; more common in females) •
Immobility
 The most common causes of lower limb •
swelling are chronic venous disease and
lymphoedema
Other causes include heart failure and •
. vasodilator medications
 Palpitation
Palpitation is an unexpected awareness of •
.the heart beating in the chest
It may be rapid, forceful or irregular, and •
described as thumping, pounding,
fluttering, jumping, racing or skipping. The
patient may be able to mimic the rhythm
by tapping it out
Palpitation may occur in sinus rhythm with •
anxiety, with intermittent irregularity of the
,heart beat
extrasystoles, or with an abnormal rhythm •
.(arrhythmia)
 Palpitation can be induced by excessive •
caffeine or nicotine intake. Prescription or
‘over-the-counter’ drugs can cause
palpitation, e.g. decongestants,
antihistamines, as can stimulant
recreational drugs, e.g. amphetamines,
ecstasy and cocaine
 Descriptions of arrhythmias
Site •
Extrasystoles •
Onset Sudden •
Character ‘Jump’, missed beat or flutter R •
Associated feature nil •
Timing Brief •
Exacerbating/ relieving factors Fatigue, caffeine, •
alcohol may trigger. Often relieved by walking
(increases sinus rate)
Severity Mild (usually) •