Diagnostic process in Cardiovascular Disease

Faculty of Medicine University of Brawijaya

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Doctor-Patient relationship:
Empathy : the ability to recognize and to some extent share the emotions and states of mind of another and to understand the meaning and significance of that person's behavior. Empathy is different from sympathy in that to be empathetic one understands how the person feels rather than actually experiencing those feelings, as in sympathy. Patient: human being mimics feelings Appreciate or honor each other honest may be positive / Negative

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Doctor-Patient Relationship

Interaction
My feelings affect my behaviour My behaviours affect patients feelings

Patients behaviour affect my feelings

Patients feelings affect their diseases

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Examination of patient the central point needs scientific background

Phase I :

- Anamnesis - Physical notes - Data recording Needs patience, discipline, sensitive, curious

Phase II :

- Data analysis - Integrating data Diagnosis, Prognosis, Process, Diagnosis

Phase III :

-M anagement - Treatment Consideration, experience, advice

Primum Non Nocere Do No Harm (=Pertama jangan melakukan tindakan yang merugikan). Page 4

The Cardiovascular Data Base

1. 2. 3. 4. 5. 6. Patient history Physical examination Electrocardiogram Chest X-ray Routine blood exams Additional Tests: 1. Two-dimensional echocardiography with Doppler studies 2. Exercise treadmil ECG test 3. Ambulatory Holter Monitoring 4. Nuclear imaging 5. Cardiac catheterization

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Classification of Common Heart Disease (according to the causes)

Cardiovascular malformations (congenital heart disease)
Involving the valve, heart structure, and other large vessels, etc.

Acquired heart disease

Artery thrombosis disease : leading to ischemia or infarction, such as coronary heart disease Rheumatic heart disease: heart inflammation, valvular disease

Hypertension: primary, secondary, hypertensive heart disease

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Classification of Common Heart Disease (according to the causes)

Acquired heart disease
pulmonary and pulmonary-vascular heart disease: pulmonary heart disease, pulmonary hypertension, pulmonary embolism, etc.

Infection: bacteria, viruses invade the heart Diseases of other systems involve the heart: hyperthyroidism, anemia, malnutrition,
immune abnormalities, physical and chemical damage, mental factors, etc.

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Classification of Common Heart Disease (according to pathology )

Endocardial disease
Endocarditis, valvular disease, etc.

Myocardial disease
Inflammation, ischemia or necrosis, hypertrophy, fibrosis, damage, etc.

Great vascular diseases

Atherosclerosis, dissection, inflammation, thrombosis, angioma, embolism, etc.

Pericardium disease
Inflammation, plot (gas, water, blood, pus, etc), coarctation, etc.

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Classification of Common Heart Disease (according to pathophysiology )

Heart Failure

Left heart, right heart; acute, chronic; systolic, diastolic Shock Dysfunction of coronary circulation Papillary muscle dysfunction Arrhythmia Cardiac tamponade Others: high or low blood pressure (of systemic or pulmonary vascular), shunt, etc.
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Format of Heart Disease Diagnosis

Etiological diagnosis
Such as rheumatic heart disease, coronary artery disease

Pathological or anatomical diagnosis

Such as mitral stenosis

Pathophysiology diagnosis
Such as heart failure, atrial fibrillation, pulmonary hypertension

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Methods of Cardiovascular Disease Diagnosis

Patient history
present history, past history, personal history, the history of surgery, vaccination history, marriage and procreation, family history, etc.

Physical examination
Symptoms and signs

Laboratory examination
Blood, urine, faeces, serous effusions (from pericardial effusion), sputum, biopsy, etc.

Equipment inspection
X-ray, ultrasound (echocardiography), electrocardiography, radionuclide, angiography, etc.
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Evaluation of the Methods in Cardiovascular Disease Diagnosis

History and physical examination
basic skills, first-hand information, many diseases can be diagnosed through this

Laboratory examination
Most supportive, but some can be used to make a definite diagnosis, such as myocardial necrosis marker, BNP (brain natriuretic peptide), etc.

