Chest Pain – Oppressive, Retrosternal, Radiating
Angina pectoris is probably the first symptom that comes into a medical student’s mind when thinking of cardiac diseases. A persistent, oppressive, retrosternal pain, not responding to nitroglycerin, is beyond question an important evidence for an impaired cardiac circulation.
Typically, the pain is radiating into the left shoulder and the left arm, but can also be conducted into the jaw, the abdomen or the back. That’s why you should also be considering a cardiac origination when a patient is having toothaches or stomach-aches, and you should consequently clarify the pain’s root, especially in women untypical pain localizations or radiations appear, so that immediate treatment is endangered.
Furthermore, exercise capacity is indicative for an AP, be it of physical or psychical kind. Pain should suspend after 5 – 10 min at rest. Often, an amplification caused by coldness, is observed. Quite often the pain comes with anxiety and panic.
The severity of an AP can be appointed by using the CCS-classification (similar to NYHA-stages) for:
|CCS1||Angina during strenuous/prolonged physical activity|
|CCS2||Angina during moderate physical activity|
|CCS3||Angina during low physical activity|
|CCS4||Angina at rest|
Cyanosis – Pale and Blue
A livid discoloration of hands, feet or lips, is a sign for an insufficient oxygen supply of the periphery. A distinction is made between central and peripheral cyanosis, where the central cyanosis also shows a blue coloration of mucous membranes. In the case of a central cyanosis, a vitium, including a right-to-left shunt, or left-to-right shunt, have to be considered.
Thereby, oxygen-rich blood mixes with deoxygenated blood, so that the peripheral oxygen concentration is decreased. A peripheral, generalized cyanosis is an evidence for cardiac insufficiency, which also can be based on valvular heart diseases, arrhythmia, a cardiac tamponade or a cardiomyopathy.
Dyspnea – The Heart Causes Heavy Breathing
In the case of a left ventricular insufficiency, the left ventricle does not eject an adequate amount of blood, so that the blood is backing up into the pulmonary circuit. Increase of pressure and pulmonary edema follow; that’s why dyspnea can not only have pulmonary, but also cardiac causes, especially chronic dyspnea.
The dysfunction of the left ventricle can be of a myocardial (myocardial infarction, myocarditis, cardiomyopathy) or be the result of a mitral or aortic valve defect. Other less common reasons are a patent ductus arteriosus, a defective ventricle or interatrial septum or a constrictive pericarditis.
Edema – Not Only Swollen Legs
Edema is a pathological accumulation of fluid in the interstitial space. Typically, left ventricle insufficiencies cause pulmonary congestion and right ventricle insufficiencies cause peripheral edema: Usually, the legs are affected at first. Already on inspection a firm skin is visible, dents, which persist, can be pressed during palpation.
Have a look at both legs! A one-sided leg edema is often has extracardial reasons (usually phlebothrombosis). Examination of the toes can also be determining. These are only affected in the case of a disturbed drainage of the lymph.
An ascites or a congestive hepatopathy shows the impact of the abdominal blood stasis. The latter can cause hepatic dysfunction and splenomegaly. Men are quite commonly affected by scrotal edema, whereupon they are assigned to an urologist.
Syncopes Cause Falls
Syncope is defined as a sudden, only a few minutes persisting loss of consciousness, which comes along with a loss of tonicity of skeletal muscles.
A possible reason can be an insufficient oxygen supply of the brain, which possibly can be ascribed to a cardiac arrhythmia.
Anamnesis: How to Ask for Heart Diseases?
In the anamnesis, the named cardinal symptoms have to be asked, i.e.:
Do you have chest pain? Is this pain rather sharp or rather oppressive and dull? When does it arise? Is it associated with preceding physical activity? Do the symptoms improve when breathing deeply? How long does it last? Does it stop spontaneously? How often do you feel the pain (per month/year?)
Do you have dyspnea at times/more often? Did it also precede physical activity here? Do the symptoms improve when you are lying down or sitting?
Did you become unconscious recently? Did you fall more often?
Edema and cyanosis are noticeable by inspection.
Furthermore, nycturia can be an evidence for heart insufficiency. Palpitations or tachycardia suggest a cardiac anomaly or cardiac arrhythmias.
Cardiovascular risk factors also need to be determined. Thereto belong:
- Arterial hypertension
- Diabetes mellitus
- Consumption of alcohol or nicotine (not only ask whether, but also how much!)
- Exercise during daily life
- Family anamnesis: the above-named diseases, myocardial infarction, strokes have occurred?
In every internistic anamnesis also questions regarding B-symptoms and the autonomous nervous system need to be asked:
Did you have fever, shivering attacks or night sweats? How is your sleep? Do you sleep well through the night? How is stool and urination?
Physical Examination – Looking for Evidence
The following summarizes what to pay attention to when doing a physical examination with a cardiac focus:
- Paleness (central or peripheral)
- Hippocratic fingers, hippocratic nails (evidence for chronic hypoxy)
- Engorged neck veins (inducible by the hepatojugular reflux test)
- Apical impulse translocated? (left ventricular hypertrophy)
- Checking pulses (heart defects, dysrhythmia)
- Pleural effusion
- Heart sounds, cardiac murmur
- Heart rate
- Heart rhythm
- Respiratory sounds (decreased in the case of pleural effusion, crackles in the case of pulmonary vascular congestion)
Methods of Medical Imaging – Behind the Scenes
Every basic cardiac diagnostic needs an x-ray of the chest. Except of a cardiomegaly, there can hardly be made other statements regarding the heart. However, you can judge the lung, so that pulmonary causes can be ruled out.
A long-term blood pressure measurement, and a long-term ECG, can give evidence for cardiac diseases, like i.e. arterial hypertension as a risk factor of the coronary heart disease, cardiac arrhythmias or myocardial infarction.
Doppler sonography can visualize blood flow in vessels and make it audible. Extracardiac diseases like arterial or venous stenosis can be identified as the reason for heart stress, cyanosis or syncope, so that on the other hand a primary cardiac disease can be ruled out.
An abdominal sonography can visualize signs of a right ventricular insufficiency, like i.e. a congestive hepatopathy, a splenohepatomegaly or an ascites, so conclusions can be drawn about the severity of the consequences and relieving arrangements can be arranged.
Echocardiography allows either a transthoracic or a transesophageal view onto the heart. Here, the pumping action in total, the movements of the heart’s walls and the morphology, as well as the functionality of the heart valves (ability to close, opening areas), are judged. Also pathological phenomena of the blood flow (i.e. reflux) and turbulences can be registered. The ejection fraction can be calculated.
For further diagnostics, CT is available, i.e. to quantify coronary calcification. A cardio-MRT allows the detection of malformations of the heart or heart vessels, valve malformations, tumors and thrombi. Older infarction scars or myocarditis can be made visible by different contrast agents.
Different from the previous methods, the cardiac catheter examination and the percardiocentesis are invasive techniques. The latter is used for the treatment of pericardial effusion to relieve the heart and possibly perform microbiological diagnostics (inflammatory heart diseases).
The cardiac catheter can be applied as a right or left ventricular catheter. In doing so, different pressures can be measured, the coronary vessels can be visualized, myocardial biopsies can be taken and, if necessary, electrophysiological measurements (rhythm diagnostics) can be taken.