Federal budgetary educational establishment of higher education Ulyanovsk State University The Institute of medicine, ecology and physical culture Smirnova A.Yu., Gnoevykh V.V. INTERNAL DISEASES PROPEDEUTICS PART II DIAGNOSTICS OF CARDIOVASCULAR DISEASES Textbook of Medicine for medicine faculty students Ulyanovsk, 2016 1 УДК 811.11(075.8) БКК 81.432.1-9я73 С50 Reviewers: Savonenkova L.N. – MD, professor of Department of faculty therapy Smirnova A.Yu., Gnoevykh V.V. Internal diseases propedeutics (Part II). Diagnostics of cardiovascular diseases: Textbook of Medicine for medicine faculty students/Ulyanovsk: Ulyanovsk State University, 2017.-96 This publication is the second part of “ Internal diseases propedeutics”, which main goal is the practical assistance for students in the development of the fundamentals of clinical diagnosis of diseases of the cardiovascular system. It contains a description of the main methods of laboratory and instrumental diagnostic tests of diseases of the cardiovascular system. The publication is illustrated with charts, drawings and tables . The textbook is intended for students of medical universities. Smirnova A.Yu., Gnoevykh V.V., 2017 Ulyanovsk State University, 2017 2 THE CONTENTS OF A TEXT BOOK QUESTIONING OF PATIENTS WITH WITH CARDIOVASCULAR 5 DISEASES . Main complains of patients with with cardiovascular diseases . 5 EXAMINATION OF PATIENTS WITH WITH CARDIOVASCULAR 9 DISEASES . General inspection 9 Heart palpation 10 Palpation of vessels 14 Heart percussion 15 Defining of relative cardiac dullness borders. 15 Measurement of heart diameter. 18 Defining of vascular bundle borders 18 Defining of heart configuration. 19 Auscultation of the heart and blood vessels. 28 The heart auscultation: heart sounds abnormalities 31 The heart auscultation: heart murmurs 36 Intracardiac murmurs. 36 Extracardiac murmurs 42 Auscultation of vessels 43 Techniques for improving the auscultation 44 Palpation of the radial pulse 45 Blood pressure 48 3 CIRCULATORY FAILURE 50 HYPERTENSION 62 ATHEROSCLEROSIS. ISCHEMIC HEART DISEASE 75 Angina pectoris 77 Myocardial infarction 78 TEST CONTROL 82 Application 95 References 99 4 QUESTIONING OF PATIENTS WITH CARDIOVASCULAR DISEASES . Main complains of patients with cardiovascular diseases . Cardinal symptoms of cardiac diseases are chest pain or discomfort, symptoms of heart failure: dyspnea, edema, fatigue, cough and hemoptysis, nocturia; palpitation, syncope. Chest pain is a common presenting symptom of cardiovascular disease and must be characterized carefully. Chest pain may be cardiac (myocardial or pericardial) or noncardiac in etiology. Ischemic pain is usually of sudden onset, located centrally and stabbing or constricting; it may radiate to the left arm, occasionally to the right, into the neck and to the back. It may be brought on by exercise, emotion, fright or sexual intercourse. Angina pectoris usually lasts less than 30 minutes and may be relieved by rest or administration of nitrates. The pain of myocardial infarction usually lasts for more than 30 minutes, often as long as several hours. Site The pain of cardiac ischaemia (angina / acute myocardial infarction) is often felt centrally in the mid-sternal area, sometimes higher up across the chest, and occasionally it may be felt in the epigastric region or at the back between the shoulder blades. The pain over the precordium or the one that a patient can localize with a finger is seldom cardiac. Character Classically, the pain is constricting, squeezing, crushing or pressing and the patient may clench the fist while describing the sensation. It can be numbing, stinging or burning but not sharp, stabbing or shooting. After the initial waxing it remains constant: brief, repetitive pains are not due to cardiac ischaemia. Duration The pain usually lasts for 2-3 minutes but sometimes may linger for 10-15 minutes. It is neither momentary nor lasts for hours. Recurrent episodes with increasing severity (crescendo/unstable angina) last longer than a few minutes, are easily provoked 5 and may result in acute myocardial infarction (cessation of the coronary flow to part of the myocardium leading to ischaemic necrosis). Radiation The pain of angina radiates centrifugally across the chest, up the neck and jaws, and down the arms on both sides through the inner aspect of the left arm and hand is the commonest region. The reason for this radiation of a cardiac pain is that the inferior cervical sympathetic (stellate) ganglion, which receives the cardiac nerve plexus, contributes fibres to the lower brachial plexus. Precipitating and aggravating factors By definition, angina (inadequate coronary flow for the demands of the myocardium at exercise) is provoked by effort of walking briskly, uphill, in the cold or