Signs and Symptoms of Heart Disease
Highly Suggestive Symptoms of Heart Disease
Major Signs and Symptoms of Heart Diseases are Chest pain, shortness of breath, palpitation, syncope,Pheripheral edema.
Less Suggestive Symptoms of Heart Disease
In few patients the Signs and Symptoms of Heart Disease may as Fatigue, dizziness, cough, hemoptysis, anorexia, cyanosis, nocturia, sweating, abdominal pain or bloating, weight loss, peripheral embolic events, visual disturbances.
Chest pain
Signs and Symptoms of Heart Disease
Causes of Chest Pain
- Cardiac
Coronary artery disease, aortic stenosis, perticarditis, myocarditis, obstructive hypertrophic cardiomyopathy, pulmonary hypertension, mitral valve prolapse.
- Noncardiac
Pulmonary
Pleuritis, Pneumonitis or Pneumonia,
Pulmonary embolus with or without infarction,
Pneumothorax.
Musculoskeletal
Costochondritis, myositis, trauma, herpes zoster.
Gastrointestinal
Esophagitis with or without spasm,
Gastric or duodenal ulcer,
Gallbladder disease,
Pancreatitis,
Aortic dissection class
Functional
Cardiac Syncope
Sudden, no prodrome, brief duration, rapid, complete recovery, no localizing seizure activity, occurs independent of body position.
Syncope
Causes (3Cs)
1.Common faint (vasovagal attack)
Emotion, heat, carotid sinus hypersensitivity.
2.Cardiac
(a) Inadequate LV output: Arrhythmias, AS.
(b) Inadequate LV filling : CHD, postural hypotension,Cough, micturation, PPH.
3.Cerebral
Hypoxia due to anaemia.
High altitude
Hypoglycemia
Dyspnoea
Dyspnoea
Physiological
Exercise, high altitude
Pathological
Alveolar (Pulmonary) : COPD, embolism
Blood disease : Anaemia
Cardiovascular : CHD, cardiac failure
Diabetic acidosis (Also renal failure)
Endocrine : Thyrotoxicosis
Fat (Obesity)
Gas (and other causes of abdominal distension)
Hysterical
Paroxysmal dyspnoea
Low : Larngeal : Foreign body, laryngismus striculus.
Cardiac : Cardiac : Acute LV failure, valvular disease, cardiac tamponade.
Reserve:Respiratory : Bronchial asthma, spontaneous pneumothorax,acute pul. oedema, pul. embolism.
Nocturnal dyspnoea
Cardiac: LVF, hypertrophic cardiomyopathy, coronary spasm
Pulmonary: Asthma, extrinsic allergic alveolitis, emboli
CNS/pharyngeal: Sleep apnoea
Cough
Cardiac Causes of Cough
Pulmonary edema,
Pulmonary venous hypertension,
Pulmonary infarction,
Tracheo-bronchial compression.
Hemoptysis
Cardiac Causes of Hemoptysis
(i) Mild to moderate hemoptysis
Pulmonary edema, mitral stenosis, Pulmonary infarction,Pulmonary hypertension,especially in Eisenmenger syndrome.
(ii) Massive hemoptysis
Rupture of pulmonary AV aneurysm, rupture of aortic aneurysm into tracheobrochial tree.
Cyanosis
Bluish discoloration of skin and mucous membranes, requires 50 gm / L reduced hemoglobin for detection.
Cyanotic Congenital Cardiac Defects
Central Cyanosis
Decreased arterial oxygen saturation
Right to left shunts
Pulmonary insufficiency
Hereditary methemoglobinemia
Peripheral cyanosis
Increased tissue oxygen extraction due to depressed perfusion
Low cardiac output with vasoconstriction
Localized arterial or venous obstruction
Decreased Hb > 5 gm / 100 ml. blood (30% of total Hb in capillaries)
Deficient, oxygenation of blood in lungs e.g. pneumonia, chronic bronchitis
Decreased O2 transfer across alveolar capillary membrane e.g. fibrosing alveoliltis
Decreased amount of air ventilating the lungs e.g. poliomyelitis
Causes
I. Central : (Skin, mm., limbs warm, clubbing)
1. Cardiac : Congenital heart defects,Eisenmenger, Congestive Heart Failure (severe)
2. Respiratory: COPD
3. High altitude : Decreased O2
4. Primary polycythemia : Absolute excess of desaturated Hb.
II. Peripheral : (Skin only, limbs cold, no clubbing)
Cold Cardiac failure
Collapse (shock)
Differential cyanosis
Lower limbs only : Eisenmenger,PDA or interrupted aortic arch
Upper limbs only : Transposition of great arteries (TGA)
Pulse
Types of abnormal: ABCDJPs
Alternans : LV failure
Anacrotic : AS
Bounding : Hyuperkinetic status
Bisferiens : AR (severe) with moderate AS, HOCM.
