Cardiovascular Exam

1. Cardiovascular Exam Melanie Dowling Melanie.dowling@doctors.org.uk Bleep 4518

2. What I’m going to cover….. • Potential stations • Revise Cardiovascular system exam • Important points: MI, Heart failure, Atrial Fibrillation and Hypo/hyperkalemia • A couple of ECGs • Questions • All the information in this talk is from the notes I collected/made before finals- to make sure it was up to date I checked it with a registrar from the cardiothoracic team/ against current trust protocol.

3. Potential Stations to prepare for… • Pacemaker (if you have never seen a paced ECG go find one) • CABG • Prosthetic Valves- tissue and mechanical • Murmurs • Atrial fibrillation • There was no Cardiovascular examination in finals last year so you might be more likely to have one!

4. Cardiovascular Exam • Wash hands • Introduce self • Check identity + what do you want me to call you • Expose • Reposition – 45°

5. General inspection • Around the bed: GTN spray, ECG leads, Warfarin book • State of patient: Well? Old/young? Using Oxygen? • Scars: mid sternotomy+/- saphenous vein harvest scar, • Brusing (warfarin) • Malar flush (mitral stenosis) • Body habitus: • Thin hyperthyroidism (atrial fibrillation) • Marfans syndrome • Listen – Audible click • Condition + Association • Downs syndrome – Congenital heart disease • Turner’s syndrome- Coarctation of the aorta • Marfan’sSundrome- Aortic regurg • Ankylosing Spondylitis- Aortic reguritation

6. Hands • Perfusion- temperature + cap refil (hold 5secs –nomal <2 secs), peripheral cyanosis • Clubbing (chronic IE, atrial myxoma, cyanotic heart disease) • Tar staining • Tendon xanthomata • Quinkeys sign (pulsation of nail bed- aortic regurg) • Stigmata if IE: • Oslers nodes • Splinter haemorrhages • Janeways lesions

7. Pulse and Bp • Radial pulse- Rate and Rhythm • Radial – Radial delay • Collapsing pulse (Aortic regurg) • Brachial/ Carotid pulse- Character and volume • BP: • Narrow pulse pressure (aortic stenosis) • Wide pulse pressure (aortic regurg)

8. Face Eyes Mouth • Corneal arcus • Jaundice • Xanthelasma • Conjunctival pallor and haemorrhage • Fundoscopy- roth spots • Central cyanosis • Oral hygiene • Glossitis • Angular stenosis • High arched pallor (Marfans)

9. JVP • Elevated in: • Heart Failure • Constrictive pericarditis • Tricuspid valve disease • Fluid overload • SVC obstruction • Cardiac tamponade • Revise pg 94 Mcleod’s • Different from carotid as it: • Is a double pulsation • Changes with respiration • Non-palpable • Eliminated by pressure • Changes with the • Hepatojugular reflex

10. The right atria contracts causing a raise in pressure in the right ventricle (a wave). The contraction ends and the pressure decreases. The tricuspid valve closes and the pressure increases slightly (c). The atria relaxes and the pressure decreases (C to X) The atria fills and the ventricles contract causing an increase in pressure • A- Atrial contraction • C- Tricuspid closure • V- Atrial filling during ventricular systole

11. Palpation • Thrills • Palpable murmurs • Heaves • Volume overload- laterally displaced (Aortic regurg) • Pressure overload – not displaced (Aortic stenosis) • Apex beat (5th intercostal space mid clavicular line)

12. Auscultation • Start from the apex beat • listen for two distinct heart sounds + palpate carotid (the first heard sound coincides with closure of the mitral and tricuspid valves • To revise murmurs go to Dr Clarke website – there is a recording of heart sounds and it is really easy to use.

