(6) Signs, Symptoms, Complications and Risk Factors for Cardiac Disease

What is the definition of a 'sign' in cardiac disease?

Objective evidence of disease that can be seen, such as edema or cyanosis.

What is the definition of a 'symptom' in cardiac disease?

Subjective evidence of disease, which is a feeling that only the patient can perceive, such as a headache or chest pain.

What are three examples of patient history regarding prior testing that should be reviewed?

Chest x-ray, nuclear medicine, and MRI.

Which specific types of cardiovascular medications should be noted during history taking?

Those related to HTN, diabetes, cholesterol, and coagulation therapy.

History of which two types of cancer treatments are relevant to cardiac disease?

Chemotherapy or radiation therapy.

What is the medical term for chest pain caused by myocardial ischemia?

Angina

How is 'stable angina' characterized?

Chest pain controlled by nitroglycerin or by reducing/eliminating activity.

What does 'unstable angina' refer to?

Chest pain occurring at rest.

What are the two common medications mentioned to treat angina?

Propranolol (beta blocker) and nitroglycerin.

Which cardiac imaging modality is used to identify wall motion abnormalities and reduced EF%?

Echocardiogram (Echo)

What type of echo might be required to induce symptoms and visualize changes in angina patients?

Stress echo

What does the abbreviation 'SOB' stand for?

Shortness of Breath

What cardiac conditions are associated with SOB and Dyspnea on Exertion (DOE)?

Valvular stenosis, pulmonary HTN, significant regurgitation, CHF, and decreased EF%.

What is the term for difficulty breathing while lying down?

Orthopnea

Which condition is specifically associated with Orthopnea?

Congestive Heart Failure (CHF)

What is Paroxysmal Nocturnal Dyspnea, and what condition is it seen with?

Difficulty breathing that interrupts sleep; it is seen with pulmonary edema.

What is the term for difficulty breathing when lying on the left or right side?

Trepopnea

What does the term 'Apnea' mean?

Cessation of breathing

What is 'Hemoptysis'?

Bloody sputum

What causes Hemoptysis in cardiac patients?

Pulmonary edema and hemorrhage.

Which valvular issues are associated with Hemoptysis?

Significant mitral stenosis or significant acute mitral regurgitation.

What is 'Cyanosis'?

Bluish discoloration of the skin and mucous membranes (lips, nail beds).

What are three conditions associated with Cyanosis?

Pulmonary disease, Eisenmenger syndrome, and Tetralogy of Fallot.

What physical sign can cyanotic heart disease lead to in fingers and toes?

Clubbing

What is 'Edema'?

The accumulation of fluid in tissues or cells.

Which failures in the heart lead to edema?

Left ventricular failure and right ventricular failure.

What does 'pitting edema' refer to?

The ability to indent the skin and the time it takes for the skin contour to return to normal.

On the pitting edema scale, what score is given for deep indentation with very slow normalization?

$$+4$$

What is 'Brawny edema'?

Occurs when chronic tissue edema leads to tissue fibrosis; skin discoloration occurs without pitting.

What condition is bilateral pedal edema commonly associated with?

Right heart failure

How can swelling from venous insufficiency be distinguished from heart failure?

Venous insufficiency causes swelling in the legs but NOT the feet; heart failure causes swelling of both.

Where is edema seen in left heart failure?

Pulmonary edema

What causes Jugular Vein Distention?

Increased right heart pressure causes a back log of blood into the vena cava and their tributaries.

What four conditions are associated with Jugular Vein Distention?

Tricuspid stenosis, significant pulmonary HTN, severe tricuspid regurgitation, and constrictive pericarditis (also cardiac tamponade).

What is the definition of 'Pulsus Paradoxus'?

A drop of $>10\,mmHg$ in systolic BP with inspiration.

Name four conditions associated with Pulsus Paradoxus.

Cardiac tamponade, constrictive pericarditis, pulmonary embolism, and COPD.

What are 'Palpitations'?

When the patient is aware that their heart is beating, feeling as though it is pounding or fluttering.

What four factors can cause palpitations besides arrhythmia?

Exercise, anxiety, caffeine, and smoking.

What is 'Arrhythmia'?

An abnormal heart rate or rhythm.

What is the medical term for fainting or passing out?

Syncope

What valvular condition is a cause of Syncope?

Severe aortic valvular stenosis

What is an audible sound associated with turbulent flow called?

Murmur

What is a 'Thrill'?

Palpable vibrations of loud, harsh murmurs.

Which septal defect is associated with a Thrill?

Ventricular Septal Defect (VSD)

Which conditions are associated with Fever and Malaise according to the notes?

Endocarditis

What is 'Cachexia'?

An overall state of ill health, malnutrition, and wasting caused by chronic heart disease.

Elevated levels of which three substances indicate acute myocardial infarction (MI)?

Troponin, creatine kinase-MB, and lactic dehydrogenase (LDH).

How long do Troponin, CK-MB, and LDH levels usually stay increased after an MI?

During and for $24-48\,hrs$ after an acute MI.

What is 'Hyperkalemia' and how does it affect the heart?

Elevated potassium levels; it causes reduced heart rate and strength of contraction.

What is 'Hypernatremia' and how does it affect the heart?

