Diagnostic process in

Cardiovascular Disease
Faculty of Medicine
University of Brawijaya

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Doctor-Patient relationship:

Empathy : the ability to recognize and to some extent share the

emotions and states of mind of another and to understand the
meaning and significance of that person's behavior.
Empathy is different from sympathy in that to be empathetic one
understands how the person feels rather than actually
experiencing those feelings, as in sympathy.

Patient: human being  mimics

 feelings
 Appreciate or honor each other
 honest  may be positive / Negative

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Doctor-Patient Relationship

Interaction
My feelings My behaviours
affect my affect patient’s
behaviour feelings

Patient’s feelings
affect their
Patient’s behaviour diseases
affect my feelings

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 Examination of patient  the central point  needs scientific background

Phase I : - Anamnesis
- Physical notes
- Data recording
Needs patience, discipline, sensitive, curious

Phase II : - Data analysis

- Integrating data
Diagnosis, Prognosis, Process, Diagnosis

Phase III : -M anagement

- Treatment
Consideration, experience, advice

“Primum Non Nocere”

 Do No Harm (=Pertama jangan melakukan tindakan yang merugikan).
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The Cardiovascular Data Base

1. Patient history
2. Physical examination
3. Electrocardiogram
4. Chest X-ray
5. Routine blood exams
6. Additional Tests:
1. Two-dimensional echocardiography with Doppler
studies
2. Exercise treadmil ECG test
3. Ambulatory Holter Monitoring
4. Nuclear imaging
5. Cardiac catheterization

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Classification of Common Heart Disease
(according to the causes)
• Cardiovascular malformations (congenital heart
disease)
– Involving the valve, heart structure, and other large vessels,
etc.
• Acquired heart disease
– Artery thrombosis disease : leading to ischemia or
infarction, such as coronary heart disease
– Rheumatic heart disease: heart inflammation, valvular
disease
• Hypertension: primary, secondary, hypertensive
heart disease

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Classification of Common Heart Disease
(according to the causes)
• Acquired heart disease
– pulmonary and pulmonary-vascular heart disease:
pulmonary heart disease, pulmonary
hypertension, pulmonary embolism, etc.
– Infection: bacteria, viruses invade the heart
– Diseases of other systems involve the
heart: hyperthyroidism, anemia, malnutrition,
immune abnormalities, physical and chemical
damage, mental factors, etc.

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Classification of Common Heart Disease
(according to pathology )
• Endocardial disease
– Endocarditis, valvular disease, etc.
• Myocardial disease
– Inflammation, ischemia or necrosis, hypertrophy,
fibrosis, damage, etc.
• Great vascular diseases
– Atherosclerosis, dissection, inflammation,
thrombosis, angioma, embolism, etc.
• Pericardium disease
– Inflammation, plot (gas, water, blood, pus, etc),
coarctation, etc.

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Classification of Common Heart Disease
(according to pathophysiology )
• Heart Failure
– Left heart, right heart; acute, chronic;
systolic, diastolic
• Shock
• Dysfunction of coronary circulation
• Papillary muscle dysfunction
• Arrhythmia
• Cardiac tamponade
• Others: high or low blood pressure (of
systemic or pulmonary vascular), shunt, etc.

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 Format of Heart Disease Diagnosis

• Etiological diagnosis
– Such as rheumatic heart disease, coronary
artery disease
• Pathological or anatomical diagnosis
– Such as mitral stenosis
• Pathophysiology diagnosis
– Such as heart failure, atrial fibrillation,
pulmonary hypertension

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Methods of Cardiovascular Disease
Diagnosis
• Patient history
– present history, past history, personal history,
the history of surgery, vaccination history,
marriage and procreation, family history, etc.
• Physical examination
– Symptoms and signs
• Laboratory examination
– Blood, urine, faeces, serous effusions (from
pericardial effusion), sputum, biopsy, etc.
• Equipment inspection
– X-ray, ultrasound (echocardiography),
electrocardiography, radionuclide,
angiography, etc.

