EVALUATION OF THE PATIENT WITH CARDIOVASCULAR DISEASE



The history is the most important tool in the evaluation of a patient (Table 2-1). Chest pain is the most common presenting symptom of cardio vascular disease and must be characterized care­fully. Chest pain may be cardiac (myocardial or pericardial) or noncardiac in etiology (Tables 2-2 and 2-3). Ischemic myocardial pain is a visceral discomfort caused by insufficient oxygen delivery to an area of the heart. A transient oxygen supply/de­mand mismatch causes angina pectoris, whereas ischemia followed by myocardial necrosis is termed myocardial infarction. Angina pectoris is typically evoked by emotion, exertion, or a heavy meal, but more severe episodes can occur at rest or awaken the patient from sleep. It generally lasts only a few minutes and diminishes after exertion is stopped. When it is due to fixed coronary ob­struction, the same degree of activity tends to re­liably reproduce the pain. When due to coronary arterial spasm, with or without fixed obstruction, the level of activity that causes pain may vary. Nitroglycerin typically relieves the pain in about 5 minutes. Pain of a prolonged duration (>30 min­utes) suggests either myocardial infarction or non-cardiac pain. Respiration does not influence is­chemic chest pain. The pain of both angina pectoris and myocardial infarction can be atypical in some patients and difficult to diagnose. Many patients describe a chest discomfort or fullness that they do not consider pain. Any patient who has chest discomfort provoked by exertion and re­lieved by rest and any patient who has chest dis­comfort similar to the pain of a previous myo­cardial infarction should be suspected of ischemic myocardial chest pain.
The pain of pericardial inflammation (Table 2-3) may be difficult to differentiate from ischemic pain in a patient with pericarditis following my­ocardial infarction.

Patients with mitral valve prolapse sometimes present with a chest pain syndrome that may or may not resemble ischemic myocardial pain. The etiology of this chest pain is unclear.

Dyspnea is a subjective sensation of shortness of breath and often is a symptom of cardiac dis­ease, especially in patients with congestive heart failure (Table 2-4). When left ventricular failure occurs, left atrial and subsequently pulmonary venous pressures rise. Pulmonary compliance de­creases (stiff lungs) and causes a subjective sen­sation of air hunger before hypoxia, hypercapnia, or low cardiac output occur. As congestive heart failure worsens, transudative fluid accumulates in the alveoli and hypoxemia results. Because the supine position compared with the upright po­sition augments venous return, patients with congestive heart failure demonstrate orthopnea, i.e., shortness of breath in the supine position re­lieved by sitting up. They also may demonstrate paroxysmal nocturnal dyspnea, i.e., awakening with shortness of breath two to three hours after falling asleep.







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