Cardiovascular disease affects the majority of the elderly population and is one of the most common causes of death. Cardiac dysfunction causes both cardiac symptoms as well as pulmonary and other circulatory symptoms and signs. Cardiac diagnostics are important to assess whether cardiac disease may be causing the symptoms. This article will introduce you to the cardinal symptoms of cardiac disease, as well as associated non-invasive examination techniques.
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Auscultation

Image : “Auscultation of a man in Vietnam” by JoAnn Moravac. License: Public Domain


Common Cardiac Symptoms

Chest Pain – Oppressive, Retrosternal, Radiating

Angina pectoris is likely the first symptom that comes into a medical student’s mind when thinking of cardiac diseases. A persistent, oppressive, retrosternal pain that does not respond to nitroglycerin is concerning for symptoms of impaired cardiac circulation.

Typically, anginal pain radiates to the left shoulder and the left arm, but can also radiate to the jaw, the abdomen, or the back. A cardiac cause should be considered even for patients with toothache or stomach pain, especially in women where atypical pain localization and radiation is more common.

In addition, pain with effort or exercise is highly suggestive of angina, whether the effort is physical or emotional. Anginal pain should stop with rest, usually within 510 minutes. Pain may increase with cold temperature and can be accompanied by anxiety and panic.

The severity of angina can be classified using the CCS classification (similar to NYHA stages) as follows:

CCS0 Silent, asymptomatic
CCS1 Angina during strenuous/prolonged physical activity
CCS2 Angina during moderate physical activity
CCS3 Angina during low physical activity
CCS4 Angina at rest

Cyanosis

Arterial_thrombosis_causing_cyanosis

Image: “Cyanosis of the right foot distal to an occlusion caused by acute arterial thrombosis of the right leg” by James Heilman, MD. License: CC BY-SA 3.0

A livid discoloration of hands, feet, or lips is a sign of an insufficient oxygen supply within the peripheral circulation. For central cyanosis, blue coloration of mucous membranes may also be present in addition to signs for peripheral circulation. In the case of a central cyanosis, consider a right-to-left shunt where the blood returning to the right heart bypasses the lungs and mixes with oxygenated blood returning from the lungs, ready to enter the aorta.

In these situations, deoxygenated blood mixes with oxygen-rich blood, causing a reduction in peripheral oxygen concentration. Peripheral, generalized cyanosis is evidence for cardiac insufficiency and increased oxygen extraction by the tissues, which may be caused by valvular heart diseases, arrhythmia, a cardiac tamponade, or cardiomyopathy. In peripheral cyanosis, tissues furthest from the heart suffer the most from lack of oxygen.

Dyspnea

In the case of a left ventricular insufficiency, the left ventricle does not eject adequate blood, thereby causing blood to back up into the pulmonary circulation. This leads to an increase in pressure and pulmonary edema, which is why dyspnea can have pulmonary as well as cardiac causes, especially chronic dyspnea.

Left ventricular dysfunction can be due to myocardial or valvular disease: such as myocardial infarction, myocarditis, cardiomyopathy, or mitral or aortic valve disease. Other less common reasons include patent ductus arteriosus or a defect between ventricles or the interatrial septum.

Edema

Edema is a pathological accumulation of fluid in the interstitial space. Typically, left ventricular insufficiency causes pulmonary edema while right ventricular insufficiency causes peripheral edema; usually, the legs are affected first. On inspection, the skin may be taut, and with pressure on palpation, there may be pitting of the subcutaneous tissue.

Have a look at both legs! Edema on only one leg is often due to non-cardiac causes, most often phlebothrombosis.

Generalized edema, ascites, or congestive hepatopathy may lead to hepatic dysfunction and splenomegaly. Men may also develop scrotal edema.

Syncope

Syncope is defined as a sudden, brief, and self-limited episode of loss of consciousness which is accompanied by a loss of tone of the skeletal muscles.

There are many causes of syncope, but one cause is cerebral hypoperfusion due to a cardiac arrhythmia.

History Taking

Important questions to ask:

Do you have chest pain? Is the 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? Is this associated with physical activity? Do the symptoms improve when you are lying down or sitting?

Did you become unconscious recently? Did you fall more often?

On examination, pay attention to edema and cyanosis.

Furthermore, nocturia can be an evidence for heart insufficiency. Palpitations or tachycardia may suggest cardiac arrhythmia.

Cardiovascular risk factors should be determined, including:

Additional questions of the autonomic nervous system should be asked:

Did you have a fever, shivering attacks, or night sweats? How is your sleep? Do you sleep well through the night? How are your stool and urination?

Summary

  1. The symptoms that the patient describes, along with any history of prior illness on the part of the patient and his/her family, is 90% of the information needed to make a diagnosis
  2. The physical exam and various laboratory tests constitute the final 10% of the information needed by the cardiologist

Purpose

  • Provide information about potential cardiovascular symptoms and how they developed
  • A complete cardiovascular history gives the examiner indications concerning potential or underlying cardiovascular illnesses or disease states

Taking the history

  • Accurate and useful history taking requires time and interpretation since the patient will often not tell their history in a perfectly organized manner – only occasionally is the patient a healthcare professional
  • The history starts with the chief complaint:

Why did you come to see me today?

