Differential Diagnosis of

Cardiovascular system
 Terminologies
• Circulatory system …..Cardiovascular system

• Fatigue
• Weakness
– True or neuromuscular
– Perceived or non neuromuscular
• Central , Peripheral and Neural
 Essentials of Diagnosis

• Chest Pain may be caused by cardiac, pulmonary, or gastrointestinal

disease.

• Pain that results from cardiac disease may be due to stable angina
pectoris, unstable angina, acute myocardial infarction, or aortic dissection.

• Pulmonary causes of chest pain include pulmonary embolism,

pneumothorax, pulmonary hypertension, bacterial pneumonia, and cancer.

• Pain resulting from gastrointestinal causes may be due to esophageal

rupture, gastroesophageal reflux disease, and abnormal esophageal
motility.
 Essentials of Diagnosis

• For example, coronary disease is diagnosed in less than 10%

of persons with chest pain who are younger than 35 years of
age.

• However, the incidence of cardiac diagnoses may exceed 50%

in persons over 40 years of age.

• Once coronary disease has been excluded, other life-

threatening causes of acute chest pain (eg, pulmonary
embolus, aortic dissection, esophageal rupture, or tension
pneumothorax) must also be considered.
 Chest Pain or Discomfort
• Most common
• Cardiac or non cardiac origin
• Radiate to jaw , neck , upper trapezius , upper back ,shoulder & arm
(mostly left) ulnar nerve distribution.
• Cardiac origin C3 –T4

• Cardiac pain associated with vomiting , nausea , diaphoresis , dysponea ,

fatigue & pallor.

• Cardiac chest pain due to anemia when coronary circulation normal

• Non cardiac chest pain …cervical disk disease , arthritic changes etc
• Also anxiety ,trigger point & cocaine use.
Cardiac
• Crushing , Squeezing or Pressure
• Radiating
• More than few minutes
• Dysponea , dizziness , sweating

Non cardiac
• Burning sensation behind sternum
• Trouble swallowing
• Body position change pain
• Pain interface with deep breathing
• Tenderness when you push
 Palpitations
• Conscious awareness
• Abnormal awareness of heart beat

• Whether it is too slow, too fast, irregular, or at its normal frequency.

• Palpitations may be brought on by

• Overexertion, adrenaline, alcohol, nicotine, caffeine, cocaine, amphetami
nes, and other drugs
 Palpitations
• Arrhythmia
• Mitral valve prolapsed
• Athlete ‘s heart
• Caffeine , anxiety , exercise
• Bump ,jump , pound

• Normal less than 6 per minute

• Lasting for hours & with associated symptoms pain ,SOB , fainting &
lightheadedness.

• Family history of sudden death needs immediate medical referral.

 Dyspnea

• SOB
• Secondary to pulmonary pathology ,fever , obesity .
• Dyspnea on exertion …..impaired left ventricles…..pulmonary
congestion……later dysponea at rest

• Severity of dyspnea depend on extent of disease

• Extreme dyspnea PND(paroxysmal nocturnal dyspnea) & orthopnea
• Anyone who can not climb a single flight stairs ,awakes at night ,lying
down…….evaluated by clinicians.
• Dyspnea relieved by purse lip breathing or leaning forward to lock the
shoulder is more pulmonary origin than cardiac
 Cardiac syncope

• Syncope without warning…….heart valve or arrthymia

• Unexplained syncope referral

• Examination of cervical spine….vertebral artery

• If eye Nystagmus ,changes in pupil size ,visual disturbances
dizziness take concern for treatment
Fatigue
• Cardiac & non cardiac
• Heart problems ….beta blockers cause excessive fatigue
• Testing

Cough
• Mostly pulmonology but cardiac also

Cyanosis
• Central and peripheral
• The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin
 Edema
• Edema , Effusion and swelling
• Underlying pathology of Edema
• Types of edema
• Pitting and non Pitting

• More than 3 pounds or greater weight gain in ankles ,abdomen & hands.
• Associated with SOB ,fatigue , dizziness red flag sign of CHF

• Non cardiac edema ……Pulmonary HTN, kidney dysfunction etc

Cardiac Pathophysiology
 Conditions Affecting the Heart Muscle
• Obstruction or restriction
• Inflammation
• Dilation or distention.

