Screening for cardiovascular disease

Lecture objectives
In this lecture we will:
 Review the cardiac anatomy

 Differentiate between the types of cardiac diseases and

their characteristics
 Learn about various cardiovascular disorders

 Discuss the common signs and symptoms of cardiac

disease
 Signs and symptoms of cardiovascular
disease

CHEST PAIN OR DISCOMFORT

 Common presenting symptom of cardiovascular disease

 May be cardiac or noncardiac in origin.

 Cardiac – angina, MI, pericarditis, mitral valve prolapse, dissecting aortic
aneurysm
 Non cardiac – anemia (physical exertion), cervical disc disease, anxiety, trigger
points etc

 Follows pattern of ulnar nerve distribution (heart supplied by C3-T4 spinal

segments)
 Radiating pain to neck, jaw, upper trapezius, upper back, shoulder or arms
(commonly left)
PALPITATION

presence of an irregular heart beat – arrythmia or

dysrhythmia. Benign such as mitral valve prolapse,
caffeine, anxiety, exercise

Severe such as over active thyroid, coronary artery disease,

complete heart block etc
 Considered physiologic when < 6 per minute

 Lasting for hours with pain, shortness of breath, light

headedness or history of sudden death in family needs
medical referral
 Described by patients as skipped beat, bump, flutter ,
racing etc
DYSPNEA
Breathlessness or shortness of breath
 Cardiovascular or pulmonary in origin. More severe
disease, severe dyspnea
 DOE – dyspnea on exertion (shortness of breath with mild
exertion)
PND - Proximal nocturnal dyspnea. Dyspnea in sleeping
recumbent patient. Common in CHF
Orthopnea – breathlessness relieved by sitting upright
 Dyspnea relieved by specific breathing patterns and or
body positions is likely pulmonary in origin
 Anyone unable to climb flight of stairs, waking at night or
progressively worse dyspnea in cardiac patient needs
evaluation
CARDIAC SYNCOPE fainting or mild light headedness
caused by reduced oxygen delivery to brain.
 Orthostatic hypotension – sudden drop in BP due to quick
change in prolonged posture and deconditioning
 Hyperventilation in non cardiac conditions – vasovagal
syncope. Initiation and regulation of cardiac medications such
as vasodilators
 Syncope without warning period of lightheadedness is a sign
of heart valve or arrythmia problems
FATIGUE fatigue of cardiac origin accompanied by associated
symptoms. Chest pain, dyspnea etc
 In patients with fatigue without prior diagnosis of heart
disease, monitoring BP may indicate a failure of BP to rise
with increasing workloads. Do further tests such as ETT to
check if cardiac - induced
 Betablockers cause unusual fatigue symptoms
COUGH usually associated with pulmonary conditions but may
occur as pulmonary complication of cardiovascular complex
eg. Left ventricular dysfunction, mitral valve dysfunction,
pulmonary edema. Cough can also be aggravated by exercise,
metabolic stress, supine, PND.

CYANOSIS bluish discoloration of lips, nail beds of fingers and

toes. Usually in CNS or hematologic disorders

CLAUDICATIONleg pain with peripheral vascular disease.

Vascular when pitting edema with leg pain, skin discoloration
and trophic changes – cool skin; trophic changes, warm skin;
inflammation

differentiate from sciatica, back pain, gout, peripheral neuropathy

Emergency due to thromboembolism if sudden worsening of

intermittent claudication or abrupt ischemic rest pain!!
VITAL SIGNS look for abnormal response - too high or too low
heart rate, irregular pulse rate, systolic BP not rising
progressively or falling in response to exercise, change in
diastolic BP 15 – 20 mmHg.
 Monitor HR as a gauge or heart work load but use RPE rating
of perceived exertion in patients using BP lowering
medications as some will not allow HR to be > 90 bpm

EDEMA non cardiac origin: pulmonary hypertension, kidney

dysfunction, cirrhosis, burns, infection, lymphatic obstruction,
using NSAIDs or allergic reaction
 Cardiac origin – right heart failure, 2ndry to cardiac surgery,
CAD, venous valve incompetence
 Edema in form of 3 pound or greater weight gain or gradual
continuous weight gain with ankle, hand swelling, SOB,
fatigue and dizziness – red flag for CHF
 Can be accompanied by jugular venous distention and
cyanosis of lips
Cardiac diseases

Heart muscle Heart valves Cardiac nervous system

Coronary artery disease Rheumatic fever Arrythmias

Myocardial infarct Endocarditis Tachcardia

Pericarditis Mitral valve prolapse Bradycardia

Congestive heart failure Congenital deformities

aneurysms
Conditions affecting heart muscle
 Obstruction or restriction

 Inflammation

 Dilation or distention

Can occur in combination. Underlying obstruction such as

pulmonary embolus leads to congestion and subsequent
dilation of vessels blocked by embolus.
Hyperlipidemia
Metabolic abnormality
 Elevated serum total cholesterol

