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HISTORY TAKING: ISCHEMIA AND HYPERTENSIONADRIEL E. GUERRERO, MD, FPCP, FPCCSection of Cardiology, Dept of Medicine The Medical CityTraining Officer

Typical AnginaPrecipitated by effort and relieved by rest and/or nitroglycerin sublingualFixed coronary obstructionAtypical coronary spasm +/- obstruction

Differential Diagnosis of Chest Pain according to Location

Pain Patterns of Myocardial Ischemia

Your initial questions should be broad Do you have any pain or discomfort in your chest? Ask the patient to point to the pain and to describemove on to more specific questions such as Is the pain related to exertion?What kinds of activities bring on the pain? How intense is the pain, on a scale of 1 to 10? Does it radiate into the neck, shoulder, back, or down your arm? Are there any associated symptoms like shortness of breath, sweating, palpitations, or nausea? Does it ever wake you up at night? What do you do to make it better?

Exertional chest pain with radiation to the left side of the neck and down the left arm in angina pectoris;

sharp pain radating into the back or into the neck in aortic dissection.

Features Differentiating Ischemic from Non-Ischemic Chest PainIschemicNon-IschemicExertion (most predictive)Pain after exercise completionAnger, excitement, mental stressProvoked by a specific body motionCold weatherAfter mealsNicotineTachycardiaFACTORS PROVOKING PAIN

Features Differentiating Ischemic from Non-Ischemic Chest PainIschemicNon-IschemicHeaviness, heavy feelingknife-like, sharp, stabbingCrushingjabs aggravated by respirationConstrictingSqueezingBurningQUALITY OF PAIN

Features Differentiating Ischemic from Non-Ischemic Chest PainIschemicNon-IschemicSubsternalLeft submammary areaAcross mid-thorax, anteriorlyIn the left chestIn both arms, shouldersCan be pointed with 1 fingerIn the neck, lower jawA diffused areaLOCATION OF PAIN

AMIPericarditisAorticDissectnTracheobronchitisPleuriticPainAngina Pectoris

GERDDESCostochondritisAnxiety

Clinical Spectrum of Myocardial Ischemic syndromesStable anginaUnstable anginaNon Q wave MI/NSTEMIST Elevation MI/Q wave MISudden death

STABLE ANGINA PECTORISdeep, poorly localized chest or arm discomfortprecipitated by physical exertion or emotional stressrelieved within 5 15 minutes by rest and/or SL nitratesUNSTABLE ANGINA occurring at rest (or minimal exertion) and usually lasting >20 minutessevere (described as frank pain), and of new onsetcrescendo patternNSTEMI/STEMIevidence of myocardial necrosis

dynamic coronary obstruction:Prinzmetal variant anginaCoronary vasoconstriction causing microcirculatory angina results from constriction of the small intramural coronary resistance vessels

HYPERTENSIONMost patients have no specific symptoms referable to their blood pressure elevationWhen symptomatic, they are related to:The elevated blood pressure itselfThe hypertensive vascular diseaseThe underlying disease, in the case of secondary HPN

Symptoms from the BP itselfHeadache (most popular)More in severe HPN Occipital, present upon waking up and subsides spontaneously after several hoursOTHERS:Dizziness, palpitations, easy fatigability, impotence

Symptoms referable to Vascular DiseaseEpistaxis, hematuria, blurring of vision (retinal changes), episodes of weakness or dizziness due to transient cerebral ischemia, angina pectoris, dyspnea due to cardiac failure,Pain due to dissection of the aorta or a leaking aneurysm

Symptoms related to underlying disease in secondary HPNPrimary AldosteronismPolyuria, polydipsia, muscle weakness from hypokalemiaCushings SyndromeWeight gain, emotional labilityPheochromocytomaEpisodic headaches, palpitations, diaphoresis and postural dizzinessThyrotoxicosisPalpitations, weight loss, heat intolerance

Symptoms attributable to End-organ damage of HPNCardiac /Vascular effectsCardiomegaly (CHF), angina and ischemic syndromes, peripheral arterial occlusive disease (fingers/toes)Neurologic/OphthalmologicRetinopathy (BOV), papilledema, cerebral infarction/hemorrhages/Charcot-Bouchard aneurysmsHypertensive encephalopathy (severe HPN, disordered conciousness, inc. ICPRenalChronic renal failure (pallor, anemia with HPN, bipedal /facial edema

Thank You!!!

