OS 213: Cardiovascular System LEC 02: CARDINAL SYMPTOMS OF HEART DISEASE Exam 1 | Dr. Donato Marañon | September 24, 2012 OUTLINE Common Cardiac Symptomatology B. Dyspnea A. Chest Pain C. Palpitations 1. Attributes of Pain D. Edema 2. Definitions E. Cyanosis 3. Chronic Recurrent Chest Pain Syndrome F. Syncope 4. Acute Chest Pain Syndrome II. Importance of History and PE 5. Case Discussion The lecture is similar from block B’s Lecture but we changed the formatting though kasing ang gulo nung topic. So if mas naguluhan kayo sorry. Some changes: 1. All the symptomatology are now under common cardiac symptomatology. 2. Differentials for chest pain have been divided into chronic and acute. I. COMMON CARDIAC SYMPTOMATOLOGY Symptoms: complaints of the patient (most common complaint: pain); Includes chest pain, dyspnea, palpitations, edema, cyanosis, syncope Signs: doctors’ objective findings and observations A. CHEST PAIN Chest pain: most common but not exhaustive - can be caused by other factors such as hypertension ATTRIBUTES OF PAIN (PPQRSTO) Provocative – what provokes/triggers the pain o Is it precipitated by effort (exertional)? o At what time does it appear? When you are trying to get up, moving the body, etc… Palliative – what relieves/palliates the pain o Medications, therapy, etc… Quality – the nature of the pain o Sharp, burning, pricking, stabbing, strangulating, oppressing, ache similar to muscle ache, etc. Region/Radiation – location (primary region where the pain is felt), central region, how wide the coverage is and where the pain radiates or is worst o Central precordial pain where does it radiate? Back? Leg? o Hard to interview Filipinos – “doon, diyan” – vague descriptions of location Severity – intensity: mild, moderate, severe o May use a scale from 0 to 10 (worst) o Give open-ended questions Timing o Onset – abrupt, worse at start, insidious, builds up/gradual Ian, Aca, Hannah UPCM 2016A: XVI, Walang 1 of Kapantay! 14 OS 213: Cardiovascular System LEC 02: CARDINAL SYMPTOMS OF HEART DISEASE Exam 1 | Dr. Donato Marañon | September 24, 2012 o Duration – how long does it last: few seconds, minutes, hours o Frequency – once every month, once every 2 years, etc.; avoid using phrases such as rarely, sometimes Other associated symptoms – important to be able to identify the etiology o Nausea and vomiting, cold sweats, palpitations, co-morbidities and other risk factors, etc. o Always observe while you are examining (these might give you clues on the symptoms of the patient) DEFINITIONS From 2015 Block B: Spontaneous: comes and goes, not related to effort Rest: pain gradually subsides when the effort is eliminated Nitrates: coronary vasodilators; this as a palliative factor is characteristic of myocardial ischemia. o Fastest acting- sublingual nitrates Diffuse: not more than one fingerbreadth Time: anything exceeding 20 minutes is associated with myocardial infarction Severe: acute coronary syndrome CHRONIC RECURRENT CHEST PAIN SYNDROME DDX 1. CARDIAC ETIOLOGY: Classic AnginaA Fixed arterial stenosis causing symptoms, usually while exerting self o Quality of chest pain of aortic stenosis is the same as that of angina o Imbalance in myocardial oxygen demand outstripping the supply ▪ In anemics, the same amount of oxygen will be distributed to the tissues as normal if there is increase in Cardiac Output or if there is increase in Oxygen Extraction Rate in the tissues. o American Heart Association (AHA): "a medical term for chest pain or discomfort due to coronary heart disease." o Chronic angina- myocardial ischemia o Nocturnal angina- provoked during sleep o 2014: chest pain due to temporary myocardial ischemia, usually secondary to coronary atherosclerosis o 2014 trans: Less than 15-20 minutes unstable coronary syndrome, if greater than 30 minutes, acute Ian, Aca, Hannah UPCM 2016A: XVI, Walang 2 of Kapantay! 14 OS 213: Cardiovascular System LEC 02: CARDINAL SYMPTOMS OF HEART DISEASE Exam 1 | Dr. Donato Marañon | September 24, 2012 2. CARDIAC ETIOLOGY: Atypical Angina/Angina PectorisA the chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or squeezing (Harrison’s 17th Edition page 87). o While at rest or while having atypical workload Table 1. Differentiating the quality of angina TYPICAL ATYPICAL DIABETICS FEATURES FEATURES Heaviness Burning May have (vague ache in Stabbing paresthesia/ the chest) Pin Pricking change in Squeezing sensorium, will Constricting describe things Strangling differently builds up over time A Coronary Artery Diseases (CAD) most common etiology for coronary insufficiency common symptom IS ANGINA. ANGINA is a symptom not a disease! (http://www.nhlbi.nih.gov/health/health-topics/topics/angina/) The aforementioned features are usually