• Obstruction ….pulmonary embolus……congestion……dilation…..

• The most common cardiovascular conditions to mimic musculoskeletal dysfunction

are angina, myocardial infarction, pericarditis, and dissecting aortic aneurysm.
 CAD
• Blood to myocardium …..Blocked…….ischemic…..infarction
• Major disorder MI & angina pectoris …..CAD …IHD
• Includes atherosclerosis (fatty buildup)

• Atherosclerosis …..medium size arteries….brain ,kidney ,heart ,legs.

• Thrombus (blood clot)

• Spasm (intermittent constriction) anxiety , cold air

• Lumen 75% narrow show symptoms

• CAD is progressive or non progressive
Risk factor
 WOMEN AND HEART DISEASE

• Many women know about the risk of breast cancer , but in truth, they are 10 times
more likely to die of cardiovascular disease.
• While 1 in 30 deaths is from breast cancer, 1 in 2.5 deaths are from heart
disease.

• So whenever screening chest pain, keep in mind the demographics:

• Older men and women, menopausal women, and black women are at greatest
risk.

• Diabetes alone poses a greater risk than any other factor in predicting
cardiovascular problems in women.
 WOMEN AND HEART DISEASE

• Women experience symptoms of CAD, which are more subtle and are "atypical"
compared to the traditional symptoms such as angina and chest pain.

• Unexplained, severe episodic fatigue and weakness associated with decreased

ability to carry out normal activities of daily living (ADLs).

• The classic pain of CAD is usually substernal chest pain characterized by a crushing,
heavy, squeezing sensation commonly occurring during emotion or exertion.
 Angina
• Angina

• Acute pain in the chest, called angina pectoris, results from the imbalance
between cardiac workload and oxygen supply to myocardial tissue.

• The present theory of heart pain suggests that pain occurs as a result of an
accumulation of metabolites within an ischemic segment of the myocardium.
 TYPES OF ANGINAL PAIN
1-Chronic stable angina
• After stress…….responds to rest or nitroglycerin

2-Resting angina, or angina decubitus

• Supine position , No effect of rest or exercise

3-Unstable angina, also known as crescendo angina, preinfarction angina,

• The duration of these attacks is longer than the usual 1 to 5 minutes; they may last for up to 20 to 30
minutes
• Pain unrelieved by rest or nitroglycerin…..chance of MI ….consultation

4-Nocturnal angina
Same as exertion….dreams….CHF

5-Atypical angina refers to unusual symptoms

• (e.g., toothache or earache) rest and nitroglycerine improves

6-Prinzmetal's angina

• Similar to those of typical angina but is caused by coronary artery spasm. morning ,estrogen reduction
causes spasm
 Clinical Signs and Symptoms of
Angina Pectoris

• Location ….. clenched fist against the sternum

• Gripping feeling of pain or pressure behind the breast bone

• Pain that may radiate to the neck, jaw, back shoulder, or arms (most often
the left arm in men)

• Toothache
• Burning indigestion
• Dyspnea (shortness of breath); exercise intolerance
• Nausea
• As to location, 80% to 90% of client experience the pain as retrosternal or
slightly to the left of the sternum.

• The duration of angina as a direct result of myocardial ischemia is typically

1 to 3 minutes and no longer than 3 to 5 minutes.

• If the pain is not relieved by rest or up to 3 nitroglycerin tablets (taken one

at a time at 5-minute intervals) in 10 to 15 minutes, the physician should be
notified and the client taken to a cardiac care unit.
• A 60 yr old male came with complaint of chest pain & dyspnea
• History of smoking
• Compensation by pursed lip breathing and leaning forward

• What is important in this scenario ???

