SYMPTOMS of CVS Dyspnea Orthopnea Paroxysmal nocturnal dyspnea (PND) Cough Haemoptysis Syncope Fatigue Palpitations Chest pain

DYSPNEA “Awareness of respiratory effort” Causes of dyspnea: Physiological Cardiac Respiratory Abdominal Metabolic Anaemia Psychogenic

Cardiac causes of dyspnea: Left ventricular failure Mitral valve disease Cadiomyopathy Constrictive pericarditis and pericardial effusion

ORTHOPNEA “Respiratory distress on lying down” Mechanism: Venous return and cardiac output are increased by 25% on lying down Reabsorption of edema fluid from lower limb into the circulation Viscera push the diaphragm up and encroach on the lung

Paroxysmal Nocturnal dyspnea “ Attacks of severe dyspnea occurring at night and waking the patient up from sleep” Mechanism: Same mechanism + Sliding down from semi-sitting position after falling asleep Blunting of respiratory and cough center response during sleep allows pulmonary congestion to accumulate Bad dreams increase the heart rate and blood pressure

Haemoptysis “ coughing of blood” Cardiovascular causes: Mitral valve disease (due to pulmonary congestion) Acute left ventricular failure ( pulmonary oedema) Pulmonary infarction ( pulmonary embolism)

Palpitation “Awareness of heart beats” Mechanism: - Increased force of cardiac contraction - Change in the heart rate - Change in the rhythm

Chest pain A. Cardiac causes: Ischaemia Pericardial pain Great vessel pain

1. ISCHEMIC CHEST PAIN Atherosclerosis of coronaries is the most common cause Ischemic chest pain may be due to: ANGINA PECTORIS: transient myocardial ischemia during exercise. The coronaries are only partly occluded UNSTABLE ANGINA: Prolonged severe myocardial ischemia with or without patches of necrosis MYOCARDIAL INFARCTION: Complete arterial occlusion with myocardial tissue necrosis

ANGINA PECTORIS CHARACTER: SITE: RELIEVING FACTORS: Dull aching, squeezing, compressing or burning. Never stitching or throbbing SITE: Mostly retrosternal, usually radiates to left arm Sometimes may spread to root of neck, both shoulders and arms, back, epigastrium or jaw. Not under left breast. RELIEVING FACTORS: Relieved by rest-after 1-3 min and by sublingual nitroglycerin

PRECIPITATING FACTORS: Exertion Emotion Heavy meals Exposure to cold Sexual intercourse ASSOCIATED MANIFESTATIONS: Sweating Tachycardia Anxiety Rise in blood pressure

MYOCARDIAL INFARCTION Pain is identical with that of angina in character, site and radiation but is much more severe and prolonged and is not relieved by rest or sublingual nitroglycerin May be accompanied by vomiting and sense of impending death

2. Pericardial pain: Site: to the left of the sternum overlying the heart, may radiate to shoulder or neck Character: sharp and cutting Constant or made worse by sudden movement Worse on lying back, eased by leaning forward Increased by coughing, swallowing or inspiration

3. Great vessels pain: Aneurysm of the aorta Dissecting aneurysm in the aorta Pulmonary embolism

B-NON CARDIAC CAUSES: Pain from chest wall Pain from lungs, pleura or mediastinum Pain from abdominal causes

How these symptoms occur: 1. Manifestations of the cause as chest pain in IHD 2. Manifestations of pulmonary congestion 3. Manifestations of low cardiac output

Manifestations of pulmonary congestion Causes of pulmonary congestion * Left heart failure due to : - Valvular disease (AS – AR – MR) - Hypertension - IHD - Cardiomyopathy * Mitral stenosis

Effects of left ventricular failure leading to congestive heart failure

There is increased LVEDP  increased LAP  increased pulmonary venous and capillary pressure  interstitial edema The lungs are overfilled, stiff, difficult to distend leading to dyspnea, orthopnea and PND Dyspnea also results from reflexes initiated from the stiff lungs and distended left atrium

4. Transudation of small amount of serum in the alveoli makes the alveolar wall sticky and their inflation with inspiration produces fine crepitations 5. With severe congestion the alveoli become filled with transudate resulting in pulmonary edema

In pulmonary edema there is severe dyspnea, cyanosis, cough with expectoration of large amount of frothy sputum tinged with blood The flow of air in the fluid produces bubbling crepitations heard all over the chest Some distended pulmonary and bronchial veins and capillaries may rupture and release blood in the alveoli and bronchi causing haemoptysis

Congestion of bronchial mucosa increases the secretion of mucus which is expectorated as white or colorless sputum Congestion of the visceral pleura may result in pleural effusion

Pulmonary vessels react to congestion by arteriolar vasoconstriction Blood flow from pulmonary arteries to pulmonary veins will be limited by the resistance of the arterioles leading to: Decrease in severity of pulmonary congestion and relief of its symptoms Increase in the pressure in the pulmonary arteries  Pulmonary Hypertension Right ventricular hypertrophy and failure may result

Low cardiac output Causes: Resistance to cardiac emptying: Severe valvular stenosis Severe pulmonary hypertension Incomplete cardiac filling: External compression limiting diastolic filling: massive pericardial effusion Limitation of diastolic filling by severe tachycardia Reduction of venous return by dehydration

Clinical features of low COP Symptoms Easy fatigability Dizziness, blurring of vision, syncope Angina Signs Small volume of pulse Sinus tachycardia Peripheral cyanosis Cold extremities Pallor Oliguria