13. Heart sounds…. • Fourth heart sound-(Le lub dub) • Always abnormal • Atrial contraction into a non-compliant or hypertrophied ventricle • Low pitched • Caused by: Heart failure, MI, Hypertension, Cardiomyopathy • Third heart sound (lub de dub) • Can be normal • Ventricular sound of blood rushing in during the rapid filling phase of early diastole, • Stiff or dilated ventricles suddenly reaches its limit of elasticity and decelerates the incoming rush of blood. • Caused by: Heart failure, MI, Cardiomyopathy, hypertension, constrictive pericarditis, Mitral and aortic regurg(volume overload apex displacedbut not powerful.

14. Murmurs - Systolic • Aortic Stenosis • Ejection systolic murmur • Cresendo-decresendo • Best heard on expiration + leant forwards + diaphragm • Slow rising pulse • Apex forceful not displaced • Caused by: Calcification, congenital bicuspid valve, IE, Rheumatic HD. • Mitral Regurgitation (Burrr) • Pansystolic murmur • Quiet S1, S2 not heard separately • Best heard at apex + expiration + diaphragm • Radiated loudly to axilla • Pt. likely to be in sinus rhythm • Caused by: Rheumatic HD, IE, and post MI (papillary muscle dysfunction), valve prolapse, chordae (Marfans)

15. Murmurs - Diastolic • Aortic Regurgitation (Lub tarrr) • Early diastolic murmur • Follows S2 • Decrescendo • CF: Collapsing pulse (+/- Corrighans sign), JVP not raised, Apex beat is displaced. • Caused by: Rheumatic heart disease, IE, connective tissue disease (marfans), syphilis. • Mitral Stenosis (Lubdeederr) • Low pitched rumbling, mid diastolic murmur • Loud 1st HS + opening snap • Best heard on expiration + at LSE + left lateral position + bell • Malar flush + AF • JVP = late sign • Apex not displace but tapping • L. parasternal heave • Caused by: Rheumatic HD, IE, congenital abnormality, inflammatory

16. To complete • Auscultate lung bases • Check ankles and sacrum for swelling • Radial –femoral delay • Splenomegaly (infective endocarditis) • Peripheral Vascular exam

17. Present • Practice!!! if you can present with confidence and identify key points it make you look good. • Eg “I have examined Mr. Smith’s cardiovascular system. Mr. Smith was well at rest and had a heart rate of 82 bpm and a respiratory rate of 12 breaths per minute. He has presented with a midsternotomy scar and the click of metallic valve was audible from the end of the bed, and on auscultation this coincided with the second heart sound. There were no added sounds. From this I have concluded that Mr. Smith has had a mechanical Aortic valve replacement. Mr. Smith is of tall stature and has a high arched palette. There is also brusing to the limbs and trunk. To summerise Mr. Smith has had an AVR secondary to Marfan’s syndrome and is now taking Warfarin”

18. To finish • They may ask you about tests depends on the examiner… • Bloods: • FBC, UEs, TFT, CRP, …. • Trop T, CKMass • Urine dip + blood cultures - IE • ECG • Repeat 1hr later if no initial changes • Echo • CXR

19. How to approach a station if your unsure/ don’t have a clue…. • Don’t panic- LOOK • Be systematic and thorough • Eg (real pt. I came across in A&E who volunteers for finals) • Youngish (late 20s) female • Clubbed – and nails look a bit blue • Her tongue is a beefy red colour • She has a mid sternotomy scar • What are you thinking ? • What are you going to look for to confirm this? • Can you show off some knowledge?

20. Acute coronary syndrome • Complications of MI • Pump failure • Rupture of papillary muscle or septum • Aneurysm and arrhythmias • Embolism • Dressler's syndrome (post myocardial syndrome – anticardiac antibodies- pericarditis) • Acute coronary syndrome: • Unstable angina • NSTEMI • STEMI • ECG: • ST Elevation- infarction • ST Depression- ischemia • Q waves – transmural infarct

21. ECG MI ST elevation in II, III and AVF- Inferior leads, Infarct- RCA

22. ECG lead changes • Circumflex • V4-V6, I AVL • Anterio-lateral infarct • Pt presents with pump problems • RCA • AVF, II, III • Inferior infarct • Pt. may present with a bradyarrthymia • LAD • V2-V4 • Anterior septal infarct • Pt presents with pump problems • LMS • V2-V6 • Large anterior infarct • Pt presents with pump problems