• Which system is more likely to involve ???
 Myocardial Infarct
• Myocardial infarct (MI), also known as a heart attack, is the development of
ischemia and necrosis of myocardial tissue.
• Severe fatigue several days before infarct

• 40% higher chance in morning….clotting system more active , BP increases , heart

rate increases ,stress hormones Catecholimines induce vasoconstriction.

• Difficult to diagnose with nausea & vomiting …hiatal hernia ,peptic ulcer
,gallbladder

• Infarctions process may take up to 6 hours to complete.

• Deaths generally due to severe arrhythmias , Cardiogenic shock , CHF , Rupture of
heart , Recurrent MI
 Clinical Signs and Symptoms of
Myocardial Infarction

 May be silent (smokers, diabetics: reduced sensitivity to pain)

 Prolonged or severe sub sternal chest pain or squeezing pressure

 Pain possibly radiating down one or both arm and/or up to the throat, neck, back,
jaw,
 shoulders, or arms

 Feeling of indigestion
 Angina lasting for 30 minutes or more

 Angina unrelieved by rest, nitroglycerin, or antacids

 Pain of infarct unrelieved by rest or a change in position
 Nausea
 Pericarditis
• Inflammation of parietal pericardium (a fluid like membrane between fibrous &
visceral epicardium)
• Acute or chronic

Sign & symptoms

• Substernal pain radiates to neck , upper back ,upper trapezius ,left supraclavicular
area.
• Difficulty in swallowing
• Pain relieved by leaning forward or sit upright
• Pain increase by movement or breathing
• History of chills , fever ,MI etc
• A hospital has published an annual report on myocardial ischemia . They
reported that some pts with no active sign of myocardial ischemia ,they
have no history of cardiac disease

• Which people are the suitable case for this problems ???
 CHF
• Physiologic state in which the heart is unable to pump enough blood to
meet the metabolic needs of the body.

• Not disease itself , manifestations of problem of myocardium & valves.

• Whatever the cause ,heart fails to propel blood forward , congestion in
pulmonary circulation …..pulmonary edema.

• Ventricular interdependence
 Left ventricular failure
• Fatigue and dyspnea after mild exertion or exercise
• Persistent spasmodic cough especially when lying down

• PND
• Orthopnea
• Tachycardia

• Fatigue & muscle weakness

• Edema (legs & ankles)
• Weight gain
• Restlessness

• Decrease renal function

• Urination at night
 R i g h t - S i d e d Heart F a i l u re

• CHF or as a result of pulmonary embolism. Right ventricular failure results

in peripheral edema and venous congestion of the organs.

• Liver congested
• Increased fatigue

• Dependent edema (usually beginning in the ankles)

• Pitting edema (after 5 to 10 pounds of edema accumulate)
• Edema in the sacral area or the back of the thighs
• How can you differentiate mild , moderate & severity of disease on the basis of
dyspnea

A patient has history of MI ,risk factor include obesity & high cholesterol level.
This pt suddenly went to syncope without alarming sign (dizziness , nausea
,lightheadedness)

What happened ???

 Aneurysm
• Abnormal dilatations in artery ,vein & heart
• Infection ,congenital vascular disease , trauma & atherosclerosis

Thoracic type
• HTN & 40 to 70 yr

Abdominal type
• abdominal aortic aneurysm (AAA)
• Just below kidney
• Referred pain to thoraco lumber junction

Peripheral type
• Common site popliteal fossa
• Above 50yr
 Aneurysm
• Asymptomatic
• Palpable, pulsating mass (abdomen , popliteal space)
• low back
• Groin and/or leg pain
• Weakness or transient paralysis of legs.
• A patients presents with edema of hands and ankles .during examination
no cardiac sign observed , history of knee pain , habitual of using self
medication for pain.

• What do you suspect ??

• Non cardiac causes of edema are ????

 Rheumatic fever
• Streptococcal bacteria
• Fever lead to rheumatic heart disease….chronic condition caused by
scarring & deformity of valves.

