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Signs and Symptoms of Heart Disease

Signs and Symptoms of Heart Disease

Highly Suggestive Symptoms of Heart Disease

Major Signs and Symptoms of Heart Diseases are Chest pain, shortness of breath, palpitation, syncope,Pheripheral edema.

Less Suggestive Symptoms of Heart Disease 

In few patients the Signs and Symptoms of Heart Disease may as Fatigue, dizziness, cough, hemoptysis, anorexia, cyanosis, nocturia, sweating, abdominal pain or bloating, weight loss, peripheral   embolic events, visual disturbances.

Chest pain

Signs and Symptoms of Heart Disease

Signs and Symptoms of Heart Disease

Causes of Chest Pain

  • Cardiac

Coronary artery disease, aortic stenosis, perticarditis, myocarditis, obstructive hypertrophic cardiomyopathy, pulmonary hypertension, mitral valve prolapse.

  • Noncardiac


 Pleuritis, Pneumonitis or Pneumonia,

 Pulmonary embolus with or without infarction,



Costochondritis, myositis, trauma, herpes zoster.


Esophagitis with or without spasm,

Gastric or duodenal ulcer,

Gallbladder disease,


Aortic dissection class


Cardiac Syncope

Sudden, no prodrome, brief duration, rapid, complete recovery, no localizing seizure activity, occurs independent of body position.

Signs and Symptoms of Heart Disease


  Causes (3Cs)

1.Common faint (vasovagal attack)

Emotion, heat, carotid sinus hypersensitivity.


(a)  Inadequate LV output: Arrhythmias, AS.

(b)  Inadequate LV filling : CHD, postural hypotension,Cough, micturation, PPH.


Hypoxia due to anaemia.

High altitude



Signs and Symptoms of Heart Disease



Exercise, high altitude


         Alveolar (Pulmonary) : COPD, embolism

         Blood disease : Anaemia

         Cardiovascular : CHD, cardiac failure

         Diabetic acidosis (Also renal failure)

         Endocrine : Thyrotoxicosis

         Fat (Obesity)

         Gas (and other causes of abdominal distension)


   Paroxysmal dyspnoea

Low : Larngeal : Foreign body, laryngismus striculus.

Cardiac : Cardiac : Acute LV failure, valvular disease, cardiac tamponade.

Reserve:Respiratory : Bronchial asthma, spontaneous pneumothorax,acute pul. oedema, pul. embolism.

    Nocturnal dyspnoea

Cardiac: LVF, hypertrophic cardiomyopathy, coronary spasm

Pulmonary: Asthma, extrinsic allergic alveolitis, emboli

CNS/pharyngeal: Sleep apnoea


    Cardiac Causes of Cough

            Pulmonary edema,

            Pulmonary venous hypertension,

            Pulmonary infarction,

Tracheo-bronchial compression.


     Cardiac Causes of Hemoptysis

(i) Mild to moderate hemoptysis

Pulmonary edema, mitral stenosis, Pulmonary infarction,Pulmonary hypertension,especially in Eisenmenger syndrome.

(ii) Massive hemoptysis

Rupture of pulmonary AV aneurysm, rupture of aortic aneurysm into tracheobrochial tree.


Bluish discoloration of skin and mucous membranes, requires 50 gm / L reduced hemoglobin for detection.

Signs and Symptoms of Heart Disease

Cyanotic Congenital Cardiac Defects

   Central Cyanosis

Decreased arterial oxygen saturation

Right to left shunts

Pulmonary insufficiency

Hereditary methemoglobinemia

  Peripheral cyanosis

Increased tissue oxygen extraction due to depressed perfusion

Low cardiac output with vasoconstriction

Localized arterial or venous obstruction

           Decreased Hb > 5 gm / 100 ml. blood (30% of total Hb in capillaries)

           Deficient, oxygenation of blood in lungs e.g. pneumonia, chronic bronchitis

           Decreased O2 transfer across alveolar capillary membrane e.g. fibrosing alveoliltis

           Decreased amount of air ventilating the lungs e.g. poliomyelitis


I. Central : (Skin, mm., limbs warm, clubbing)

1. Cardiac : Congenital heart defects,Eisenmenger, Congestive Heart Failure (severe)

2. Respiratory: COPD

3. High altitude : Decreased O2

4. Primary polycythemia : Absolute excess of desaturated Hb.

 II. Peripheral (Skin only, limbs cold, no clubbing)

         Cold                 Cardiac failure

         Collapse (shock)

      Differential cyanosis

Lower limbs only : Eisenmenger,PDA or interrupted aortic arch

Upper limbs only : Transposition of great arteries (TGA)


Types of abnormal: ABCDJPs

     Alternans : LV failure

      Anacrotic : AS

      Bounding  : Hyuperkinetic status

      Bisferiens : AR (severe) with moderate AS, HOCM.

