1. THE CARDIOVASCULAR SYSTEM University of TEESSIDE Nurse Practitioner Course Dr. Phil Jennings. James Cook University Hospital

2. Introduction History Taking –Features of common symptoms –Presentation of common problems Examination Routine –What do to –Important physical signs Investigations –A quick look at X rays and ECGs

3. Symptoms: Chest Pain Important points to establish –Site –Radiation –Character –Exacerbating and Relieving factors –Duration –Associated symptoms

4. Symptoms: Chest Pain CARDIAC Angina Myocardial Infarct Pericarditis Aortic dissection PULMONARY Pleurisy Pulmonary Embolus Pneumothorax GASTRO Ulcer or Reflux Gallstones Pancreatitis MUSCULOSKELETAL Chostochondritis Trauma NON ORGANIC Anxiety

5. Chest Pain: Angina Angina pains are typically central crushing chest pains. Patients describe angina as feeling like a heavy weight in the middle of the chest Angina can present in unusual positions

6. Chest Pain: Angina Angina pains commonly radiate to the arms, neck and jaw Typically angina lasts for several minutes

7. Chest Pain: Angina Angina pains normally occur during periods of physical exertion. This is the single most important factor to consider when deciding if a patient has angina or not The term ‘unstable angina’ is used to describe pains which occur at rest and signifies severe coronary disease

8. Chest Pain: MI Features suggesting MI –The pains are usually more severe –There are more associated symptoms such as sweating, nausea or vomiting –Duration is > 30 minutes –Usual relieving factors such as rest or GTN spray do not help

9. Chest Pain: Pericarditis Pericarditis –Similar distribution to angina / MI –Often sharper or stabbing –Helped by sitting forward –Typically has a long duration –Often seen in otherwise well, young patients without coronary disease –May be a history of a viral illness of fever

10. Chest Pain: Dissection Features of Dissection –Pains are described as tearing and can be excruciating –Often radiates through to the back

11. Symptoms: Palpitations Important points to establish Onset Rate Rhythm Duration Termination Associated symptoms

12. Symptoms: Palpitations Supraventricular Atrial Fibrillation Atrial Flutter Atrial Tachycardia Reentrant Tachycardia Ventricular Ventricular Ectopics Ventricular Tachycardia

13. Symptoms: Palpitations Features of Atrial Fibrillation –Common. Especially elderly or IHD –Pulse is irregularly irregular in other words unpredictable from one beat to the next –Can be an incidental finding or presents with palpitations, fatigue, chest pain or breathlessness –The mainstay of treatment is rate control and anticoagulation –Electrical cardioversion may be used in some patients

14. Symptoms: Breathlessness Breathlessness or dyspnoea can have a number of causes –Heart Failure –Valve disease –Myocardial Ischaemia –Pericardial disease There are also non cardiac causes of dyspnoea - Pulmonary disease - Anaemia, Obesity or being unfit

15. Symptoms: Breathlessness Important points to establish –Occurrence of symptoms: All the time Woken from sleep During exertion –Assess normal exercise tolerance –Associated symptoms Chest pain, palpitations Cough, wheeze, sputum, haemoptysis Ankle oedema

16. Symptoms: The End Any Questions So Far ???

17. Examination Suggested CVS Exam routine –General Inspection –Hands –Pulse –BP –Head & Neck JVP, Carotids, Anaeimia, Cyanosis –Praecordium –Auscultation –Extras

18. Examination What is the most important start to any exam ?? Introduce yourself to the patient and let them know what you are about to do …

19. Exam: General Inspection If the patient is not exposed then ask if you may expose them The patient should be reclined at a 45º angle Look for obvious –Breathlessness –Pallor –Sweating –Scars –Props: Oxygen pipes, Inhalers, GTN spray Make some comments

20. Exam: Hands Start with the nails and look for clubbing –Increased Curvature –Loss of nail bed angle –Fluctuant nail Beds Examine BOTH hands at eye level

21. Exam: Hands Cardiovascular causes of clubbing can be –Congenital Cyanotic Heart Disease –Atrial Myxoma –Endocarditis

22. Exam: Hands Next look for Splinter Haemorrhages –A sign of systemic vasculitis which may indicate Infective Endocarditis. –They can also be caused by trauma so remember to bear in mind the patient’s occupation

23. Exam: Hands Other points to note –Temperature –Perfusion –Pallor –Nicotine staining –Extensor tendon swellings (xanthomas)

