[02.02] CMD - Diagnosis of Cardiovascular Disease V2.2.pdf

Paolo Prado, MD, FPCP, FPCC, FPSCCI

Who is the lecturer for the Diagnosis of Cardiovascular Disease?

Confirmation and assessment of a suspected cardiac lesion or disease

What is the primary reason a patient is usually referred to a cardiologist?

Orthopnea and paroxysmal nocturnal dyspnea

What are identified as the most common cardiac symptoms?

The heart has a hard time circulating blood so it gets stuck in the pulmonary circulation

Why does orthopnea occur physiologically?

Indicative of high left atrial pressure

The presence of orthopnea or nocturnal dyspnea is specifically indicative of what hemodynamic state?

Triad of dyspnea, chest pain, and exertional presyncope or syncope

What three symptoms are caused by fixed cardiac output lesions like aortic stenosis?

Aortic stenosis

In which condition does the issue in the aortic valve prevent blood from exiting the left ventricle, causing high left ventricular end diastolic pressure?

Fatigue, lassitude, and lightheadedness

What are three symptoms induced when the heart is unable to pump, known as low cardiac output symptoms?

Severe inflow obstructive lesions, severe cardiomyopathy, constrictive pericarditis, cardiac tamponade, or severe pulmonary hypertension

Name five causes of low cardiac output symptoms besides outflow obstruction.

The brain shuts down due to lack of blood flow

Why does syncope occur in outflow obstruction or significant arrhythmias?

Significant bradyarrhythmia or significant tachyarrhythmia

What are two electrical causes of syncope mentioned?

Micturition Syncope

What is the term for syncope that occurs after urination?

Vagal reactions

What type of reactions are described as causing a slow heart rate that leads to a fall?

Cyanotic

What classification of congenital heart disease occurs because the patient cannot oxygenate properly?

Acyanotic

Is a ventricular septal defect initially classified as cyanotic or acyanotic based on the provided comparison to TOF in the text?

30 mmHg

What is the normal pressure of the right side of the heart as a low pressure system?

Oxygenated blood from the left side mixes with deoxygenated blood on the right

In VSD, what happens because the left sided pressures are higher than the right?

Eisenmenger Syndrome

What is the name for uncorrected VSD that leads to end stage heart disease and shunt reversal?

Pulmonary vascular remodeling due to overcirculation

In Eisenmenger Syndrome, what causes the development of severe pulmonary hypertension?

Anything above 60 mmHg

How does the text define severe pulmonary hypertension?

Reversal of the shunt and circulation of unoxygenated blood

What hemodynamic change in Eisenmenger Syndrome causes the patient to become cyanotic?

Clogged arteries

What is the lay term given for ischemic heart disease?

Thickened left ventricle due to prolonged uncontrolled hypertension

What characterizes hypertensive heart disease?

Hypertrophic, restrictive, and dilated

What are the three types of cardiomyopathies mentioned?

Myocarditis

What condition can be caused by COVID 19, RSV, or paramyxovirus?

Acute pericarditis

What is inflammation of the lining that covers the heart called?

TB, radiation, drugs, or virus

Name four potential causes of acute pericarditis.

Chronic constrictive pericarditis

Which pericardial condition is usually due to TB?

Atrial myxoma

What is a common type of cardiac tumor mentioned?

Chest pain

In terms of symptoms, what is the most common complaint of patients?

Tightness, heaviness, squeezing or burning sensation, or sensation of oppression

How is the central chest discomfort of typical angina often described?

Rest or nitroglycerin

Typical angina is usually relieved within a few minutes by what two things?

Exertion

Typical angina is aggravated by what?

LAD stenosis

What was found on an angiogram of a patient presenting with atypical symptoms like toothache or jaw pain?

Diabetics

Which specific patient population may not manifest typical chest pain even when at high risk?

Musculoskeletal, pleuritic, and esophageal

Noncardiac chest pain is often related to which three causes?

Pleuritic pain

What type of pain is felt when breathing in but disappears after breathing out?

Musculoskeletal pain

What type of pain is sharp, localized, and felt only when moving?

Rate, rhythm, pulse deficit, symmetry, and radio femoral delay

What five things should be noted upon palpation of the arterial pulse?

Atrial fibrillation

Which condition is characterized by irregular heartbeats manifested as both strong and weak pulses?

Slow upstroke

What is the characteristic upstroke of the pulse in aortic stenosis?

Pulsus alternans

What is the term for alternating weak and strong pulses?

Heart failure or hypovolemic states

Pulsus alternans is very prominent in which two conditions?

Pulsus bisferiens

Which arterial pulse waveform is characterized by double peaking?

Hypertrophic cardiomyopathy and high cardiac output states

Pulsus bisferiens is found in which two conditions?

Pulsus paradoxus

What is an exaggerated decline in blood pressure during inspiration called?

