1、Signs and symptoms of some common heart diseases,Wei Meng Shanghai sixth peoples hospital Shanghai jiaotong university,Contents,Mitral stenosis(MS) Mitral regurgitation(MR) Aortic stenosis(AS) Aortic regurgitation(AR) Pericardial effusion Heart failure(HF),Mitral stenosis,Conditions causing left ven

2、tricular inflow obstruction,Mitral stenosis,Cause of MS requiring intervention(n=1050),Pathophysiology of Mitral stenosis,LV inflow obstruction Left atrial pressure Lung congestion O2 supply shortage pulmonary A & V hypertension(RHF hemoptysis left atrial enlargement Atrial fibrillation thrombosis &

3、 embolism hoarseness,Common Symptoms of Mitral stenosis,Asymptomatics Exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea Palpitation due to arhythmia Miscellaneous Hemoptysis, blood-tinge sputum, pink frothy sputum, chest pain, mitral facies, Cough, hoarseness, dysphagia,Relation between dy

4、spnea and MVA,Signs of Mitral stenosis,Inspection Mitral facies, increased impulse at precardial area &/or with local elevation of the thoracic cavity, those due to right heart failure Palpation Apical impulse is normal or decreased Right ventricular heave is present if with pulmonary hypertension A

5、pical diastolic thrill may be present,Symptoms of Mitral stenosis,Percussion Dullness area of the heart shifts toward the left at waist of the heart as well as toward the right if marked enlargement of right heart Auscultation,Symptoms of Mitral stenosis,Symptoms due to chronic HF Edema, Effusion, H

6、epatomegaly, Jaundice, Wet Rales Cachexia,Mitral regurgitation,Etiology of MR(1) Organic MR Rheumatic heart disease Myxomatous changes(mitral valve prolapse) Infectious endocarditis Chordal rapture or dysfunction of papillary muscles Collagen vascular disease Trauma: pentrating or nonpenerating,Mitr

7、al regurgitation,Etiology of MR(2) Functional MR Coronary heart disease Hypertrophic cardiomyopathy Dilated cardiomyopathy Left atrial dilatation,Pathophysiology of MR,Preload increase caused by blood return to the left ventricle from LA Increased left atrial volume & pressure Diastolic volume augme

8、ntation Ventricular contraction increase compensately (Frank-Starling mechanism) Ventricular remodeling progressively(heart failure eventually),Symptoms of MR,Asymptomatic Dyspnea on exertion, cough,progressing paroxysmal nocturnal dyspnea, orthopnea ultimately, even acute pulmonary edema(less than

9、MS) Fatigue Palpitation due to arhythmia Atypical chest pain, inappropriate sympathetic nerve system activation, panic attack (often in valve prolaps),Signs of MR(1),Inspection Some having increased impulse of the apex Palpation Enhanced apical impulse is to the left lower Percussion Dullness area o

10、f the heart shifts toward the left lower,Symptoms of MR(2),Auscultation(1) Normal or muffled S1 , P2 if pulmonary pressure high S3 is common, not always indicating HF Holosytolic murmur is classical at the apex, radiating to the axilla even the back, the base of the heart . Murmur at late systolic c

11、an be heard at the valve prolapse or at mild MR,Symptoms of MR(3),Auscultation(2) Music-like murmur can be heard at severe MR, at the valve prolapse Midsystolic click with or without murmur presents at the valve prolapse Occasionally diastolic rumbling can be heard at severe MR because of relative M

12、S No murmur can be heard at mild even moderate MR sometime,Aortic stenosis,Etiology Congenital Bicuspid valve (very common) Fusion of the valve leaflet (rare) Degeneration Rheumatic fever Others SLE, ochronosis, severe familial hyper-cholesterolemia,Pathophysiology of AS,Afterload of left ventricle

13、increased LV hypertrophy, ischemia Compliance, LA large & pressure high Low cardiac output Insufficient blood supply to heart, brain, kidney, etc,Symptoms of AS(1),Asymptomatic Angina with or without coronary artery stenosis Typical chest pain like effort angina Atypical chest pain Syncope, usually

14、on effort Heart failure, diastolic common, Complaint related to Low (output) BP,signs of AS(1),Inspection Pale, carotid pulsation weaken Apical impulse increased Occasional impulse caused by S4 can be seen Palpation Carotid upstroke low in volume and delayed Forceful and sustained apex beat Occasion

15、al oscillation caused by S4 Thrill in the aortic area Percussion dullness area of the heart shifting left lower,Symptoms of AS(2),Auscultation Reduced and even inaudible A2, paradoxic splitting P2 increased in pulmonary hypertension Ejection murmur radiating to the carotid arteries with or without t

16、hrill in the aortic area S4 caused by atrial kick against the stiff ventricle S3 in advanced stage,Differentiation of systolic murmur,Etiology of AR(1),Aortic cups abnormalities Rheumatic fever Infectious endocarditis Non-specific inflammation: SLE, rheumatoid arthritis, Behcets syndrome Degenerativ

17、e: myxomatous change, calcification Others: trauma, postaortic valvularplasty, diet drug valvulopthy,Etiology of AR(2),Aortic root abnormalities The root dilatation Marfans, syndrome, syphilis, ankylosing spondylitis, relapsing polychondritis, idiopathic aortitis, annuloaortic ectasia, cystic medial

