Sign and Symptoms of

Cardiovascular
Disease
dr. Nurhikmawati, M.Kes, Sp.JP, FIHA

MEDICAL FACULTY
MOSLEM UNIVERSITY OF INDONESIA
Importance of the history

The richest source of information concerning the patients

illness

Establishes a bond with the patient & improves his co-

operation

Allows evaluation of the impact of the disease

BREATHLESSNESS
OR
SHORTNESS OF
BREATH
Breathlessness(dyspnoea)
abnormally uncomfortable awareness of breathing
regarded as abnormal only when it occurs
at rest or
at level of physical activity not expected to cause it
associated with diseases of
heart
lungs
chest wall
respiratory muscles
also associated with anxiety
Breathlessness(dyspnoea)
Exertional dyspnoea

Comes on during exertion and subsides with rest

Commonly due to HF or lung disease

Orthopnoea

breathlessness on lying flat

A symptom of left ventricular failure

due to redistribution of fluid from the lower extremities to
the lungs
Breathlessness(dyspnoea)
Paroxysmal Nocturnal dyspnoea
a variant of orthopnoea
patient awakes from sleep
severely breathless
persistent cough, may have white frothy sputum
a manifestation of left ventricular failure
CHEST PAIN
Chest Pain or Discomfort
history is very important
although a cardinal manifestation of heart disease, also
originates from
Non-cardiac intrathoracic structures
aorta, pulmonary artery, bronchopulmonary tree, pleura, mediastinum,
oesophagus and diaphragm
tissues of the neck and thoracic wall
skin, thoracic muscles, cervicodorsal spine, costochondral junctions,
breasts, sensory nerves and spinal cord

subdiaphragmatic organs
stomach, duodenum, pancreas and gallbladder
Functional or factitious
Chest Pain
Points to note in the history
location
radiation
character
aggravating factors
relieving factors
time relationships
duration, frequency and pattern of occurrence
setting in which it occurs
associated factors
OEDEMA
Oedema
Peripheral Oedema
a feature of chronic heart failure
due to excessive salt and water retention
In ambulant patients
found in the ankles, legs, thighs and lower abdomen
In patients who are recumbent
over the sacrum
associated with other features of heart failure
Usually pitting except if it has been long standing
Oedema
Causes of peripheral oedema
cardiac failure
Chronic venous insufficiency
Hypoalbuminaemia nephrotic syndrome, liver
disease, protein losing enteropathy
Drugs
retaining sodium (fludrocortisone, NSAID)
increasing capillary permeability (nifedipine)
PALPITATION
Palpitations
definition
unpleasant awareness of forceful or rapid beating of the heart
caused by disorders of cardiac rhythm and rate

history in palpitation
isolated jump or skips
extrasystoles
attacks with abrupt beginning, rapid heart rate with regular or irregular rhythm
paroxysmal tachycardias
independent of exercise or excitement to account for the symptom
atrial fibrillation, atrial flutter, thyrotoxicosis, anaemia, anxiety states
Palpitations
associated with drug use
tobacco, coffee, tea, alcohol epinephrine,
aminophylline, MAOI
on standing
postural hypotension
middle aged women, associated flushes and sweats
menopausal syndrome
associated with normal rate and rhythm
anxiety state
Syncope

definition
sudden temporary loss of consciousness
associated with loss of postural tone
with spontaneous recovery
not requiring electrical or chemical cardioversion

due to sudden vasodilation or sudden fall in cardiac output

or both simultaneously
Cough

defined as explosive expiration for clearing the

tracheobronchial tree of secretions and foreign bodies
cardiovascular causes include those that lead to
pulmonary venous hypertension
interstitial and alveolar oedema
pulmonary infarction
compression of the tracheobronchial tree
Cough
the nature of the sputum is often helpful
pink frothy sputum - pulmonary oedema
clear white mucoid sputum viral infection or
longstanding bronchial irritation
thick, yellowish sputum infection
rusty sputum pneumococcal pneumonia
blood streaked sputum tuberculosis, bronchiectasis,
Ca lung or pulmonary infarction
fatigue
non-specific
common in patients with impaired cardiovascular function
consequent to a reduced cardiac output
associated with muscular weakness
may be caused by drugs e.g. -blockers
may also result for excessive blood pressure reduction in
patients with hypertension or heart failure
caused by excessive diuresis or diuretic induced
hypokalaemia
Other symptoms
Nocturia
common in early heart failure
Anorexia
Abdominal fullness
right upper quadrant abdominal discomfort
weight loss
cachexia
Physical Examination
General examination
pallor indicate anaemia
cyanosis: bluish discolouration of the mucous mucosa and
skin due to arterial hypoxaemia
central cyanosis
poor gaseous exchange in the lungs pulmonary disease or pulmonary oedema
right to left shunt in congenital heart disease
peripheral cyanosis
obesity
associated with hyperlipidaemia and diabetes
features of hyperlipidaemia
corneal arcus
xanthelasma
Physical Examination
facial abnormalities
ptosis and frontal baldness dystonia myotonica(cardiomyopathy and conduction
defects)
high arched palate and ocular lens abnormalities Marfans syndrome(Aortic
aneurysm)
unusual facial features(congenital heart diseases)
finger clubbing
cyanotic congenital heart diseases
infective endocarditis(advanced)
Splinter haemorrhages
trauma
infective endocarditis
Moist palms
cold anxiety
warm thyrotoxicosis
CVS examination
Pulse
Rate
bradycardia
tachycardia
Rhythm
regular
irregular
regular with dropped beats
completely irregular
sinus arrhythmia (speeds up in inspiration and slows with expiration)
Volume
depend on the cardiac stroke volume and the compliance of the arterial system
State of the arterial wall
Synchronicity
radio-femoral delay
Other pulses
brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis
Blood pressure

