1. Goodman

2.  Chest pain or discomfort: local vs. systemic?  Local : provoked by local palpation; usually with good reason (history of local trauma)  Systemic: can also radiate to neck, jaw, upper trapezius, upper back, shoulder or arms  **IF cardiac AND due to ischemia>>ANGINA  **IF cardiac, radiation is most common to left arm (NOT exclusive to left arm)  **Signs of ischemia > can be seen on ? What

3.  Angina: chest pain due to ischemia  Stable angina> exertional ; relieved with rest/stopping activity; responds well to NTG  Unstable angina> non-exertional; can be present at rest; sudden onset; may be different from patient’s usual angina pattern; when supply cannot keep up with demand  How do we know of ischemia? EKG changes and can show up with cardiac enzymes  Know about angina EQUIVALENT

4.  Palpitations : feeling irregular heart beats/rhythm  Can be extra or skipped  Can feel like a “fluttering” in the chest  Other words that patients use to describe: a bump, pounding, jump, flop, butterfly, racing sensation  Sign of palpitations: EKG assessed arrhythmias

5.  Dyspnea: SOB, breathlessness, uncomfortable feeling with breathing  Dyspnea that occurs in recumbant position (including supine) >>orthopnea  Signs of dyspnea: tachypnea, nasal flaring, accessory muscle use  Signs that dyspnea is due to a medical emergency include: wheezing, cyanosis, drops in BP, irregular cardiac rhythm  WHAT condition can cause these things??

6.  Cardiac syncope: fainting! Due to cardiac issue  What do you think the BP is doing??

7.  Vasovagal Syncope: fainting! Due to non-cardiac issue  BP drops but not due to cardiac issue  WHAT do you think could cause this?  Vasovagal syncope is the cause of many of these events?? Do you know what?

8.  Fatigue: at a minimum exertion can be due to cardiac pathology  If so, it usually includes other symptoms such as dyspnea, chest pain, palpitations  Or signs such as drop in BP, ECG abnormalities, abnormal heart or lung sounds

9.  Cough: Dry vs. wet  Productive vs. non-productive (does something come up or get swallowed?)  Dry can be a sign or early onset of CHF (low specificity)  Specificity increases if highly repeatable with physical exertion/fatigue

10.  Cyanosis: bluish discoloration due to lack of oxygen  Can be due to low oxygen in the blood (Hct and/or SpO2); or due to oxygen delivery (blood flow)  Blood flow problems can be local (vascular issues) or systemic (low cardiac output)

11.  Peripheral edema: hallmark sign of right ventricular failure  Do you know WHY??  Most common cause of right ventricular heart failure is left ventricular heart failure  DO NOT get confused here….  Another cause of right ventricular heart failure is pulmonary hypertension  AND pulmonary hypertension is most commonly caused by left sided heart failure  Are you following…???

12.  Claudication: can think of as ‘stable angina in the legs’  Pain in the legs brought on by activity due to peripheral vascular disease (PVD)  Patients may describe this as the symptom limiting their walking, especially up hills or increased distance  Typically relieved with rest  ‘Claudication is to leg cramping /pain as angina is to chest pain’

13.  A. Specific effects of aging  “Aging of the heart is associated with a number of typical morphologic, histologic, and biochemical changes, although not all observed changes with age are associated with deterioration in function.”  HUH?  Aging vs. disease is difficult to separate in the CV system due to the high prevalence of high blood pressure and ischemic cardiac diseases  (is this from normal aging process or from a disease process)?

14.  A. Specific effects (cont.)  Disease independent changes include:  1. reduction in myocytes and conduction system cells  2. cardiac fibrosis  3. decreased calcium transport across membranes  4. lower capillary density  5. decreased response to beta-adrenergic stimulation  6. impaired autonomic reflex control

15.  B. Effects of aging on function:  Aging is inversely proportional to function during load  Think of load as increased metabolic demand (from exercise, activity, disease)  The changes in the cardiovascular system with aging do not have clinical relevance at rest (relatively unaffected at rest) but may have considerable consequences during cardiovascular stress  “Allostatic” load vs. homeostatic imbalances

16.  C. Effects of exercise on aging:  Blunts but does not stop the changes of aging (as outlined in section A) and their functional consequences (as outlined in section B)

17.  Female hearts are smaller than male hearts and constructed differently and respond to age and hypertrophic stimuli differently  Women vs. men: women have a higher prevalence of MVP, greater risk of long QT syndrome (increased predisposition for ventricular tachycardia), increased LVH with aging, higher incidence of bleeding episodes with thrombolytics, differential outcomes with surgery and angioplasty

18.  Same CAD mortality (after 60’s)  **Under diagnosis is a problem due to previous assumptions and slightly different presentations  *Women are more likely to have CAD without chest pain and can have microvascular problems that do not show up easily with stress testing  **Are differences in outcomes due to biological or social factors? Difficult to discern  *Studies show that women are treated less aggressively following initial signs of cardiac disease as compared to men

19.  **There is an increased risk of heart disease after menopause, but HRT does not seem to change the risk  *More women than men develop hypertension (related to longevity most likely)

20.  A. Ischemic heart disease  B. Angina Pectoris  C. Hypertensive cardiovascular disease  D. Myocardial infarction  E. CHF  F. Orthostatic (postural) hypotension  G. Myocardial disease  H. Trauma  I. Myocardial neoplasm  J. Congenital heart disease

21.  A. Arrhythmias

22.  A. Mitral stenosis  B. Mitral regurgitation  C. MVP (mitral valve prolapse)  D. Aortic stenosis  E. Aortic regurgitation  F. Tricuspid regurgitation and stenosis  G. Infective endocarditis  H. Rheumatic fever and heart disease

23.  A. Pericarditis

24.  A. Aneurysm  B. PVD (peripheral vascular disease)  C. Vascular neoplasms

25.  A. Cardiogenic shock  B. Collagen and vascular diseases  C. Cancer treatment

26.  1. Goodman  2. Acute Care Handbook for Physical Therapists, 3 rd ed., 2009. Paz, JC and West, MP.  3. www.mayoclinic.com/ ‎

28. In collaboration with Sean M. Collins PT, ScD October 2013 Created by Andrea C. Mendes PT, DPT