18、 necrosis, Ehlers-danlos syndrome Loss of commissural support Aortic dissection, trauma, ventricular septal defect,Etiology of AR (3),Increased afterload Hypertension Supravalvular aortic stenosi,Pathophysiology of AR,Preload increase caused by blood return to LV from AO Increased LV volume & pressu

19、re Ventricular contraction increase compensately (Frank-Starling mechanism) Ventricular remodeling progressively(heart failure eventually),Symptomes of AR,Asymptomatic Palpitation due to forceful beating or arhythmia Chest pain, typical or atypical Dyspnea on exertion, cough, orthopnea, paroxysmal n

20、octurnal dyspnea,Signs of AR(1),Inspection Visible cardiac impulse enhanced toward left lower Palpation The apical impulse is increased and displaced caudally and laterally Auscultation (1) A2 may be decreased, S4 is often present, S3 is audible when HF occurs,Signs of AR(2),Auscultation(2) Soft, hi

21、gh-pitched idastolic decrescendo murmur is heard best at 3rd intercostal space along the left sternal border at end expiration with the patient sitting and leaning forward, may be best at the right of the sternal in the presence of aortica root dilatation Murmur radiating to the left lower sternum a

22、nd the apex,Signs of AR(3),Auscultation(3) A systolic ejection murmur may be present at the aortic area A diastolic murmur may be heard at the apex (Austin flint murmur) Peripheral sings Pulse pressure is increased, other signs,Other peripheral signs of AR,Pericardial effusion,Etiology(1) Infection:

23、 virus, bacterium, tuberculosis, AIDS Malignancy Iatrogenic cause Surgery related syndrome Trauma Radiation therapy Connective tissue disorders,Pericardial effusion,Etiology(2) Myocardial infarction Acute phase in 1st week Dresslers syndrome (post myocardial infarction syndrome) 1-6 week later Uremi

24、a Hypothyroidism Drug-related Procainamide, hydralazine, methydopa, etc,Pathophysiology of pericardial effusion,Pericardial pressure increased Obstruction of venous flow return Filling volume of LV insufficient Cardiac output decreased,Pericardial effusion,Classification Acute pericardial effusion (

25、pericarditis) Chronic pericardial effusion Cardiac pamponade Constrictive pericarditis Effusive-constrictive pericarditis,Pericardial effusion,Symptome depends on the effusive volume and the rapidity of accumulation Common seen Asymptomatic Chest discomfort, dyspnea, cough, dysphagia, hoarseness, hi

26、ccup, nausea, abdominal fullness, even cardiac tamponade Signs of primary diseases,Pericardial effusion,Signs(1) Inspection Weaken pulsation of apex, Palpation Apex beat weaken or not palpable, if palpable it has a distance to the dullness border,Pericardial effusion,Signs(2) Percussion Dullness are

27、a of the heart is enlarged to both sides and the shape changes with body position Auscultation Tachycardia, muffuled heart sound, pericardial rub and pericardial knock are infrequent,Pericardial effusion,Other manifestations Pulse pressure narrowing with or without BP Pulse paradoxus: Pulse weaken o

28、r disappears at inspiratory phase. inspiratory fall of systolic BP 10mmHg. Ewart sign left lower lobe lung become nullness engorgement of jugular vein, positive sign of hepatojugular reflux,Pericardial taponade,Circulation collapse or shock caused by rapid or large volume fluid accumulation HR , BP

29、decreased, pulsus paradoxus, jugular vein pressure Extremities are cold and wet Dyspnea, restlessness, diminished response , unconsciousness Pulse pressure diminished,Heart failure,A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate met

30、abolic requirements and the venous return.,Etiology of Heart Failure,What causes heart failure? The loss of a critical quantity of functioning myocardial cells after injury to the heart due to: Ischemic Heart Disease Hypertension Idiopathic Cardiomyopathy Infections (e.g., viral myocarditis, Chagas

31、disease) Toxins (e.g., alcohol or cytotoxic drugs) Valvular Disease Prolonged Arrhythmias,Volume Overload,Pressure Overload,Loss of Myocardium,Impaired Contractility,LV Dysfunction EF 40%, Cardiac Output,Hypoperfusion, End Systolic Volume, End Diastolic Volume,Pulmonary Congestion,Left Ventricular D

32、ysfunction,30%,70%,Diastolic Dysfunction,Systolic Dysfunction,(EF 40%),(EF 40 %),Left Ventricular Dysfunction,Systolic: Impaired contractility/ejection Approximately two-thirds of heart failure patients have systolic dysfunction1 Diastolic: Impaired filling/relaxation,1 Lilly, L. Pathophysiology of

33、Heart Disease. Second Edition p 200,Hemodynamic Basis forHeart Failure Symptoms,LVEDP Left Atrial Pressure Pulmonary Capillary Pressure Pulmonary Congestion,Left Ventricular DysfunctionSystolic and Diastolic,Symptoms Dyspnea on Exertion Paroxysmal Nocturnal Dyspnea Tachycardia Cough Hemoptysis,Physical Signs Basilar Rales Pulmonary Edema S3 Gallop Pleural Effusion Cheyne-Stokes Respiration,Right Ventricular FailureSystolic and Diastolic,Symptoms Abdominal Pain Anorexia Nausea Bloating Swelling,Physical Signs Peripheral Edema Jugular Venous Distention Abdominal-Jugular