Cardiac Quiz

• Chest Pain

  • With lack of MSK findings
  • AROM of shoulder or trunk does not reproduce symptoms
  • Resistance (MMT) does not reproduce symptoms
  • Heat and stretching does not reduce or relieve symptoms
• Palpitations

  • Lasting for hours or occurring with pain, SOB, fainting, or lightheadedness
• Dyspnea

  • Inability to climb a flight of stairs without feeling moderately to severely winded
  • Awakened at night or SOB when supine
  • Known cardiac disease
• Cardiac Syncope

  • Syncope with lightheadedness, dizziness, nausea - at risk for heart attack or stroke
• Edema

  • Concurrent symptoms of jugular vein distention, SOB, fatigue, dizziness, syncope
  • CHF exacerbation
  • Sudden 3 pound weight gain with worsening of symptoms
• Signs of Myositis (from SAMS – Statin Associated Muscle Symptoms)

  • Muscle aches/pains
  • Unexplained fever
  • Nausea and vomiting
  • Dark urine
• CAD

  • Crushing, heavy, squeezing sensation
  • Occurs during emotion or exertion (ex. climbing up stairs)
• CAD in Women


  • Weakness, fatigue, trouble sleeping
  • Very subtle symptoms for ~1 month may indicate impending MI
• Angina


  • Radiating pain to left shoulder and/or down ulnar nerve distribution to arm/fingers
  • Neck, jaw, upper back, right arm pain
  • Squeezing, burning, pressing, choking, aching, or bursting
  • Frequent "heartburn"
  • Patient may locate symptoms by placing closed fist over sternum
  • Duration of pan = 1 to 5 minutes
• Cardiac Arrest / MI - Warning Signs

  • Unrelenting, crushing chest pain >30 minutes not relieved by nitro
  • Radiating pain to arms, throat, back for hours
  • Pallor
  • Nausea/vomiting
• Signs of Sudden Cardiac Arrest

  • Sudden loss of responsiveness
  • No normal breathing, movement, or coughing
  • No signs of circulation
• Pericarditis - Both

  • Substernal chest pain
  • Dry cough
  • Radiating pain
• Pericarditis - Only

  • Pain relief with quadruped positioning, leaning forward, sitting upright
  • Pain worse with breathing, swallowing, neck/trunk movements
  • Substernal pain may radiate anteriorly to the costal margins, neck, upper back, upper trap, left supraclavicular area, or down the left arm
• Left Sided Heart Failure

  • Coughing
  • Pulmonary edema (pink, frothy sputum)
  • Dyspnea (orthopnea)
  • Fatigue
• Right Sided Heart Failure

  • Edema
  • Jugular vein distention
  • Fatigue
  • Cyanosis
• Abdominal Aortic Aneurysm

  • Often asymptomatic
  • Pulsating mass in abdomen more noticeable in supine
  • Accompanied by back or abdominal pain
  • Pain may radiate to neck, chest, back
  • Dull ache in mid abdominal left flank or low back
• Heart Valve Disorders

  • Fatigue
  • Dyspnea
  • Palpitation
  • Chest pain
  • Pitting edema
  • Orthopnea
  • Dizziness and syncope
• Dysrhythmias


  • Irregular heart rhythm → "heart skips a beat"
  • Palpitation
  • Hypotension
  • Fatigue
  • SOB
• HTN

  • Headache
  • Dizziness
  • Flushed face
  • Spontaneous epistaxis (nose bleeds)
  • Vision changes
• Arterial Disease

  • Hair loss on toes, feet, legs
  • Numbness in foot after exercise
  • Decreased circulation in foot
  • Intermittent claudication (consistent, dull, aching, squeezing)
• Venous Disease - Acute

  • Redness, warmth, swelling
• Venous Disease - Chronic

  • Thick, brown skin at ankles (tree bark)
  • Venous stasis ulcers
  • Swollen limbs
  • May also be hairless like arterial disease
• Diuretics

  • Decrease fluid → CHF, HTN
  • –thiazide, Lasix
• Diuretics - Side Effects

  • Lightheaded, dizzy
  • Hypotension → take vitals
  • Muscle weakness, spasm
  • Headache
  • Nausea
• Beta Blockers

  • HTN, arrhythmias
  • – olol, Metoprolol, Labetalol
• Beta Blockers - Side Effects

  • Depression
  • Worsening asthma
  • Fatigue
  • Blunted HRmax → use RPE scale
• Alpha-1 Blockers

  • HTN (vasodilation)
  • –zosin
• Alpha-1 Blockers - Side Effects

  • Hypotension
  • Reflex tachycardia
• ACE Inhibitors

  • HTN (prevents vasoconstriction)
  • –pril, Lisinopril
• ACE Inhibitors - Side Effects

  • Dry cough (common side effect)
  • Rash
  • Can cause hypotension with the use of NSAIDs → monitor BP
• Calcium Channel Blockers

  • HTN
  • –pine, Amlodipine
• Calcium Channel Blockers - Side Effects

  • Swelling in feet and ankles
  • Orthostatic hypotension
  • Headache
  • Nausea
• Nitrates

  • Angina, CAD
  • Nitroglycerine
• Nitrates - Side Effects

  • Headache
  • Dizziness
  • Tachycardia
  • Orthostatic hypotension
• The 3 P's

  • 2/3 P's → MI is unlikely
  • Pleuritic Pain → patient holds breath and symptoms resolve = pulmonary
  • Pain with Palpation → positive = MSK
  • Pain with changes in Position → positive = MSK or pulmonary
• Van Gelderen Bicycle Test

  • Vascular → pain when upright and persists with forward lean
  • Vascular pain usually begins after 3-5 minutes
  • Neurogenic → pain lessens with forward lean
• IMMEDIATE MEDICAL ATTENTION

  • Sudden worsening of intermittent claudication → DVT
  • Symptoms of TIA
  • Angina lasting >20 minutes or no relief after nitro
  • Accompanied by nausea, vomiting, sweating
  • Changes in pattern of angina
  • Signs of MI
• GUIDELINES FOR PHYSICIAN REFERRAL

  • Palpitations with family hx of unexplained sudden death
  • More than 6 palpitations in 1 minute
  • Palpitations lasting for hours with pain, OSB, dizziness
  • Inability to climb stairs without moderate to severe mindedness
  • SOB in supine
  • Fainting without warning
  • New arrhythmia