1、1Main Symptoms and Signsof CommonCardiovascular DiseasesOutline2010 Clinical DiagnosticsValvular Heart DiseaseMitral Stenosis(MS)Mitral Regurgitation/Insufficiency(MR/MI)Aortic Stenosis(AS)Aortic Regurgitation/Insufficiency(AR/AI)Heart FailurePericardial EffusionValves of Heartvalve annulus/valve ri
2、ngvalve leaflet/cuspmitr4Mfi1llUfl0f Clf)Yalves of Heart Q(heart in diastole:vieed ir0m base wah aria emoec6Mitral Stenosis(MS)Predominantly caused by rheumatic fever.7mitral valve areaMSnormal MVAmildmoderatesevere46cm21.52.0cm21.01.5cm21.0cm2Normal-the cross-sectional area 46 cm2AbnormalMild MS-or
3、ifice 2 cm2bloodLA LV propelled by a small and abnormal pressure gradient 20 mmHgModerate MS:-orifice 1.5 cm2PVP,PCWP,interstitial edema means LV pressure of 25 mm HgSevere MS-orifice 1 cm2PAP RV overload RV failurePathophysiologyCross-sectional area of the mitral valve orifice Rate of blood flow ac
4、ross the mitral orifice Left atrial pressure Dilation of LAPulmonary venous and capillary pressures Pulmonary congestion and edemaPulmonary hypertensionRight heartfailureDyspnea2010 Clinical Diagnostics10LA pressurePulmonary circulation pressureRight heart failurePathophysiologydilationhypertrophyfa
5、ilure11Symptomsdyspnea:is defined as an abnormally uncomfortable awareness of breathing.That is shortness of breath,difficulty in breathing/labored breathing.It is a subjective symptom.It is one of the principal symptomsof cardiac and pulmonary disease.Symptomsdyspneaexertional dyspnea,dyspnea on re
6、st,paroxysmal nocturnal dyspnea,orthopneapulmonaryedemacoughhemoptysis If orthopnea causes awakening during the night andis relieved by sitting,it is called paroxysmal nocturnal dyspnea.Shortness of breath even in the upright position andcough with pink frothy sputum(粉红色泡沫痰粉红色泡沫痰)in pulmonary edema.
7、The most common complaint is shortness ofbreath,chiefly exertional dyspnea at first and then progressing to rest dyspnea,paroxysmal nocturnal dyspnea,andorthopnea.Physical Signs1.Inspection2.Palpation3.Percussion4.Auscultation视视触触叩叩听听2010 Clinical DiagnosticsMS16Inspection:Mitral facePatients show m
8、alar flush(pinkish-purplepatches on the cheeks)and lip cyanosis.Apex beat displaces to left because of right ventricular hypertrophy.二尖瓣面容二尖瓣面容17PalpationDiastolic thrill over apical area.tiny vibration,small shaking18PercussionCardiac dullness becomes pear-shaped.19梨形心，x ray film左房增大（左前斜位）20Auscult
9、ationMid and late diastolic crescendorumbling murmur in apical area21AuscultationAccentuatedS1 over apical areaOpening snapS2 Splitting or accentuatedGraham Steell murmurA high-pitched decrescendo diastolic murmur secondary to pulmonary regurgitation,can be heard in pulmonary valve area.肺动脉瓣区肺动脉瓣区 吹
10、风样吹风样 舒张早期舒张早期 杂音杂音 “二狭二狭”导导致致 肺动脉肺动脉压增压增高高、肺动脉扩肺动脉扩张张引起引起肺动脉肺动脉瓣瓣 相对性关相对性关闭不闭不全全 所致所致的的 功能性杂功能性杂音音.22Mitral Regurgitation(MR)Mitral regurgitation(MR)is defined as an abnormal reversal of blood flow from the left ventricle(LV)to the left atrium(LA).It is caused by disruption in any part of the mitra
11、l valve apparatus.valve annulus/valve ringvalve leaflet/cusp24Etiology Mainly rheumatic fever,mitral valve prolapse,infective endocarditis,calcification,ischemic heart disease withpapillary muscle dysfunction,et al.SystolePathophysiologycompensatory LA dilationpart of blood in LV returns to LAmore b
12、lood and pressure in LAIn MRDiastoleLV receivesnormal contentregurgitantof bloodbothvolume load of LV compensatory LV dilation2010 Clinical DiagnosticsMRWhen volume load of LV continuously increasingLV end diastolic pressure and LA pressure increaseLeft heart failurePulmonary congestion and edema(肺淤