 Elevated triglycerides

 Elevated low density lipoproteins

 Decreased high density lipoproteins

STATIN INDUCED MUSCULAR SYMPTOMS

 Myalgia common in elderly especially females, small body frame,
kidney or liver disease, drinking excessive grape fruit juice. Normal
creatinekinase levels
 Myositis – muscle pain, fever, nausea, vomiting. Increased CK levels

 Rhabdomyoliysis – marked CK elevation

Coronary artery disease
When coronary artery becomes narrow or blocked, the area of
heart muscle supplied by the artery becomes ischemic and
injured resulting in infarction

Coronary artery disease CAD or Ischemic heart disease IHD

includes:
 atherosclerosis (fatty buildup) hardening of medium sized
arteries. Heart attacks and strokes most common fatal sign of
disease
 thrombus (blood clot) – coronary thrombosis; clot formation in
coronary artery
 spasm (intermittent constriction) –brief such as nicotine intake,
anxiety, cold air and healthy persons. Prolonged can cause
heart damage
Risk factors for coronary artery disease
Angina
 Acute pain in chest – angina pectoris

 Symptom of reduced blood supply to heart muscle, results

from imbalance between cardiac workload and oxygen
supply to myocardial tissue
 SYMPTOMS
 Pain radiating to back, neck, jaw, arm
 Gripping feeling
 Toothache
 Dyspnea
 Belching
 Nausea
Coronary circulation
Cardiac arrest OR myocardial
infarction?
 Sudden death can be the first sign of heart disease
 The onset of an infarct may be characterized by severe fatigue for
several days before the infarct – prodromal symptom
 Chances of heart attack 40% higher in the morning
 Cardiac arrest strikes without warning.
 Sudden loss of responsiveness
 No normal breathing
 No signs of circulation
Call for help and begin CPR immediately!
Myocardial infarction
 Heart attack, coronary occlusion – development of
ischemia and necrosis of myocardial tissue
 Results from sudden decrease in coronary perfusion or
increase in myocardial oxygen demand without adequate
blood supply.
 Usually preceded by occlusion of major cardiac artery due
to a clot or sclerosed artery with thrombosis
 cause with interrelated factors such as coronary artery
spasm, platelet aggregation, embolism, thrombus
secondary to rheumatic heart disease, cold, exercise, spasm
of arteries etc
 Clinical signs and symptoms of MI
May be silent – smokers, diabetics, reduced sensitivity to pain

Sudden cardiac death

Prolonged sub sternal chest pain/ squeezing pressure
Pain down one or both arms, jaw, throat, neck, back
Feeling of indigestion
Angina lasting 30 minutes or more
Angina unrelieved by rest, nitroglycerin, or antacids

Pain of infarct unrelieved by rest or change in position

nausea
pallor
Diaphoresis (heavy perspiration)
Shortness of breath
Weakness, numbness, feeling of faintness
Sudden dimness, loss of vision or speech
Isolated biceps aching
Pericarditis

 Inflammation of the pericardium, sac like covering of the heart

 May develop as a primary condition or secondary to

conditions such as influenza, TB, HIV, kidney failure,
autoimmune disorders, cancer or idiopathic
 Acute or chronic and recurring with scarred and thickened
pericardium
 Can occur in any age group therefore a history of recent
pericarditis with new onset of chest, neck or L arm pain is
important .
 Post infection onset can be 1-3 weeks later
•No signs symptoms initially
•Accumulation of fluid in
pericardium causes pain with
breathing

•Closely mimics MI pain pattern

•BUT MI pain unaffected by

position breathing or movement

•PERICARDITIS PAIN
relieved by kneeling on all
fours, forward or sitting
upright
•Worse pain with breathing,
swallowing, neck movements
•Pain diminishes if the breath is
held
•History of recent fever, chills
and infection
•Sharp pain with intermittent
bursts
Congestive heart failure or Heart failure

Also called cardiac decompensation or cardiac insufficiency

 Physiologic state in which the heart is unable to pump enough blood to meet the
metabolic needs of the body at rest or during exercise even though filling
pressures are adequate
 Not a disease itself, inadequate pump performance from cardiac valves or
myocardium
 Aneurysm
 Abnormal dilatation (saclike formation) in wall of artery, vein or
heart.
 Occurs when vessel or heart wall become weakened from trauma,
congenital vascular disease, infection or atherosclerosis
 Named according to artery or vein and the region.
 DISSECTING ANEURYSM – spits and penetrates the arterial wall
creating a false vessel.
 Thoracic aneurysms most common among men 40 – 70 years
 Most common site for peripheral arterial aneurysms – popliteal
space. May have an enlarged area behind knee without discomfort
Abdominal aortic aneurysms
AAA
 Most common places for aneurysm are aorta and cerebral arteries
 Progression of AAA – expansion and rupture
 Most common aortic aneurysm site just below kidney
 Can be caused by trauma, weight lifting in aging athletes, congenital
vascular disease, infection, atherosclerosis, clients having anterior
spinal procedures of any kind
 Exacerbated by anticoagulant therapy
 Therapist should be careful in prescribing resisted exercises, monitor
vital signs, instruct patients to avoid Valsalva maneuver
 Now recommendation of ultrasonographic screening for abdominal
aortic aneurysm for men aged 65 to 75 who smoke or have history of
smoking
Aortic aneurysm signs and
symptoms

