Cardiac examination

stable angina

chest pain that follows consistent patterns for at least 2 months, predictable, goes away with rest or medication

unstable angina

chest pain that does NOT follow a pattern, new or worse, doesn’t always go away with rest or medications

variant angina

either prinzmetal or vasospastic

• occurs at night

• coronary artery spasm

silent ischemia

reduced blood flow & oxygen to the heart without any chest pain or warning

angina

pain that occurs when the heart does NOT receive enough oxygen/blood

• pressure, squeezing, constriction, tightness, heaviness feeling in the chest above the waist

• shortness of breath

• fatigue

• weakness

• lightheaded/syncope

• vomiting

• sweating

• often associated with heavy meals, cold weather, emotional stress

pericarditis

inflammation of the pericardium (sac that surround the heart)

• sharp stabbing pain in chest or upper back between the scapula

• pain worsens with:

  • cough

  • swallowing

  • deep breaths

  • laying down

• pain feels better with:

  • sitting up

  • leaning forward

aortic dissection

a tear forms in the inner layers of the aorta

• extreme sudden pain in chest or upper back between scapula

• tearing/ripping pain

pleuritic chest pain

sharp stabbing chest pain that worsens with deep breaths, coughing, or sneezing

inflammation of the pleura

GERD

chronic condition where stomach acid often flows back through the esophageal sphincter

• burning

• heart burn

• pain in chest that worsens when laying down & after eating

musculoskeletal chest pain

chest pain/discomfort that originates from the muscles, bones, cartilage, or joints within the chest wall

• pain can be provoked

pulses

wave of blood in the artery created by contraction of the LV during cardiac cycle

peripheral pulses

pulses that can be found throughout the body by palpating an artery

apical pulse

central pulse located at the apex of the heart that can be heard via a stethoscope

• located to the left of the sternum in the 5th intercostal space

• count beats for 60 seconds (lub-dub = 1 beat)

heart rate recovery post exercise

assesses how well autonomic NS is working

• ability to return to normal after exertion

• (max HR - HR at 1 min into recovery)

  • >12-18 beat decrease at 1 min = NORMAL

  • <12 beat decrease at 1 min = ABNORMAL

• not affected by beta blockers in pt with heart failure

blood pressure

= cardiac output x total peripheral resistance

barorecepetors

detect BP changes!

• one in aortic arch

• others throughout body

systolic blood pressure

highest pressure in the artery that occurs during ventricular systole

• when heart contracts!

• NO activity if SBP is <80 or >180

diastolic blood pressure

lowest pressure in the artery that occurs during ventricular diastole

• when heart relaxes & ventricles fill

• NO activity if DBP is <40 or >110

mean arterial pressure

average pressure exerted by the blood as it travels through the arteries

= [SBP + (2xDBP)] / 3

• normal = 70-100 mmHg

• ABNORMAL = <60 mmHg

  • decreased perfusion of vital organs

  • clinical hypotension

blood pressure recovery post exercise

SBP should return to pre-exercise levels or 10-20 mmHG lower than initial value within 6 min post exercise

• delayed SBP recovery —> ischemic abnormality

pulse pressure

force the heart generates when it contracts

PP = SBP - DBP

increases with exercise

• elevated PP: >60 mmHg

  • increased CV risk

• low PP: <40 mmHg

  • heart failure

  • blood loss

rate pressure product

index of myocardial oxygen consumption

RPP = HR x SBP

• increases with activity

• decreased at a given workload with training

normal BP

Systolic: <120

&

Diastolic: <80

elevated BP

Systolic: 120-129

&

Diastolic: <80

hypertension stage 1

Systolic: 130-139

OR

Diastolic: 80-89

hypertension stage 2

Systolic: 140 or higher

OR

Diastolic: 90 or higher

hypertension crisis

Systolic: higher than 180

OR

Diastolic: higher than 120

orthostatic hypotension

a drop in BP of >20 mmHg, or drop of DBP >10 mmHg, or experiencing lightheadedness or dizziness is considered abnormal

postural hypotension

respiratory rate

number of breaths taken per minute measured by watching the rise and fall of the chest; Count for at least 30 sec then x 2

• Normal: 12-18 per min

• bradypnea: less than 10-12 per min

  • caused by —> opioids, hyperthyroidism, brain disorders

• tachypnea: greater than 18-24 per min

  • caused by —> pain, emotions, fever, respiratory conditions, hypoxia

Proceed with caution if RR >35 at rest

STOP activity if RR >45 at rest

pulse oximetry

measures amount of hemoglobin saturated with oxygen

Normal: SpO2 > 95%

If SpO2 is <88% —> supplemental oxygen

jugular venous distention

indicates increased volume in venous system OR right sided heart failure

seen when:

• supine

• 45 degrees cervical flexion

• head turned to the LEFT

Present if veins distend ABOVE clavicles

capillary refill test

assess peripheral perfusion and circulatory status by measuring how quickly blood returns to capillaries after being compressed

• press finger for 5 seconds

• release & observe time taken for normal color to return

Normal = ~2 seconds

Delayed = more than 2 seconds

• hypothermia

• shock

• dehydration

• PVD

S1 heart sound

closure of mitral & tricuspid valves; onset of ventricular systole

“lub”

S2 heart sound

closure of the aortic & pulmonary valves; start of ventricular diastole

“dub”

S3 heart sound

extra “dub” after S2,, “lub-dub-dub”

• normal in healthy children/young adults

• can indicate heart failure (noncompliant LV)

heard with bell of stethoscope at apex of heart in a left lateral position

S4 heart sound

“la” before S1,, “la-lub-dub”

associated with increase resistance to ventricular filling, MI, or HTN

pressure measurement

tests edema levels

• press finger into body part for 2-3 seconds

• if impression —> pitting or dependent edema

leg circumference measurement

tests of edema levels; measure girth of LE at specific locations to monitor changes in edema

• thigh girth

• calf girth

• ankle girth

rating of perceived exertion

borg scale; measured effort of exertion during physical task; indicates exercise intensity

exercise intolerance

• moderate - severe - increasing angina

• marked dyspnea

• cyanosis or pallor

• excessive fatigue

• leg cramps or claudication

• dizziness/lightheadedness

• poor coordination