Sintomas y signos Cardinales en Cardiologia.Francisco Albornoz, MD, MSCI.

Semiologia I, UCSC.

• Mismas reglas generales de la entrevista y el examen fisico.

•El proceso diagnostico se basa en historia, examen fisico y examenes de laboratorio.

•No olvidar historia familiar y uso de medicamentos/drogas.

Historia presenteHistoria remotaRevision por sistemasFactores de riesgo cardiovascularAntecedentes familiaresUso de medicamentos terapeuticosUso de drogas recreacionalesExamen generalExamen segmentario.

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Disnea:Sensacion de dificultad respiratoria

• Sintoma cardinal en patologia cardiaca y pulmonar.

• En sujetos sanos ocurre durante el ejercicio intenso.

• Desde leve a sensacion de distress respiratorio intenso.

• Debe considerarse patologica cuando ocurre en reposo o a un nivel de ejercicio desproporcionadamente bajo para el paciente.

• La disnea de causa cardiaca usualmente es secundaria a congestion pulmonar.:Se estimulan receptores “J” en pulmon que estimulan la ventilacion.

• Rara vez es debida a bajo gasto cardiaco sin congestion pulmonar, Ej. Tetralogia de Fallot.

Causas de disnea Aguda y Cronica

Aguda:

Edema pulmonarAsmaTrauma toracicoNeumotorax espontaneoEmboliaNeumoniaSindrome de distress respiratorioDerrame pleuralHemorragea pulmonar

Cronica:

EBOCInsuficiencia cardiacaFibrosis Intersticial difusaAsmaDerrame pleuralEnf. pulmonar tromboembolicaEnf. Vascular pulmonarDisnea psicogenicaAnemia severaEstenosis traqueal postintubacionDesordenes de hipersensibilidad.

Escala de la American Thoracic Society de la disnea

0 no Sin disnea caminando rapido en plano o moderadamente una pendiente.

1 Leve Disnea camiando rapido en plano o moderadamente una pendiente.

2 Moderada Disnea a caminar regularmente en plano.

3 Severa Disnea que obliga a detenerse a menos de 100 metros o al caminar unos pocos minutos.

4 Muy severa Muy sintomatico para salir de su casa. Se cansa al vestirse/desvestirse.

Ortopnea: En pacientes con insuficiencia cardiaca cronica, disnea es la expresion clinica de hipertension pulmonar venosa y capilar.Cuando esto ocurre en reposo en posicion supina y es aliviada rapidamente al sentarse o ponerse de pie, se llama ortopnea.Los pacientes aprenden a dormir semisentados usando 2 o mas Almohadas para evitar este sintoma.

Disnea Paroxistica Nocturna: Usualmente secundaria a falla ventricular izquierda y es debida a edema intersticial/alveolar. El sintoma usualmente comienza 2-4 hrs despues de acostarse y a menudo se acompana de tos (de comienzo posterior a la disnea), sibilancias y sudoracion.Es aliviado sentandose en el borde de la cama o caminando fuera de ella 15 a 30 minutos mas tarde.

Angina de Pecho (angor pectoris)

• Discomfort en el pecho y/o areas adyacentes asociado con isquemia Miocardica pero sin necrosis. Importante, angina significa opresion, no dolor.

• Caracteristicas tipicas y atipicas.• Localizacion mas comun es retroesternal.• Usualmente exacerbada por cualquier actividad que aumente consumo de oxigeno.• Si dura mas de 30 minutos de dolor continuo sospechar infarto en evolucion.• A veces se produce un “equivalente anginoso”.

Caracteristicas de la angina tipica y atipica

Tipica: Retroesternal, sensacion de pesadez, quemadura o de pecho “apretado”, precipi tado por ejercicio o emocion, rapidamente aliviado por nitroglicerina.

