Lesson 7: Cardiovascular Dysfunction

1. Chest Pain

a. Typical Angina Pectoris due to Local Myocardial Ischemia

• Manifestations:

• Heavy, squeezing, crushing chest pain.

• Onset during exertion.

• Pain behind the breastbone.

• Radiates to the left shoulder, left arm, left jaw, inner left forearm, little finger of the left or right hand.

• Pain duration < 20 minutes.

• Relieved by rest, vasodilator use.

• May be accompanied by sweating, nausea.

• Note:

• Angina pectoris is a warning sign of the risk of myocardial infarction and needs to be managed promptly.

• It is necessary to differentiate from chest pain due to other causes.

b. Chest Pain due to Aortic Dissection

• Manifestations:

• Severe, stabbing pain, radiating to the back or only pain in the back and abdomen.

• Sudden onset, shock state, pale, cold extremities.

• History of hypertension (HTN), Marfan syndrome.

• Note:

• This is a dangerous condition, immediate medical attention is required.

c. Chest Pain due to Pulmonary Embolism

• Manifestations:

• Severe chest pain accompanied by cough (hemoptysis), dyspnea, anxiety.

• History of deep vein thrombosis (DVT), after hip or knee replacement surgery, after childbirth due to amniotic fluid entering the venous system.

• Usually pulmonary artery embolism (PAE).

• Note:

• It is necessary to differentiate from myocardial infarction.

d. Chest Pain due to Pericarditis

• Manifestations:

• Pain in the intercostal spaces, radiating to the neck and shoulder.

• Sharp, stabbing pain, especially when breathing and when the chest moves.

• Pain decreases when sitting forward, increases when lying on the side.

• Beck’s triad of acute cardiac tamponade:

• Hypotension to the point of collapse.

• Heart sounds muffled or sometimes very difficult to hear.

• Distended jugular veins.

• Note:

• It is necessary to differentiate from chest pain due to other causes.

e. Unstable Angina and Acute Myocardial Infarction

• Unstable angina:

• Onset at rest.

• Severe pain.

• >30 minutes.

• Accompanied by severe symptoms.

• No relief with rest, vasodilator use.

• Acute myocardial infarction:

• Severe, terrible chest pain, “feeling like tons of bricks are crushing the chest.”

• First appearance or previous history of stable or unstable angina.

• Sometimes chest pain is unclear or mild, vague. Often in patients with diabetes or the elderly.

f. Dyspnea

• Causes:

• Increased oxygen demand.

• Fluid redistribution.

• Orthopnea + arterial compression of the bronchi.

• Due to severely reduced cardiac output.

• Alveolar edema.

• Types of dyspnea:

• Dyspnea on exertion.

• Frequent dyspnea, even at rest.

• Paroxysmal dyspnea.

• Cheyne-Stokes breathing.

• Dyspnea classification according to NYHA:

• NYHA 1: no dyspnea on exertion.

• NYHA 2: dyspnea on significant exertion.

• NYHA 3: dyspnea on minimal exertion.

• NYHA 4: dyspnea at rest, when lying down. Paroxysmal dyspnea.

g. Edema

• Mechanism:

• Increased hydrostatic pressure.

• Increased vascular permeability.

• Decreased oncotic pressure – accumulation of Hyaluronic acid in the skin – allergies.

• Edema classification:

• Generalized edema: seen in congestive heart failure, hypothyroidism, cirrhosis, pulmonary hypertension, renal failure, protein loss through the gastrointestinal tract, excessive fluid infusion, malnutrition, hypothyroidism.

• Localized edema: seen in deep vein thrombosis, allergic edema, signs of upper TMC compression, lymphangitis, lower TMC obstruction.

• Nutritional edema, edema due to hormones.

• Edema manifestations in heart failure:

• Generalized edema, pitting edema.

• Edema in both lower extremities first, then generalized edema.

• Edema associated with dyspnea and cyanosis.

• Reduced after treatment with diuretics, positive inotropic drugs, aldosterone antagonists.

h. Syncope

• Mechanism:

• Due to a sudden decrease in blood flow to the brain.

• Reduced cerebral blood flow.

• Cardiovascular causes:

• Arrhythmias -> decreased cardiac output -> decreased brain perfusion.

• Complete atrioventricular block.

• Aortic valve stenosis: usually during exertion.