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 Evaluation of the Methods in
Cardiovascular Disease Diagnosis

• History and physical examination

– basic skills, first-hand information, many
diseases can be diagnosed through this
• Laboratory examination
– Most supportive, but some can be used to
make a definite diagnosis, such as
myocardial necrosis marker, BNP (brain
natriuretic peptide), etc.

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 Evaluation of the Methods in
Cardiovascular Disease Diagnosis
• Equipment inspection
– Major method for cardiovascular disease
diagnosis, Divided into invasive and non-invasive
method.
– non-invasive method can easily be accepted by
patients, and is safe, however, the information
may be limited (eg. ECG, echocardiography)
– Invasive method: the opposite to non-invasive
ones (eg. Cardiac catheterization)
– Semi-invasive examination，such as those via the
esophagus (eg. Trans-esophageal echocardiography)

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 Basic skill
Inspection: Skin, mucosae(cyanosis?,pale?),
movement of
chest wall,
Palpation : - Sensitivity of the hands/fingers
- Muscle tone
- Tumor
Percussion : Sonor, dulness, timpanic
Auscultation : Sounds/Voices
- Breath
- Friction
- Heart sounds
- Additional sounds: gallop, murmurs

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Problem Oriented Medical Record

POMR is oriented to problem

1.Baseline data
2.Problem list
3.Problem oriented medical record
4.Summary of problem

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Common symptoms and signs related to
Cardiovascular problem

1. Chest pain
2. Dyspnea
3. Syncope
4. Palpitations
5. Lower extremity edema
6. Heart murmur
7. Hypertension
8. Fever associated with cardiac
symptoms and signs

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Chest Pain

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 Differential diagnosis of chest pain
System involved Pathology
Cardiac Myocardial infarction
Angina pectoris
Pericarditis
Prolapse of the mitral valve
Tamponade
Vascular Aortic dissection
Respiratory (all tend to give rise to Pulmonary embolus
pleuritic pain) Pneumonia
Pneumothorax
Pulmonary neoplasm
Gastrointestinal Esophagitis due to gastric reflux
Esophageal tear
Peptic ulcer
Biliary disease
Pancreatitis

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Differential diagnosis of chest pain
System involved Pathology
Musculoskeletal Cervical nerve root compression by
cervical disc
Costocandritis
Fractured rib
Neurological Herpes zoster
Respiratory (all tend to give rise to Pulmonary embolus
pleuritic pain) Pneumonia
Pneumothorax
Pulmonary neoplasm
Psychogenic Anxiety
Panic disorder
Conversion disorder
Malingering

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Dyspnea

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Differential diagnosis of dyspnea:

System involved Pathology

Cardiac Cardiac failure
Coronary artery disease
Valvular heart disease – aortic
stenosis, aortic regurgitation. Mitral
stenosis/regurgitation, pulmonary
stenosis
Cardiac arrhythmias
Respiratory Pulmonary embolus
Airway obstruction-COPD, asthma
Pneumothorax
Pulmonary parenchymal disease (eg.
Pneumonia, interstitial lung disease,
lung neoplasm)
Pleural effusion
Chest wall limitation-myopathy,
neuropathy (eg Guillain-Barre
disease), rib fracture,
kyphoscoliosis
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Differential diagnosis of dyspnea:

System involved Pathology

Other Obesity (limiting chest wall movement
or sleep apnea)
Anemia
Psychogenic hyperventilation, panic
attack, anxiety.
Acidosis (eg aspirin overdose,
diabetic ketoacidosis)

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Syncope

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 Differential diagnosis of syncope :

System involved Pathology

Cardiac Tachyarrhyhtmias- supraventricular or ventricular
Bradyarrhythmia- sinus bradycardia, complete or
second-degree heart block, sinus arrest
Stokes-Adam attack- syncope due to transient asystole
Left ventricular outflow tract obstruction- aortic
stenosis, HOCM (hypertrophic obstructive
cardiomypathy)
Pulmonary hypertension
Vasovagal After carotid sinus massage and also precipitated by
pain (simple faint), micturition, anxiety; these result in
hyperstimulation by vagus nerve, which leads to AV
node block (and therefore bradycardia, hypotension
and syncope)

