Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Professional Skills Review Cardiovascular System Prepared by: Ali JassimAlhashli Based on: Macleod’s Clinical Examination; 13th Ed

2. History • Chest pain and discomfort (reflecting Coronary Artery Disease CAD): • Elderly and diabetics may not present with chest pain (this is known as atypical angina) → pain is absent in 20% of these patients who suffer from Myocardial Infarction (MI). • Stable angina: • Retrosternal chest pain felt as tightness or heaviness. • This pain is triggered by exertion and relieved by rest/nitroglycerin. • The pain lasts > 10 minutes. • Pain may radiate to shoulders, arms, back, neck or jaw. • Unstable angina: • Pain occurs at rest. • It lasts ≥ 30 minutes. • If patient had MI before and then experiences angina → this will be considered as unstable angina (post-MI angina). • Unstable angina is also defined as angina which increases in severity, duration or frequency. • Myocardial Infarction (MI): • Symptoms of unstable angina + sweating + nausea/vomiting.

3. History • Angina (ECG): • ST-segment elevation (STEMI): this is defined as • ≥ 2 mm ST-segment elevation in 2 chest leads OR ≥ 1 mm ST-segment elevation in 2 limb leads. • (+) troponin-I (which will usually be detected 4 hours after onset of chest pain). • ST-segment depression: • If there is (-) troponin-I → this is unstable angina. • If there is (+) troponin-I → this is NSTEMI. • Classification of stable angina: • Grade-I: no limitation of ordinary activities (e.g. walking or climbing stairs); symptoms are felt only with strenuous exertion. • Grade-II: slight limitation of ordinary activities. • Grade-III: marked limitation of ordinary activities (e.g. walking 1-2 blocks; climbing less than one flight). • Grade-IV: discomfort even with rest. • Pericardial pain: this is defined as sharp pain which is increased by inspiration and relieved by leaning forward. • Aortic dissection: sharp tearing pain (due to tear in tunica intima thus blood flows in tunica media under increased pressure). This pain radiates to the back.

4. History

5. History • Dyspnea: • May be caused by MI and presenting as chief complaint in elderly/diabetics who experience MI instead of chest pain. • It can also be caused by heart failure: associated with fatigue and general weakness: • NYHA classification of heart failure: • Class-I: no limitation of activity. • Class-II: slight limitation; patient is comfortable at rest. • Class-III: marked limitation; ordinary activities cannot be achieved. • Class-IV: symptoms of Congestive Heart Failure (CHF) are present at rest. • Dyspnea can also be due to Pulmonary Embolism (PE). • With left-sided heart failure: • Orthopnea: dyspnea on lying flat (↑ venous return resulting in pulmonary edema). • Paroxysmal Nocturnal Dyspnea (PND): sudden breathlessness waking the patient from his sleep (this might be confused with asthma).

6. History • Palpitation: • Definition: awareness of heart beating in the chest. • Etiology: • Sinus rhythm (with anxiety). • Arrhythmias: • Extrasystole: • Described as a missed beat followed by a strong heart beat. • What would you see in ECG: sinus rhythm → ventricular beat → a pause → then restoration of sinus rhythm. • Supraventricular tachycardia: • Defined as regular tachycardia (140-250 beats/minute) with no P-wave. This is treated with adenosine or increasing vagal stimulation through carotid massage or valsalvamenauver. • Ventricular Tachycardia (VT): defined as ≥ 3 consecutive Premature Ventricular Contractions (PVCs); wide QRS complexes in a regular rapid rhythm. • Atrial fibrillation (AF): irregular-irregular rhythm with no P-waves.

7. History Ventricular extrasystole Supraventricular tachycardia Ventricular tachycardia Atrial fibrillation

8. History • Syncope: • Definition: loss of consciousness due to cerebral hypoperfusion. • Etiology: • Postural hypotension: ≥ 20 mmHg drop in systolic blood pressure upon stnading. • Arrhythmias. • Mechanical obstruction to cardiac output: • Aortic stenosis. • Hypertrophic cardiomyopathy. • Edema (lower limbs): • Unilateral: Deep Vein Thrombosis (DVT), soft tissue infection or trauma. • Bilateral: Heart Failure (but notice if JVP is not increased → this indicates that edema is not due to a cardiogenic cause), hypoproteinemia (with nephrotic syndrome or liver cirrhosis).

