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Cardiovascular Exam
Melanie Dowling Melanie.dowling@doctors.org.uk Bleep 4518

What Im going to cover..

Potential stations
Revise Cardiovascular system exam Important points: MI, Heart failure, Atrial Fibrillation and Hypo/hyperkalemia A couple of ECGs Questions

All the information in this talk is from the notes I collected/made before finals- to make sure it was up to date I checked it with a registrar from the cardiothoracic team/ against current trust protocol.

Potential Stations to prepare for

Pacemaker (if you have never seen a paced ECG go find one)
CABG Prosthetic Valves- tissue and mechanical

Murmurs
Atrial fibrillation There was no Cardiovascular examination in finals last year so you might be more likely to have one!

Cardiovascular Exam

Wash hands
Introduce self Check identity + what do you want me to call you

Expose
Reposition 45

General inspection

Around the bed: GTN spray, ECG leads, Warfarin book

State of patient: Well? Old/young? Using Oxygen? Scars: mid sternotomy +/- saphenous vein harvest scar, Brusing (warfarin) Malar flush (mitral stenosis) Body habitus:

Condition + Association
Downs syndrome Congenital heart disease Turners syndromeCoarctation of the aorta Marfans Sundrome- Aortic regurg Ankylosing SpondylitisAortic reguritation

Thin hyperthyroidism (atrial fibrillation) Marfans syndrome

Listen Audible click

Hands

Perfusion- temperature + cap refil (hold 5secs nomal <2 secs), peripheral cyanosis
Clubbing (chronic IE, atrial myxoma, cyanotic heart disease) Tar staining

Tendon xanthomata
Quinkeys sign (pulsation of nail bed- aortic regurg) Stigmata if IE:

Oslers nodes Splinter haemorrhages Janeways lesions

Pulse and Bp

Radial pulse- Rate and Rhythm

Radial Radial delay Collapsing pulse (Aortic regurg)

Brachial/ Carotid pulse- Character and volume

BP:

Narrow pulse pressure (aortic stenosis)

Wide pulse pressure (aortic regurg)

Face
Eyes

Mouth

Corneal arcus Jaundice Xanthelasma Conjunctival pallor and haemorrhage Fundoscopyroth spots

Central cyanosis Oral hygiene Glossitis

Angular stenosis
High arched pallor (Marfans)

JVP

Elevated in:

Different from carotid as it:

Heart Failure

Is a double pulsation

Constrictive pericarditis
Tricuspid valve disease Fluid overload SVC obstruction

Changes with respiration

Non-palpable Eliminated by pressure Changes with the

Cardiac tamponade

Hepatojugular reflex

Revise pg 94 Mcleods

The right atria contracts causing a raise in pressure in the right ventricle (a wave). The contraction ends and the pressure decreases. The tricuspid valve closes and the pressure increases slightly (c). The atria relaxes and the pressure decreases (C to X) The atria fills and the ventricles contract causing an increase in pressure

A- Atrial contraction C- Tricuspid closure V- Atrial filling during ventricular systole

Palpation

Thrills

Palpable murmurs

Heaves

Volume overload- laterally displaced (Aortic regurg) Pressure overload not displaced (Aortic stenosis)

Apex beat (5th intercostal space mid clavicular line)

Auscultation

Start from the apex beat listen for two distinct heart sounds + palpate carotid (the first heard sound coincides with closure of the mitral and tricuspid valves To revise murmurs go to Dr Clarke website there is a recording of heart sounds and it is really easy to use.

Heart sounds.

Fourth heart sound-(Le lub dub)

Third heart sound (lub de dub)

Always abnormal
Atrial contraction into a non-compliant or hypertrophied ventricle Low pitched Caused by: Heart failure, MI, Hypertension, Cardiomyopathy

Can be normal Ventricular sound of blood rushing in during the rapid filling phase of early diastole, Stiff or dilated ventricles suddenly reaches its limit of elasticity and decelerates the incoming rush of blood. Caused by: Heart failure, MI, Cardiomyopathy, hypertension, constrictive pericarditis, Mitral and aortic regurg (volume overload apex displacedbut not powerful.

Murmurs - Systolic

Aortic Stenosis

Mitral Regurgitation (Burrr)

Ejection systolic murmur Cresendo-decresendo Best heard on expiration + leant forwards + diaphragm Slow rising pulse Apex forceful not displaced Caused by: Calcification, congenital bicuspid valve, IE, Rheumatic HD.

Pansystolic murmur Quiet S1, S2 not heard separately Best heard at apex + expiration + diaphragm

Radiated loudly to axilla

Pt. likely to be in sinus rhythm Caused by: Rheumatic HD, IE, and post MI (papillary muscle dysfunction), valve prolapse, chordae (Marfans)

Murmurs - Diastolic

Aortic Regurgitation (Lub tarrr)

Mitral Stenosis (Lub dee derr)

Early diastolic murmur Follows S2 Decrescendo CF: Collapsing pulse (+/Corrighans sign), JVP not raised, Apex beat is displaced. Caused by: Rheumatic heart disease, IE, connective tissue disease (marfans), syphilis.

