Approach To The Cardiac Patient

1. Approach To The Cardiac Patient Howard Sacher, D.O. Long Island Cardiology and Internal Medicine

2. Lecture Goals and Objectives • Understand the signs and symptoms of dyspnea, chest pain, palpitations, presyncope/syncope, and fatigue • Know the NYHA classification of heart dis. • Appreciate the different appearances patients with heart disease present with • Understand changes in pulses, and pulsus paradoxus and pulsus alternans • Realize the value and role of the pulmonary exam in the cardiac patient • Understand the basic types of murmurs and the classification of anti-arrhythmic drugs

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

4. Dyspnea More often than not is a result 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

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

6. 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

7. Ischemic Chest Pain • Usually subsides within 30min (depends) • Often precipitated by • Cold • Exertion • Post prandial • Stress

8. Usually pain > 30min is indicative of an AMI • Usually associated with • Anxiety and uneasiness • Substernal Chest Pain (SSCP) that may radiate

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

10. Palpitations • The awareness by a patient of a heart beat • Usually normal • Pathologies include: • Cardiac abnormalities that increase Stroke Volume • Regurgitant diseases • Bradycardia • Ventricular or Atrial Premature beats • Supraventricular Tachycardia (SVT) • Ventricular Tachycardia (VT)

11. These pathologies can cause a significant decline in Cardiac Output (CO) leading to impaired cerebral blood flow causing • Dizziness • Blurring of vision • Syncope

12. Most commonly a result of Sinus node arrest “Exit block” Atrioventricular (AV) block VT Ventricular fibrillation (V-fib) Other significant causes: Aortic valve disease Idiopathic Hypertrophic Subaortic Stenosis (IHSS) Hyperstimulation of the Vagus nerve Cardiogenic Syncope

13. Peripheral Edema • Right heart failure most commonly presents with dependent edema • Also • Pericardial diseases • Tricuspid and Pulmonic Valve diseases • Cor Pulmonale (Must look for a nutmeg liver as well)

14. New York Heart Association Functional Classification of Heart Disease • Class I • No limitation of physical activity • Ordinary activity does not induce symptomology

15. 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 pain

16. Look at your patient: • Appearance: • Diaphoretic? – Think hypotensive, cardiac tamponade, tachyarrhythmias, or an AMI • Cachectic? – Think CHF, low cardiac output states • Cyanotic? – Ask yourself is it central or peripheral? • Central – arterial desaturation states • Peripheral – impaired tissue delivery • Vital Signs: • HR • BP – bilaterally as well as sitting and standing • RR • Temp

17. Pulses • Peripheral • Central • Carotid for delayed upstroke and/ or Bisferiens • Pulsus Paradoxus – decrease in blood pressure > 10 mmHg with inspiration • Pulsus Alternans – amplitude of the the pulse alternates with each beat during normal sinus rhythm (NSR), most commonly seen with Pericardial effussions • Jugular venous pulsations – evaluating right atrial pressure • Cannon A waves – 3rd degree heart block

20. Pulmonary Exam • Rales (what pulmonologists call “crackles”) – CHF • Wheezing – COPD (COLD) • Rhonchi – COPD (COLD) • Pleural effusion on CXR – CHF most commonly • Precordial Pulsations • Parasternal lift – Right Ventricular Hypertrophy (RVH), Left Atrial Hypertrophy (LAH), Pulmonary Hypertension (PHTN) • Displaced or Exaggerated Point of Maximal Intensity (PMI) – Left Ventricular Hypertrophy (LVH)

21. 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)

22. OS - The fourth heart sound during the tail end 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 is usually silent but accentuated with MVS) • S3– normal in young adults, peds patients and pregnancy. A sound made by the deceleration of 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 textbook

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