Материал: Internal_diseases_propedeutics._Part_II._Diagnostics_of_cardiovascular_diseases

and may result in acute myocardial infarction (cessation of the coronary flow to part of the myocardium leading to ischaemic necrosis).

Radiation

The pain of angina radiates centrifugally across the chest, up the neck and jaws, and down the arms on both sides through the inner aspect of the left arm and hand is the commonest region. The reason for this radiation of a cardiac pain is that the inferior cervical sympathetic (stellate) ganglion, which receives the cardiac nerve plexus, contributes fibres to the lower brachial plexus.

Precipitating and aggravating factors

By definition, angina (inadequate coronary flow for the demands of the myocardium at exercise) is provoked by effort of walking briskly, uphill, in the cold or against the wind; by hurrying after meals; by unaccustomed exercise; or by excitement associated with physical and sympathetic activity (sexual intercourse) or caused by anger (verbal interchanges, unpleasant telephone call), fear, frustration and apprehension.

Relieving factors

Angina is relieved within a couple of minutes by the cessation of the activity that induced it and by nitrates, which dilate small vessels and reduce the afterload (blood pressure) and the preload (venous pressure and cardiac output), and thereby reduce the work of the heart. The pain of oesophageal spasm, which may be confused with angina, may also be relieved by nitrates. The pain that lasts for more than a few minutes after inhalation or sublingual trinitrate is not angina. The pain of unstable angina and myocardial infarction may occur without any provocating factors, is often associated with an increased sympathetic activity (e.g. sweating, tachycardia, pallor, anxiety, etc.), and is not relieved by a nitrate spray.

Associated symptoms

Breathlessness, sweating, nausea and restlessness may all be due to apprehension and fear but these symptoms can also accompany left heart failure.

The pain of acute pericarditis is usually sharper and lasts much longer than that of angina. It is felt over the precordium and referred to the neck. It is little affected by effort

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but is often aggravated by breathing, turning, twisting, swallowing food, by lying flat in bed, and may lessen if the patient leans forward.

In dissecting aneurysm of the aorta, the pain is felt as tearing sensation; its onset is abrupt, and it radiates to the back along the course of the vessel. The signs and symptoms depend on the location and the extent of the dissection.

Dyspnea is a subjective sensation of shortness of breath and often is a symptom of cardiac disease, especially in patients with congestive heart failure.

Failure of the heart to pump efficiently may lead to the accumulation of blood in the lungs and dyspnoea (an uncomfortable awareness of breathing). Heart failure should be defined in the four categories of the New York Heart Association (Table 1).

As for the chest pain, questions should be asked about its frequency and onset, provocating, aggravating and relieving factors, duration and about the associated symptoms. A suddenly developing dyspnea suggests pulmonary embolism, pneumothorax, acute pulmonary oedema, exposure to toxic fumes, or a haemorrhage in a tumour obstructing a major airway. In heart failure dyspnea reflects pulmonary venous hypertension secondary to a raised left ventricular end-diastolic pressure. Dyspnea occurs classically in a resting patient in the recumbent position and is relieved promptly by sitting upright (orthopnea). With deteriorating left ventricular function, the end-diastolic, left atrial and the pulmonary venous pressures all rise causing interstitial pulmonary

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oedema and breathlessness. The clinical expression of these events is that the patient is unable to sleep without the use of the increased number of pillows. In the night, such a patient may slip down on the bed and become breathless a few hours after the onset of sleep (paroxysmal nocturnal dyspnea) associated with wheezing, sweating and apprehension. The patient finds relief by sitting on the side of the bed or getting out of the bed and walking a few paces. In chronic pulmonary disease, the patient may also awaken at night but cough and expectoration often precede the dyspnea.

Edema. This is helpful in elucidating the etiology of edema. Thus a history of edema of the legs that is most pronounced in the evening is characteristic of heart failure.

Fatigue. This is among the most common symptoms in patients with impaired cardiovascular function. Cough and hemoptysis may be associated with cardiac disease, but it may be difficult to differentiate cardiac from pulmonary disease on the basis of these two symptoms alone. A cough, often orthostatic in nature, may be the primary complaint in some patients with pulmonary congestion.

Nocturia, secondary to resorption of edema at night, is common in patients with congestive heart failure.

Syncope, which may be defined as a loss of consciousness, results most commonly from reduced perfusion of the brain. The most common causes of syncope are in the table 2.

brownish because of diapedesis of erythrocytes. Cardiac edema decreases in the morning, increases in the evening. Options for edema: anasarca – widespread, extensive peripheral edema, hydrothorax, hydropericardium, ascites.

Before palpation and auscultation, the precordium should be inspected. With good lighting, the point of maximal cardiac impulse may be visible. Cardiac impulses are not normally observed in any other area. The normal apical impulse occurs in early systole and is located within an area of approximately 1 cm2 in the fourth to fifth left inter-costal space near the midclavicular line.

Inspection of the precordium should reveal any abnormalities of the bony structures (e.g., pectus excavatum) that may displace the heart to produce unusual findings on physical examination.

Epigastric pulsation - visible lifting and retraction of the epigastrium, synchronous with the heart activity can be observed in the right ventricular hypertrophy (RVH), pulsations of the abdominal aorta and the liver. Right ventricular pulsation due to RVH is defined under the xiphoid process and becomes more distinct with a deep breath, while the pulsation caused by the abdominal aorta is localized slightly lower and becomes less pronounced with a deep breath.

The true liver pulsation, in combination with a positive venous pulse is found in patients with insufficiency of the tricuspid valve. When this defect during systole, there is reverse flow of blood from the right atrium into the inferior caval and hepatic vein, that is why every heartbeat we observe swelling of the liver.

Transfer the pulsation of the liver is caused by transmission of heart contractions.

Heart palpation

The main goals of heart palpation are:

1.disclosure of ventricular myocardial hypertrophy;

2.disclosure of ventricular dilatation;

3.disclosure of main vessels dilatations (indirectly);

4.disclosure of aortic and left ventricular aneurysms.

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