against the wind; by hurrying after meals; by unaccustomed exercise; or by excitement associated with physical and sympathetic activity (sexual intercourse) or caused by anger (verbal interchanges, unpleasant telephone call), fear, frustration and apprehension. Relieving factors Angina is relieved within a couple of minutes by the cessation of the activity that induced it and by nitrates, which dilate small vessels and reduce the afterload (blood pressure) and the preload (venous pressure and cardiac output), and thereby reduce the work of the heart. The pain of oesophageal spasm, which may be confused with angina, may also be relieved by nitrates. The pain that lasts for more than a few minutes after inhalation or sublingual trinitrate is not angina. The pain of unstable angina and myocardial infarction may occur without any provocating factors, is often associated with an increased sympathetic activity (e.g. sweating, tachycardia, pallor, anxiety, etc.), and is not relieved by a nitrate spray. Associated symptoms Breathlessness, sweating, nausea and restlessness may all be due to apprehension and fear but these symptoms can also accompany left heart failure. The pain of acute pericarditis is usually sharper and lasts much longer than that of angina. It is felt over the precordium and referred to the neck. It is little affected by effort 6 but is often aggravated by breathing, turning, twisting, swallowing food, by lying flat in bed, and may lessen if the patient leans forward. In dissecting aneurysm of the aorta, the pain is felt as tearing sensation; its onset is abrupt, and it radiates to the back along the course of the vessel. The signs and symptoms depend on the location and the extent of the dissection. Dyspnea is a subjective sensation of shortness of breath and often is a symptom of cardiac disease, especially in patients with congestive heart failure. Failure of the heart to pump efficiently may lead to the accumulation of blood in the lungs and dyspnoea (an uncomfortable awareness of breathing). Heart failure should be defined in the four categories of the New York Heart Association (Table 1). Table 1. Functional grading of heart disease (New York Heart Association) Grade I No limitations of activities, i.e. free symptoms Grade II No limitation under resting conditions, but symptoms appear on sever activity Grade III Limitation of activities on mild exertion Grade IV Limitation of activities at rest, restricting the person to bed or chair As for the chest pain, questions should be asked about its frequency and onset, provocating, aggravating and relieving factors, duration and about the associated symptoms. A suddenly developing dyspnea suggests pulmonary embolism, pneumothorax, acute pulmonary oedema, exposure to toxic fumes, or a haemorrhage in a tumour obstructing a major airway. In heart failure dyspnea reflects pulmonary venous hypertension secondary to a raised left ventricular end-diastolic pressure. Dyspnea occurs classically in a resting patient in the recumbent position and is relieved promptly by sitting upright (orthopnea). With deteriorating left ventricular function, the end-diastolic, left atrial and the pulmonary venous pressures all rise causing interstitial pulmonary 7 oedema and breathlessness. The clinical expression of these events is that the patient is unable to sleep without the use of the increased number of pillows. In the night, such a patient may slip down on the bed and become breathless a few hours after the onset of sleep (paroxysmal nocturnal dyspnea) associated with wheezing, sweating and apprehension. The patient finds relief by sitting on the side of the bed or getting out of the bed and walking a few paces. In chronic pulmonary disease, the patient may also awaken at night but cough and expectoration often precede the dyspnea. Edema. This is helpful in elucidating the etiology of edema. Thus a history of edema of the legs that is most pronounced in the evening is characteristic of heart failure. Fatigue. This is among the most common symptoms in patients with impaired cardiovascular function. Cough and hemoptysis may be associated with cardiac disease, but it may be difficult to differentiate cardiac from pulmonary disease on the basis of these two symptoms alone. A cough, often orthostatic in nature, may be the primary complaint in some patients with pulmonary congestion. Nocturia, secondary to resorption of edema at night, is common in patients with congestive heart failure. Syncope, which may be defined as a loss of consciousness, results most commonly from reduced perfusion of the brain. The most common causes of syncope are in the table 2. Table 2. Causes of syncope Vasodilatation Vasovagal attack, drugs, micturition syncope Cardiac causes Heart block, paroxysmal