Atipica: Hemitorax izquierdo, abdomen, espalda, o brazos en la ausencia de dolor retroesternal. Caracteristicas cortantes, repetitivo, muy prolongado, no aliviado por TNT o reposo, no relacionado a ejercicio, aliviado con antiacidos, acompanado de palpitaciones.

Causas cardiovasculares de dolor toracico

Angina de esfuerzo. Angina de reposo o inestable. Infarto agudo al miocardio. Pericarditis. Diseccion de la aorta. Embolia pulmonar. Hipertension pulmonar.

Causas no cardiovasculares de dolor toracico

Dolor esofagico Lesiones del mediastino Musculoesqueletico Pancreatico biliar. Tubo digestivo. Irritacion pleural. Neuralgia intercostal.

Cianosis

Coloracion azulada de la piel y mucosas debido a un aumento de Hemoglobina reducida o de pigmentos anormales de hemoglobina en la sangre arterial.

Cianosis central: Debido a desaturacion arterial debidoa shunt derecha-izquierda o deterioro de la funcion pulmonar. Aparent a 4 gm/dl de hemoglobina reducida( o 0.5 mg/dl de metahemoglobina).Saturacion arterial < 85% sujetos blancos y delgados.Causas: Malformacion congenita con shunt derecha-izquierda, Metahemoglobinemia hereditaria.

Cianosis Periferica: Secundaria a vasoconstriccion cutanea debido a bajo gasto cardiaco o exposicion a aire/agua fria.

Sincope

Perdida subita de conciencia debido a hipoperfusion cerebral.

Historia es valiosa en diferenciar causas:-Episodios diarios: Stoke-Adams (Asistolia o fibrilacion ventricular.Transitoria en la presencia de bloqueo AV de tercer grado); otras arritmias cardiacas, epilepsia (petit mal).-Comienzo gradual: Vasodepresor, hiperventilacion, hipoglicemia.

Sincope

El sincope de origen cardiaco es de comienzo subito, sin aura, usualmente no asociado a convulsiones, incontinencia urinaria o estado confusional Post-ictal yde rapida recuperacion.

El sincope de la estenosis aortica es usualmente precipitado por el esfuerzo.

La perdida de conciencia gradual y que tarda solo segundos sugiere sincope vasodepresor o hipotensionpostural. Un tiempo mayor sugiere estenosis aortica o hiperventilacion.

Sincope histerico se asocia con sindrome ansioso.

Palpitaciones

Sensacion desagradable del latido cardiaco. Descrito como golpeteo, salto, irregularidad del latido cardiaco en el torax o golpeteo en el cuello.

Causado por : ritmo normal, latidos extras, diferentes arritmias.

Edema

Edema de extremidades inferiores, bilateral,

simetrico de predominio nocturno

es caracteristico de insuficiencia cardiaca.

Generalizado es denominado anasarca.

Otros Sintomas

Tos: Congestion o edema pulmonar, infarto pulmonar, compresion del arbol traqueobronquial por aneurisma de la aorta.

Hemoptisis: Expectoracion de sangre: Edema pulmonar,Estenosis mitral, infarto pulmonar.

Fatiga: Severa disfuncion sistolica, betabloqueadores,Hipokalemia-diureticos.

Poliuria, Nicturia, anorexia, ronquera (compresion del Laringeo recurrente), fiebre, calofrios (endocarditis).

Chronic venous insufficiency with venous skin changes at the ankle and varicose veins

Varicose veins

Venous ulceration

Ankle edema

Bilateral pitting edema in a patient with congestive heart failure

CT recostruction: Aortic aneurysm post stenting

The hand at the left is that of a young woman with Marfan's syndrome, while the hand at the right is a normal male. Both persons were of the same height, 188 cm. However, note that the hand at the left demonstrates arachnodactyly.

Seen here in the finger at the right are small splinter hemorrhages in a patient with infective endocarditis. These hemorrhages are subungual, linear, dark red streaks. Similar hemorrhages can also appear with trauma.

Xanthelasma palpebrarum in a patient with familial hypercholesterolemia.

