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Home , Auscultation

CARDIAC CONSIDERATIONS OF THE PODIATRIC PATIENT

Kem McGrath, D.O. Micbael C. McGlaffitA, DPl[

This paper is not meant to be a detailed descrip- neck, chest, teeth, forearms, and infrascapular tion of every cardiovascular problem that may region. is less likely to be isolated to the present itself, br-rt instead a practical approach to Ieft submammary or left hemithorax. the podiatric patient who may have an underlying Another important consideration in the eval- cardiovascular problem. uation of is its timing. Angina pectoris usually occurs during the actual exercise, excite- CARDIOVASCUIAR HISTORY ment, or other stressful activity as opposed to other types of chest pain which sometimes occur In spite of all the recent advances in high-tech after the completion of the exercise. The duration diagnostic modalities, the patient's history is still of the discomfort is also important. Most episodes the richest source of information. Therefore, the of angina last five to ten minutes per occasion, patient's history is a logical place to begin. In pur- but may last slightly longer. A patient that suing the carclior.ascular history, there are five describes pain that has lasted "a11 afternoon over areas which should be carefully evaluated: chest the last three days" is usually not having angina pain, . dyspnea, hypertension and risk pectoris, but rather some other noncardiac origin factors. of chest pain. It should also be remembered that in most cases, angina is not painful. It can also be Chest Pain described as an unpieasant sensation, or merely \7hen asking a patient about chest pain or tight- an awareness of a mild tightness in the previously ness, the character. location, and factors provok- described areas. ing the uncomfortable sensations should be delin- Even in patients with known coronary afiery eated. Since there are many types of chest disease and angina, the severity and frequency discomfot, it is sometimes difficult to differentiate should be put in perspective prior to any elective the discomfort that is consistent ischemic surgical procedure. Obviously, a new onset of disease (angina pectoris) from other etiologies. In angina or the presence of unstable angina war- terms of the character of the pain, a constricting, rants further evaluation and treatment prior to any squeezing or "hear,y feeling" in the chest is usual- elective surgical procedure, Those individuals ly consistent with an ischemic origin. This is in with well-controlled chronic, stable angina may comparison to a sharp knifelike stabbing or jab- be perfectly safe to proceed with their elective bing pain which is most often due to some cause procedure afler a basic cardiovascular evaluation. other than ischemia. Angina pectoris is the chest discomfort Palpitations which is secondary to coronary disease. The occurrence of palpitations is another clinical The discomfort is usually substernal but can radi- condition which should be carefully considered ate across the mid thorax to both arms. shoulders. when taking a cardiovascular history. Al1 patients