• Hypertrophic obstructive cardiomyopathy.

• Left atrial myxoma: patients feel dizzy while walking -> faint due to myxoma blocking the mitral valve -> patients may wake up when the myxoma moves away from the valve or die.

• Thrombus lodged in the artificial heart valve.

• Other causes:

• Postural hypotension.

• Gastric distention.

• Severe anemia.

• Hypoglycemia.

• Seizures.

i. Cyanosis

• Cause:

• When reduced Hb >5g/l or there are abnormal Hbs (MetHb).

• Classification:

• Central cyanosis:

• Due to decreased arterial oxygen saturation due to p-t shunt: congenital heart disease -> dark blood enters the systemic circulation -> cyanosis.

• Poor lung function: arterial blood is not well oxygenated -> cyanosis (chronic lung disease).

• Peripheral cyanosis:

• Mostly due to vasoconstriction under the skin, low cardiac output, exposure to cold.

• Heart failure.

• Raynaud’s syndrome.

• Localized cyanosis in one limb: arterial obstruction, venous thrombosis.

j. Raynaud’s Syndrome

• Manifestations:

• Painful episodes in the cold.

• Often occurs in the fingertips (less often in the feet).

• Finger numbness and tingling followed by sudden cyanosis, loss of sensation.

• May resolve or progress to severe pain, at which point there is a feeling of being bitten.

• Soaking the hands in hot water relieves pain.

• Pain from a few minutes to a few hours.

• Occurring multiple times -> digital necrosis.

k. Palpitations

• Manifestations:

• Rapid, strong heartbeat, an uncomfortable feeling.

• Feeling like the heart is jumping out of the chest, racing heart, irregular heartbeat, a feeling of pulsation in the neck.

• Causes:

• Stress.

• Hyperthyroidism (Basedow’s disease, hyperthyroidism, hyper-sympathetic).

• Heart failure, arrhythmias, paroxysmal tachycardia.

• Atrial fibrillation, sinus tachycardia.

• Extrasystoles: occasional premature beats followed by compensatory pause.

• Bradycardia: long diastole, a lot of blood returning to the heart, the heart has to pump harder.

l. Cough

• Causes:

• Respiratory system, lung parenchyma.

• Cardiovascular disorders.

• Types of cough:

• 1. Dry cough at night, cough after exertion + dyspnea and crackles in the lungs.

• 2. Coughing up blood, pink frothy sputum seen in heart failure, acute pulmonary edema.

• 3. Rusty sputum seen in pulmonary embolism; due to lung tissue necrosis.

• 4. Large amounts of fresh blood-tinged sputum may be accompanied by dyspnea seen in mitral stenosis.

• 5. Large amounts of blood-tinged sputum seen in rupture of pulmonary arteriovenous malformation.

m. Fatigue

• Causes:

• A cardinal symptom of heart failure but not very specific.

• Due to reduced cardiac output -> muscle weakness.

• Using HA drugs too strongly, using diuretics too much.

• Sudden severe fatigue can be a symptom accompanying acute AMI.

n. Heart Failure

• Early symptoms:

• Nocturia.

• Progressive symptoms:

• Poor appetite, abdominal distention, heaviness and fullness in the right hypochondrium, weight loss, weakness.

• Symptoms of Digoxin toxicity:

• Nausea, vomiting, visual disturbances.

o. Other symptoms:

• Recurrent laryngeal nerve compression: seen in aortic aneurysm, PAE, dilated left atrium.

• Hoarseness: infective endocarditis.

• Skin and mucous membranes gradually turn yellow: cardiac cirrhosis with severe chronic heart failure.

p. Symptoms suggestive of heart failure:

• May cause dry cough, coughing up pink frothy sputum.

• Pitting edema of both legs, decreased in the early morning and increased in the evening.

• Dyspnea on exertion.

q. Symptoms suggestive of acute pulmonary edema:

• Severe dyspnea.

• Moist crackles at the lung bases rising like a tide.

• Coughing up pink frothy sputum.

• Anxiety and panic.

General Notes:

• This article is for informational purposes only and cannot replace the advice of a doctor.

• If you have any cardiovascular symptoms, please see a doctor for timely diagnosis and treatment.

• Always maintain a healthy lifestyle, exercise regularly, and control risk factors such as blood pressure, blood sugar, and cholesterol to prevent cardiovascular disease.