9. Physical Examination of Cardiovascular System • Wash your hands; introduce yourself to the patient; explain for him what you are going to do and take permission; make sure of privacy. • Patient’s position: patient must be lying 45 degrees on bed with chest exposed to upper abdomen. • General appearance of the patient: • Is patient conscious and alert (to time, place, person)? • Is he lying comfortably on bed? • Is he in pain or has toxic-appearance? • Is he in respiratory distress? • Is he obese or cachexic? • Is he connected to any devices? (such as: pulse oximetry, ECG leads, pressure cuff, IV line or nasal cannula). • Vital signs: • Temperature: normal is between 36.5-37.5 C. • Pulse: • Radial pulse: place the pads of your index and middle fingers over patient’s radial artery. • You have to comment on the following: • Rate: calculated by number of beats in 30 seconds multiplied by 2. normal: 60-100 beats/minute. • Rhythm: regularly-irregular (ectopic beats or 2nd degree AV block); irregularly-irregular (atrial fibrillation). • Volume. • Character (preferred from carotid artery): • Collapsing pulse: hold patient’s hand (above the wrist) then raise his arm vertically above his head (if there is collapsing pulse you will feel it tapping your hand). Notice that collapsing pulse is present with aortic regurgitation. • Slow-rising pulse: aortic stenosis. • Pulsusparadoxus: < 10 mmHg drop in blood pressure on inspiration → indicating cardiac tamponade.

10. Physical Examination of Cardiovascular System Checking for radial pulse

11. Physical Examination of Cardiovascular System • Vital signs: • Pulse (continued): • Radio-radial delay: by comparing radial pulse of both hands at the same time. • Radio-femoral delay: indicating the presence of coarctation of the aorta. • Brachial pulse: felt by index and middle fingers placed in anti-cubitalfossa medial to biceps tendon. • Carotid pulse: NEVER ASSESS BOTH CAROTIDS TOGETHER!... Feel it anterior to sternocleidomastoid muscle. • Femoral pulse: felt 1 cm inferior to midpoint between anterior superior iliac spine and pubic symphysis. • Rate: • Tachycardia (< 100 beats/minute): • Exercise, sympathomimetics, pain, fever or hyperthyroidism. • Arrhythmias: atrial fibrillation, supraventricular tachycardia and ventricular tachycardia. • Bradycardia (> 60 beats/minute): • Sleep, athletic training, β-blockers or hypothyroidism. • Arrhythmias: 2nd / 3rd degree heart block. • Blood pressure (measured by sphymomanometer): • Place the blood pressure cuff above anti-cubitalfossa of right arm at heart level. Then, place your stethoscope over brachial artery. Inflate to 180 mmHg then start to deflate gradually. When sound appears → this is systolic blood pressure(Korotkoff sound). When the sound disappears → this is diastolic blood pressure. • Ideal blood pressure = 120/80 mmHg. Hypotension ≤ 90/60 mmHg. Hypertension ≥ 140/90 mmHg. • Complications of hypertension: Coronary Artery Disease (CAD), stroke or renal failure. • Etiology of hypertension: • Essential hypertension (95% of cases): increased blood pressure with no identifiable cause. • Secondary hypertension (5% of cases): there are many causes. Examples include: renal artery stenosis, pheochromocytoma and Cushing syndrome. • Respiratory rate: normal = 12-16 breaths/minute.

12. Physical Examination of Cardiovascular System

13. General inspection: • Hands: • Peripheral cyanosis: indicated by bluish discoloration of the fingers. • Tobacco staining. • Clubbing of fingers. Remember grades of clubbing: • Grade-I: nail bed fluctuation. • Grade-II: loss of Schamroth window. • Grade-III: parrot-beaking. • Grade-IV: drum-stick appearance. Cardiovascular causes of clubbing: cyanotic heart diseases, chronic hypoxia and infective endocarditis. • Severe anemia manifested by pallor of hands and koilonychia(spoon-shaped nails in iron-deficiency anemia). Notice that severe anemia can result in heart failure. • Signs of infective endocarditis: • Splinter hemorrhage: linear red-brown streaks on nails. • Janeway lesions: painless red spots of the palm which are blanching on pressure. • Osler’s nodes: painful raised erythematous lesions. • Xanthomata: due to hyperlipidemia. • Fine tremor: use to β-agonists. • Flapping tremor (asterixis): due to hypercapnia or hyperammonemia. • Face: • Pallor of conjunctiva → anemia. • Xanthelasma → hyperlipidemia. • Corneal arcus→ caused by cholesterol deposition. • Central cyanosis → occurs with heart failure. • Ophthalmoscope: • Papilledema → malignant hypertension. • Diabetic retinopathy. • Roth’s spots → infective endocarditis. Physical Examination of Cardiovascular System

14. Physical Examination of Cardiovascular System Splinter hemorrhage Osler node and Janeway lesion Xanthelasma Xanthoma Corneal arcus Roth’s spots

