Cardiovascular Problems

1. Cardiovascular Problems Virginia T. Sullivan, RN, BSN, MSN, FNP-C, CCA

2. Common Complaints Chest Pain Dyspnea Leg Aches Palpitations Peripheral edema Syncope Common Problems Coronary Artery Disease Acute Coronary Syndromes Heart Failure Dysrhythmias Valve Disease and murmurs PVD, DVT & thromboembolus Cardiovascular Problems:Primary Care

3. Common Complaints • Chest Pain • Dyspnea • Leg Aches • Palpitations • Peripheral edema • Syncope

4. Chest Pain • “An uncomfortable sensation in the chest area”

5. Chest Pain • Differential Diagnoses: • Anxiety • Asthma • Muscle strain, costochondroitis • Mitral Valve Prolapse • Pericarditis • PUD, GERD, hiatal hernia • Pneumothorax • Pulmonary Embolus • Dissecting aortic aneurysm • Pericarditis • Angina: stable or unstable • Acute Myocardial Infarction

6. Chest Pain • Subjective data • Location • Duration • Quality • Aggravating/Relieving factors • Associated symptoms

7. Chest Pain • Objective data • Vital Signs • Physical Exam • 12 lead EKG • Assessment of Cardiovascular Risk Factors

8. Chest Pain • Anxiety • Location: variable • Quality: variable • Duration: variable • Aggravating factors: emotional stressors, work or personal stress • Alleviating factors: removal or avoidance or stressors • Associated symptoms: breathlessness, sighing, hyperventilating, palpitations

9. Chest Pain • Asthma • Location: anterior chest, substernal • Duration: several minutes, usually following exertion • Quality: tight, heavy • Aggravating factors: exertion, respiratory infections • Relieving factors: rest, rescue inhalers • Associated symptoms: dyspnea, coughing, fatigue, activity intolerance

10. Chest Pain • Muscle strain, costochondritis • Location: variable • Duration: variable but usually several days • Quality: sharp, stabbing, crampy, dull, constant, palpable, worse with specific activity or position • Aggravating factors: specific activities or positions • Relieving factors: rest, NSAID’s, position changes, heat application • Associated symptoms: sometimes numbness/tingling, usually none

11. Chest Pain • Mitral Valve Prolapse • Location: left parasternal region • Duration: present intermittently for days or weeks • Quality: squeezing, crampy • Aggravating Factors: stress, anxiety, caffeine, stimulant herbs/medications, dehydration, over-exertion • Relieving Factors: stress reduction, hydration, rest • Associated Symptoms: anxiety, palpitations, dyspnea (non-exertional), cardiac murmur • Echocardiogram for definitive diagnosis of MVP

12. Chest Pain • PUD, GERD • Location: epigastric • Duration: may last a few minutes to several hours but generally 15 – 20 minutes • Quality: burning, deep ache • Aggravating factors: lying flat, acidic foods, caffeine beverages, alcohol • Relieving factors: eating, anti-acids, belching, sitting up • Associated symptoms: sweating, nausea, dark/tarry stools

13. Chest Pain • Hiatal hernia • Location: epigastric • Duration: may last a few minutes to several hours but generally 15 – 20 minutes • Quality: sharp, severe • Aggravating factors: lying flat, bending over, heavy meal • Relieving factors: anti-acids, walking, sitting up • Associated symptoms: sweating, difficulty swallowing, nausea

14. Chest Pain • Pneumothorax • Location: lateral chest wall • Duration: lasting several minutes to hours • Quality: sudden onset, constant, severe • Aggravating factors: normal respirations • Relieving factors: oxygen, analgesics • Associated symptoms: dyspnea, tachycardia, decreased breath sounds • Transfer to Emergency Department

15. Chest Pain • Pulmonary Embolus • Location: over lung fields • Duration: lasting several minutes to hours • Quality: sudden onset, stabbing • Aggravating factors: inspiration • Relieving factors: supplemental oxygen, analgesics • Associated symptoms: tachycardia, dyspnea, hypoxia, cough, hemoptysis • Transfer to Emergency Department

16. Chest Pain • Dissecting Aortic Aneurysm • Location: retrosternal, upper abdominal or epigastric; may radiate to back, neck, shoulders • Duration: lasting several minutes to hours • Quality: sudden onset, excruciating, tearing • Aggravating factors: none • Relieving factors: analgesics may help • Associated symptoms: hypotension, disparity in blood pressures between right and left arm • Transfer to Emergency Department

17. Chest Pain • Pericarditis • Location: substernal, may radiate to neck, left arm • Duration: lasting several minutes to hours • Quality: sudden onset, sharp • Aggravating factors: lying down, deep breathing • Relieving factors: sitting up, leaning forward, analgesics, NSAID’s • Associated symptoms: dyspnea, local tenderness, friction rub, abnormal ECG • More common in patients with auto-immune disorder

