4. Dyspnoea
• Classified according to NYHA (New York Heart
Association):-
1. Class I
• No limitation and symptoms during ordinary
activity
2. Class II
• Symptoms with ordinary activity, slight limitation
in physical activity
5. Dyspnoea
3. Class III
• Symptoms with less than ordinary activity,
marked limitation of activity
4. Class IV
• Symptoms even at rest, unable to carry out any
activity without symptoms
8. Mechanism of dyspnoea in heart
disease
• Left heart dysfunction
– Increased pulmonary venous pressure
• Transudation of fluid into the interstitial space
– Thickening of vessel wall (perivascular cells and fibers)
• Causes decreased compliance of lungs
– Increased airway resistance
– Both lead to increased work of breathing leading to
dyspnoea
9. Orthopnoea
• Dyspnoea on lying down/ in recumbent
position
• Relieved on sitting up or elevation of head
10. Orthopnea
• Mechanism
– Increased venous return
– Fluid returns to the vascular system
– Failing heart is unable to cope with the extra volume of
fluid / blood delivered to it
• Results in increase in pulmonary venous and capillary pressure
leading to pulmonary interstitial edema and decreased airway
resistance
– Elevated diaphragm leads to decreased vital capacity of
the lung
11. Paroxysmal nocturnal dyspnoea
• Episodes of dyspnoea which occurs at night
and awakens patient after 2-4 hours of sleep
and takes 10-30 minutes for recovery after
assuming upright postion
12. Mechanism
• Similar to orthopnoea
• Fall in PaO2 and decreased sympathetic
support to left ventricular function during
sleep
13. Causes of PND
• Ischemic heart disease
• Aortic valve disease
• Hypertension
• Cardiomegaly
• Atrial fibrillation
• Rarely in mitral disease
• Earliest symptom of Left ventricular failure
14. Dyspnoea
• Trepopnea
– Dyspnoea in left or right lateral decubitus position
• Platypnoea
– Dyspnoea in upright position
– Left atrial thrombus
– Left atrial tumors- myxomas
– Pulmonary arterio-venous fistula
15. Chest pain
• Also called angina pectoris
• Typical chest pain
– Central/ substernal/ retrosternal chest pain
– Increased on exertion
– Relieved on rest, or by nitrates
16. Systems Causes
Cardiovascular Coronary artery disease
Myocardial ischemia, MI
Spasm or narrowing of coronary
arteries
Aortic dissection
Aortic aneurysm
Myocarditis
Pericarditis
MVP
Aortic stenosis, Aortic regurgitation
Esophageal Esophagitis
Esophageal spasm
Mallory- Weiss syndrome
Lungs/ pleura Brochospasm
Pulmonary infarct
Pneumonia
18. Edema
• Accumulation of fluid in the interstitial spaces
• Occurs especially in heart failure
• Leads to defective systolic emptying by the
heart or impaired relaxation
– Accumulation of blood in the heart and venous
circulation
19. Mechanism
• Due to the failing heart, the circulation in the kidney also
decreases resulting in ischemic kidney
– Secretion of renin
– Renin- Angiotensin system is activated
– Secretion of aldosterone
• Sodium and water retention
– Due to aldosterone and ADH secretion
– The excretion of sodium from the kidney is reduced when heart
is not working efficiently. So sodium and water retention occurs
20. Mechanism
• Results in increase in plasma volume and
hydrostatic pressure in the capillaries, veins
and lymphatics
– Leads to transudation of the fluid into interstitial
spaces
– Results in EDEMA
21. Palpitation
• Awareness of ones own heartbeat
• Different kinds of palpitation patient might
experience
– Fast and regular e.g. Paroxysmal tachycardia
– Fast and irregular e.g. atrial fibrillation
– Fleeting and repetitive e.g. premature ectopics
– Fleeting and heavy heart beat
• Increased stroke volume
• Physical exertion, anxiety, emotion, fear, anemia, aortic,
mitral regurgitation, patent ductus arteriosus, VSD, ASD
22. Cyanosis
• Normally, the arterial blood is 95% oxygen
saturated whereas venous blood is 70%
saturated. The capillary blood is somewhere in
between
• Oxygen in the blood is attached to the
hemoglobin.