15. General inspection (continued): • Neck: • Jugular Venous Pressure (JVP): • Estimated by observing level of pulsation of Internal Jugular Vein (IJV) and it reflects the right atrial pressure. • Patient must be lying at 45 degrees (to relax SCM muscle); JVP normally should be > 9 cm. • You might apply abdomino-jugular or occlusion tests to confirm you are watching the JVP. • Comparison between carotid and jugular venous pulsation: • JVP increases with: • Right-sided heart failure. • COPD (corpulmonale). • Superior vena cava obstruction (e.g. tumor of lung cancer compressing superior vena cava). Physical Examination of Cardiovascular System

16. Physical Examination of Cardiovascular System

17. Chest: • Inspection: • Chest symmetry? Is the chest moving with respiration and what is the pattern (abdomino-thoracic in males; thorac-abdominal in females). • Chest deformities (pectusexcavatum/carinatum)? If chest deformity is severe this can result in displacement of the heart thus affecting palpation and auscultation. • Scars: • Midline sternotomy: Coronary Artery Bypass Grafting (CABG) or aortic valve replacement. • Infraclavicular: pacemaker implantation. • Normal hair districuation? Skin rash? Skin discoloration? • Palpation: • Apex beat: • Definition: most lateral and inferior position where cardiac impulse can be felt. Normally, it is felt at left 5thintercostal space at mid-clavicular line (just below the nipple). If you cannot feel it, ask the patient to rotate to left-lateral position and check again. • Thrill: • It is the tactile equivalent of a murmur and is felt as vibration. Normally, it is not present. • Use pads of your fingers to feel for thrill at the sites of heart valves. • Heave: • Palpable impulse which lifts up your hand. Normally, it is not present. • If there is a heave at left parasternal boarder → this indicates right ventricular hypertrophy. Physical Examination of Cardiovascular System

18. Physical Examination of Cardiovascular System Sternotomy scar Pacemaker scar Apex beat Heave

19. Chest (continued): • Auscultation: • Heart valves produce sounds only when they close. • Stethoscope bell is used to listen for low-frequency sounds (mitral stenosis, S3 and S4). • Sites where you have to auscultate: • Aortic valve: 2ndintercostal space on the right side of the sternum. • Pulmonary valve: 2ndintercostal space on the left side of the sternum. • Mitral valve: left 5thintercostal space at midclavicular line. • Tricuspid valve: 5thintercostal space on the left side of the sternum. • Listen at each site of a valve with the diaphragm of your stethoscope for S1 (M1T1) and S2 (A2P2) and check if there is a murmur. • Listen for bruits over carotid arteries (aortic stenosis) and left axilla (mitral regurgitation). • Roll patient to his left side and listen to the apex with the bell of your stethoscope (mitral stenosis). • Ask the patient to sit up and lean forward + full expiration and hold his breath → listen over left sternal border (aortic regurgitation). • S3 (third heart sound): occurs due to rapid ventricular filling (it is normally heard in children, young adults and pregnant females). • S4 (forth heart sound): it is caused by forceful atrial contraction against a stiff ventricle (hypertrophic cardiomyopathy). Physical Examination of Cardiovascular System

20. Physical Examination of Cardiovascular System

21. Chest (continued): • Auscultation: • Murmurs: • They are produced by turbulent blood flow across an abnormal valve. • Auscultate the heart for S1/S2 and murmurs. If there is a murmur → determine if it is systolic or diastolic by palpating the carotid pulse. • Grades of intensity of murmur: • Grade-I: heard by an expert in optimum conditions. • Grade-II: heard by a non-expert in optimum conditions. • Grade-III: easily heard but there is no thrill. • Grade-IV: loud murmur with a thrill. • Grade-V: very loud murmur heard over a wide area with thrill. • Grade-VI: extremely loud murmur heard without a stethoscope. • Systolic murmurs: • Aortic stenosis: mid-systolic cresendo-decresendo murmur with ejection click; audible all over anterior chest; harsh, high-pitched and musical; radiating to right carotid artery. • Mitral regurgitation: pan-systolic murmur; blowing in character; radiating to left axilla. • Diastolic murmurs: • Aortic regurgitation: early diastolic decresendo murmur; heard at left sternal border with patient learning forward and holding his breath in full expiration. • Mitral stenosis: mid-diastolic murmur with an opening snap; rumbling sound; heard with stethoscope bell at the apex with patient rolled to the left lateral side. Physical Examination of Cardiovascular System

22. Physical Examination of Cardiovascular System

23. Don’t forget to end your examination by palpating the liver (heart failure →hepatomegaly) and checking lower limbs for edema. Thank your patient