Past health

It is important to ask questions about the patients’ health history, including the presence of any of the following conditions:

  • Hypertension
  • Elevated blood cholesterol or triglycerides
  • Heart murmurs
  • Congenital heart disease
  • Rheumatic fever
  • Unexplained joint pains in childhood

Current lifestyle and psychosocial status

  • Nutrition
  • Smoking
  • Alcohol
  • Exercise
  • Drugs
  • Family history

Cardiovascular disease is the leading killer of both men and women among all racial and ethnic groups throughout the world. A thorough cardiovascular assessment will help to identify significant factors that can influence cardiovascular health such as:

  • High blood cholesterol
  • Cigarette use
  • Diabetes
  • Hypertension

Physical Examination

The following summarizes what to pay attention to when doing a physical examination focused on the cardiac system:

Inspection

  • Clubbing of the fingers/nails (evidence for chronic hypoxia)
  • Engorged neck veins (inducible by the hepatojugular reflux test) – measure jugular venous pressure

Eyes

The presence of yellowish plaques on the eyelids (xanthelasma) usually indicates hypercholesterolemia, a risk factor for atherosclerosis.

Chest

pectus-carinatumObserve the chest for overall torso contour. Do you see pectus excavatum (caved-in chest)? Do you see pectus carinatum (pigeon chest, right picture)?

Cyanosis

The presence of cyanosis (bluish color) denotes poor oxygen delivery to the peripheral tissues of the hands and feet.

Other elements to look for

  • Bulging eyes
  • Bounding or very irregular pulse
  • Facial flushing
  • Swollen limbs or joints
  • Rashes or skin bleeding

Palpation

  • Translocated apical impulse? (suggests left ventricular hypertrophy)
  • Check pulses (heart defects, dysrhythmia)
  • Edema
  • The quality of the carotid pulse
  • Missing pulses
  • Swollen abdomen – is the liver enlarged?
  • Displaced apical impulse of the heart, i.e. the heart is enlarged
  • Extent and severity of body edema

Percussion

  • Pleural effusion
  • Hepatomegaly
  • Ascites

Auscultation

  • 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)

Auscultation points

auscultatation-points

auscultatation-points-2

Heart sounds — S1 and S2

S1 S2
  • The ‘lub’ of the ‘lub-dub’
  • Is produced by the closure of tricuspid and mitral valves
  • Is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis
  • It is most audible in tricuspid area (T-lub-dub)
  • The ‘dub’ in ‘lub-dub’
  • Is produced by the closure of aortic & pulmonic valves
  • Normal physiological splitting is best heard at pulmonic area. It occurs on inspiration
  • Persistent wide splitting can indicate an atrial septal defect or a bundle branch block in the conduction system

Additional sounds

  • S3 implies severely abnormal ventricular function, usually the left ventricle
  • S4 implies that one or both ventricles are stiffer than normal, known as decreased ventricular compliance
  • Abnormally thickened valves may cause extra sounds or increased loudness of one of the heart sounds

Murmurs

Murmurs an abnormal heart sound caused by turbulent blood flow. The sound may indicate that:

  • Blood is flowing through leaking or narrowed heart valve
  • There may be a hole in one of the heart’s walls
  • There may be a narrowing in one of the heart´s or circulatory system’s blood vessels

Methods of Medical Imaging

Chest X-ray is an important part of the cardiac exam, with attention to cardiomegaly, and evaluate for pulmonary causes of symptoms.

Frequently repeated and recorded measurements of blood pressure along with continuous cardiac monitoring (with a Holter monitor) may provide evidence for cardiac diseases, such as arterial hypertension which as a risk factor for coronary heart disease, cardiac arrhythmias, or myocardial infarction.

Doppler ultrasound can be used to visualize blood flow, allowing extracardiac diseases like arterial or venous stenosis to be identified as the cause of heart stress, cyanosis, or syncope while ruling out other primary cardiac diseases.

An abdominal sonography may reveal signs of a right ventricular insufficiency, e.g., congestive hepatopathy, a splenohepatomegaly, or ascites, which may help assess the severity of the disease and help promote therapeutic options.

Echocardiography can be done via a transthoracic or transesophageal approach which will identify ejection fraction, cardiac wall motion, and morphology, as well as valvular function (ability to close, open, and rapidity of transvalvular flow). In addition, the pathological causes of blood flow abnormalities (i.e. reflux) and turbulence can be identified. The ejection fraction can be calculated.

For further diagnostics, CT is available which can help quantify coronary calcification, particularly the newest helical CT’s with 3D reconstructions. A cardio-MRI may allow the detection of malformations of the heart or heart vessels, valvular malformations, tumors, and thrombi. Older infarction scars or myocarditis can be made visible by different contrast agents.

Cardiac catheter examination and pericardiocentesis are invasive techniques used in cardiac diagnostics; the latter is used for the treatment of pericardial effusion to relieve the heart and possibly perform microbiological diagnostics (inflammatory heart diseases).

During cardiac catheterization (also known as cardiac angiography), the cardiac catheter can be placed as a right or left ventricular catheter. In doing so, this procedure will allow measurement of pressures, visualization of the coronary vessels, acquisition of myocardial biopsies, and if necessary, electrophysiological measurements (rhythm diagnostics).

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