Corrigan :
Physiological : Heat, pregnancy, alcohol
Hyperkinetic states : e.g. thyrotoxicosis
Cardiac : AR, PDA, VSD (large), complete heart block
Dicrotic : Fevers (typhoid), severe CCF (usually secondry to dilated cardiomyopathy), tamponade, low output following aortic valve replacement for AR.
Jerky : HOCM
Plateau : AS
Parvus et tardus : AS
Paradoxus : Pericardial effusion, constrictive pericarditis
Pulmonary: asthma.
Absent pulse
Aortitis
Block (Arteriosclerotic obstruction)
Coarctation
Dissection of aorta
Embolism
E(I)njury
Heart sounds
First Heart Sound (S1)
Intensity of first heat sound is influenced by position of mitral leaflets at onset of ventricular systole, rate of rise in ventricular pressure pulse and structural integrity of mitral valve.
(a) Loud S1 : Tachycardia (short diastole), Raised cardiac output, Mitral stenosis, Short P-R (WPW Syndrome)
(b) Wide Split S1 (> 30 ms) Right bundle branch block.
(c) Reversed splitting of S1 Left bundle branch block, Severe mitral stenosis, Left atrial myxoma
(d) Soft S1 Mitral regurgitation
Calcified mitral leaflets, Long P-R interval
Accentuated
Decreased
Variable
Split
Second Heart Sound(S2)
Cause of a Widely Split second heart sound
(i) Delayed Pulmonary valve Closure as in
Right Bundle Branch block, Pulmonary embolism,Pulmonary stenosis, Atrial septal defect
(ii) Early Aortic valve closure as in Mitral regurgitation, Ventricular septal defect.
Reverse splitting of S2
Aortic stenosis(AS) Patent ductus arterious(PDA)
Hypertension(HTN) Ischaemic heart disease (IHD)
Cardiomyopathy(CMP)
Causes of Single Heart Sound
Tetralogy of Fallot, Truncus arteriosus, Tight pulmonary stenosis, Tricuspid atresia.
|
Accentuated |
Decreased |
Wide |
Split |
|
|
Fixed |
Paradoxical |
|||
|
A2 |
RV abn : | ASD | Elec. LV | |
|
Hyper |
aS, AR | RBBB | RV | delay |
| tension | LVF | ASD | disease | LBBB |
| Aortic dil | APVD | VSD | WPW | |
| Exercise | PS | (large) | RV pacing | |
| AR (some) | RVF | PVC (RV) | ||
|
P2 |
LV pacing | Mech | ||
| Mitral dis., PS | PVCs | delay : | ||
| Pul. hyper. | (LV) | AS, PDA | ||
| LVF | LV abn : | Myocardial | ||
| ASD | VSD | disease | ||
| MR | AR (severe) | |||
Third Heart Sound (S3)
Low pitched, occurs 0.14 to 0.16 Sec after S2, normally heard in children.
Its presence in patients over 40 years indicates
Ventricular decompensation, AV valve regurgitation
Left sided S3 best heard at apex in expiration
Rights sided S3 best heard in lower left sternal border during inspiration.
Before 40 Physiological or pathological by the company it keeps.
After 40-to be considered pathological
Left sided : Right sided
Hypertension : Massive pulmonary embolism
Myocardial infarction Cardiomyopathy
Cardiomyopathy
Fourth Heart Sound (S4)
Low pitched sound, best heart in apex at left lateral position
Is present in patients of : Hypertension, HOCM, Coronary artery disease, Acute mitral regurgitation, Delayed A.V. Conduction, Hyperdyamic circulation.
To Distinguish S4 from Split S1
S4 is best heart at apex where as S1 at left lower sternal border
S4 disappears on standing (decreased venous return) of if bell is pressed against chest wall.
S1 splitting varies with respiration but not S4
Palpable presystolic impulse confirms S4.
Opening Snap (OS)
Occurs 0.14 to 0.12 sec after S2
High pitched, best heard at lower left sternal border radiating to base of heard in A-V valve stenosis / obstruction or increased flow across normal A-V value
Nearer OS to A2, more sever is AV valve obstruction, OS diminishes in intensity as MS progresses.
4th heart sound (Atrial gallop)
Causes
High end: diastolic pressure : Early stage of Rt.or Left ventricular failure
Hypertrophy (severe ventricular) e.g. Aortic Stenosis.
