--- module: 012-01 language: en chapter: 12 title: "Cardiovascular History, Examination, and Core Investigations" module_title: "Foundations" source_sha256: afdf5df1feefa48d4d9529f35bcc2b59c73c86af613949f540531d8976142a73 --- # Cardiovascular history, examination and core tests ## What the assessment must deliver ### Instability, symptoms, haemodynamics, localisation ### Same finding, several mechanisms ### Function and trajectory, not a label ## Presenting symptoms ### Chest discomfort #### Exertional pressure suggests ischaemia #### Equivalents: burning, indigestion, dyspnoea, nausea #### Tearing pain to the back: acute aortic disease #### Pleuritic pain: pericardium, lung, chest wall #### Palpable reproduction does not exclude disease ### Dyspnoea #### Orthopnoea: supine venous return and redistribution #### Nocturnal dyspnoea more specific for congestion ### Palpitations #### Capture the rhythm during symptoms ### Syncope #### Global cerebral hypoperfusion, rapid recovery #### High risk: exertional, structural, family sudden death ### Vascular symptoms: rest pain, cold limb, stroke ## Risk and background ### Vascular risk factors and kidney disease ### Family history of premature disease or sudden death ### Medication review #### Antithrombotic, anti-inflammatory, stimulant drugs #### Agents affecting electrolytes or Q T interval ### Functional status: baseline and rate of change ## General examination and vital signs ### Distress, work of breathing, colour, mental state ### Accurate pulse, pressure, saturation, temperature ### Compare arms, measure standing pressure ### Peripheral stigmata have limited specificity ## Pulse and venous pressure ### Slow-rising low-volume pulse: outflow obstruction ### Collapsing pulse: high stroke volume, rapid runoff ### Radiofemoral delay or unequal pulses ### Pulse deficit: beats not reaching the periphery ### Jugular venous pressure estimates right-atrial pressure #### Vertical height above the sternal angle #### Raised: overload, right failure, tamponade, constriction #### Inspiratory rise: impaired right-sided filling #### Technique and body habitus limit accuracy ## Precordium and periphery ### Parasternal heave: right-ventricular pressure load ### Added sounds #### Third sound from rapid filling #### Fourth from atrial contraction into a stiff ventricle ### Murmurs #### Timing, site, radiation, intensity, shape #### Diastolic murmurs are generally pathological #### Intensity does not equal severity at low flow #### Manoeuvres alter return, afterload, chamber size ### Oedema is not specific to heart failure ## Electrocardiography and monitoring ### Rhythm, conduction, axis, ischaemia, drug effect ### Record promptly during pain, syncope, instability ### Serial tracings reveal dynamic change ### A normal tracing excludes little ### Monitoring duration matched to symptom frequency ### Symptom-rhythm correlation is the aim ## Biomarkers and imaging ### Troponin: assay-specific timing and change ### Natriuretic peptides vary with age, kidney, rhythm ### Chest radiograph can be normal in serious disease ### Echocardiography: chambers, valves, pericardium, pressures ### Coronary computed tomography defines anatomy ### Stress testing provokes demand ### Magnetic resonance characterises tissue and scar ### Best test follows probability and the pending decision ## Bedside synthesis ### Stable or unstable ### Congested or dry, warm or poorly perfused ### Coronary, pump, valve, pericardial, vascular, non-cardiac ### Time-critical alternatives and the next decision ## Vascular investigations ### Ankle-brachial index compares ankle with arm #### Calcified vessels give falsely high values #### Toe pressure or waveform may help ### Duplex ultrasound: anatomy plus flow velocity ### Computed-tomography angiography: radiation and contrast ### Deep-vein thrombosis: probability, D-dimer, compression ultrasound ### Pulmonary embolism: probability, oxygenation, selected imaging ### Testing must not delay a limb or aortic emergency ### Recheck after intervention: bleeding, embolism, contrast injury