• Most common joint pain & fever

• 5-15 age …50% heart disease

Sign & Symptoms

• Initial cold or sore throat
• Migratory arthritis…shoulder , knees , feet , ankles ,elbows .
• Fever 99-103 F
• 24 hours migratory arthritis
• Joint hot , synovitis , swelling , effusion
• Skin rash

• Subcutaneous nodule on extensor surface

• Rheumatic chorea after 1-3month & ployarthitis
• All muscles except eyes

• Carditis
• Weakness , malaise ,weight loss & anorexia
• A 50 yr old male pt presents with CAD sign and symptoms , he has history of using
nicotine and cocaine .

• During examination which kind of Pathophysiology you will consider ??

•
• Which type of Angina ???
 Endocarditic
• Inflammation of cardiac endothelium & damage the tricuspid , aortic ,
mitral valve.
• Bacterial

• Injection drug users ….high risk

• Post cardiac surgical clients …. High risk

• Can be consequences of renal shunt ,urinary catheter , dental treatment.

• Antibiotic during such treatments

• 45 % have musculoskeletal problems..arthalgia , arthritis , low back pain ,

myalgias .
• Most common arthalgia
• Shoulder mostly than knee hip etc
• Warmth ,tenderness ,redness

• No morning stiffness ….RA

• Osteoarticular infection ……..injection drug use.

• Most common joints vertebrae ,wrist , Sc joint , SI joint
• Destruction in SI joint

• One third with low back pain

• Endocarditis induced low back pain ….similar to herniated
disk…..radiation …..SLR…neurological deficits not in endocarditis
 MVP
• 10% variation in structure
• Different name ..floppy valve syndrome , Barlow ‘s syndrome , click
murmur syndrome
• Young women
• Connective tissue abnormalities in leaflets

Sign & symptoms

• Dysautonomia
• Triad ……fatigue , palpitations , dyspnea
• Chest pain minutes to hours , often at rest
• Migraine headache , tachycardia
• Joint hyper mobility ,TM joint syndrome .myalgias
• Not life threatening
• A 64 yr old patient with low back pain
• Discomfort with buttocks , legs & thigh
• Pain on walking
• Increased by prolong standing
• Improves with rest & flexion

• What comes in your mind after this ???

• What will be diagnosis ??

• What is differential test ??
• A 45 yr old male comes with chest pain, he has severe
,crushing ,knife like sharp pain . duration of pain is more than
10 minutes

• What will your immediate concerns ??

• What kind of angina you suspect ??
• Which ventricles is prone to failure mostly ??

• Which ventricles failure is related to pulmonary diseases ??

• A pt comes with sign and symptoms of heart failure , he has complaint of

edema at ankles ,on the basis of edema how you will diagnose whether its
right or left heart failure ??
• A 53 yr old pt complaint of pressure behind sternum ,pain radiation to jaws , neck.
• Complaint of dyspnea and nausea
• Repeated palpitations
• Fatigue & weakness for last few days
• No smoking history
• Pain at right biceps

• Any special ??
• What do you expect???
• An 47 yr old male presented with complaint of chest pain which last
more than 30 minutes .
• No history of any other systemic disease, other symptoms included
nausea ,diaphoresis and dyspnea after some exertion.
• Family history of cardiac failure
• No smoking
• Pain is severe

• What do you suspect ???

How you will DD the CVS disease

On basis of duration of pain

• 1-5 mints ??
• 30 mints ??
• Mints to hour ??
• Hours to day ??

On basis of angina
• rest or sleep ??
• Exertion ??
• At rest ??
• Worse with breathing ??
• If a patient comes with thoraco lumber pain & you observe no
significant history of musculoskeletal origin.

• During questioning patient tells that he has history of

aneurysm ,dull ache pain in the left mid abdominal pain.

• What do you think ??

• If he has cardiac issues ,what type of disease ??
• A 76 yr old patient admitted in ward , he was known case of
cardiac pathology , when you tried to examine him ,he
repeatedly complaint of night urination frequently , fatigue ,
edema and weakness .After that he refused to talk , so on the
basis of this short examination.

• What is important in examination ???

• What do you expect ???