79 at one time or another have had "skipped beats". cholesteremia, tobacco use. famiir l-riston. dia- This is an ubiquitous sensation. However, a betes mellitus, and hypertension. Identifi-ing indi- patient's description of the sensation of sustained viduals at increased risk for ischemic hean diserse accompanied by dizztness, light- and directing them for further er-aluation m:rr headedness, near syncope, of syncope may be have a significant impact on their rlorbidin and extremely important and reflect significant under- mortality. lying tachyarrhythmia. Some of these same symp- In those individuals who har-e knon'n coro- toms, in the absence of palpitations or sensations nary artery disease, a prior history of mr-ocardial with tachycardia may be due to significant brad- infarction is obviously significant. Er-aluarion of yarrhlthmia. A sensation of a chaotic or irregular these patients prior to any surgical procedure is fast beating of the heart may represent the onset particularly impofiant for those undergoing .rnr of . Atrial fibrillation with a con- general . Prior to anesthesia and trolled ventricular response is not a contra- surgery, these individuals should be er-aluated lor indication to any surgical procedure. However, a the stabiiity of their angina, their or-erall r'enrricu- new onset of atrial fibrillation or atrial fibrillation, lar function and for any possible arrhr-thmia-s. with a vast ventricular response needs further evaluation and treatment prior to any surgical EXAMINATION procedures. During examination of the lower extremir\. there Dyspnea are signs which may suggest underlr-ing cardio- The symptom of dyspnea is another important . Vhen evaluating and treatinq :r shor-rld be factor which should be evaluated when consider- diabetic patient for diabetic ulcers, it recognized rs lead- ing the cardiac history prior to any surgical proce- that the dure. Dyspnea, the uncomfortable sensation of ing cause of death among diabetic patienrs diabetic patienis oilen breathiessness. can be associated with an Unlike other individuals, have the usual symptoms of angina. and extremely wide variety of diseases. There are cer- do not are therefore high risk for "silent" rr-ir-ocardia tain types, however, which are suggestive of con- at gestive . Dyspnea associated with ischemia and injury. Peripheral vascular disease also occurs much more frequently in the diabetrc exertion may represent a cardiomyopathy or sig- nificant . The patient patient, with a propensity for the smaller describing or paroxysmal nocturnal below the knee. dyspnea may also have significant cardiomy- Any patient who presents with signiiicant peripheral vascular disease may have ditTuse opathies. The history of dyspnea should always be thoroughly evaluated prior to any surgical atherosclerotic cardiovascular disease. Therefore. vascular status the procedure. further evaluation of the of lower extremities with doppler flon- studies Hypertension should be initiated, and the patient should be carefully questioned regarding the possibilin of One should always question the patient about a coronary arlery disease. prior history hypertension as part com- of of a Ischemic ulcerations are characteristicalh- plete cardiovascular history. It is important to seen above the lateral malleolus. These ma\- rep- know the duration of the hypertension as well as resent significant underlying; hypertensive disease. the method and degree of control in the past. \[hen these lesions are found, the patient shou]d Obviously, if the patient has had hypertension for be thoroughly evaluated for hypertension and anr- many years and has been suboptimally controlled other end organ damage which may har-e or non-compliant with their medications, then he occurred secondary to hypertension. Any indir"id- is much more 1ikely to have end organ damage ual with both hypertension and diabetes must be secondary to the disease. included in a group with a dramatic increase in Even in asymptomatic patients, one should incidence of cardiovascular disease. always question the patient for the usual risk fac- Edema of the lower extremities can be due tors associated ischemic heart disease. The most to any number of causes, however, it is a com- commonly evaiuated factors are hyper-

20 mon finding in patients with congestive heart fail- mal. It should also be noted that an electrocardio- ure and should lead one to consider this possibili- gram only demonstrates prior injury or an acute ty when other similar etiologies have been ruled ischemic change. One can have severe triple ves- out. The edema associated with congestive heart sel coronary artery disease and have an absolutely failure usr-rally starts in the foot and ankle and normal twelve-lead electrocardiogram. Therefore, then progresses up through the pretibial area and an abnormal electrocardiogram should definitely then into the thighs ancl groin. If rhe parienr is stimulate further evaluation and treatment. How- confined to bed, it is usually limited to the poste- ever) a normal-appearing electrocardiogram does rior area in the thighs. Ambulatory parients will not necessarily represent the absence of coronary discover that their edema is usually worse at the artery disease. end of the day and better when they rise in the A simple, twelve-lead preoperative electro- morning, after having been in the horizontal posi- cardiogram will also demonstrate whether the tion all night. The presence of this pitting edema patient is in a normal sinus rhyhm. The presence should stimulate further discussion regarding of a significant or high-grade AV block, or any other symptoms of congestive heart failure such arrythmia may warrant further evaluation and as dyspnea, fatigue, weakness, or exercise treatment prior to any elective surgical procedure. exerlion. Clubbing of the digits may also suggesr car- 2-D Doppler Echocardiogram diovascular disease. This condition is suggestive The 2-D Doppler Echocardiogram is an ultra- of central cyanoses and may reflect a cyanotic sound of the heart measured in real time with a congenital heart disease or a pulmonary disease doppler evaluation of the blood flow through the with hypoxia. heart. This is used to evaluate the various gradi- Osler nodes and Janeway's lesions, as well ents across each of the four valves of the heart, as as petechiae noted on the extremities are all con- well as to evaluate the left ventricular function sistent with infective . An additional and assess for prior myocardial injury. peripheral finding is that of Xanthoma tendi- \[hen a patient has a suspicious electrocar- nosum. This entity shows nodular swelling of the diogram suggesting a prior myocardial injury, a tendons, notably those on the , hands and 2-D echocardiogram can quickly establish achilles tendon. Patients affected usuallv demon- whether or not the patient has actually had previ- strate a Type 2 hyperlipoproteinemia. ous myocardial injury. If the patient has had a previous transmural infarction, then a segmented wal1 motion deficit will be noted on the echo. This str-rdy is commonly available in most commu- Although a complete cardiac exam is beyond the nity hospitals and can be done quickly in the pre- scope of most podiatrists in an office setting, sim- operative setting to clear a patient for surgery. It ple auscultation of the heart can reveal the pres- is not uncommon to find a pseudo-infarction pat- ence or absence of a murmur or irregular rhythm. tern on the electrocardiogram which can be Findings of either would warrant further medical qtrickly clarified by a 2-D echocardiogram and evaluation. then allow the patient to proceed with their surgi- cal procedure. COMMON CARDIOVASCUIAR TOOLS The most important information available FOR PATIENT EVALUATION from the echocardiogram is the overall evaluation of the left ventrictilar function or ejection fraction. EKG This is particularly true for those patients under- Electrocardiogram can establish the diagnosis of a going general anesthesia. Risks during surgery are prior myocardial injr-rry. However, it should be directly related to the patient's overall left ventric- noted that not every individual with a prior ular function. Anyone with significant deteriora- myocardial infarction has an abnormal electrocar- tion of their ejection fraction warrants further diogram. In fact, approximately 750/o of individuals evaluation and treatment prior to any surgical with prior inferior wall myocardial infarctions procedure. have had their electrocardiograms return to nor- In a patient with suspected valvular disease,

