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Approach To The Cardiac Patient


Title: Approach To The Cardiac Patient Author: Daniel Varghese Last modified by: Humayun Chaudhry Created Date: 7/2/2001 11:05:25 PM Document presentation format – PowerPoint PPT presentation

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Title: Approach To The Cardiac Patient

Approach To The Cardiac Patient
  • Howard Sacher D.O.
  • Chief, Division of Cardiology, New York College
    of Osteopathic Medicine.
  • Adjunct Clinical Associate Professor of Medicine,
    New York College of Osteopathic Medicine

Signs and Symptoms
  • Most Common are non-specific
  • Dyspnea
  • Chest Pain
  • Palpations
  • Presyncope/ Syncope
  • Fatigue

  • More often than not is a results of either
  • Elevated left atrial pressure
  • LV dysfunction
  • valvular obstruction
  • Elevated pulmonic venous pressures
  • Pulmonary Edema secondary to acute LA HTN
  • Hypoxemia
  • Pulmonary Edema
  • Intracardiac shunting

  • Paroxysmal Nocturnal Dyspnea
  • Most specific for cardiac disease
  • Occurs acutely with 30min to 2hrs of going to bed
  • Relieved by sitting or standing up

Chest Pain
  • Most commonly associated with angina pectoris
  • Not always associated with acute myocardial
    infarction (AMI)
  • Patients usually complain not of pain but rather
  • Pressure
  • Tightness
  • Squeezing
  • Gassy/Bloated feeling

Ischemic Chest Pain
  • Usually subsides within 30min (depends)
  • Precipitated by
  • Cold
  • Exertion
  • Meals
  • Stress

  • Usually pain gt 30min is indicative of an AMI
  • Usually associated with
  • Anxiety and uneasiness
  • SSCP that may radiate

Other causes of cardiac chest pain
  • Ventricular hypertrophy
  • Valvular heart disease
  • Myocarditis
  • Endocarditis
  • Pericarditis
  • Cardiomyopathies
  • Aortic Dissection

  • The awareness of ones heart beat
  • Usually normal
  • Pathologies include
  • Cardiac abnormalities that increase Stroke Volume
  • Regurgitant diseases
  • Bradycardia
  • Ventricular or Atrial Premature beats
  • Supraventricular Tachycardia
  • Ventricular Tachycardia

  • These pathologies can cause a significant decline
    in CO leading to impaired cerebral blood flow,
  • Dizziness
  • Blurring of vision
  • Syncope

Cardiogenic Syncope
  • Most commonly a result of
  • Sinus node arrest
  • Exit block
  • Atrioventricular block
  • Ventricular tachycardia
  • Ventricular fibrillation
  • Other significant causes
  • Aortic valve disease
  • Idiopathic hypertrophic subaortic stenosis
  • Hyperstimulation of the vagus nerve

  • Right heart failure most commonly presents with
    dependent edema
  • Other causes
  • Pericardial diseases
  • Tricuspid and pulmonic Valve diseases
  • Cor Pulmonale
  • Should also look for a nutmeg liver as a
    possible etiology

4 Functional Classes of Heart Disease(Very
  • Class I
  • No limitation of physical activity
  • Ordinary activity does not induce symptomology

  • Class II
  • Slight limitation on physical activity in which
    the patient becomes symptomatic
  • Class III
  • Marked limitation on physical activity
    comfortable only at rest. With ordinary
    activities the patient becomes symptomatic
  • Class IV
  • Pt is symptomatic at rest and is unable to engage
    in any limited activities without discomfort and

  • Look at your patient
  • Appearance
  • Diaphoretic? Think hypotension, cardiac
    tamponade, tachyarrhythmias, or an acute MI
  • Cachectic? Think CHF, low cardiac output states
  • Cyanotic? Ask is it central or peripheral?
  • Central think arterial desaturation states
  • Peripheral think impaired tissue delivery
  • Check Vital Signs
  • HR
  • BP check bilaterally as well as sitting and
  • RR
  • Temp

  • Pulses
  • Peripheral
  • Central
  • Check carotid pulse for evidence of delayed
    carotid upstroke and/or a bisferiens pulse
  • Pulsus Paradoxus decrease in blood pressure gt
    10 mmHg with inspiration
  • Pulsus Alternans amplitude of the the pulse
    alternates with each beat during normal sinus
    rhythm (most commonly seen in patients with
    pericardial effussions)
  • Jugular venous pulsations helps in evaluating
    right atrial pressure
  • Cannon A waves suggest 3rd degree heart block

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  • Pulmonary Exam
  • Crackles (aka Rales) CHF
  • Wheezing COPD (COLD)
  • Rhonchi COPD (COLD)
  • Pleural effusion on CXR CHF is cause most
  • Precordial Pulsations
  • Parasternal lift think RVH, LAH, PHTN
  • Displaced or Exaggerated PMI think LVH

Heart Sounds
  • S1 First heart sound closing of the MV and
    TV occurs during isovolumetric systole
  • Ej Second heart sound as the contraction begins
    to take place and the blood is ejected
  • S2 Third heart sound as diastole begins with
    isovolumetric relaxation forcing the AoV and PV
    closed (on inspiration S2 has a normal
    physiologic splitting)

  • OS - The fourth heart sound during the tailend
    of isovolumetric relaxation a point in which
    the ventricular pressure falls below atrial
    pressure and one can hear the opening snap of the
    MV/TV (this usually silent but accentuated with
  • S3 normal in young adults, peds and pregnancy.
    A Sound made by the deceleration of the blood as
    it hits the ventricular wall. Pathologic in all
    other patients sign of a stiff ventricle
  • S4 abnormal in all patients if heard, this last
    heart sound of the cardiac cycle is indicative of
    an atrium that is trying to pump blood into a
    very stiff ventricle
  • Please review heart sounds in Harrisons textbook

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  • Innocent murmurs vary with inspiration most
    commonly in adolescence and diminishes in the
    upright position located along the lower left
    sternal border
  • Most murmurs are diagnostic for valvular disease
  • Systolic Murmurs
  • Holosystolic start with S1 ending with S2
  • Ejection start with S1 and end before S2
  • Diastolic Murmurs
  • Associated with a palpable vibration - Thrills

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