13、血和肺水肿肺淤血和肺水肿)Pulmonary hypertensionRight heart failure27compensatory dilation of LAcompensatory LV dilationleft heart failureRight heart failurePathophysiologyEarly Stage-asymptomatic-heart failureLate StagePalpitationCoughExertional dyspneaFatigue/very great tiredness(secondary to cardiac output)Sy
14、mptoms2010 Clinical DiagnosticsMRPhysical SignsInspectionApex beat displaced to left and downwardsPalpationApex beat displaced to left and downwards,heaving apex beat,hyperdynamic cardiac impulsePercussionThe area of cardiac dullness shifts to left anddownwards at first,then to right later2010 Clini
15、cal DiagnosticsMR30Auscultation:In apical area,harsh blowingpansystolic murmur,widely spread,transmitting to left axilla or subscapular region.S1 is weakened and P2 is accentuated and split.主动脉瓣狭窄（主动脉瓣狭窄（aortic stenosis,AS）Etiology Mainly caused by rheumatic fever.Others caused by senile calcificati
16、on or congenitally bicuspid valve.图图主动脉瓣和冠状动脉开口示意图主动脉瓣和冠状动脉开口示意图Aortic stenosis(AS)2010 Clinical DiagnosticsASNormal cross-sectional area 3.0cm2 1.0cm2，cross-sectional pressure5 mmHgshows clinical signs.ASis the obstruction of blood flow across the aortic valve.2010 Clinical DiagnosticsAortic Stenos
17、is(AS)ASPathophysiologyAortic stenosisLV outflow obstructionLV systolic pressure cardiac outputLV hypertrophyLV dysfuctioncerebral ischemiamyocardial ischemiaLV failureEarly stage-asymptomatic.Late stage-symptoms occur lateafter years of obstruction.Symptoms2010 Clinical DiagnosticsAS(common)(relati
18、vely late)Symptoms2010 Clinical DiagnosticsAngina pectoris90%Syncope(typical)60%Dyspnea30%AS Angina pectoris(myocardial ischemia)it is commonly precipitated/induced by exertion and relieved by rest.Dyspnea(relatively late symptom)exertional dyspnea with orthopnea,paroxysmal nocturnal dyspnea,and pul
19、monary edema reflect varying degrees of pulmonary venous hypertension.40Syncope(cerebral ischemia)which may be defined as a loss of consciousness,results most commonly from reduced perfusion of the brain.Syncope is typically exertional and may be due toarrhythmias,hypotension,or decreased cerebral p
20、erfusion resulting from increased blood flow to exercising musclewithout compensatory increase in cardiac output.signsInspection:The apex beat displaces to left and below.Percussion:The cardiac dullness may be normalor shifts to left and below.palpation The apical impulse is forceful.A systolic thri
21、llmay be palpated in the second intercostal space on right side of the sternum.Auscultation The systolic ejection murmur，harsh and rasping,can be heard in the aortic area transmitted to the neck.A weak A2,or paradoxical splitting S2is present.2010 Clinical DiagnosticsAortic regurgitation(AR)AR45Etio
22、logyMainly caused by rheumatic fever;Sometimes caused by non-rheumaticfever such as infective endocarditis,congenital valve deformity,valve prolapse,syphilis,Manfans syndrome.PathophysiologyFrom Braunwalds Heart Disease 8thARblood returning from aorta to LVDBP more blood lift upleaflets of mitral va
23、lveblood volume in LV compensatoryLV dilatationpulse pressure relative MSAustin-Flint murmurLV Heart Failureperipheralvascular signsInsufficient ofcoronary artery2010 Clinical DiagnosticsARSymptomsEarly stage-asymptomatic.Late stage-PalpitationFatigueDizzinessAngina pectorisExertional dyspnea2010 Cl
