14/03/2006 YLM 1

CVS Examination

Prof Yan-Lynn Myint

MBBS,MMedSc (Int.Med.)

MRCP(UK) FRCP Edin.

14/03/2006 YLM 2

Why CVS in Dental practise?

• Dental practise/ procedures that induce

CVS diseases

• CVS diseases that can be exacerbated by

dental procedures

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History

• Name, age, sex, address, occupation

• Chief complaints

• HOPI

• PH

• FH/SH

• Personal history

• O & G history

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Cardinal/common symptoms Symptoms CVS causes Other causes

Chest discomfort 1. MI

2. Angina

3. Pericarditis

4. Aortic dissection

1. Oesophageal spasm

2. Pneumothorax

3. MS pain

Breathlessness 1. Heart failure

2. Angina

3. Pul embolism

4. Pul HT

1. Resp disease

2. Anaemia

3. obesity

Palpitation1. Tachyarrhythmia

2. Ectopic beats

1. Anxiety

2. Hyperthyroidism

3. drugs

Syncope/dizziness 1. Arrhythmias

2. Postural hypertension

3. Aortic stenosis

4. HOCM

5. Atrial myxoma

1. Simple faints

2. epilepsy

oedema 1. Heart failure

2. Constrictive pericarditis

3. Venous stasis

1. Nephrotic syndrome

2. Liver disease

3. drugs

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Type of cardiac pain

Type Causes Characteristics

Angina Coronary stenosis (rarely aortic stenosis, HOCM)

Ppt by exertion, eased by rest and/or GTN

Characteristic distribution

Myocardial infarction

Coronary occlusion Similar sites to angina, more severe, persist at rest

Pericarditic pain Pericarditis Sharp, raw or stabbing

Varies with movement or breathing

Aortic pain Dissection of aorta Severe, sudden onset,

Radiate to back

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Angina pectoris• Site and radiation

• Duration, precipitation and relieving factors

• Character, severity

• Special types – Unstable, crescendo, nocturnal,

Aggravating Relieving

•Exertion•Emotional excitement•Cold weather•Exercise after meal

•Rest•GTN•Warm up before exercise

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Differential Diagnosis

Angina Oesophageal pain

Usu. Ppt by exertion Can be worsened by exertion, but often present at other time

Rapidly relieved by rest Not rapidly relieved by rest

Retrosternal and radiate to arms and jaw

Retrosternal or epigastric, sometimes radiate to arms or back

Seldom wakes patient from sleep Often wakes patient from sleep

No relation to heartburn (but often have wind)

Sometimes related to heartburn

Rapidly relieved by nitrates Often relieved by nitrates

Typical duration 2-10mins Variable duration

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Differential Diagnosis

Angina Myocardial infarction

Site: retrosternal, radiate to arm, epigastrium, neck

As for angina

Ppt by exercise or emotion Often no obvious precipitant

Relieved by rest, nitrates Not relieved by rest, nitrates

Mild/moderate severity Usually severe (may be silent)

Anxiety absent or mild Severe

No increased sympathetic activity Increased sympathetic activity

No nausea or vomiting Nausea and vomiting are common

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Pericardial pain

Site Retrosternal, may radiate to left shoulder or back

Prodrome May be preceded by a viral illness

Onset No obvious initial precipitating factor;tends to fluctuate in intensity

Nature May be stabbing or raw – like sandpaper. Often described as sharp, rarely as tight or heavy

Made worse by Changes in posture, respiration

Helped by Analgesics, especially NSAIDs

Accompanied by Pericardial rub

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Dissection of thoracic aorta

Site Often first felt between shoulder blades, and/or behind the sternum

Onset Usually sudden

Nature Very severe pain, often described as tearing

Relieved by No, tend to persist. Patient often restless with pain

Accompanied by Hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur, syncope, focal neurological symtoms and signs

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Breathlessness

• Awareness of one own breathing

– Dyspnoea on exertion

– Orthopnoea

– Paroxysmal nocturnal dyspnoea

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Palpitation

• Sensation of the heart beating in the chest

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Syncope and dizziness

• Postural hypotension

• Arrhythmias

• Left ventricular outflow obstruction

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Peripheral oedemaUnilateral•Deep vein thrombosis•Soft tissue infection•Trauma•Immobility, e.g. hemiplegia