Eruptive xanthomas on the back of a patient with hypertriglyceridemia.

Schematic representation of clubbing of a finger in a patient with Eisenmenger syndrome (right-to-left shunt).

Sternotomy scar following bypass surgery.

Pallor seen in a patient with anemia due to erythrocyte damage from a prosthetic aortic valve.

Cutaneous bleeding in a patient on warfarin (Coumadin) therapy for atrial fibrillation.

Patient showing pacemaker swelling under the left subclavicular region.He also has a midsternal bypass graft scar.

The cardiac silhouette is the most prominent central feature of the chest x-ray and it produces a familiar gourd shape with the apex of the left ventricle located just behind the left chest nipple. The inferior left ventricle wall lies on the left diaphragm and the superior base of the heart shows the aortic knob lying just to the left of the spine. A linear line descending from it, lying to the left of the spine, represents the lateral edge of the descending aorta.

When the horizontal diameter of the lower cardiac silhouette well exceeds one half of the internal diameter of the thorax, cardiomegaly is diagnosed. It is wise to assess the depth of the inspiration by noting whether the diaphragm lies lower than the ninth or tenth rib posteriorly as it should if there is an adequate inspiratory effort.

The PA (postero-anterior) radiograph at first appears to provide reassuring evidence that the tip of the pacemaker lies in the right ventricular apex. The slightly thickened metal tip of the pacemaker is seen just lateral to the border of the descending aorta near the diaphragm. The value of a lateral radiograph is best exemplified (click the "Lateral X-ray"button located on the right side of the main screen) when the course of the pacemaker wire is followed inferior and is found to lie well posterior to the expected position of the right ventricular cavity.

Coronary angiography requires multiple separate views to completely examine coronary anatomy and resolve potential vessel overlap. Several separate sequential injections of left (LCA) and right coronary arteries (RCA) are shown. Here, "postero - anterior" (PA), "left anterior oblique" (LAO), and "right anterior oblique" (RAO) views of a normal coronary tree are provided. The "Left Ventriculogram" is an RAO view with direct contrast injection into the cavity to examine myocardial function.

Computed tomography is a digitally based x-ray technique. The resulting images arise from differential x-ray absorption of tissue. The technique uses a narrowly collimated x-ray beam to irradiate a slice of the body. The amount of radiation transmitted along each projection line is collected by photo-multiplier tubes and counted digitally. By rapidly acquiring views from numerous different projections, achieved by quickly rotating the tube and detectors around the body, the transmissivity of the body from different angles can be established externally.

The SPECT camera is a large scintillation crystal connected to multiple photo-multiplier tubes which detect radiation emanating from the body. The technology of single photon emission tomography arises from positioning the camera head at multiple angles around the body accumulating as many as 180° of views at specific angular intervals. A certain number of counts are obtained from each view. In some cases multi-headed cameras are used to increase the speed of acquisition. Software then allows integration of all individual projection views into a composite data set which can be re-displayed as tomographic slices.

The medical imaging portion of the sound spectrum begins in the megahertz range, well above the maximum audible frequency of 15 kilohertz. In the 2 to 7 megahertz range used by ultrasound imaging, the wavelength of the acoustic pulses are less than a millimeter and are therefore capable of resolving fine anatomic structures.

Transesophageal echocardiography is performed by using a miniature high-frequency (5 MHz) ultrasound transducer mounted on the tip of a directable gastroscope-like tube about 12mm in diameter. Using topical mouth anesthesia and a little sedative, most individuals can swallow the probe without difficulty. Because the transducer lies in the lower esophagus in close direct fluid contact with the posterior of the heart, the images are superb since there is no interference by lung tissue.

Some modern "whole-body" (i.e. apertures wide enough to accept a person's thorax) machines now operate at 4 or more Tesla. Hydrogen atoms, pervasive in the water which makes up about 70% of the body's mass, have a dipole property by virtue of their characteristic spins