Risk Factors for Ischemic Heart Disease, Myocardial Infarction and HypertensionAge (older than 55 for men, 65 for women)Gender ( male > female)Smoking historyHyperlipidemiaDiabetes mellitusHypertensionObesityFamily history of premature CAD

AtherosclerosisLeading cause of death and disability in developed countriesHeart AMINervous system strokesPeripheral circulation gangrene & limb ischemiaSplanchnic circulation mesenteric ischemia

Risk Factors for Ischemic Heart Disease, Myocardial Infarction and HypertensionAge (older than 55 in men, older than 65 in women) GenderExcess coronary risks in men vs premenopausal womenRelatively higher HDL levels in premenopausal womenSmoking History# of years X pack of cigarette/dayHyperlipidemiaLDL increased atherogenicity

DyslipidemiaTotal Cholesterol > 5.0 mmol/l (190 mg/dl)or LDL-C>3.0 mmol/L (115 mg/dl) orHDL-C Male < 1.0 mmol/L (40 mg/dl)Female 1.7 mmol/L (150 mg/dl)

Cigarette smokingAccelerates coronary atherosclerosis in both sexes,At all agesincreases thrombosis, plaque instability, MI and deathIncreases myocardial oxygen needs and reduces O2 supply aggravates angina

DiabetesCHD risk equivalentAbnormal lipoprotein profile + insulin resistanceHypertensionTx thereof reduce stroke and heart failure riskObesity (>102 cm [M]; >88 cm [W])Family History of premature CAD (men under age of 55 or women below 65)

DiabetesInsulin resistanceHyperinsulinemia increases BP- produces renal sodium retention andinc. sympathetic activity- produces vascular smooth mucle hypertrophy(mitogenic action of insulin)- modifies ion transport across cell membrane(inc. cytosolic calcium)

HypertensionOne of the most common complex genetic disordersGenetic heritability =30%

Emerging risk factorsLipoprotein (a)Modulates fibrinolysisElevated = increased CHD riskHomocysteineAtherosclerosis at a young ageProthrombotic factorsPlasminogen activator inhibitor (PAI)Proinflammatory factorsHigh-sensitivity CRP on going inflammation to predict risk of MIImpaired fasting glucoseSubclinical atherogenesis

METABOLIC SYNDROMERISK FACTORSDEFINING LEVELAbdominal Obesity Men (waist circumference)>102 cm (>40 in.) Women>88 cm (>35 in.)Triglycerides>1.7 mmol/L (>150 mg/dL)HDL cholesterol Men110 mg/dL)

ADRIEL E. GUERRERO, MD, FPCP, FPCCSection of Cardiology, Dept of Medicine The Medical CityTraining OfficerHISTORY TAKING AND PHYSICAL EXAM OF VALVULAR HEART DISEASE

Inspection and Palpation - Pulsations and PMI are transmitted by the great arteries and cardiac chambers - Can appreciate dilatation and hyper- trophy of cardiac structures - Percussion may aid in determining visceral situs

PalpationThrillPMILiftHeave

Use of the stethoscopeBELLPlaced lightly on the chest wallDetects low pitched sounds and murmursE.g S3, S4 and mitral stenosis rumble

DIAPHRAGMPress firmly on the chest wallDetects high pitched sounds and murmursE.g. S1, S2, clicks (mitral valve prolapse), opening snaps (mitral stenosis), ejection sounds (aortic stenosis)

Cardiac Auscultation - the character of the heart sounds should be assessed and include: a) S1 and S2 ( S3 and S4 ) b) systolic and diastolic heart sounds c) murmurs and their timing, intensity, duration and location

Grading of MurmursGRADE 1Faintest under optimal conditions (quiet room)GRADE 2Soft, but readily audibleGRADE 3Prominent. Loudest murmur without a thrillShould always provoke investigationGRADE 4Loud with a palpable thrillGRADE 5Audible with a portion of the diaphragm off the chestGRADE 6Audible with the stet held off the chest wall

CARDINAL RULE:

S1 > S2 apex; S2 > S1 base

Systolic Sounds

a) early- aortic and pulmonary ejection sounds, mechanical prosthesis b) mid to late- clicks of the Mitral Valve Prolapse

Cardiac Murmurs Systolic a) mid-systolic Aortic valve stenosis Pulmonary Valve Stenosis, b) holosystolic- MR, TR, VSD d) late systolic- MVP

Symptoms of Common Valvular Heart diseasesMitral Stenosisexertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, hemoptysisMitral Regurgitationeasy fatigue, then exertional dyspneaAortic Stenosischest pain, effort syncope, easy fatigueAortic RegurgitationEasy fatigue then exertional dyspnea

Diastolic Sounds a) early- opening snap of Mitral Stenosis, pericardial knock of Constrictive Percarditis, tumor flop of Myxoma b)mid and late S3 and S4

Diastolic Murmurs a) early- Aortic Regurgitation, Pul- monary Regurgitation, Graham- Steel b) middle- MS, TS, PI, Austin-Flint c) late pre-systolic component of MS and TS in sinus rhythm

Peripheral Signs of Chronic ARCorrigans pulse: Pulses with abrupt distension and quick collapse; water hammer pulseDe Mussets sign: head bobbingTraubes sign: Pistol shot sound on the femoral arteryDuroziezs sign: Systolic murmur heard over the femoral artery when compressed proximallyMullers sign: systoic pulsation of the uvulaQuinckes sign: Capillary pulsationHills sign: Popliteal cuff SBP > brachial cuff SBP by 60mmHg

Mitral Valve Prolapse

Mismatch between elongated MV and LV cavity

Innocent MurmursMost likely occurs inChildren and adolescentPregnant womenAnxious personsFunnel-breasted or flat-chestedHyperthyroid and anemic persons

Types of Innocent MurmursCervical venous humSupraclavicular arterial bruitEarly soft systolic murmur