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

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

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

4. 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

5. 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

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

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

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

9. 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

10. 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

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

12. 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

13. 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

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

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

16. 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

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

18. Effects of left ventricular failure leading to congestive heart failure

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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