21 the doppler portion of the echo can delineate trocardiogram in a continlrous fashion for a which of the patient's lesions are hemodynamical- 24- hour period. 1y significant and which are not. There are also devices called event recorders, about the size of a hand-held tape Thallium Exercise Stress Testing recorder. These devices can be carried by the In the evaluation of ischemic heart disease, the patient and are placed on the chest during a most common screening tool is the thallium exer- symptomatic episode to record a thirty-second cise stress test. However, since many podiatric rhythm strip. The recorder is then placed oYer a patients have impaired or restricted ambulation, telephone ancl the recording is transmitted to a an exercise thallium stress test mzly not be a central serwice where it is placecl on strip recorder viable option as part of the preoperative evalua- and forwarcled to the patient's physician. These tion. The aclvent of persantine thallium stress test- devices are particularly helpful for patients who ing a11ows the patient to merely lie in the supine have symptomatic palpitations only every week or position while the test is performecl. two. All the previously mentioned non-invasive An injection of dipyrimaclole (persantine) is tests may be performed relatively quickly on an given intravenously over approximately four min- out-patient basis to better evaluate the patient ancl utes. This redistributes the blood flow through the his risk in terms of any operative procedute. heart in much the same way that exercise wou1d. At the end of the infusion of the dipyrimadole, SUMMARY thallium is injected intravenously ancl the initial A significant amount of cardiac pathology can be scintigrams are performed. Two hours later, the discovered during a careful history and physical same views are re-evaluated to look for any pcrformed in the office. This process reperfusion abnormalities, thus demonstrating examination may lead tc simple non-invasive tests that will ischemic heart disease. A positive persantine thal- better define the patient's cardiac status. If the lium test may lead to further studies such as a c21r- results of these tests rule out any significant diac catheterizalion with coronary arteriography underlying cardiac disease, then the planned sur- to further delineate the extent of disease. gical procedures can proceed without delay. If, Tkenty-Four Hour Halter on the other hand, the finclin5ls are positive, then further evaluation and treatment needs to be per- palpitations sugges- For those patients who have formed prior to proceeding with any elective sur- hour tive of underlying arrhyhmias, a tu,'enly-four gical procedure, and possibly avoid a significant halter monitor can measllre two leads of an elec- cardiac complication from a routine elective procedure.

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