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Evaluation of the Methods in Cardiovascular Disease Diagnosis

Equipment inspection
Major method for cardiovascular disease diagnosis, Divided into invasive and non-invasive method. non-invasive method can easily be accepted by patients, and is safe, however, the information may be limited (eg. ECG, echocardiography) Invasive method: the opposite to non-invasive ones (eg. Cardiac catheterization) Semi-invasive examinationsuch as those via the esophagus (eg. Trans-esophageal echocardiography)
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Basic skill
Inspection: Skin, mucosae(cyanosis?,pale?), movement of chest wall, Palpation : - Sensitivity of the hands/fingers - Muscle tone - Tumor Percussion : Sonor, dulness, timpanic Auscultation : Sounds/Voices - Breath - Friction - Heart sounds - Additional sounds: gallop, murmurs
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Problem Oriented Medical Record

POMR is oriented to problem 1.Baseline data 2.Problem list 3.Problem oriented medical record 4.Summary of problem

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Common symptoms and signs related to Cardiovascular problem

1. 2. 3. 4. 5. 6. 7. 8. Chest pain Dyspnea Syncope Palpitations Lower extremity edema Heart murmur Hypertension Fever associated with symptoms and signs

cardiac

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Chest Pain

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Differential diagnosis of chest pain

System involved Cardiac Pathology Myocardial infarction Angina pectoris Pericarditis Prolapse of the mitral valve Tamponade Aortic dissection Pulmonary embolus Pneumonia Pneumothorax Pulmonary neoplasm Esophagitis due to gastric reflux Esophageal tear Peptic ulcer Biliary disease Pancreatitis

Vascular Respiratory (all tend to give rise to pleuritic pain)

Gastrointestinal

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Differential diagnosis of chest pain

System involved
Musculoskeletal

Pathology
Cervical nerve root compression by cervical disc Costocandritis Fractured rib Herpes zoster

Neurological

Respiratory (all tend to give rise to pleuritic pain)

Pulmonary embolus Pneumonia Pneumothorax Pulmonary neoplasm

Anxiety Panic disorder Conversion disorder Malingering

Psychogenic

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Dyspnea

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Differential diagnosis of dyspnea:

System involved
Cardiac

Pathology
Cardiac failure Coronary artery disease Valvular heart disease aortic stenosis, aortic regurgitation. Mitral stenosis/regurgitation, pulmonary stenosis Cardiac arrhythmias Pulmonary embolus Airway obstruction-COPD, asthma Pneumothorax Pulmonary parenchymal disease (eg. Pneumonia, interstitial lung disease, lung neoplasm) Pleural effusion Chest wall limitation-myopathy, neuropathy (eg Guillain-Barre disease), rib fracture, kyphoscoliosis Page 21

Respiratory

Differential diagnosis of dyspnea:

System involved
Other

Pathology
Obesity (limiting chest wall movement or sleep apnea) Anemia Psychogenic hyperventilation, panic attack, anxiety. Acidosis (eg aspirin overdose, diabetic ketoacidosis)

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Syncope

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Differential diagnosis of syncope :

System involved
Cardiac

Pathology
Tachyarrhyhtmias- supraventricular or ventricular Bradyarrhythmia- sinus bradycardia, complete or second-degree heart block, sinus arrest Stokes-Adam attack- syncope due to transient asystole Left ventricular outflow tract obstruction- aortic stenosis, HOCM (hypertrophic obstructive cardiomypathy) Pulmonary hypertension After carotid sinus massage and also precipitated by pain (simple faint), micturition, anxiety; these result in hyperstimulation by vagus nerve, which leads to AV node block (and therefore bradycardia, hypotension and syncope)

Vasovagal

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Differential diagnosis of syncope :