use of a sphygmomanometer
inflatable cuff connected to mercury or aneroid
manometer
stethoscope over the branchial artery
inflate cuff above the POP
reduce the pressure in the cuff slowly
reappearance of Korotkov sound systolic pressure
disappearance of Korotkov sounds diastolic
pressure
Blood pressure
Pitfalls in BP measurement
apparatus
small cuff overestimation of the BP by 20 - 30 mmHg
large cuff underestimation of the blood pressure
calibration of the sphygmomanometer
Patient
emotional state of the patient
anxiety(white coat hypertension)
posture and the position of the sphyg
observer
auscultatory gap
Jugular venous pulse
observed from the right internal jugular vein
usually examined with patient at 45
2 major pulsations can be observed a and v waves
measurement of the JVP
height above the sternal angle usually < 4cm
Abdomino-jugular reflux
seen in right heart failure
Causes of raised JVP
Rt heart failure
Tricuspid incompetence
Pericardial effusion
SVC obstruction
Constrictive pericarditis
Tricuspid stenosis
Praecordium
Inspection
evidence of respiratory difficulty
visible veins obstruction of SVC
praecordial bulge or prominence long standing
cardiac enlargement before puberty
abnormalities of the chest wall
Praecordial hyperactivity suggests severe valvular
abnormality
Apex beat
Praecordium: palpation
apex beat
lowermost and outermost point of cardiac impulse
normally in the 5LICS at the mid-clavicular line
when displaced suggests cardiac enlargement
heaving apex LVH
tapping apex beat (palpable 1st heart sound) mitral
stenosis
Praecordium: palpation

Right ventricle
left parasternal heave indicate RVH
Palpable sounds
Palpable 2nd heart sound loud P2 or A2
Thrills
palpable murmurs with low frequency components
Cardiac auscultation

Areas for auscultation

cardiac apex

right and left sternal borders interspace by interspace

Heart sounds

4 basic heart sounds

other sounds i.e. clicks, prosthetic valve sounds

time the sounds with palpation of the carotid artery

Heart sound
1st heart sound
two major components
due to closure of the atrio-ventricular valves
loud in
tachycardia
short PR interval
short circle lengths in AF
mitral stenosis with a pliable leaflet

2nd heart sound

due to closure of the semi-lunar valves
normally two components A2 and P2
splitting of the 2nd heart sound in inspiration
3rd heart sound
due to sudden limitation of ventricular expansion during
early diastolic filling
heard normally in children
and in patients with high cardiac output
in patients over 40 years old
an S3 usually indicates
impairment of ventricular function
AV valve regurgitation
other conditions that increase the rate or volume of ventricular
filling
4th heart sound
a low-pitched, presystolic sound produced in the ventricle during
ventricular filling
it is associated with an effective atrial contraction and is best heard
with the bell piece of the stethoscope
absent atrial fibrillation
occurs when diminished ventricular compliance increases the
resistance to ventricular filling
seen in
patients with systemic hypertension
aortic stenosis
hypertrophic cardiomyopathy
ischemic heart disease
acute mitral regurgitation
Murmurs
result from vibrations set up
in the blood stream
and the surrounding heart and great vessels
as a result of
turbulent blood flow,
formation of eddies,
cavitation (bubble formation as a result of sudden decrease in pressure)

graded I VI
grade I faint, heard only with special effort
grade II soft
grade III loud
grade IV loud with thrill
grade V audible with stethoscope barely touching the chest
grade VI murmur is audible with the stethoscope removed from contact with the chest
Murmurs
for a murmur, determine its
timing
intensity
pitch
site of maximal intensity
radiation
configuration
relationship with posture and respiration
three major categories of murmurs
systolic, diastolic and continuous
other cardiac sounds

Pericardial rubs
the hallmark of acute pericarditis
generated by the parietal and visceral pleura rubbing
against each other
Other relevant examination

lung bases
crepitations in left heart failure
abdomen
hepatomegaly in right heart failure
 CARDIAC
INVESTIGATION
 CARDIAC CATHETERIZATION

Werner ForSmann

Mason Sones
 CARDIAC BYPASS SURGERY

Robert Gross

John Gibbon
 ECHOCARDIOGRAPHY

Inge Edler
ELECTROCARDIOGRAPHY
THANK YOU
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