Intrathoracic pressure becomes more negative and sucks more blood into the right ventricle

What normally happens to intrathoracic pressure and blood flow during inspiration?

Cardiac tamponade and constrictive pericardial pathology

In which two conditions is pulsus paradoxus seen?

Reverse Bernheim effect

What is the term used to describe the interventricular septum bowing towards the LV due to RV pressure in tamponade?

A drop in systolic BP of more than 10 mmHg with inspiration

What specific measurement defines significant pulsus paradoxus?

Emergency pericardiocentesis

What is the medical emergency treatment for cardiac tamponade?

JVP increases upon inspiration

If a patient has a tamponade, what happens to the JVP during inhalation?

Seated comfortably, back supported, bare arm, legs uncrossed

What is the proper patient positioning for BP measurement?

80 percent

The cuff length should be what percentage of arm circumference?

40 percent

The cuff width should be what percentage of arm circumference?

Less than 3 mmHg per second

What is the recommended deflation rate for a BP cuff?

First audible sound

Which Korotkoff sound indicates systolic pressure?

Last audible sound

Which Korotkoff sound indicates diastolic pressure?

Subclavian artery disease

A blood pressure difference of greater than 10 mmHg between arms suggests what?

Aortic coarctation

What might a higher blood pressure in one arm compared to the other hint at besides subclavian disease?

Severe aortic regurgitation or Hill sign

Systolic leg pressure 20 mmHg or more higher than the arm indicates what?

Fall in systolic BP greater than 20 mmHg and or diastolic BP greater than 10 mmHg within 3 minutes of standing

What is the definition of orthostatic hypotension?

Autonomic insufficiency or drugs like Alpha 1 blockers

What are two possible causes of orthostatic hypotension?

Compensatory tachycardia

What normally happens to the heart rate when standing to maintain blood pressure?

Vasoconstriction

How does the cardiovascular system maintain BP to reach the brain when standing?

Events occurring in the right atrium

What do jugular venous pulsations represent?

a, c, x, v, y

Name the five waves of the JVP.

ContrAct

What is the mnemonic for the 'a' wave?

Closure of the tricuspid valve

What does the 'c' wave represent?

RelaX

What is the mnemonic for the 'x' wave?

Vill or Fill

What is the mnemonic for the 'v' wave?

EmptY

What is the mnemonic for the 'y' wave?

Atrial filling while the tricuspid valve is closed

What event causes the 'v' wave?

Patient at a 45 degree angle

What is the specific patient position for measuring JVP?

Internal Jugular Vein

Which vessel has an undulating, biphasic pulse with two peaks and two troughs?

Falls

What happens to the height of the IJV blood column during inspiration?

IJV is generally not palpable

Can the IJV be palpated?

Can be obliterated with gentle pressure

How does the IJV respond to pressure at the base of the vein?

External Jugular Vein

Which vein is seen to bulge in the neck during a Valsalva maneuver or singing?

Kussmauls Sign

What is the term for an abnormal increase in JVP during inspiration?

The blood is unable to proceed to the RV and enter the heart

Why does Kussmaul’s sign occur?

Constrictive pericarditis, pulmonary embolism, or RV infarction

Name three conditions associated with a positive Kussmaul’s sign.

Tricuspid stenosis, pulmonary hypertension, or pulmonary stenosis

What are three causes of a large 'a' wave?

Cannon wave

What wave occurs when the right atrium contracts against a closed tricuspid valve?

Atrial fibrillation, complete heart block, VVI pacing, or ventricular tachycardia

Name four conditions that cause cannon waves.

Constrictive pericarditis or cardiac tamponade

A steep 'x' and 'y' descent is a clue for which two conditions?

Tricuspid regurgitation

A large 'v' or 'cv' wave is caused by what?

A CV wave

In severe tricuspid regurgitation, the ACXVY waves fuse into what?

Complete AV block

In which condition are atrial contractions entirely separate from ventricular contractions?

Relative refractory period

Why are not all atrial complexes conducted in atrial fibrillation?

At least 30 seconds

How long should compression be applied for the Hepato Jugular Reflux test?

Suggestive of congestive heart failure

A positive Hepatojugular Reflex where venous pressure stays increased is suggestive of what?

1 to 1.5 cm

What is the normal diameter of the apex of the heart?

Diffuse apex beat or diffuse point of maximal impulse

What is it called when the heart is big and pushes more intercostal muscles away?

Vibration felt on palpation

What is a thrill?

RV enlargement or hypertrophy

If the PMI is felt in the epigastric area, what does it indicate?

Apical impulse

What is the lateral most point of systolic outward motion felt on the chest wall?

10 cm from the mid sternum

Where is the apex beat normally located relative to the sternum?

Auscultatory areas do not reflect the anatomic location of the valves

What is the key rule regarding the location of auscultatory sounds versus valve anatomy?

Laminar flow

Why do normal opening and closing of valves not produce sound?