• Hemoglobin content is 15gm%
23. Cyanosis
• In the capillaries, out of 15gm% of Hb
– If 5gm% or more of Hb is devoid of oxygen
(reduced hemoglobin),
– It leads to bluish discoloration of skin and mucous
membrane leading to CYANOSIS
24. Cyanosis
• Central
– When oxygen saturation is very low
– Conjunctiva, palate, tongue, inner surface of the lips
and cheeks and outer lips
– Causes
• Congenital heart disease with right to left shunt
• Arterio-venous fistula of the lung
• Diseases of the lung e.g. COPD with corpulmonale
• Congestive heart failure with severe lung congestion
25. Cyanosis
• Peripheral
– Arterial oxygen saturation is normal
– Tissues extract excess of oxygen from the blood and
increase in the amount of reduced hemoglobin in the
blood
– Low cardiac output e.g. congestive heart failure
– Exposure to excess cold
– Fingers, earlobes, nose, cheeks, outer lips
26. Syncope/ presyncope
• Transient loss of consciousness resulting from
sudden and momentary reduction or stoppage of
blood supply to the brain.
• May or may not be preceded by feeling of
faintness or lightheadedness
28. Syncope
• Non cardiac causes
– Epilepsy
– Head injury
– Burns
– Drugs
– Pain, emotion and fear
– Cerebrovascular accidents
– Severe cough for prolonged periods
29. Fatigue
• Manifestation of cardiac failure
• Heart doesn’t pump enough blood to meet
the oxygen demand
– Leading to FATIGUE
30. Cough
• Left heart failure – venous pressure falls – fluid
goes into the bronchioles – peri-bronchial edema
– irritates the bronchi
• Sudden transudation of fluid in the alveoli – pt
tries to cough it out
• ACE inhibitors used in several cardiac diseases
31. Hemoptysis
• Causes
– Mitral stenosis
• Pressure in veins and venules is high due to rise in LA
pressure, if this pressure increases further, after physical
exertion, pulmonary venules rupture and cause hemoptysis
• Recurrent bronchitis- hemoptysis
• Acute pulmonary edema – pink frothy sputum
• Pulmonary infarction – hemoptysis
32. Causes
• Left ventricular failure/ acute pulmonary
edema
• Arterio-venous aneurysm and syphilitic or
mycotic aneurysm
33. Recurrent bronchitis
• Recurrent respiratory infections may occur in
patients with heart disease
• Those with large amount of blood going to the
lungs due to left to right shunt e.g. ASD, VSD, PDA
• Those with pulmonary congestion e.g. LVF, MS
• Chronic corpulmonale due to COPD
34.
35. Systemic embolus
• Thrombus or clot in the left side of the heart
• May get detached and reach different parts of
the body
• Embolism
36. Signs
• General examination including appearance
• Vitals
– Pulse
– BP
– Temperature and respiratory rate if relevant
• Examination of the JVP
• Proper examination of the cardiovascular system
37. Appearance
• Indicators of increase in accumulation of lipid in
the blood
– Yellowish deposits along the eyelids – Xanthelasma
– Over the skin and extensor surfaces – Xanthomas
– Around the rim of cornea – corneal arcus
– BMI
39. Character of the pulse
• Normal pulse
– Percussion wave followed by a dicrotic notch
which coincides with aortic valve closure. This is
followed by dicrotic wave
– We can only feel the percussion wave
40. Pulse
• Plateau pulse
– Anacrotic pulse/
Pulsus parvus et tardus
– Slow rising pulse
– Seen in AS
• Pulsus bisferiens
– Twice beating pulse
– Two systolic peaks
– Seen in AS+AR
41. Pulse
• Bounding pulse
– Sudden rise and sudden fall of the pulse wave
– Pulse amplitude is also high
– Bounding character felt best on lifting arm high up
– Also known as Water Hammer pulse/ Corrigan’s pulse
– Found in
• AR High fever
• Thyrotoxicosis Pregnancy
• Severe anemia Chronic corpulmonale
• PDA Carbon dioxide retention
• AV fistula
42. Pulse
• Bounding pulse
– Consists of closed glass tube with little water
inside it, the rest of the tube is vaccum
– If it is turned upside down, water from one end of
the tube suddenly falls to the other end and
strikes suddenly at the finger.
43. Pulse
• Dicrotic pulse
– Twice beating pulse
– After the percussion wave, a second wave is felt –
dicrotic wave
– Occurs in diastole
– Found in
• Severe congestive cardiac failure
• Cardiac tamponade
• Typhoid fever
45. Pulse
• Pulsus bigeminus
– Pulse is felt in pairs when one normal beat is
alternating with a premature ventricular
contraction
– Two beats are felt followed by a long pause
– Digitalis toxixity
46. Pulse
• Pulsus paradoxus
– During deep inspiration, the pulse becomes feeble or
disappears
– During expiration, the pulse is felt again
– Accentuation of the normal phenomenon
– Normally there should be a fall of SBP by 10mm Hg during
inspiration
– In pulsus paradoxus, it falls > 10mmHg