24、inical DiagnosticsARSignsInspectionFace may be pale;Apex beat displaced to left and below.PalpationApex beat is rather diffuse and displaces to downwards and left;/heaving apex impulsePercussioncardiac dullness-shape of a boot2010 Clinical DiagnosticsARAuscultationSighing diastolic decrescendo murmu
25、r,can be heard in the 2nd aortic area.Austin-Flint murmurA rumbling mid-diastolic murmur caused byrelative MS,can be heard over the apex area.(主动脉瓣关闭不全时回流血液限制二尖瓣开放所致）主动脉瓣关闭不全时回流血液限制二尖瓣开放所致）2010 Clinical DiagnosticsAR-caused by pulse pressureHead bobbingVisible pulsation of carotid arteriesSigns of c
26、apillary pulsationWater hammer pulsePistol shot sounds over femoral arteries and Duroziez murmurPeripherial Vascular Signs2010 Clinical DiagnosticsAR52Heart FailureBrief account：In certain pathological circumstances,if cardiac output is below the level ofadaptation to the needs of humanbody,heart ca
27、nnot maintain effectivecirculation.Therefore a series ofsymptoms and signs develop.53 Classified as acute and chronic heart failure according to its clinical course.Classified as left,right and bilateral heart failure according to the clinical manifestations.54Left heart failure The main pathologica
28、l change is pulmonary congestion，pulmonary edema develops in severe cases.55Symptoms Dyspnea:Exertional dyspnea;Paroxysmal nocturnal dyspnea;Orthopnea;Cough with pink frothy sputum(粉粉红色红色 泡沫痰泡沫痰)in pulmonary edema;Cough with sputum or cough with blood stained sputum.56Signs Inspection:Tachypnea（呼吸急促
29、）（呼吸急促）,cyanosis and orthopnea;Percussion:Signs of primary heart diseases;Auscultation:Findings of primary organic heart diseases;Fast heart rate and diastolic gallop rhythm；moist rales(湿罗音湿罗音)at the lung bases;in pulmonary edema bubble and wheezing rales(哮鸣音哮鸣音)over both lungs.5758Right ventricular
30、 failureBrief account：The main pathological change is systemic congestion（体循环淤血）（体循环淤血）.59Symptoms Edema(水肿水肿)occurs in the lower part ofbody(abdomen,the lower extremities).Bloat(胃胀胃胀),nausea（恶心恶心),anorexia(食欲不振食欲不振),oliguria 少尿少尿.60Signs Inspection:Dilatation of the jugular vein.Cyanosis and edema
31、in the lower partof body.62 Palpation:Enlargement of liver with tenderness,positive hepatojugular reflux(肝颈静脉回流征阳性肝颈静脉回流征阳性).Percussion:Pleural effusion(胸腔积液胸腔积液)and ascites(腹水腹水);signs of primary heart diseases.63 Auscultation:Signs of primary heart diseases.64Pericardial effusionBrief account：May
32、be caused by infective pericardial changes such as tuberculosis(肺结核肺结核)and non-infective pericardial changes such as tumor.65SymptomsSensation of pressing or pain over theprecordial region（心前区压迫感或疼痛）（心前区压迫感或疼痛）;Dyspnea,palpitation（心悸（心悸),abdominal distension（腹胀）（腹胀）or edema.66SignsInspection:Dyspnea
33、;Jugular venous distention;Diminution in strength of the apex beat or absence of the apex beat (weak and undetectable cardiac pulsation);67Palpation:Little effusion-sense of pericardial friction.Diminution in strength of the apex beat;Rapid and weak pulse orparadoxical pulse（奇脉）（奇脉）in large effusion
34、.enlargement of liver with tenderness,positive hepatojugularreflux.68Percussion:Enlargement of cardiac dullness bilaterally;Heart border changesaccording to bodys position-it becomes triangular in sitting position and the widening ofbase of heart insupine position.（坐位时心尖部增宽，卧位时心底部增宽）（坐位时心尖部增宽，卧位时心底部增宽）69Auscultation:Little effusion-pericardial friction sound;Large effusion-fast heart rate,diminution of intensity of heart sounds(Muffled heart sounds,心音弱而遥远心音弱而遥远),Becks triad(acute compression triad)贝克三贝克三联征联征 Jugular venous distention,Muffled heart sounds hypotension or shock!
