cardiovascular-symptoms心血管症状

Common symptoms of the Cardiovascular System,Dr. hechao The cardiology department of first clinic medical college,Interesting facts.,The heart does not rest for more than a fraction of a second at a timeDuring a lifetime it contracts more than 4 billion timesCoronary arteries supply more than 10 million liters of blood to the myocardium in a lifetime,Interesting facts.,Cardiac output (heart rate X stroke volume) can vary under physiologic conditions from 3 to 30 liters/minuteRemember: Normal cardiac output for adults is 5-6 liters/minuteCardiac index corrects for body size (Cardiac output divided by body surface area),Common Diseases of the Heart,Coronary artery diseaseHypertensionRheumatic heart diseaseBacterial endocarditisCongenital heart disease,OTHER VERY COMMON DISEASES OF THE HEART,CONGESTIVE HEART FAILURECARDIOMYOPATHYARRHYTHMIAS,Common Symptoms,chest painPalpitationoedema DyspneaSyncope,Chest Pain,Chest Pain,Cardiovascular disease is the 1st cause of death in the United States5.4% of all visits to the ED are for chest pain2.5% of patients with an acute myocardial infarction (AMI) are sent home 20% of all ED malpractice claims are for misdiagnosed chest pain complaints.Be difficult to diagnose,Chest Pain,Why the diseases of different organ systems present with similar symptoms?Visceral painSomatic pain,9,Visceral Pain,Sensory nerves from internal organs enter the spinal cord at multiple levels and thus the pain is difficult to describe and localizeAchingPressureHeaviness,Somatic Pain,Sensory nerves from these structures enter the spinal cord at specific levels and the pain is easily described and localizedSharp, stabbingPatients will point to an area of well localized painBone, skin, muscle, parietal pleura,Causes of chest pain,CardiovascularA.C.S. (Acute Coronary syndrome)PericarditisAortic dissectionAortic stenosisPulmonaryPulmonary embolismPleurisyPneumothoraxPneumoniaPediatricsKawasaki diseaseHypertrophic cardiomyopathyCongenital heart disease,GastrointestinalEsophageal refluxEsophageal spasmEsophageal rupturePeptic ulcer diseaseGallbladder diseasePancreatitisChest Wall PainHerpes ZosterCostochondritisCervical radiculopathyRib fractureAnxiety,Evaluation of Chest Pain,GOALEarly detection and safe management of life-threatening diseasesComplete history is very importantTimely and appropriate testingDo not focus on a benign disease and miss a life-threatening illness,14,Evaluation of chest pain,Maintain a high index of suspicion for life-threatening illness Rapid triage Is the patient at risk for serious illness?Abnormal vitals signsPatient looks sick, diaphoretic, short of breath, altered level of consciousness.Risk factors or history of cardiovascular diseaseCardiac monitor, IV, oxygenEKG within 10 minutes of patient arrival,History,Complete history most importantFocus on the characteristics of the pain, associated symptoms, risk factors, and history of cardiovascular diseasePain scale 1-101-no pain10-worst possible pain,History,Duration of the painPain lasting seconds probably not cardiacConstant pain for longer than 8-12 hours with negative workup probably not cardiacIntensity of painImmediate onset of severe pain Aortic dissectionPain reaches maximum intensity gradually ACS (Acute Coronary syndrome),History,Quality of the painBurning pain GastrointestinalTearing pain Aortic dissectionSharp, stabbing pain Usually not ischemicUp to 20% of patients with AMI describe pain as sharpBe worse with breathing or coughingPleuritic pain-Lung, musculoskeletal, pericardialPleuritic chest pain is described in up to 6% of MI patients.,History,Quality of the painLocalized pain reproduced by movement or palpation of the affected areaChest wall painVisceral pain radiates to the jaw, arms, and neckACSShortness of breathNausea & VomitingDiaphoresisfatiguepalpitations,Risk factors,Age 40MalePost-menopausal femaleHypertensionHyperlipidemiaCigarette smokingDiabetesFamily historyObesityDrug abuseCocaineThe absence of risk factors does not rule out cardiac disease,20,Acute Coronary Syndrome(ACS),Unstable AnginaNew onset of symptomsSymptoms that occur at restA change in the patients usual pattern of anginaNo ST elevation, no elevation of cardiac enzymesEKG will be normal about 50% of patientsEvidence of ischemia-ST