--- module: 012-02 language: en chapter: 12 title: "Cardiovascular History, Examination, and Core Investigations" module_title: "Bedside haemodynamics, test selection, and longitudinal cardiovascular inference" source_sha256: cc9e28338ab6d37ea9e4e47a9f865649aa5d45f25e28459ffa9ff4f37cbc1868 --- # Bedside haemodynamics and test selection ## Symptoms as physiological stress tests ### Demand exposes limited reserve ### Exertional pressure: flow cannot meet demand ### Exertional dyspnoea #### Filling pressure, output, pulmonary limitation #### Anaemia and deconditioning ### Ask what the patient has stopped doing ### Pillow count is not a diagnosis ### Nocturnal dyspnoea: delay, severity, need to sit ### Abrupt onset suggests an electrical transition ### Gradual acceleration suggests sinus tachycardia ### Capturing rhythm during symptoms is decisive ## Perfusion and congestion ### Temperature, refill, pulse volume, mentation, urine ### Cold hands or warm skin can both mislead ### Trends and coherence over single signs ### Venous pressure is not total body fluid #### High: right failure, tamponade, constriction, pulmonary hypertension #### Low value supports reduced central filling ### Venous waveform #### a wave: atrial contraction, absent in fibrillation #### Large a wave against resistance or a closed valve #### v wave prominent in tricuspid regurgitation ### Hepatojugular test: can the right heart accept more ### Oedema names fluid, not its cause #### Unilateral swelling: venous, lymphatic, infection, injury ## Pulses, murmurs and manoeuvres ### Delayed low-amplitude upstroke: aortic obstruction ### Severe low output flattens every pulse ### Murmur timing localises the gradient #### Ejection murmurs rise and fall with flow #### Holosystolic while a pressure difference persists ### Manoeuvres change loading #### Standing and strain reduce venous return #### Squatting raises return and resistance #### Handgrip raises afterload #### Inspiration fills the right heart ### Unreliable in tachycardia, low output, obesity ### Fever or embolic signs: suspect valve infection ### New murmur after infarction: mechanical complication ### Urgency follows physiology, not elegance ## Electrocardiography and rhythm capture ### Confirm identity, time, calibration, speed, leads ### Lead reversal imitates axis change and infarction ### Compare with prior tracings ### Rate and rhythm before morphology #### Is atrial activity present and related #### Narrow or broad ventricular activation ### Monitoring duration matched to event frequency ### Patient-triggered devices need consciousness ### Loop recorders capture pre-event rhythm ### Single-lead wearables cannot replace twelve leads ## Imaging by clinical question ### Echocardiography answers structure and filling ### Windows, loading, rhythm and geometry limit it ### Ejection fraction must not eclipse the rest ### Computed tomography defines coronary anatomy ### Calcification, motion and kidney function limit it ### Stenosis does not prove flow limitation ### Stress tests examine functional reserve ### Inadequate stress weakens a negative result ### Magnetic resonance: scar, oedema, infiltration ## Biomarkers and serial inference ### Troponin: myocardial injury ### Natriuretic peptide: myocardial wall stress ### C-reactive protein: inflammation without a source ### Creatinine and potassium shape treatment safety ### No marker replaces causal assessment ### Serial change outweighs a single value ### Rising creatinine during diuresis has several causes ### Read markers with volume, pressure, urine output, symptoms ## Exercise capacity as a vital sign ### Standardised walk, stairs, rehabilitation workload ### Cardiopulmonary testing separates limitations #### Circulatory, ventilatory, muscular, motivational ### Peak oxygen uptake and ventilatory efficiency ### Repeat only when protocol and state match ### Specialist interpretation for high-stakes decisions ## Closing the loop ### Every investigation ends in an action statement ### Which dangerous alternative remains ### Proportionate follow-up for incidental findings ### State stability, rhythm, perfusion, congestion, trajectory ### Name the next test and what changes the plan