23. ACS management • Unstable angina and NSTEMI • Clopidogrel 300mg • Enoxaparin 1mg/kg/12hrs (SC) • B-blocker atenolol 5mg IV • STEMI • PCI is gold standard for STEMI where available • Thrombolysis (most beneficial <12hrs), streptokinase, tPA • Heperin (24-48hrs) • CABG for those not suitable for stenting/balloon. • If pt id diabetic – stop metformin and start insulin (risk of metabolic acidosis) • Consider: B-blocker, Statin, Aspirin, Clopidogrel, ACEI • Morphine (5-10mg IV + antiemetic ) • Oxygen 15L NRM • Aspirin 300mg chewed • Nitrate GTN spray (SL)

24. ECG AF Absent P waves, Irregular rhythm

25. Atrial Fibrillation • Complications • Loss of atrial contraction Co2  HF • Risk of thromoboembolism (CHADS2 score) • Drug interactions (verapamil + B blockers) • Pulse – Irregularly Irregular • ECG • Absent P waves • Caused by… • Post MI • Pneumonia • PE • Thyrotoxicosis • Rheumatic heart disease • Alcohol • Drugs • CHADS2- risk of stroke • Cardiac failure 1 • Hypertension 1 • Age >75yrs 2 • Diabetes 2 • Previous Stroke 2 • 0= low (aspirin), 1=moderate, 2= high (warfarin)

26. Atrial fibrillation - Management • Acute • Treat underlying cause • Rate- digoxin, B blockers, calcium antagonists • Rhythm- amioderone or cardioversion. • Anticogaulation • Chronic • 1st line- B blocker • 2nd line- Digoxin • 3rd line- Amioderone • Anticoagulation – warfarin • Target INR= 2-3

27. Heart Failure- Failure to maintain a cardiac output sufficient to meet bodies requirements despite and adequate filling pressure. • Right heart failureclinical features • Systemic venous congestion • Raised JVP • Palpable liver • Peripheral odema • Ascites • Left heart failureclinical features • Pulmonary venous congestion • Basal Crackles • Breathlessness due to alveolar oedema + orthopnea • Pink frothy sputum • Wheeze – cardiac asthma

28. Heart failure - causes • Damaged myocardium ( contractility) • Alcohol, Post MI, Cardiomyopathy • Damaged heart valve (outflow distrubance) • Aortic stenosis, Mitral regurgitation • Increased arterial resistance • Arterial or pulmonary hypertension • Increased blood volume • Renal failure, over transfusion • Rhythm disturbance • Arrthythmias • Compromised cardiac filling • Constrictive pericarditis, pericardial effusion • Increase demand • Anaemia, thyrotoxicosis, L to R shunt

29. Heart failure - Investigation • Radiography • A- Alveolar odema (bat wings) • B- Kerly B lines (intersitial odema) • C-Cardiomegaly • D- Diversion (upper lobe diversion) • E- Pleural Effusion & engorged pulmonary arteries (LHF) • CXR… • Echo

30. Heart failure – Management • Acute • 15 L O2 NRM • Morphine • Furosemide (40-80mg IV) • IV nitrate infusion (unless hypertensive) • ECG • Coronary care or acute anesthetic referral • Chronic • Treat underlying cause • Lifestyle changes • Medical: loop diuretics, ACEI, B blockers, aldosterone anatagonists (spironolactone) • Monitor electrolytes

31. Hyper/hypokalemia • Hyperkalemia • Calcium gluconate (cardio protective) • Salbutamol • Insulin + dextrose • ECG changes • Flattened P waves • Widened QRS • Slurring of ST segment • Tall tented T waves • Hypokalemia • <3.5 +>2.5- Sandok (K supplement) for 3 days • <2.5 IV KCL (max 40mmol at 10mmol/hr) • ECG changes • Flattened T waves • ST segment depression • Prolonged QT interval • Can progress to VT/VF

32. Thanks for listening…Any questions?