18. Chest Pain • Angina – result of myocardial ischemia • Myocardial ischemia – insufficient oxygen to the myocardium • Causes of insufficient myocardial oxygen • Significant coronary plaque • Coronary plaque rupture • Coronary artery spasm • Anemia • CHF • Pulmonary Obstruction • Malignant hypertension • Pericardial effusion

19. Chest Pain • Typical Presentation of Angina • Typical angina occurs in substernal area • Pain may radiate across chest, to left shoulder, left arm, jaw, neck, back • Pain is described as pressure, tightness, indigestion, band-like sensation around the chest, “elephant sitting on my chest” • Pain is predictable with exertion and relieved by rest • Pain is associated with dyspnea, nausea, sweating/diaphoresis, dizziness, weakness, activity intolerance, fatigue, numbness/tingling in the arm(s)

20. Chest Pain - Angina • Atypical Presentation of Angina • More likely in elderly, diabetics, and women • Angina occurs in the anterior or posterior chest from the “neck to the belly button” • Quality of angina described is highly variable • Angina is predictable with exertion and relieved by rest • Angina is associated with dyspnea, nausea, sweating/diaphoresis, dizziness, weakness, activity intolerance, fatigue

21. Chest Pain - Angina • Angina may also be “painless” especially in diabetics • Painless angina may present as dyspnea, nausea, sweating/diaphoresis, dizziness, weakness, activity intolerance, fatigue which is elicited with exertion and relieved by rest • Document suspicion and description of painless angina clearly in patient history

22. Chest Pain - Angina • Stable Angina • Symptoms not actively occurring, are predictable with exertion, relieved by rest • Patient with known CAD, coronary vasospasm, prinzmetal angina • Urgent evaluation of symptoms • Vital Signs, Physical Exam • 12-lead EKG • Cardiac Stress Test • Appropriate Treatment for CAD • Cardiology Consult

23. Chest Pain - Angina • Unstable Angina: • Active symptoms which do not resolve with rest or use of 1-2 SL NTG; hemodynamically unstable; ischemic changes on ECG • Acute Myocardial Infarction • Sudden onset of angina that lasts in excess of 20 minutes despite rest and/or NTG • Activate EMS!

24. Dyspnea • “Shortness of Breath” • Poor sensitivity and specificity for cardiovascular disease

25. Dyspnea • Differential Diagnoses • Obesity • De-conditioning • Reactive Airway Disease • COPD • URI • Angina • CHF • Valvular Heart Disease • Pulmonary Hypertension

26. Dyspnea • Note onset of dyspnea • sudden vs. gradual • Assess for concurrent symptoms • chest pain, wheezing, activity intolerance, weight gain, edema, coughing, fever/chills • Assess for: • dyspnea on exertion • paroxysmal nocturnal dyspnea (PND) • orthopnea (number of pillows)

27. Dyspnea • Angina • Exertional dyspnea alone may represent “painless angina” • Exertional dyspnea due to angina may occur concurrently with exertional chest pain • Dyspnea is first noted when walking up hills or stairs but may progress to dyspnea with minimal exertion • Assess for cardiovascular risk factors • Evaluate and treat angina, CAD

28. Dyspnea • Valvular Heart Disease • Assess for cardiac murmur in patients presenting with exertional dyspnea • Common valvular disorders include • Aortic Stenosis • Aortic Regurgitation • Mitral Regurgitation • Mitral Valve Prolapse (with or without MR) • Echocardiogram to assess for source of murmur • Cardiology Consult for patients with dyspnea plus cardiac murmur

29. Dyspnea - CHF • CHF – Subjective • Note onset, duration, quality, aggravating/relieving factors of symptoms • Dyspnea is worse with exertion • Dyspnea is first noted when walking up hills or stairs but may progress to dyspnea with minimal exertion or event at rest • May also report PND or orthopnea, nocturia, wheezing, weight gain, activity intolerance, easy fatigue, angina

30. Dyspnea - CHF • CHF - Objective • Bilateral lower extremity edema may be present • Breath sounds may be diminished to the bases bilaterally • Crackles, rales or “cardiac wheezing” may be present • Tachypnea • JVD present on exam • Cardiac murmur may be present on exam • Tachycardia • Peripheral cyanosis

31. Dyspnea - CHF • Diagnostic studies • 12 lead EKG • Chest X-Ray • BMP, hepatic function, thyroid function • BNP may be helpful • Echocardiogram • Cardiology Consult for high suspicion

32. Leg Aches • Differential Diagnoses: • Peripheral Artery Disease (PAD) • Varicose veins, venous insufficiency • Thrombosis • Phlebitis • Neuropathy • Arthritis • Muscle fatigue • Raynaud’s disease

33. Palpitations • “awareness of the beating of one’s heart”

34. Palpitations • Palpitations are a symptom, not a diagnosis! • Palpitations are common but can also be sign of serious heart condition