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 Differential diagnosis of syncope :

System involved Pathology

Circulatory Postural hypotension – usually due to antihypertensive
drugs or diuretics; also caused by autonomic
neuropathy as in diabetes
Pulmonary embolus – may or may not preceded by
chest pain
Septic shock – severe peripheral vasodilatation results
in hypotension

Cerebrovascular Transient ischemic attack

Vertebrobasilar attack
Neurological Epilepsy
Metabolic Hypoglycemia

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Palpitations

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Palpitations :

Palpitations may be caused by any

disorder causing a change in cardiac
rhythm or rate and any disorder
causing increased stroke volume

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Palpitations :
Rapid Palpitations:
1. Regular palpitations may be a sign of:
1. Sinus tachycardia
2. Atrial flutter
3. Atrial tachycardia
4. Supraventricular re-entry tachycardia
2. Irregularly irregular palpitations may indicate:
1. Atrial fibrillation
2. Multiple atrial or ventricular ectopic beats
3. Multifocal atrial tachycardia (MAT): usually
found in patients with lung pathology

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Palpitations:
Slow palpitations: patients often describe these as
missed beats or forceful beats (after a pause the
next beat is often more forceful due to a long
filling time and therefore a higher stroke volume).

Causes of slow palpitations:

1. Sick sinus syndrome
2. Atrioventricular block
3. Occasional ectopics with compensatory pauses

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 Normal ECG

• Rate 90-95 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 s
• QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm
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 Sinus Tachycardia

• Etiology: SA node is depolarizing faster

than normal, impulse is conducted
normally.
• Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.

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 Atrial Fibrillation

• Deviation from NSR

– No organized atrial depolarization, so
no normal P waves (impulses are not
originating from the sinus node).
– Atrial activity is chaotic (resulting in an
irregularly irregular rate).
– Common, affects 2-4%, up to 5-10% if
> 80 years old
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 Atrial Flutter

• Deviation from NSR

– No P waves. Instead flutter waves (note
“sawtooth” pattern) are formed at a rate
of 250 - 350 bpm.
– Only some impulses conduct through
the AV node (usually every other
impulse).
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Lower Extremity Edema

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 Differential diagnosis of lower
extremity edema
Pathology Cause
Congestive heart Myocardial infarction, recurrent tachyarrhythmias
failure (particularly atrial fibrillation), hypertensive
heart disease, myocarditis, cardiomyopathy due
to drugs and toxins, mitral, aortic or pulmonary
valve disease
Right heart failure Chronic lung disease, primary pulmonary
secondary to hypertension
pulmonary
hypertension (cor
pulmonale)
Hypoalbuminemia Excessive protein loss (due to nephritic
syndrome, extensive burns, protein losing
enteropathy), reduced protein production (due
to liver failure), or inadequate protein intake (due
to protein-energy malnutrition)
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 Differential diagnosis of lower
extremity edema
Pathology Cause
Renal disease Any cause of renal impairment ( e.g. hypertension,
diabetes mellitus, autoimmune disease, infection)
Liver cirrhosis Alcohol, hepatitis A, B, C, etc, autoimmune
chronic active hepatitis, biliary cirrhosis, Wilson’s
disease, hemochromatosis, drugs
Idiopathic Premenstrual edema
Arteriolar dilatation Dihydropyridine calcium channel blockers ( e.g.
(exposing the nifedipine, amlodipine)
capillaries to high
pressure, thus
increasing
intravascular
hydrostatic pressure)

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 Differential diagnosis of lower
extremity edema
Pathology Cause
Sodium retention Cushing’s disease resulting in excessive
mineralocorticoid activity, corticosteroids
Local causes Cellulitis, venous thrombosis, lymphedema