System involved
Circulatory

Pathology
Postural hypotension usually due to antihypertensive drugs or diuretics; also caused by autonomic neuropathy as in diabetes Pulmonary embolus may or may not preceded by chest pain Septic shock severe peripheral vasodilatation results in hypotension Transient ischemic attack Vertebrobasilar attack Epilepsy Hypoglycemia

Cerebravascular Neurological Metabolic

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Palpitations
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Palpitations :
Palpitations may be caused by any disorder causing a change in cardiac rhythm or rate and any disorder causing increased stroke volume

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Palpitations :
Rapid Palpitations: 1. Regular palpitations may be a sign of: 1. Sinus tachycardia 2. Atrial flutter 3. Atrial tachycardia 4. Supraventricular re-entry tachycardia 2. Irregularly irregular palpitations may indicate: 1. Atrial fibrillation 2. Multiple atrial or ventricular ectopic beats 3. Multifocal atrial tachycardia (MAT): usually found in patients with lung pathology

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Palpitations:
Slow palpitations: patients often describe these as missed beats or forceful beats (after a pause the next beat is often more forceful due to a long filling time and therefore a higher stroke volume). Causes of slow palpitations: 1. Sick sinus syndrome 2. Atrioventricular block 3. Occasional ectopics with compensatory pauses

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Normal ECG

Rate Regularity P waves PR interval QRS duration Interpretation?

90-95 bpm regular normal 0.12 s 0.08 s

Normal Sinus Rhythm

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Sinus Tachycardia
Etiology: SA node is depolarizing faster than normal, impulse is conducted normally. Remember: sinus tachycardia is a response to physical or psychological stress, not a primary arrhythmia.

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Atrial Fibrillation
Deviation from NSR
No organized atrial depolarization, so no normal P waves (impulses are not originating from the sinus node). Atrial activity is chaotic (resulting in an irregularly irregular rate). Common, affects 2-4%, up to 5-10% if > 80 years old
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Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves (note sawtooth pattern) are formed at a rate of 250 - 350 bpm. Only some impulses conduct through the AV node (usually every other impulse).
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Lower Extremity Edema

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Differential diagnosis of lower extremity edema

Pathology
Congestive heart failure

Cause
Myocardial infarction, recurrent tachyarrhythmias (particularly atrial fibrillation), hypertensive heart disease, myocarditis, cardiomyopathy due to drugs and toxins, mitral, aortic or pulmonary valve disease Chronic lung disease, primary pulmonary hypertension

Right heart failure secondary to pulmonary hypertension (cor pulmonale) Hypoalbuminemia

Excessive protein loss (due to nephritic syndrome, extensive burns, protein losing enteropathy), reduced protein production (due to liver failure), or inadequate protein intake (due to protein-energy malnutrition) Page 35

Differential diagnosis of lower extremity edema

Pathology
Renal disease
Liver cirrhosis

Cause
Any cause of renal impairment ( e.g. hypertension, diabetes mellitus, autoimmune disease, infection)
Alcohol, hepatitis A, B, C, etc, autoimmune chronic active hepatitis, biliary cirrhosis, Wilsons disease, hemochromatosis, drugs Premenstrual edema

Idiopathic

Arteriolar dilatation Dihydropyridine calcium channel blockers ( e.g. (exposing the nifedipine, amlodipine) capillaries to high pressure, thus increasing intravascular hydrostatic pressure)

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Differential diagnosis of lower extremity edema

Pathology
Sodium retention Local causes

Cause
Cushings disease resulting in excessive mineralocorticoid activity, corticosteroids Cellulitis, venous thrombosis, lymphedema

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Heart Murmur

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Differential Diagnosis of Heart Murmur

Phase of cardiac cycle Systolic Nature of murmur Valve lesion Cause of valve lesion

Ejection systolic

Aortic stenosis

Valvular stenosis, congenital valvular abnormality, rheumatic fever, supravalvular stenosis, senile valvular calcification Aortic valve roughing

