APPROACH CARDIOLOGY

(SIGN AND SYMPTOMS)

Cyntia septriyanti.,dr
 Chest Pain
Rapid and accurate characterization of chest pain
(OPQRSTUVW Mnemoic)
1. Ongoing
2. Prior
3. Quality
4. Radiation
5. Severity
6. Timing
7. Underlying disease
8. Various symptom
9. Worse or better
 CARDIAC RISK FACTOR
• Diabetes
• Smoking
• Hypertension
• High cholesterol
• Hyperlipidemia
• Sedentary lifestyle
• High-fat diet
• Stress
• “Metabolic syndrome”
• Family history of CHD
(including
history of MI, sudden
• cardiac death, and first-degree
relatives who underwent
• coronary revascularization)
• Age
• Male sex
• Obesity
 DYSPNEU
Dyspnea refers to the sensation of difficult or uncomfortable
breathing

Dyspnea on exertion (DOE) is SOB present with exercise and improved

with rest.
Orthopnea is the sensation of breathlessness in the recumbent
position, relieved by sitting or standing
Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of
breath that awakens the patient, often after 1 or 2 hours of sleep, and
is usually relieved in the upright position.
 Anamnesis Dyspneu
Keluhan utama: Sesak nafas
• Sifat sesaknya
• Derajat berat ringannya (progresivitas)
• Lamanya penyakit/sejak kapan: (onset)
• Onset/timbul mendadak/berangsur
• Apa yang terjadi kemudian :
• Menetap/periodik
• Keparahan
• Faktor yang mempengaruhi keluhan:
• Saat duduk sdh sesak (orthopnea)
• Gejala lain yang menyertai:
• Apakah jantung suka berdebar (palpitasi)
• Apakah disertai mengi / tidak (bronkospasme)
• Apakah beberapa bulan sebelunya sudah ada
sesak bila melakukan aktivitas dan hilang
dengan istirahat (dyspnea d’effort)
• Apakah suka terbangun malam hari karena
sesak (paroxysmal nocturnal dyspnea = PND)
• Apakah suka bengkak di tungkai (menyingkirkan
defisiensi vitamin / beri-beri)
• Selain sesak juga dirasakan badan lemah dan
suka berkunang-kunang
• Riwayat penyakit terdahulu • Riwayat kanak-kanak; pendidikan; lingkungan
• Penyakit; perawatan; operasi; kecelakaan: kerja;

• Apakah pernah ada keluhan nyeri dada

beberapa waktu yang lalu (PJK) • High-risk behaviour
• Apakah ada riwayat hipertensi

• Alergi

• Pengobatan yang didapatkan

• Riwayat keluarga

• Riwayat pribadi, sosial ekonomi dan budaya

 mMRc Scale For Dyspneu
Grade Degree Characteristics
0 None Only with strenuous activity
1 Slight When hurrying on level ground or climbing a slight
incline
2 Moderate Needs to walk more slowly than others of the same age
or has to stop for
breath when walking at own pace on level ground

3 Severe Stops for breath after 100 yards or after a few minutes
4 Very severe Housebound or dyspnea when dressing or undressing
Goldman classification
Differential diagnosis of Dyspneu
 Syncope

Episode of self-limited, transient loss of consciousness due to global cerebral

hypoperfusion

Syncope is based on specific pathophysiologic etiologies.

Syncope with an identifiable cardiac etiology carries a higher risk of mortality
approaches 45% at 1 years

There are three key questions that need to be answered

1. Is lose of consciousness attributable to syncope or not?
2. Is heart disease is present or not?
3. Are there important clinical feature in the history that sugest the diagnostic?
 Palpitation

Palpitations refer to an increased awareness of the heart beating

Evaluasi palpitasi perlu ditanyakan

1. Kualitas berdebar (cepat, lambat, hilangnya denyut)
2. Sifat rasa berdebar ( tiba-tiba, perlahan-lahan)
3. Waktu terjadinya ( Saat bekerja/aktivitas, saat istirahat, emosional?)
4. Hal yang mengurangi/ menambah gejala ( istirahat, dengan gerakan
tertentu)
5. Keluhan lain ( keringat dingin, pingsan, muntah, pusing dll)
6. Riwayat penyakit lain
 Key Clinical Findings with Palpitations and Suggested Diagnoses
FINDING
Single “skipped” beats
Feeling of being unable to catch one’s breath
Single pounding sensations
Rapid, regular pounding in neck
Palpitations that are worse at night
Palpitations associated with emotional distress
Palpitations associated with activity
General anxiety
Medication or recreational drug use
Rapid palpitations with exercise
Positional palpitations
Heat intolerance, tremor, thyromegaly
Palpitations since childhood
Rapid, irregular rhythm
Palpitations terminated by vagal maneuvers
Heart murmur
Midsystolic click
Friction rub
SUGGESTED DIAGNOSIS
Benign ectopy
Ventricular premature contractions
Ventricular premature contractions
Supraventricular arrhythmias
Benign ectopy or atrial fibrillation
Psychiatric etiology or catecholamine-sensitive
arrhythmia
Coronary heart disease
Panic attacks
Drug-induced palpitations
Supraventricular arrhythmia, atrial fibrillation
Atrioventricular nodal tachycardia, pericarditis
Hyperthyroidism
Supraventricular tachycardia
Atrial fibrillation, tachycardia with variable block
Supraventricular tachycardia
Heart valve disease
Mitral valve prolapse
Pericarditis
 Differential Diagnosis of Palpitations