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Heart Murmur

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 Differential Diagnosis of Heart Murmur
Phase Nature of Valve lesion Cause of valve lesion
of murmur
cardiac
cycle
Systolic Ejection Aortic stenosis Valvular stenosis,
systolic congenital valvular
abnormality, rheumatic
fever, supravalvular
stenosis, senile valvular
calcification
Aortic sclerosis Aortic valve roughing
(murmur that
does not radiate
to the carotids)
HOCM Left ventricular outflow
tract (sub aortic) stenosis
Increased flow High output states (eg
across normal anemia, fever, pregnancy,
valve thyrotoxicosis)
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 Differential Diagnosis of Heart Murmur
Phase Nature of Valve lesion Cause of valve lesion
of murmur
cardiac
cycle
Systolic Holosystolic Mitral Functional MR due to
regurgitation dilatation of mitral valve
(MR) annulus
Valvular MR: rheumatic
fever, infective
endocarditis, mitral valve
prolapse, chordal rupture,
papillary muscle infarct
Tricuspid Functional TR
regurgitation Valvular TR : rheumatic
(TR) fever, infective
endocarditis
VSD with left-to- Congenital, septal infarct
right shunt (acquired)

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 Differential Diagnosis of Heart Murmur
Phase Nature of Valve lesion Cause of valve lesion
of murmur
cardiac
cycle
Diastolic Early diastolic Aortic Functional AR: dilatation of
regurgitation (AR) valve ring, aortic dissection,
cystic medial necrosis
(Marfan syndrome)
Valvular AR: rheumatic fever,
infective endocarditis,
bicuspid aortic valve
Pulmonary Functional PR: dilatation of
regurgitation valve ring, Marfan
syndrome, pulmonary
hypertension
Valvular PR: rheumatic fever,
carcinoid, tetralogy of Fallot

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 Differential Diagnosis of Heart Murmur
Phase of Nature of Valve lesion Cause of valve lesion
cardiac murmur
cycle
Diastolic Mid Mitral stenosis Rheumatic fever, congenital
diastolic (MS)
Tricuspid Rheumatic fever
stenosis (TS)
Left and right Tumor obstruction of valve
atrial myxomas orifice in diastole
Continuous PDA Congenital
Arteriovenous
fistula
Cervical venous
hum

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Hypertension

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 Differential diagnosis of
hypertension
• Systemic hypertension may be classified
as:
– Primary (essential) hypertension, for which
there is no identified cause. This accounts for
95% of cases.
– Secondary hypertension, for which there is a
clear cause

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 Blood Pressure Classification

BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

JNC VII
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 Causes of secondary hypertension
Mechanism Pathology
Renal Renal parenchymal disease (e.g.
chronic atrophic pyelonephritis,
chronic glomerulonephritis), renal
artery stenosis, renin-producing
tumors, primary sodium retention
Endocrine Acromegaly, hypo- and
hyperthyroidism, hypercalcemia,
adrenal cortex disorders (e.g
Cushing’s disease, Conn’s
syndrome, congenital adrenal
hyperplasia), adrenal medulla
disorders (e.g pheochromocytoma)
Vascular disease Coarctation of the aorta
Other Hypertension of pregnancy

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 Causes of secondary hypertension
Mechanism Pathology
Increased intravascular volume Polycythemia (primary or
secondary)
Drugs Alcohol, oral contraceptives,
monoamine oxidase inhibitor,
glucocorticoids
Psychogenic Stress
Neurological Increased intracranial pressure

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Fever associated with a
cardiac symptom or sign

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 Differential diagnosis of fever
• Infective endocarditis (bacterial or fungal
infection within the heart)
• Myocarditis (involvement of the myocardum in
an inflammatory proess, which is usually viral)
• Pericarditis (inflammation of the pericardium
which may be infective, postmyocardial
infarction or autoimmune)
• Other rare conditions such as cardiac myxoma

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 Summary

1. Clinical diagnosis for patient with

cardiovascular disease needs
comprehensive approach.
2. Cardiovascular data base includes
patient history, physical examination,
electrocardiogram, chest X-ray, Routine
blood exams and additional tests

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 Summary

3. Components of a complete cardiac

diagnosis include etiologic diagnosis,
pathologic or anatomical diagnosis, and
pathophysiologic diagnosis.
4. Many of symptoms and signs may lead to
differential diagnosis.

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Thank You
Good luck

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