Low pitched rumbling, mid diastolic murmur Loud 1st HS + opening snap Best heard on expiration + at LSE + left lateral position + bell

Malar flush + AF
JVP = late sign Apex not displace but tapping L. parasternal heave Caused by: Rheumatic HD, IE, congenital abnormality, inflammatory

To complete

Auscultate lung bases

Check ankles and sacrum for swelling Radial femoral delay

Splenomegaly (infective endocarditis)

Peripheral Vascular exam

Present

Practice!!! if you can present with confidence and identify key points it make you look good. Eg I have examined Mr. Smiths cardiovascular system. Mr. Smith was well at rest and had a heart rate of 82 bpm and a respiratory rate of 12 breaths per minute. He has presented with a midsternotomy scar and the click of metallic valve was audible from the end of the bed, and on auscultation this coincided with the second heart sound. There were no added sounds. From this I have concluded that Mr. Smith has had a mechanical Aortic valve replacement. Mr. Smith is of tall stature and has a high arched palette. There is also brusing to the limbs and trunk. To summerise Mr. Smith has had an AVR secondary to Marfans syndrome and is now taking Warfarin

To finish

They may ask you about tests depends on the examiner Bloods:

FBC, UEs, TFT, CRP, . Trop T, CKMass

Urine dip + blood cultures - IE ECG

Repeat 1hr later if no initial changes

Echo CXR

How to approach a station if your unsure/ dont have a clue.

Dont panic- LOOK

Be systematic and thorough Eg (real pt. I came across in A&E who volunteers for finals)

Youngish (late 20s) female

Clubbed and nails look a bit blue Her tongue is a beefy red colour She has a mid sternotomy scar What are you thinking ? What are you going to look for to confirm this? Can you show off some knowledge?

Acute coronary syndrome

Acute coronary syndrome:

Complications of MI

Unstable angina

Pump failure

NSTEMI
STEMI

Rupture of papillary muscle or septum

Aneurysm and arrhythmias Embolism

ECG:

ST Elevation- infarction ST Depression- ischemia Q waves transmural infarct

Dressler's syndrome (post myocardial syndrome anticardiac antibodiespericarditis)

ECG MI

ST elevation in II, III and AVF- Inferior leads, Infarct- RCA

ECG lead changes

RCA

LMS

AVF, II, III

V2-V6

Inferior infarct
Pt. may present with a bradyarrthymia

Large anterior infarct

Pt presents with pump problems

LAD

Circumflex

V2-V4 Anterior septal infarct Pt presents with pump problems

V4-V6, I AVL

Anterio-lateral infarct
Pt presents with pump problems

ACS management

Morphine (5-10mg IV + antiemetic ) Oxygen 15L NRM Aspirin 300mg chewed

Unstable angina and NSTEMI

Clopidogrel 300mg Enoxaparin 1mg/kg/12hrs (SC) B-blocker atenolol 5mg IV

Nitrate GTN spray (SL)

STEMI PCI is gold standard for STEMI where available Thrombolysis (most beneficial <12hrs), streptokinase, tPA Heperin (24-48hrs) CABG for those not suitable for stenting/balloon. If pt id diabetic stop metformin and start insulin (risk of metabolic acidosis) Consider: B-blocker, Statin, Aspirin, Clopidogrel, ACEI

ECG AF

Absent P waves, Irregular rhythm

Atrial Fibrillation

Pulse Irregularly Irregular ECG

Complications

Loss of atrial contraction Co2 HF Risk of thromoboembolism (CHADS2 score) Drug interactions (verapamil + B blockers)

Absent P waves

Caused by

Post MI

Pneumonia
PE Thyrotoxicosis Rheumatic heart disease

Alcohol
Drugs

CHADS2- risk of stroke Cardiac failure 1 Hypertension 1 Age >75yrs 2 Diabetes 2 Previous Stroke 2 0= low (aspirin), 1=moderate, 2= high (warfarin)

Atrial fibrillation - Management

Acute

Chronic

Treat underlying cause

1st line- B blocker

Rate- digoxin, B blockers, calcium antagonists

Rhythm- amioderone or cardioversion. Anticogaulation

2nd line- Digoxin

3rd line- Amioderone Anticoagulation warfarin Target INR= 2-3

Heart Failure
- Failure to maintain a cardiac output sufficient to meet bodies requirements despite and adequate filling pressure.

Right heart failure clinical features

Left heart failure clinical features

Systemic venous congestion

Raised JVP Palpable liver Peripheral odema

Pulmonary venous congestion

Basal Crackles Breathlessness due to alveolar oedema + orthopnea Pink frothy sputum Wheeze cardiac asthma

Ascites

Heart failure - causes

Damaged myocardium ( contractility) Alcohol, Post MI, Cardiomyopathy

Rhythm disturbance

Arrthythmias

Damaged heart valve (outflow distrubance) Aortic stenosis, Mitral regurgitation

Increased arterial resistance Arterial or pulmonary hypertension Increased blood volume Renal failure, over transfusion

Compromised cardiac filling

Constrictive pericarditis, pericardial effusion

Increase demand

Anaemia, thyrotoxicosis, L to R shunt

Heart failure - Investigation

CXR

Radiography

A- Alveolar odema (bat wings) B- Kerly B lines (intersitial odema) C-Cardiomegaly D- Diversion (upper lobe diversion) E- Pleural Effusion & engorged pulmonary arteries (LHF)

Echo

Heart failure Management

Acute

Chronic

15 L O2 NRM

Treat underlying cause

Morphine
Furosemide (40-80mg IV) IV nitrate infusion (unless hypertensive)

Lifestyle changes
Medical: loop diuretics, ACEI, B blockers, aldosterone anatagonists (spironolactone) Monitor electrolytes

ECG
Coronary care or acute anesthetic referral

Hyper/hypokalemia

Hyperkalemia

Hypokalemia

Calcium gluconate (cardio protective) Salbutamol Insulin + dextrose

<3.5 +>2.5- Sandok (K supplement) for 3 days <2.5 IV KCL (max 40mmol at 10mmol/hr)

ECG changes

ECG changes

Flattened P waves Widened QRS Slurring of ST segment Tall tented T waves

Flattened T waves
ST segment depression Prolonged QT interval Can progress to VT/VF

Thanks for listening Any questions?