24. Exam: Pulse Start by palpating the radial pulse At this site asses –Rate –Rhythm You should not asses volume at the radial artery

25. Exam: Pulse Next move to the brachial artery to assess –Volume –Character

26. Exam: Blood Pressure You may now want to measure the blood pressure A single measurement is acceptable unless the history suggests dissection

27. Exam: Head & Neck: FACE Jaundice

28. Exam: Head & Neck: FACE Anaemia

29. Exam: Head & Neck: FACE XanthelasmaArcus

30. Exam: Head & Neck: FACE Cyanosis

31. Exam: Head & Neck: JVP The JVP is best examined by looking across the neck. A double waveform should be seen for each cardiac cycle

32. Exam: Head & Neck: JVP Sternal Angle Top of venous pulsation Height Of JVP In cms

33. Exam: Head & Neck: JVP Carotid Pulsation –1 per cardiac cycle –Palpable –Position independent –Does not enhance with hepatojugualr –reflex JVP Pulsation –2 per cardiac cycle –Not palpable –Varies depending on position –Enhances with hepatojugular reflex

34. Exam: Praecordium Look For Obvious Deformity Pigeon Chest Funnel Chest

35. Exam: Praecordium Look For Obvious Scars Median Sternotomy CABG, Valve, Tx Lateral Thoracotomy Coarct Repair

36. Exam: Praecordium Locate Apex Examine for heave

37. Exam: Praecordium 1 2 3 1.Mid Clavicular Line 2.Anterior Axillary Line 3.Mid Axillary Line 2 nd 3 rd 4 th 5 th Intercostal Spaces

38. Exam: Auscultation Bell Low pitched murmurs eg. Mitral Stenosis Press hard enough only to make a seal with the skin The ‘hole’ must be rotated to the bell in order for it to work

39. Exam: Auscultation Diaphragm Normal / High pitched murmurs. Use for general purpose auscultation

40. Exam: Auscultation Earpiece Angled to provide a better fit into the auditory cannal. During use point forward unless you have an abnormal shaped head !

41. Exam: auscultation 1. Apex: Mitral Valve 2. Sternal Edge: Tricuspid Valve 3. L 2 nd Space: Pulmonary Valve 4. R 2 nd Space: Aortic Valve BELL & DIAPHRAGM

42. Exam: auscultation Heart Sounds: LubDub FirstSecond Mitral Valve Tricuspid Valve Aortic Valve Pulmonary Valve

43. Exam: auscultation Heart Murmurs: Systolic FirstSecond Pan Systolic Murmur Mitral Regurgitation Tricuspid Regurgitation

44. Exam: auscultation Heart Murmurs: Systolic FirstSecond Ejection Systolic Murmur Aortic Stenosis Pulmonary Stenosis VSD

45. Exam: auscultation Heart Murmurs: Diastolic FirstSecond Early Diastolic Murmur Aortic Regurgitation

46. Exam: auscultation Heart Murmurs: Diastolic FirstSecond Mid Diastolic Murmur Mitral Stenosis

47. Exam: auscultation Heart Murmurs: Extras Mitral Murmurs Mitral Area Patient in Left Lateral Radiate to Axilla

48. Exam: auscultation Heart Murmurs: Extras Aortic Murmurs Aortic Area Sit Patient Forward Breath Held in Expiration Radiates to Carotids

49. Exam: Extras Is there anything else you wish to do ? –Examine the peripheral pulses –Check for radio – radial or radio – femoral delay –Listen at the lung bases –Check for sacral oedema –Check for peripheral oedema –Measure the BP if not already done

50. Investigations: CXR NameMarkerProjection

51. Investigations: CXR Cardiac Silhouette Lung Fields

52. Investigations: CXR Right Hemidiaphragm Left Hemidiaphragm TracheaRight Hilum Left Ventricle Left Atrial Appendage Aortic Knuckle

53. Investigations: CXR CardiacThoracic Normal Cardio – Thoracic Ratio (CTR) is up to 0.5

54. Investigations: ECG

55. Calculating the Heart Rate Divide 300 by the number of large squares inbetween R waves 300 / 2 = 150 bpm 300 / 6 = 60 bpm

56. Investigations: ECG Rhythm In sinus Rhythm 1 P wave for each QRS complex Rate lies between 60 – 100 beats per minute

57. Investigations: ECG Normal ECG

58. Thankyou for your attention