Elevated sodium levels; it causes reduced heart rate and strength of contraction.

What two factors cause an increase in heart rate and strength of contraction?

Increased epinephrine and hypercalcemia.

What does abnormal carnitine levels result in?

Impaired muscle metabolism, which can lead to dilated cardiomyopathy.

The presence of which bacterium in blood work is a sign of infection?

Staphylococcus aureus

List three non-specific signs and symptoms of cardiac disease.

Headaches, dizziness, and tinnitus (ringing in ears).

What mechanical events cause the First Heart Sound (S1)?

Mitral valve and tricuspid valve closing after atrial contraction.

At which point on the ECG does S1 occur?

Onset of the QRS wave.

Which valve closes first in S1?

Mitral valve closes before tricuspid valve.

What mechanical events cause the Second Heart Sound (S2)?

Aortic valve and pulmonic valve closing after ventricular contraction.

At which point on the ECG does S2 occur?

The end of the T wave.

Which valve closes first in S2?

Aortic valve closes before pulmonic valve.

Which heart sound is described as a 'ventricular gallop'?

The Third Heart Sound (S3)

What causes the S3 heart sound?

Oscillation of blood back and forth between the ventricle walls due to inflow from the atria.

At what age does the S3 heart sound usually become abnormal?

After age $40$.

What does an abnormal S3 correlate with?

Dysfunction or volume overload of the ventricles.

List three conditions that cause rapid ventricular filling associated with S3.

CHF, dilated cardiomyopathy, and severe valvular regurgitation.

What is the Fourth Heart Sound (S4) also called?

Presystolic gallop or atrial gallop.

What produces the S4 heart sound?

The sound of blood being forced into a stiff or hypertrophic ventricle during the atrial kick.

Name three conditions where an S4 heart sound is seen.

HTN, severe aortic or pulmonic stenosis, and CAD (Cardiomyopathy).

What heart sound is associated with mitral stenosis and occurs at the onset of diastole?

Opening Snap

What heart sound follows S1 and is associated with congenital aortic or pulmonic stenosis?

Ejection Click

What heart sound occurs mid to late systole and is associated with MVP?

Midsystolic Click

What is a 'Pericardial Rub'?

A friction sound caused by inflammation due to acute pericarditis.

What is a 'Pericardial Knock'?

A sound occurring in early diastole associated with constrictive pericarditis where the heart knocks against the rigid pericardium.

What causes a 'Functional murmur'?

Rapid flow across a normal cardiac valve.

What causes a 'Pathologic murmur'?

Turbulence of flow across diseased cardiac valves or congenital defects.

What is the rating scale for the intensity of a murmur?

Grade $1 - 6$

Describe a Grade 1 intensity murmur.

Barely audible

Describe a Grade 6 intensity murmur.

Very loud with a palpable thrill.

What are the four qualities used to describe a murmur?

Harsh, Rubbing/Scratching, Blowing, Rumbling.

What are the three sound profiles for murmurs?

Crescendo, Decrescendo, Holosystolic.

When do systolic murmurs occur?

During the interval between S1 and S2.

Which conditions produce mid-systolic murmurs?

Aortic or pulmonic stenosis, increased flow through normal valves, or dilation of the aortic root/pulmonary trunk.

Which conditions produce late-systolic murmurs?

Mitral valve prolapse (MVP), tricuspid valve prolapse, and papillary muscle dysfunction.

What are three causes of holosystolic murmurs?

Mitral regurgitation (MR), tricuspid regurgitation (TR), and VSD.

When do holosystolic MR and TR murmurs usually start?

Immediately after S1 and continue until end systole.

What distinguishes a 'systolic ejection murmur' from a 'holosystolic murmur'?

A systolic ejection murmur starts slowly after S1 and does NOT occur during the isovolumic contraction period.

Name two conditions associated with systolic ejection murmurs.

Semilunar valvular stenosis (AS, PS) and hypertrophic obstructive cardiomyopathy.

When do diastolic murmurs occur?

During the interval between S2 of one cardiac cycle and S1 of another.

When do early diastolic regurgitant murmurs start?

Immediately after S2.

Which valves are involved in early diastolic murmurs?

Semilunar valves (aortic and pulmonic).

What causes diastolic ejection murmurs?

Atrioventricular valve (mitral and tricuspid) stenosis.

When does a 'late diastolic murmur' occur?

During complete heart block.

What is the 'Austin Flint murmur'?

A functional diastolic murmur caused by significant aortic regurgitation affecting the mitral valve.

What is the 'Dock murmur'?

An early diastolic murmur associated with stenosis of the LAD artery.

Which condition is classically associated with a continuous murmur from systole through diastole?

Patent ductus arteriosus (PDA)

How does the Valsalva maneuver affect venous return?

It causes decreased venous return.

Which murmurs increase with the Valsalva maneuver?

Hypertrophic cardiomyopathy and MVP.

What is Amyl Nitrite and its initial effect on hemodynamic parameters?

A vasodilator; upon inhalation, venous return and blood pressure drop.

Which murmurs are augmented by Amyl Nitrite?

Murmurs caused by LVOT stenosis and MVP.

Which murmurs are diminished by Amyl Nitrite?

Aortic and mitral regurgitation.