the basis for the determination of typical or atypical angina. In some references this is based on three classic signs: o (1) substernal chest discomfort with a characteristic quality – pressure /squeezing/heaviness – an duration o (2) provoked by exertion or emotional stress o (3) relieved by rest or nitroglycerin. o Typical angina if it has all these three signs and atypical if it has two. Angina symptoms resemble those of a heart attack. However, angina symptoms usually last only one to five minutes, while chest pain from a heart attack may last for hours. Angina symptoms normally diminish after resting or taking angina medications. Heart attack symptoms do not improve with rest, and angina medication will not reduce heart attack chest pain Angina (definition) – “chest pain caused by restricted blood flow to the heart (called ischemia). It often occurs when you are under emotional or physical stress, such as exercise. When the heart doesn't get enough oxygen from the coronary arteries, you feel a squeezing chest pain or pressure across your chest that usually goes away after you stop the activity. The most common cause of angina is hardening of the arteries (atherosclerosis).” (www.umm.edu) Usual Distribution of Myocardial Ischemia Retrosternal chest pain Ian, Aca, Hannah UPCM 2016A: XVI, Walang 3 of Kapantay! 14 OS 213: Cardiovascular System LEC 02: CARDINAL SYMPTOMS OF HEART DISEASE Exam 1 | Dr. Donato Marañon | September 24, 2012 Central chest radiates to neck and jaw (angina dentis- dental pain); more commonly down the left arm (following dermatomal distribution) Can also radiate to right arm (for right coronary problems), epigastrium, or back. Dermatomal origin of heart involved (hence different areas of referred pain Tooth Ache and throat ache can also be a sign of MI – “up to the neck and into the jaw. Figure 1. Usual Distribution of ischemic chest pain: dermatomal distribution of the heart *epigastrium: may suggest right coronary artery involvement 3. CARDIAC ETIOLOGY: Mitral Valve Prolapse An abnormal systolic ballooning of part of the mitral valve into the left atrium, resulting in a floppy leaky valve. o Younger patients usually have this instead of coronary insufficiency o Usually stays as it is, without hemodynamic deterioration of the valve or stroke o 2-5% of people, especially the females commonly seen in the clinics o Not very life threatening, but is associated with mitral regurgitation in the United States. Table 2. Chronic Recurrent Chest Pain Syndromes: Cardiac Differentials* Atypical Angina should be Mitral Valve Prolapse – Classic Angina distinguished from non- affects 5% of females cardiac chest pain** During effort/ exertion(e.g. Spontaneous/cold Spontaneous walking or during very hot or weather(mechanism is very cold weather); due to vasocontriction/ coronary P demand for oxygen (demand vasospasm = supply type of type) angina rather than demand type), pain at night Rest / nitrates(diagnostic if chest Nitrates Spontaneous (can be P pain goes away in a few minutes) incapacitatingneed to use a B- blocker) Variable (TYPICAL: Squeezing, Variable(burning, pricking, Variable(diagnosis is based on constricting, pin pricking, stabbing pain; found in diabetics echocardiography) stabbing tightness, pressure, and the elderly; itis not life Q heaviness, strangling,vague threatening) chest discomfort) “basta mabigat” SEVERE: parang may hollow blocks sa chest Ian, Aca, Hannah UPCM 2016A: XVI, Walang 4 of Kapantay! 14 OS 213: Cardiovascular System LEC 02: CARDINAL SYMPTOMS OF HEART DISEASE Exam 1 | Dr. Donato Marañon | September 24, 2012 Atypical Angina should be Mitral Valve Prolapse – Classic Angina distinguished from non- affects 5% of females cardiac chest pain** Retrosternal/ precordial(diffuse Retrosternal (not typical ; maybe Left anterior, variable(can be R pain, more centrallylocated) different in location); especially under the breast) with diabetics, they usually present with atypical angina Mild to moderate*** (stable = Mild to moderate Mild – severe(not life threatening S same level of intensity for some but pain is incapacitating) time now) 1-30 min 1-30 mins Mins – hours T Typically <15-20 mins Maybe 2-3 mins If > 20 mins. = Myocardial Infarction (MI) Risk factors (i.e. Age: M>55/45*, Also w/ CSAP Young female(oftentimes the F>65/55*, 5 most common risk (Chronic Stable Angina Pectoris; complication is benign) factors: Smoking, DM, higher risk in diabetic patients hypertension, dyslipidemia, and in women, presence of at genetic predisposition) least 1 risk factor for coronary Associated factors: obesity, disease) O stress *These are just common diseases (other diseases may present with similar pain/symptoms) **We should not dismiss the