depression or T-wave inversion,ACS,Acute Myocardial InfarctionSTEMIST elevation of 1 mm in at least 2 contiguous leads Elevated cardiac enzymesNon-STEMIST depression and T wave inversionNew left bundle branch block or Q wavesElevation of cardiac enzymes,STEMI-ST elevation MI,Non-STEMI,Anginal EquivalentsAtypical Chest Pain,Up to 33% of ACS will not have chest painDyspnea with exertion or at restShoulder, arm, or jaw pain onlyNauseaLightheaded, dizzy, or syncopeGeneralized weaknessDiaphoresisAcute change in mental statusPalpitations,EKG,The best test to rapidly diagnose an acute MIObtain within 10 minutes of patients arrival Up to 50% of initial EKGS will be normal or have non-diagnostic changesSerial EKGS,Biomarkers,Troponin T and IPreferred markerProtein located in cardiac musclePoor sensitivity first 6 hours after onset of symptomsRepeat in 8-12 hours after onset of symptomsCan be elevated withPulmonary embolismAortic dissectionRenal failureSepsisCardiac trauma or surgeryCHF (Chronic heart failure),Biomarkers,CPKLocated in cardiac and skeletal muscleCPK/MB is the cardiac isoenzymePoor sensitivity first 6 hours after onset of symptomsRepeat testing in 8-12 hoursUseful in detecting reinfarctionMyoglobinFound in skeletal and cardiac muscleGood sensitivity early after onset of symptomsbut poor specificity,Biomarkers,Note: Repeat in 8-12 hours,Pulmonary Embolism,Majority form in the deep veins of the pelvis and lower extremitiesSize of the clot will determine signs and symptomsLarge clots can cause syncope, abnormal vitals, sudden death,Pulmonary Embolism,Risk factorsPrevious DVT (Deep Vein Thrombosis) or PEPregnancyCancerRecent surgeryProlonged bed restAge50SmokingOral contraceptivesObesityInherited blood disorders,Pulmonary Embolism,Signs and symptomsDyspneaPleuritic chest painTachycardiaCoughHemoptysisFever rarely 39SyncopeEvidence of DVT in the extremities,Pulmonary Embolism,EKGSinus tachycardiaNon-specific ST and T wave changesRight heart strain pattern RBBB ( Right bundle branch block)Chest x-rayUsually normal or non-specific changesArterial blood gas (ABG)Not useful in the diagnosis of a PECan have a normal PO2 and A-a gradient with PE,Pulmonary Embolism,D-DimerFibrin degradation productTest sensitivity 95%, specificity low 50%What can elevate the D-DimerPregnancyCancerTraumaRecent surgeryDisseminated intravascular coagulation (DIC),Pulmonary Embolism,High risk patientsDo not obtain a D-Dimer immediately to go other testingCT ScanV/Q ScanPulmonary angiogram,Pericarditis,Inflammation of the cardiac pericardiumPain is due to irritation of the parietal pleuraSharp pleuritic substernal painRadiates to the back, neck, or shoulderWorse with cough, inspiration, supineImproves with leaning forwardPericardial friction rub, tachycardia, dyspneaEKGDiffuse ST elevationTroponin is elevated in up to 22%,Pericarditis EKG,Spontaneous Pneumothorax,Sudden rupture of a lung blebTall thin males age 20-40Underlying lung diseaseSmokersSudden onset of sharp pain, worse with inspiration, and SOB (shortness of breath)Physical examDecreased breath sounds on the affected sideTension pneumothorax-Immediate life threatDecreased venous return to the heartSevere respiratory distress, tachycardia, hypotension,Pneumothorax,Tension Pneumothorax,Aortic Dissection,Starts as a tear in the intima of the aorta that spreads through the medial wall under elevated systolic aortic pressureMortality untreated28% in 24 hours50% in 48 hours70% in one week Risk factorsHypertensionPregnancyLupus, syphilis, endocarditisMarfans disease,Aortic Dissection,HistorySudden onset of sharp, tearing, maximal painPain radiates to the neck or back,Aortic Dissection,Physical examMajority will be hypertensiveDifference in blood pressure between armsMurmur of aortic regurgitation Neurologic deficitsChest pain with neurologic deficit, THINK DISSECTIONEKG-useful to rule in or out MIChest X-rayWidened mediastinumRule out other etiologies,Gastrointestinal,Etiology in up to 40% of chest pain complaintsDifficult to discern from ACSPain described as burning, pressure, or dullAcid RefluxSubsternal, epigastric burning painPain worse with alcohol, caffeine, certain foodsWorse supine and in the morningRelieved with antacids,Gastrointestinal,Esophageal spasmOften associated with reflux