35. Palpitations • Differential Diagnosis: • Anxiety • Active Infection • Anemia • Hyperthyroid • Hypertension • Mitral Valve Prolapse • Cardiac Dysrhythmia

36. Palpitations • Consider the patient’s risk for serious adverse event • CV risk factors • Severity of symptoms • Frequency • Intensity • Duration • Concurrent symptoms • Chest Pain • Syncope or pre-syncope

37. Palpitations • Diagnostic studies: • Lab work: CBC, CMP, TFT’s • 12-lead EKG • Outpatient cardiac monitor • Echocardiogram • Cardiac Stress Test • Consider Cardiology Consult for patient with severe symptoms (esp. syncope) or high risk

38. Palpitations • Anxiety • Over-stimulation, stress, anxiety, grief can cause the sensation of palpitations with or without actual change in heart rate or rhythm • Sensation is very real to the patient • Anxiety driven palpitations develop a self-perpetuated vicious cycle • Must determine which came first: the anxiety or the palpitations

39. Palpitations • Anxiety • Quality: may be irregular beats, pounding, racing, often occurring when patient is “quiet” • Frequency: usually daily • Duration: usually frequent, intermittent and short-lived (seconds) ; but may be “constant” • Aggravating factors: emotional stressors, work or personal stress • Alleviating factors: removal or avoidance of stressors • Associated symptoms: breathlessness, sighing, hyperventilating, chest pain, trembling

40. Palpitations • Active Infection • Palpitations are usually an appropriate reaction to active infection resulting in sinus tachycardia • Assess for signs and symptoms of infection

41. Palpitations • Active Infection • Quality: rapid heart beat or hard pounding with minimal exertion • Frequency: daily, may occur late in the day • Duration: may be constant, may last hours • Aggravating factors: exertion, fever • Alleviating factors: NSAID’s, rest • Associated symptoms: fever, chest pain, dizziness/lightheaded, fatigue, headache, other signs and symptoms of infection • Treat the underlying condition

42. Palpitations • Anemia • Palpitations are usually an appropriate reaction to anemia resulting in sinus tachycardia • Assess for signs and symptoms of anemia or active bleeding

43. Palpitations • Anemia • Quality: rapid heart beat or hard pounding with minimal exertion • Frequency: daily • Duration: may last hours, may be constant • Aggravating factors: exertion, dehydration • Alleviating factors: rest • Associated symptoms: chest pain, fatigue, dizziness/lightheaded, signs and symptoms of bleeding • Treat the underlying condition

44. Palpitations • Hyperthyroid • Quality: rapid heart beat, intermittent racing of the heart beat, irregular beating, skipping, pounding, fluttering • Frequency: frequent, may occur daily • Duration: may last minutes or hours, may be constant • Aggravating factors: exertion, fatigue • Alleviating factors: none • Associated symptoms: chest pain, fatigue, dizziness/lightheaded, anxiety, insomnia, weight loss, increased appetite, tremors, exertional dyspnea, heat intolerance • Treat the underlying condition • May need temporary beta blockade until thyroid controlled

45. Palpitations • Hypertension • Quality: hard pounding heart beat • Frequency: variable • Duration: may last minutes to hours • Aggravating factors: exertion, stress, anxiety, fatigue • Alleviating factors: rest • Associated symptoms: chest pain, fatigue, dizziness/lightheaded, headache, dyspnea on exertion • Treat the underlying condition

46. Palpitations • Mitral Valve Prolapse • Quality: rapid heart beat, hard pounding, irregular beating, fluttering, squeezing • Frequency: variable • Duration: may last minutes to hours • Aggravating factors: dehydration, stress, anxiety, illness, fatigue, caffeine, stimulants • Alleviating factors: rest, removal or avoidance of stressors • Associated symptoms: chest pain, breathlessness, hyperventilating, trembling, dizziness/lightheaded • Treatment to be discussed

47. Palpitations • Cardiac Dysrhythmia • Quality: variable dependent upon the cardiac disturbance • Frequency: variable dependent upon the cardiac disturbance • Duration: variable dependent upon the cardiac disturbance • Aggravating factors: variable dependent upon the cardiac disturbance • Alleviating factors: variable dependent upon the cardiac disturbance • Associated symptoms: chest pain, dyspnea, dizziness/lightheaded, syncope, fatigue, weakness

48. Palpitations • Cardiac Dysrhythmias commonly associated with palpitations • Atrial dysrhythmias • Premature atrial contractions (PAC’s) • Atrial fibrillation • Supraventricular tachycardia • Ventricular dysrhythmias • Premature ventricular contractions (PVC’s) • Ventricular tachycardia

49. Peripheral Edema • The accumulation of fluid within the interstitial spaces of the extremities

50. Peripheral Edema • Differential Diagnosis • Congestive Heart Failure • Cellulitis • Lymphedema • Chronic Venous insufficiency • DVT • Renal or hepatic disease • Thyroid disorder • Orthopedic injury