•Mostly asymptomatic
•Pulsating mass in abdomen with or without pain
•Distended abdomen
•Change in blood pressure
•Changes in stool
•Possible back or shoulder pain
•Symptoms not relieved by change in position

RUPTURED
• SBP below 100 mmHg
•Pulse rate over 100
•Severe sudden abdominal pain
•Cold pulse less lower extremities
Conditions affecting the
valves
 Stenosis – is a narrowing or constriction that prevents the valve from opening
fully caused by growths, scars or abnormal growths on leaflets
 Insufficiency – (regurgitation) when valve does not close properly and blood
flows back into the heart chamber
 Prolapse – enlarged valve leaflets bulge back into the left atrium, only in the
mitral valve
 Require heart to work harder to pump blood. Complications might occur
secondary to bacterial infections (endocarditis)
 Pericarditis common in systemic lupus erythematosus – multi system illness
associated with release of autoantibodies in the blood stream
 Persons may be asymptommatic. Fatigue is an early sign followed by dyspnea.
Endocarditis
 Inflammation of cardiac endothelium
 Infection may be caused by bacteria entering the blood stream
by remote part of the body eg. Skin, oral cavity or growths on
previously damaged or artificial valves. Risk of embolization
of these growths or vegetations
 Injection drug users and post cardiac surgical clients at high
risk of developing endocarditis
 Musculoskeletal symptoms :
 Arthralgias
 Arthritis
 Low back/sacroiliac pain
 Myalgias
 Constitutional symptoms
 Neurologic deficits absent, morning stiffness absent
Rheumatic fever
 Infection caused by streptococcal bacteria. Can be fatal. Called such
because fever and joint pain are two most common symptoms
 Infection generally starts with strep throat in children 5 – 15 years
followed 2-3 weeks later by sudden or gradual migratory joint
symptoms in knees, shoulders, feet, ankles, elbows, fingers or neck.
Palpitations, fatigue, weakness, weight loss may also be present
 All layers of heart and the heart valves are affected

 Rheumatic Chorea – chorea in child 1-3 months after fever and poly
arthritis almost always a manifestation of rheumatic fever
 Recurrences common after 5 years of good health
Mitral valve prolapse

Mitral leaflet thickness, decrease stiffness and

strength due to connective tissue or left ventricular
cavity geometry abnormalities.
• benign or in combination with conditions such as
endocarditis, systemic lupus erythematosus,
fibromyalgia
• No symptoms in 2/3rd persons with MVP
•dysautonomia – imbalance of autonomic nervous
system
• SYMPTOMS
•Profound fatigue
•Dyspnea
•Palpitations
•TMJ syndrome
•Myalgia
•migraine
 Conditions affecting
cardiac nervous system

Failure of heart’s nervous system to conduct

normal electrical impulses
 Neurologically impaired patients susceptible
such as CVA, head trauma, spinal cord
injury
 Monitor pulse before, during and after
exercise when working with stroke patients
Sinus Tachycardia
 Heart rate >100 beats per minute
 Physiologic to stressors such as fever, anxiety, exertion,
thyrotoxicosis, MI, CHF, shock
 In patients with cardiac disease means reduced cardiac
output, CHF or arrythmia when persistent
 SYMPTOMS
 Palpitation
 Restlessness
 Chest discomfort/pain
 Agitation and anxiety
Sinus bradycardia
 Heart rate < 60 beats per minute
 Asymptomatic in athletes and youngster
 Benign arrhythmia might be beneficial by increasing longer
diastole period and increased ventricular filling
 Might occur after eye surgery, MI, jaundice
 SYMPTOMS
 Reduced pulse rate
 Syncope
 Weakness
 Sweating
 Nausea and vomiting
 Dimming of vision
Signs and symptoms immediately resolved by placing patient in
horizontal position
 Fibrillation

 Small electrical impulses by damaged atrial or ventricular muscles felt as

irregular pulses on palpation
 VENTRICULAR FIBRILLATION can result in sudden death and requires
immediate CPR with defibrillation
 ATRIAL FIBRILLATION can cause stroke by clot formation in the atria
SYMPTOMS RISK FACTORS

Palpitation Previous heart attack

Restlessness H Pylori
Fluttering, skipping, High BP
pounding Digitalis toxicity
Dyspnea CHF
Chest pain Pericarditis
anxiety Rheumatic mitral stenosis
Cardiovascular
disorders
Classification of blood pressure
For adults Systolic blood pressure Diastolic blood
pressure

Normal <120 mmHg <80mmHg

Prehypertensive 120-139 mmHg 80-89 mmHg

Stage I hypertension 140-159 mmHg 90-99 mmHg

Stage II hypertension ≥ 160 mmHg ≥ 100 mmHg

From the seventh report of the Joint National committee on prevention,

detection, evaluation and treatment of high blood pressure, NIH publication
no. 03-5233, May 2003. National Heart Lung and Blood Institute (NHLBI)
Risk factors for hypertension