(Atrial contraction has to produce considerable pressure rise to augment ventricular filling)
Differentiation of JVP from Carotid Pulse
Venous Arterial
Double wave form Single wave
Respiratory and No visible variation
Postural variation
Undulant, diffuse Localized
Not palpable Palpable
Obliterated by gentle pressure Not obliterated
Jugular Venous Pulse (JVP)
Absent : Atrial fibrillation
Regular : Junctional rhythm
Canon waves, irregular : Complete heart block, A-V
Dissociation
Rapid X and Y descent :constrictive Pericarditis
Ventricularisation : tricuspid regurgitation
Slow Y descent : mitral stenosis
Increased (a) wave : left atrial myxoma
Raised JVP
Anemia
Bradycardia (marked)
Decreased compliance (volume capacity) of RV : Pericardial effusion, constrictive pericarditis
Elevated intrathoracic pressure
Pressure on SVC
Pleural effusion (massive)
Fluid overload (IV)
Growths (or obstructive lesions) in right heat :
Tumour or thrombus iRA
TR or TS
Hyperdynamic states (besides Anaemia)
And also due to
Alcohol
Beriberi
Cor pulmonable (anoxic)
Disease of liver
Exercise
Fever
Graves disease
Heat and
Pregnancy, Pagets disease
Cardiac murmurs
I. Innocent
Systolic ejection
Soft
Short
Supine position best for auscultation
Supraclavicular or sternal border
Single S2 during expiration while standing
Satisfactory ECG and CXR
II. Physiological
Hyperkinetic
Pregnancy
Pyrexia
Pulse pressure wide
Benign
Pectus excavatum (severe)
Straight back syn.
III. Relative
(a) Dilatational : All 4 valve sites
(b) Flow :
IV. Organic
1. Systolic
(a) Ejection
Obstructive,Aortic / Pulmonary,Supravalvar,Valvar,Infravalvar
Increased now AR
Complete heart block
Post valvular Systemic hypertension
Pulmonary hypertension
50/50 murmur
(Atherosclerotic)
(b) Pansystolic
A-V valve incompetenc : MR, TR
L or R shunt : VSD, PDA.
(c) Late systolic
Coarctation
HOCM
Mitral chorda or papillary muscle abnormality
2. Diastolic
Obstruction at A-V MS, TS. Mid or late
Valves
Reg. across AR, TS. Early
Semilunar valves
Increased flow
across A-V valves (Ref. functional murmurs)
3. Continuous
Innocent : Venous hum
Mammary suffle
Uterine suffle
Pathological : 5 pairs
PDA, Aortopulmonary septal defect
Pul. atresia, Fallots triad
Pul. AV fistula, systemic AV fistula
Pul. arterial stenosis, coarctation
Rupture of sinus of Valsalva into RA or
RV, rupture of aortic aneurysm into rt. heart or pul. artery.
Ejection Systolic Murmur
(i)Aortic
Aortic Stenosis : valvular, subvalvular and supra valvular
Increased flow; Aortic regurgitation
Bicuspid aortic valve
Aortic root dilatation (aortitis, aneurysm, hypertension, idiopathic)
(ii)Pulmonary
Increased pulmonary blood flow (ASD, VSD)
Pulmonary hypertension
Early Systolic Murmur
Acute MR / TR-, TR in absence of pulmortary hypertension Small VSD
Large VSD with pulmonary hypertension
Late Systolic Murmur
Mitral valve prolapse
Papillary muscle dysfunction.
Holosystolic Murmur
Tricuspid regurgitation
VSD
Early Diastolic Murmur
Aortic regurgitation
Pulmonary regurgitation
Mitral Mid Diastolic Murmur
Mitral valve obstruction (MS, ball valve thrombus, atrial myxoma, cortiatriatum, valve vegetations)
Patent Ductus Arteriosus (PDA), VSD (increased flow across MV)
Tricuspid Mid Diastolic Murmur
Tricuspid stenosis
Right atrial tumor
ASD
Anomalous pulmonary venous connections
Continuous Murmurs
(i) Left to right shunt
Patent Ductus Arteriosus (PDA)
Aorto-pulmonary septal defects
Coronary A-V Fistula
Anomalous left Coronary artery
ASD with mitral setnosis
Rupturned Sinus of Valsalva
Palliatie surgical shunts VSD + AR
(ii) Other pathologic causes
Pulmonary artery branch stenosis
Bronchial collateral
Intercostal AV fistula
Proximal coronary artery stenosis
(iii) Nonpathologic
Cervical venous hum
Mammary suffle.
Characteristics of a Venous Hum
1. Best heard when sitting up
2. More common on right side
3. Increases during inspiration
4. Louder in diastole
5. Maximal with head turned away
6. Abolished by finger pressure over internal jugular vein