Approach To The Cardiac Patient Howard Sacher D.O. Chief, Division of Cardiology, New York College...
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Transcript of Approach To The Cardiac Patient Howard Sacher D.O. Chief, Division of Cardiology, New York College...
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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
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Signs and Symptoms
Most Common are non-specificDyspneaChest PainPalpations Presyncope/ SyncopeFatigue
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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
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Paroxysmal Nocturnal Dyspnea Most specific for cardiac diseaseOccurs acutely with 30min to 2hrs of going
to bedRelieved by sitting or standing up
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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
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Ischemic Chest Pain
Usually subsides within 30min (depends)Precipitated by
ColdExertion MealsStress
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Usually pain > 30min is indicative of an AMIUsually associated with
Anxiety and uneasiness SSCP that may radiate
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Other causes of cardiac chest pain
Ventricular hypertrophy
Valvular heart disease
Myocarditis
Endocarditis
Pericarditis
Cardiomyopathies
Aortic Dissection
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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
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These pathologies can cause a significant decline in CO leading to impaired cerebral blood flow, causing Dizziness Blurring of visionSyncope
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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
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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
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4 Functional Classes of Heart Disease
(Very Important)
Class INo limitation of physical activityOrdinary activity does not induce
symptomology
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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
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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
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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
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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
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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)
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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
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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
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