1. Dr. J.A. Coetser GKV 353 CoetserJA@ufs.ac.za 0833542861

2. A 56 year old white male presents to casualties at 3h40am, complaining of severe chest pain that started 30min earlier. WHICH IMPORTANT ASPECTS WOULD YOU ELICIT FROM THE HISTORY?

3.  When evaluating symptomatic complaints Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity

4.  Determine the cause!  4 cardinal features Duration (timing) Location (site) Quality (character) Precipitating and aggravating factors

5.  Angina Crushing pain, heaviness, discomfort or choking sensation in retrosternal area Central rather than left chest May radiate to jaw and/or arms Rarely below umbilicus Typical vs. atypical angina

6. Typical anginaMeets all 3: 1.Characteristic restrosternal chest discomfort – typical quality and duration 2.Provoked by exertion or emotion 3.Relieved by rest or GTN or both Atypical anginaMeets 2 of above Non cardiac chest painMeets 1 or none of above

7.  Pain from acute coronary syndromes (myocardial infarction and unstable angina) Often comes on at rest Pain present >30min

8. Clot dissolves Coronary blood flow returns No cardiac muscle damage Clot persists Coronary blood flow cut off Cardiac muscle dies UNSTABLE ANGINAMYOCARDIAL INFARCT Angina Acute coronary syndromes

10.  Pleuritic pain Due to movement of pleural surfaces on one another Inflammation of pleura or pericardium  Viral infection of pleura  Pneumonia  Pulmonary embolism Made worse by inspiration Often relieved by sitting up and leaning forward

11.  Dissecting aneurysm 3 features  Severe, tearing pain  Rapid onset  Radiates to back Proximal aorta dissection = anterior chest pain Descending aorta dissection = interscapular pain Hx of HPT, or connective tissue disorder e.g. Marfan’s syndrome

12.  Massive pulmonary embolism Sudden onset May be retrosternal/angina-like Can be associated with dyspnoea, collapse and cyanosis

13.  Spontaneous pneumothorax Sharp pain and severe dyspnoea Localized to one part of chest

14.  Oesophageal disorders Reflux disease can mimic angina Oesophageal spasm  Especially after drinking hot or cold fluid  Associated with dysphagia  Relieved by nitrates

15.  Don’t forget: Cholecystitis Herpes zoster

16.  Dyspnoea definition: unexpected awareness of breathing Sensation of increased force needed for work of breathing  Need to distinguish between cardiac and respiratory causes

17.  Cardiac dyspnoea LV output fails to rise during exercise Increased LV end-diastolic pressure Raised pressure in LA Raised pressure in pulmonary venous system Leakage of fluid into interstitial space Decreased lung compliance

18. NYHA classification of dyspnoea Class IDisease is present, but no dyspnoea OR Dyspnoea only on heavy exertion Class IIDyspnoea on moderate exertion (climbing stairs) Class IIIDyspnoea on minimal exertion (getting dressed, washing) Class IVDyspnoea at rest

19.  Orthopnoea Dyspnoea in the supine position In supine position, interstitial oedema distributes to all lung zones, decreasing overall oxygenation In sitting position, oedema redistributes to lower zones, leaving upper zones free for oxygenation Other causes of orthopnoea  Massive ascites  Pregnancy  Bilateral diaphragmatic paralysis  Large pleural effusion  Severe pneumonia

20.  Paroxysmal nocturnal dyspnoea (PND) Severe dyspnoea that wakes patient from sleep Has to sit up and gasps for breath Mechanism  Sudden failure of LV  Reabsorption of peripheral oedema at night while supine with overload of LV  Don’t forget anxiety as cause of dyspnoea Inability to take deep enough breath to fill lungs in satisfying way

21.  Ankle oedema of cardiac origin Usually symmetrical Worst in evenings, improves during night As failure progresses, involves legs, thighs, genitalia and abdomen Find out if pt is on a calcium channel blocker, i.e. Adalat XL ® (nifedipine), amlodipine, etc., which can also cause ankle oedema If oedema also involves face, think of nephrotic syndrome

22.  Definition palpitations: unexpected awareness of the heartbeat Ask pt to tap out beat with finger Ask if palpitations are slow or fast, regular or irregular, and what the duration is Any fast arrhythmia can produce angina if pt also has ischaemic heart disease

23.  Atrial fibrillation Completely irregular rhythm  Atrial or ventricular ectopic beat Sensation of skipped beat, followed by particularly heavy beat  Ventricular tachycardia Rapid palpitations followed by syncope

24.  Syncope = transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate cerebral blood flow  Presyncope = transient sensation of weakness without loss of consciousness (I’m about to faint)  NB: ask about family history of sudden death Long QT syndrome / Brugada syndrome

25.  Postural syncope LOC when standing for long periods or standing up suddenly  Ask about drugs that can cause postural hypotension  Micturition syncope LOC when passing urine  Vasovagal syncope LOC with emotional stress  Syncope due to arrhythmia LOC regardless of position  Exertional syncope Aortic stenosis Hypertrophic cardiomyopathy

26.  Claudication = pain in one or both calves (thighs or buttocks) on walking more than a certain distance (claudication distance)  6 P’s of peripheral vascular disease Pain Pallor Pulselessness Parasthesiae Perishingly cold Paralysed  Lumbar spinal stenosis (pseudo claudication) Pain relieved by flexing spine Exacerbated by walking downhill

27.  Common symptom of cardiac failure  Remember other causes Lack of sleep Anaemia Depression

28.  Previous ischaemic heart disease  Hypercholesterolaemia  Smoking  Hypertension  Family history 1 st degree relatives (parents of siblings) Especially if <60yrs  Diabetes mellitus DM is a coronary heart disease equivalent Risk of diabetic for MI is the same as a non-diabetic who has had an infarct  Chronic kidney disease

29.  Which medications?  Any side-effects?  Previous procedures, e.g. CABG, angioplasty Ask how many arteries were bypassed? How many stents were placed?

30.  Previous MI or angina? Increases risk for further events  Rheumatic fever  Hypertension Alcohol use Salt intake Obesity Lack of exercise Kidney disease NSAIDs

31.  Ischaemic heart disease can interfere with daily functioning Is patient still working? Has living arrangements changed?  Enquire about rehabilitation programs