Arrhythmias Nonarrhythmic cardiac causes

Atrial fibrillation/flutter
Atrial or ventricular septal defect
Bradycardia caused by advanced arteriovenous
Cardiomyopathy
block or sinus node dysfunction
Congenital heart disease
Bradycardia-tachycardia syndrome (sick sinus
syndrome) Congestive heart failure
Multifocal atrial tachycardia
Mitral valve prolapse
Premature supraventricular or ventricular
contractions Pacemaker-mediated tachycardia
Sinus tachycardia or arrhythmia Pericarditis
Supraventricular tachycardia
Valvular disease (e.g., aortic insufficiency, stenosis)
Ventricular tachycardia
Wolff-Parkinson-White syndrome Extracardiac causes
Anemia
Psychiatric causes
Anxiety disorder Electrolyte imbalance
Panic attacks Fever
Hyperthyroidism
Drugs and medications
Alcohol Hypoglycemia

Caffeine Hypovolemia
Certain prescription and over-the-counter agents Pheochromocytoma
(e.g., digitalis, phenothiazine, theophylline, beta
agonists) Pulmonary disease
Street drugs (e.g., cocaine) Vasovagal syndrome
Tobacco
 Cyanosis

Cyanosis is an abnormal bluish discoloration of the skin and

mucous membranes; it is caused by high levels of deoxygenated
(reduced) hemoglobin (or its derivatives) circulating within the
superficial dermal capillaries and subpapillary venous plexus (not, as
commonly taught, the deeper arteries and veins)
Vital importance to determine the underlying cause—a standard history and
physical examination answering the following 4 questions:
1) What is the timing of onset of cyanosis (ie, is it congenital or acquired?);
presence of cyanosis at or from birth suggests congenital heart disease;
2) Is it central or peripheral? On examination one should rule out
pseudocyanosis (as above) and warm cool extremities to abolish
peripheral cyanosis, in addition to seeking evidence of coexistent
cardiopulmonary disease;
3) Is there clubbing present ? Cyanosis and clubbing narrow the differential
to congenital heart disease, suppurative pulmonary disease, and right-to-
left shunting (cardiac and intrapulmonary);
4) what do the arterial blood gas and pulse oximetry show? These are
generally straightforward; however, if pulse oximetry is indeterminate,
perform co-oximetry for abnormal hemoglobin types.
 Etiologies of Cyanosis
Table Causes of Cyanosis
Central Cyanosis Peripheral Cyanosis
Decreased arterial oxygen saturation
Decreased atmospheric pressure (altitude)
Impaired pulmonary function
All causes of central cyanosis can cause peripheral
(extensive pneumonia, pulmonary embolism,
cyanosis
obstructive lung disease, pulmonary edema,
etc.):alveolar hypoventilation, ventilation-perfusion
Reduced cardiac output (left ventricular failure or
mismatch, impaired oxygen diffusion
shock)Cold exposure
Anatomic shunts (Venous blood → arterial circulation)
Redistribution of blood flow from extremities
Congenital heart disease (“cyanotic” types, pulmonary
arteriovenous malformations [AVMs], multiple small
Arterial or venous obstruction
intrapulmonary shunts)

Hemoglobin with low oxygen affinity

Hemoglobin abnormalities
Methemoglobinemia (hereditary or acquired)
Sulfhemoglobinemia (acquired)
Carboxyhemoglobinemia (not true cyanosis, “chocolate”
cyanosis)
 Edema

Edema is an accumulation of fluid in the interstitial space that

occurs as the capillary filtration exceeds the limits of lymphatic
drainage.
 REFERENCE
1. The Washington Manual Subspeciality Consult Series Second Edition, phillip S cuculich pg 1-30
2. Buku Ajar Kardiologi FK UI pg 21-30
3. Edema By Andrea D. Thompson , MD, PhD, Department of Internal Medicine, Division of
Cardiovascular Medicine, University of Michigan; access msdmanual.com 01/06/2019 22:32
4. Cyanosis by Sarah M. McMullen,MD Correspondence information about the author MD Sarah
M. McMullen access amjmed.com 01/06/2019 21:35
5. Nimoityn P and Chung E K : History Taking and Physical Diagnosis of the Cardiovascular System
in Chung E K , QUICK REFERENCE TO CARDIO VASCULAR DISEASE, 2nd Ed, J.B.Lippincott Co,
Philadelphia – Toronto, 1983: 1 – 19.
6. Netter’s Cardiology. 2nd ed. Elsevier Inc; 2010
7. Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea by Vaskar Mukerji. Access
https://www.ncbi.nlm.nih.gov/books/NBK213/
8. Diagnostic Approach to Palpitations by ALLAN V. ABBOTT, M.D., Keck School of Medicine of the
University of Southern California, Los Angeles, California access
https://www.aafp.org/afp/2005/0215/p743.html
Thank You