Bilateral•Heart failure

•Chronic venous insufficiency

•Hypoproteinemia, e.g. nephrotic syndrome, kwashiorkor, cirrhosis

•Lymphatic obstruction, e.g. pelvic tumor, filariasis

•Drugs, e.g. NSAIDs, Nifedipine, amlodipine, fludrocortisone

•IVC obstruction

•Thiamine deficiency (Wet Beri Beri)

•Milroy’s disease

•immobility

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CVS disease presenting with non-cardiac symptoms

System Symptom Causes

CNS Stroke

•Cerebral embolism•Endocarditis•Hypertension

GI

Jaundice •Liver congestion•2˚to heart failure

Abdominal pain Mesenteric embolism

Renal Oliguria Heart failure

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Presenting complaint

• Recent onset

• Slowly progressive

• Functional assessment

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Past history

• Rheumatic fever

• Diabetes mellitus

• Hypertension

• Thyroid disease

• Recent dental works

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Drug historyDyspnoea Exacerbation of heart failure by β-blockers, some

CCB, NSAIDs

Dizziness Vasodilators, e.g. nitrates, alpha-blockers, ACEI

Angina Aggravated by thyroxine, drug-induced anaemia, e.g. aspirin, NSAIDs

Oedema•Fluid retention from steroids, NSAIDs•Oedema from CCB (nifedipine, amlodipine)

Palpitation

•Tachycardia and/or arrhythmia from thyroxine, beta-2 stimulant (salbutamol), •digoxin toxicity, •hypokalemia from diuretics, tricyclic antidepressants

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Family history

• IHD, HT

• Sudden death at young age

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Social history

• Smoking– CHD, PVD

• Alcohol– AF, HT

• Caffeine– palpitation

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Occupational history

Occupational exposure associated with CVD

Organic solvents Arrhythmias, cardiomyopathy

Vibrating machine tools Raynaud’s phenomenon

Publicans Alcoholic cardiomyopathy

Occupational exposure exacerbating pre-existing cardiac conditions

Cold exposure Angina, Raynaud’s disease

Deep-sea diving Embolism through foramen ovale

Occupational requirements for high standards of CVS fitness

Pilots, public transport, HGV drivers, armed forces, police

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Physical examination• General examination

– face• Dyspnoeic or not• Pallor• Cyanosis• Xanthoma, xanthelesma, arcus

– hands• Signs of infective endocarditis

– Splinter haemorrhage, clubbing, Osler’s nodes, Janeway’s lesion

– Feet/sacral area• Oedema, petichial haemorrhage,

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Pulses

Fast heart rate (tachycardia, >100/min)Sinus tachycardia Arrhythmia•Exercise•Pain•Excitement/anxiety•Fever•Hyperthyroidism•Medications:

–Sympathomimetics–vasodilators

•Atrial fibrillation•Atrial flutter•Supraventricular tachycardia•Ventricular tachycardia

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Pulses

Slow heart rate (bradycardia, < 60/min)Sinus bradycardia Arrhythmia

•Sleep•Athletic training•Hypothyroidism•Medications:

–Beta-blockers

–Digoxin

–Verapamil, diltiazam

•Carotid sinus hypersensitivity•Sick sinus syndrome•Second-degree heart block•Complete heart block

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Causes of irregular pulse•Sinus arrhythmia•Atrial extrasystoles•Ventricular extrasystoles•Atrial fibrillation•Atrial flutter with variable response•Second-degree heart block with variable response

Common causes of atrial fibrillation•Hypertension•Cardiac failure•Myocardial infarction•Thyrotoxicosis•Alcohol-related heart disease•Mitral valve disease•Infection, e.g. respiratory, urinary tract•Following surgery, especially cardiothoracic surgery

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Blood pressure

• Rest

• Sitting for ambulant

• Support the arm at about heart level

• Apply the cuff

• Inflate the cuff

• Deflate the cuff

• Systolic

• diastolic

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Differences between carotid and jugular pulsation

Carotid JugularRapid outward movement Rapid inward movement

One peak per heartbeat Two peaks per heartbeat

palpable Impalpable

Pulsation unaffected by pressure at the root of neck

Pulsation diminished by pressure at the root of neck

Independent of respiration Height of pulsation varies with respiration

Independent of position Varies with position of patient

Independent of abdominal pressure

Rises with abdominal pressure