diseaseDull, pressure, substernal pain lasting for hoursCan be relieved with NitroglycerinNTG (nitroglycerin) relaxes smooth musclesPain relief with NTG NOT diagnostic of ACSPeptic ulcer diseasePancreatitis and gallbladder diseaseInclude lipase and liver function tests in your workup,Boerhaaves Syndrome,Forceful vomiting after excessive eating and drinking causes esophageal rupture.Mediastinal contamination of stomach contentsSudden onset of severe pain radiating to the backMortality is 10-50% and directly related to the delay in making the diagnosis and initiating treatment,Chest Wall Pain,The cause in up to 30% of ED visitsWell localized, sharp, positional painReproducible by palpating a specific area of the chest wallCostochondritisPain and tenderness at the costochondral or costosternal jointsTreatmentsRestHeatNSAID (non-steroidal anti-inflammatory drug),Mental Illness,The cause in up to 10% of ED visitsPatients are with vague symptoms and historyHyperventilation can cause non-specific ST-T wave changesA diagnosis of exclusion,Chest Pain,Cervical disc diseaseNerve root compression causes chest painHerpes ZosterSharp burning pain before the rashPain and herpetic rash in a dermatome distribution,Herpes Zoster,PALPITATIONS,Definition,Uncomfortable awareness of heart beat or undue awareness of heart action.Defined as thumping , pounding or fluttering sensation in the chest. Intermittent or Sustained Regular or Irregular,Etiology and Pathogenesis,Palpitation is due toAlteration in heart rateSinus tachycardia & BradycardiaAlteration in heart rhythmAtrial fibrillationAugmentation of myocardial contractionAnxiety states & Drugs,Causes of Palpitations,Cardiovascular Causes,ArrhythmiasPremature atrial and ventricular contractionsSupraventricular and ventricular arrhythmiasWPW (Wolff-Parkinson-White) syndromeAtrial fibrillationAtrial flutter with varying blockBrady-arrhythmias : complete heart blockSick-sinus syndrome,Cardiovascular Causes,Non-arrhythmic cardiac causesMitral valve prolapse (with or without associated arrhythmias)Aortic insufficiencyAtrial myxomaPulmonary embolismCongenital heart diseasesSystemic hypertensionPericarditisPacemaker induced tachycardia,Psychiatric Causes,Include Panic attacksAnxiety statesSomatization,Psychiatric Causes,Feature A longer duration of sensation 15min Multiplicity of symptoms Cardiac evaluation still may be necessary in patients with suspected panic disorder. Arrhythmic causes must be ruled out before the diagnosis of anxiety or panic disorder,Miscellaneous Causes,Hyperkinetic circulatory states :AnaemiaFever Thyrotoxicosis Hypoglycemia Phaeochromocytoma,Miscellaneous Causes,Drugs :Aminophylline Atropine Thyroxine Tricyclic antidepressants VasodilatorsDigitalis,Miscellaneous Causes,Others :CaffeineCocaine Amphetamines Tobacco Ethanol,Others,Spontaneous skeletal muscle contractions of the chest wallSystemic mastocytosisPhysiological causesExertion Excitement PregnancyNeurocirculatory astheniaVaso-vagal attack,APPROACH TO THE PATIENT WITH PALPITATIONS,“Principal goal in assessing patients with palpitations is to determine if the symptom is caused by a life threatening arrhythmia”,HOW TO EVALUATE PALPITATION,STEP 1Is palpitation continuous or intermittent ?Intermittent P. are commonly caused by premature atrial or ventricular contractionsVentricular end-diastolic dimensionPost-extrasystolic potentiation,HOW TO EVALUATE PALPITATION,STEP 2Is heart beat regular or irregular ?Regular, sustained palpitationsSVT(supraventricular tachycardia) and/or VT (ventricular tachycardia)Irregular, sustained palpitationsAtrial fibrillation,HOW TO EVALUATE PALPITATION,STEP 3 : What is the heart rate ?STEP 4 : Does palpitations occur in discrete attacks ?Is onset abrupt?What can terminate attacks?Ventricular arrhythmias are onset suddenlyHolding breath or vagal manoeuvres decrease palpitations in SVT,STEP 5Are there any associated symptoms ?Chest pain : Arrhythmogenic MI (myocardial infarction)Dyspnea : Heart failure due to arrhythmiasSyncope : Low cardiac output during arrhythmias, hypoglycemia, phaeochromocytomaSweating : Anxiety, hypoglycemiaDiarrhoea : Thyrotoxicosis,HOW TO EVALUATE PALPITATION,STEP 6 :Are there any precipitating factors ?Exercise Stress Alcohol intakeDrugsSTEP 7 :Is there a history of structural heart disease ?Coronary heart diseasesValvular heart diseases,HOW TO EVALUATE PALPITATION,Physical examination,Vital signsJugular venous pressure and pulseAuscultation of the chest and precordium,Examination,ECGResting ECGExercise ECG24-hour ECG,Examination,OthersHolterLoop recordings (external or implantable) Mobile cardiac outpatient telemetry.Event recorder,Examination,Holter monitor,Implantable loop recorders,Management in a Nutshell,Re-assuranceLifestyle modificationCorrection of co-morbid diseasesAnxiolytics and Beta-blockersAnti-arrhythmic drugs / electrical conversionRecurrent life-threatening ventricular arrhythmias are currently being treated with Implantable Cardioverter-defibrillator devices,oedema,Definition,The excessive accumulation of intestitial fluidA pathologic process caused by diseases Not accompanied with cellular edema,Classification,According to the range that edema fluid spreads to:Generalized edemaLocalized edemaAccording to the cause of edema:Renal edemaHepatic edemaCardiac edemaMalnutritional edemalymphedema,Classification,Generalized edema: Puffiness of the face Indentation of the skin “pitting edema”Ascites & HydrothoraxLocalized edeme,Edema,Pitting edema,Ascites,Etiology and pathogenesis,Imbalance of fluid exchange between plasma and interstitial compartmentImbalance of fluid exchange between extra- and intra-body,Imbalance of fluid exchange between plasma and interstitial compartment,Capillaries,Figure 7-7,Total Pressure Differences Inside and Outside Capillary,permeability,obstruction,1. Increased capillary blood pressure,Causes:Elevated plasma volume Increased venous pressure General venous pressure, i.e. congestive heart failureLocal venous pressure, i.e. venous thrombosisArteriolar dilation i.e. acute imflammation,2. Decreased plasma colloid osmotic pressure,Causes: Plasma albumin content decreaseDecrease of protein production i.e. hepatic cirrhosis, malnutritionExcessive loss of protein i.e. nephrosisElevated catabolism of protein i.e. chronic debilitating diseases, such as malignant tumor, Plasma colloid osmotic pressure,Force drawing water back into capillary from interstitium,Formation of interstitial fluid,Edema,When greater than lymphatic compensatory return,3. Obstruction of lymphtic,Causes:Blockage by cancerBlockage by infection, especially with filarial,4. Increased capillary permeability,Capillary permeability,Filtration of more protein from capillary to interstitium,formation of interstitial fluid,Edema,When greater than lymphatic compensatory return,Plasma colloid osmotic pressure,Causes: InflammationInfectionBurnAllergic responseTraumaAnoxiaAcidosis,Imbalance of fluid exchange between extra- and intra-body- Renal retention of sodium and water,In normal condition, 99-99.5% of total volume of sodium and water filtrated via glomeruli are reabsorbed by tubules.60-70% of filtrates are actively reabsorbed by proximal convoluted tubule.The reabsorptions of sodium and water at distal tubule and collection duct are regulated by hormone.,Glomerular( filtration) and tubular (reabsorption) balance(G-T balance),GFRReabsorption of proximal tubuleReabsorption of distal tubule and collection tubule,Factors determining the GFR: Filtration area and membrane permeability Filtration pressure Effective circulating blood volume or renal blood volume,1. Decreased glomerular filtration rate (GFR),1.GFR,CausesExtensive glomerular damageAcute or chronic glomerulonephritisDecrease of effective circulating blood volumeCongestive heart failure, nephrotic syndrome,- Increased reabsorption in proximal tubule,Increased filtration fraction (FF),2.,GFR: amount of plasma filtered at glomerulus into Bowmans capsule,FF is the fraction of renal plasma flow that is filtered at the glomerulus,In normal condition: FF: 20%,The protein concentration in the plasma entering the peritubular capillaries increases,The peritubular capillary oncotic pressure increases,Enhancing fluid reabsorption from the renal interstitial space to the capillary,Decreases renal interstitial pressure,favoring reabsorption across the tubular epithelium and minimizing back flux from the renal interstitial space to the tubule lumen.,Reabsorption in proximal tubule,Increased FF,Increased FF make elevated reabsorption of proximal tubule,Causes of FF increasing,Cong