Aortic sclerosis (murmur that does not radiate to the carotids) HOCM Increased flow across normal valve

Left ventricular outflow tract (sub aortic) stenosis High output states (eg anemia, fever, pregnancy, thyrotoxicosis) Page 39

Differential Diagnosis of Heart Murmur

Phase of cardiac cycle Systolic Nature of murmur Valve lesion Cause of valve lesion

Holosystolic

Mitral regurgitation (MR)

Functional MR due to dilatation of mitral valve annulus Valvular MR: rheumatic fever, infective endocarditis, mitral valve prolapse, chordal rupture, papillary muscle infarct Functional TR Valvular TR : rheumatic fever, infective endocarditis Congenital, septal infarct (acquired) Page 40

Tricuspid regurgitation (TR) VSD with left-toright shunt

Differential Diagnosis of Heart Murmur

Phase of cardiac cycle Diastolic Nature of murmur Valve lesion Cause of valve lesion

Early diastolic

Aortic Functional AR: dilatation of regurgitation (AR) valve ring, aortic dissection, cystic medial necrosis (Marfan syndrome) Valvular AR: rheumatic fever, infective endocarditis, bicuspid aortic valve Pulmonary regurgitation Functional PR: dilatation of valve ring, Marfan syndrome, pulmonary hypertension Valvular PR: rheumatic fever, carcinoid, tetralogy of Fallot

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Differential Diagnosis of Heart Murmur

Phase of cardiac cycle Diastolic Nature of murmur Mid diastolic Valve lesion Cause of valve lesion

Mitral stenosis (MS) Tricuspid stenosis (TS) Left and right atrial myxomas

Rheumatic fever, congenital Rheumatic fever Tumor obstruction of valve orifice in diastole Congenital

Continuous

PDA Arteriovenous fistula Cervical venous hum

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Hypertension

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Differential diagnosis of hypertension

Systemic hypertension may be classified as:
Primary (essential) hypertension, for which there is no identified cause. This accounts for 95% of cases. Secondary hypertension, for which there is a clear cause

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Blood Pressure Classification

BP Classification Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension SBP mmHg <120 120139 140159 >160 and or or or DBP mmHg <80 8089 9099 >100

JNC VII Page 45

Causes of secondary hypertension

Mechanism
Renal

Pathology
Renal parenchymal disease (e.g. chronic atrophic pyelonephritis, chronic glomerulonephritis), renal artery stenosis, renin-producing tumors, primary sodium retention Acromegaly, hypo- and hyperthyroidism, hypercalcemia, adrenal cortex disorders (e.g Cushings disease, Conns syndrome, congenital adrenal hyperplasia), adrenal medulla disorders (e.g pheochromocytoma)

Endocrine

Vascular disease
Other

Coarctation of the aorta

Hypertension of pregnancy

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Causes of secondary hypertension

Mechanism
Increased intravascular volume Drugs

Pathology
Polycythemia (primary or secondary) Alcohol, oral contraceptives, monoamine oxidase inhibitor, glucocorticoids Stress

Psychogenic

Neurological

Increased intracranial pressure

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Fever associated with a cardiac symptom or sign

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Differential diagnosis of fever

Infective endocarditis (bacterial or fungal infection within the heart) Myocarditis (involvement of the myocardum in an inflammatory proess, which is usually viral) Pericarditis (inflammation of the pericardium which may be infective, postmyocardial infarction or autoimmune) Other rare conditions such as cardiac myxoma

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Summary
1. Clinical diagnosis for patient with cardiovascular disease needs comprehensive approach. 2. Cardiovascular data base includes patient history, physical examination, electrocardiogram, chest X-ray, Routine blood exams and additional tests

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Summary
3. Components of a complete cardiac diagnosis include etiologic diagnosis, pathologic or anatomical diagnosis, and pathophysiologic diagnosis. 4. Many of symptoms and signs may lead to differential diagnosis.

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Thank You
Good luck

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