Makindo Medical Notes

Related Subjects: |Cardiac Examination |Cardiac History Taking |Respiratory Examination |Gastroenterology Examination |Cardiac Anatomy and Physiology |Coronary Artery Anatomy and Physiology |Cardiac Electrophysiology |Cardiac Embryology

Cardiac arrest can be the first manifestation of ischaemic heart disease, hypertrophic cardiomyopathy, or other causes of sudden cardiac death. Defibrillation for VF/VT can be lifesaving.

Introduction

• Gather a comprehensive history of the presenting complaints and try to quantify symptoms (e.g., distance walked before symptoms, number of cigarettes smoked daily, number of pillows needed for comfortable sleep).
• Establish a clear timeline for symptoms as patients may provide vague answers (e.g., "a while ago"); clarify by asking, "Is that a day, a week, a month, or longer?"
• Risk factors are essential and include smoking, hypertension, family history, diabetes, hypercholesterolaemia, rheumatic fever, and alcohol use, as these significantly impact heart disease risk.
• Assess the impact of symptoms on daily activities (e.g., ability to climb stairs, do housework, or manage personal care); enquire about help needed for these tasks.
• When discussing chest pain with suspected cardiac causes, always present associated risk factors to help assess the likelihood of ischemic heart disease. For example, the same pain in a 25-year-old woman without risk factors may be evaluated differently than in a 60-year-old male smoker with hypertension and diabetes.
• Common symptoms of cardiac disease include chest pain, fatigue, breathlessness, palpitations, syncope, and presyncope.

Chest Pain

• Differential Diagnosis of Acute Chest Pain:
  • Acute Coronary Syndrome (ACS): ECG, troponin, echocardiogram.
  • Pulmonary Embolism (PE): D-dimer, CT pulmonary angiogram (CTPA).
  • Aortic Dissection: Chest X-ray (CXR), CT scan, transoesophageal echocardiogram (TOE).
  • Oesophageal Rupture: Based on history, confirmed by CXR.
  • Pneumothorax/Tension Pneumothorax: Expiratory CXR for diagnosis.
  • Pleurisy/Pneumonia: CXR, fever, systemic symptoms.
  • Herpes Zoster (Shingles): Rash, burning pain along a dermatome.
  • Rib or Sternal Fracture: Typically traumatic history.
• Cardiac chest pain is often due to myocardial ischaemia or infarction, arising when myocardial oxygen demand is unmet, causing lactate build-up or tissue necrosis.
• Myocardial infarction (MI) pain is more severe, typically with additional symptoms such as pallor, nausea, vomiting, and a cold, sweaty appearance.
• Resting or using glyceryl trinitrate (GTN) can relieve ischemic pain; however, pain persisting at rest may indicate MI.
• Classically, cardiac pain is a central, heavy pressure, often described with a clenched fist gesture over the chest ("Levine's sign").
• In diabetics and elderly patients, ischaemia and infarction can present atypically or silently, with symptoms like fatigue or breathlessness rather than chest pain.
• Pericarditis may cause constant pain, unrelated to exertion, worsening with deep inspiration and relieved by sitting forward. A friction rub may be audible on auscultation.
• Aortic dissection typically presents with a severe, tearing pain that radiates to the back, though subtle cases may mimic ACS or be diagnosed post-mortem.
• For angina, assess the level of exertion needed to provoke pain instead of quoting scales; ask if it occurs at rest, with minimal, moderate, or severe exertion.

Breathlessness

• Breathlessness in cardiac disease often indicates heart failure, where the heart cannot meet the body’s oxygen demands.
• Alveolar oedema and incipient pulmonary oedema may worsen breathlessness.
• Orthopnea: Worsening breathlessness when lying flat, due to fluid redistribution. Often assessed by the number of pillows needed for comfortable sleep.
• Paroxysmal Nocturnal Dyspnea (PND): Sudden onset of severe breathlessness, often occurring within hours of lying down, causing the patient to sit upright to relieve symptoms.
• Oedema: Ankle swelling usually suggests right heart failure. Oedema may progress up the legs to the abdomen (ascites) and scrotum, often accompanied by hepatomegaly and pleural effusion.

Fatigue

• A common symptom of heart failure or cardiac impairment, also seen with anaemia, hypothyroidism, malignancy, and viral illnesses.
• Assess how the patient's daily life and stamina have changed compared to before symptom onset.

Palpitations

• Abnormal awareness of the heartbeat. Ask the patient to tap out the rhythm to determine regularity and speed.
• If fast and stops suddenly, inquire about polyuria post-episode, which may suggest supraventricular tachycardia (SVT).
• A single, occasional "thump" may indicate a post-ectopic beat, usually benign but notable in cardiac history.

Syncope or Presyncope

• Always take episodes seriously. Listen for murmurs and assess for arrhythmias.
• Obtain a detailed history of the events preceding the episode, including the patient’s activity and any associated symptoms.
• Gather witness reports when possible to better understand the episode.
• Investigations include ECG, echocardiogram, and 24-hour Holter monitor if cardiac causes are suspected.
• Cardiac Causes of Syncope:
  • Severe aortic stenosis.
  • Severe bradycardia (e.g., complete heart block, sinus pauses).
  • Vasovagal syncope, sometimes exacerbated by medications.
  • Ventricular tachycardia (VT).
  • Stokes-Adams attack (syncope due to heart block).

Cardiac Arrest

• Characterized by absence of cardiac output, with no pulse or breathing.
• Causes:
  • Pulseless VT.
  • Ventricular fibrillation (VF).
  • Asystole.
  • Electromechanical dissociation (EMD), also known as pulseless electrical activity (PEA).