      Corrigan :

Physiological : Heat, pregnancy, alcohol

Hyperkinetic states : e.g. thyrotoxicosis

Cardiac : AR, PDA, VSD (large), complete heart block

       Dicrotic : Fevers (typhoid), severe CCF (usually secondry to dilated cardiomyopathy), tamponade, low output following aortic valve replacement for AR.

       Jerky : HOCM

       Plateau : AS

       Parvus et tardus : AS

       Paradoxus : Pericardial effusion, constrictive pericarditis

       Pulmonary: asthma.

    Absent pulse


           Block (Arteriosclerotic obstruction)


           Dissection of aorta



Heart sounds

First Heart Sound (S1)

Intensity of first heat sound is influenced by position of mitral leaflets at onset of ventricular systole, rate of rise in ventricular pressure pulse and structural integrity of mitral valve.

(a) Loud S1 : Tachycardia (short diastole), Raised cardiac output, Mitral stenosis, Short P-R (WPW Syndrome)

(b) Wide Split S1 (> 30 ms) Right bundle branch block.

(c) Reversed splitting of S1 Left bundle branch block, Severe mitral stenosis, Left atrial myxoma

(d) Soft S1 Mitral regurgitation

Calcified mitral leaflets, Long P-R interval





Second Heart Sound(S2)

Cause of a Widely Split second heart sound

(i) Delayed Pulmonary valve Closure as in

Right Bundle Branch block, Pulmonary embolism,Pulmonary stenosis, Atrial septal defect

(ii) Early Aortic valve closure as in Mitral regurgitation, Ventricular septal defect.

Reverse splitting of S2

Aortic stenosis(AS)       Patent ductus arterious(PDA)

Hypertension(HTN)       Ischaemic heart disease (IHD)


Causes of Single Heart Sound

Tetralogy of Fallot, Truncus arteriosus, Tight pulmonary stenosis, Tricuspid atresia.








RV abn : ASD Elec. LV


aS, AR RBBB RV delay
tension LVF ASD disease LBBB
Aortic dil APVD VSD WPW
Exercise PS (large) RV pacing
AR (some) RVF PVC (RV)


LV pacing Mech
Mitral dis., PS PVCs delay :
Pul. hyper. (LV) AS, PDA
LVF LV abn : Myocardial
ASD VSD disease
MR AR (severe)


Third Heart Sound (S3)

Low pitched, occurs 0.14 to 0.16 Sec after S2, normally heard in children.

Its presence in patients over 40 years indicates

Ventricular decompensation, AV valve regurgitation

Left sided S3 best heard at apex in expiration

Rights sided S3 best heard in lower left sternal border during inspiration.

Before 40 Physiological or pathological by the company it keeps.

After 40-to be considered pathological

   Left sided                 :              Right sided

Hypertension              :               Massive pulmonary embolism

Myocardial infarction              Cardiomyopathy


 Fourth Heart Sound (S4)

Low pitched sound, best heart in apex at left lateral position

Is present in patients of : Hypertension, HOCM, Coronary artery disease, Acute mitral regurgitation, Delayed A.V. Conduction, Hyperdyamic circulation.

       To Distinguish S4 from Split S1

           S4 is best heart at apex where as S1 at left lower sternal border

S4 disappears on standing (decreased venous return) of if bell is pressed against chest wall.

S1 splitting varies with respiration but not S4

Palpable presystolic impulse confirms S4.

Opening Snap (OS)

Occurs 0.14 to 0.12 sec after S2

High pitched, best heard at lower left sternal border radiating to base of heard in A-V valve stenosis / obstruction or increased flow across normal A-V value

Nearer OS to A2, more sever is AV valve obstruction, OS diminishes in intensity as MS progresses.

4th heart sound (Atrial gallop) 


High end: diastolic pressure : Early stage of Rt.or Left ventricular failure

Hypertrophy (severe ventricular) e.g. Aortic Stenosis.

(Atrial contraction has to produce considerable pressure rise to augment ventricular filling)

     Differentiation of JVP from Carotid Pulse

             Venous                                                       Arterial

Double wave form                                       Single wave

Respiratory and                                          No visible variation

Postural variation

Undulant, diffuse                                          Localized

Not palpable                                                 Palpable

Obliterated by gentle pressure                     Not obliterated


Jugular Venous Pulse (JVP)

      Absent : Atrial fibrillation

      Regular : Junctional rhythm

      Canon waves, irregular : Complete heart block, A-V


Rapid X and Y descent :constrictive Pericarditis

Ventricularisation : tricuspid regurgitation

Slow Y descent : mitral stenosis

Increased (a) wave : left atrial myxoma

Raised JVP


       Bradycardia (marked)

       Congestive heart failure

       Decreased compliance (volume capacity) of RV : Pericardial effusion, constrictive pericarditis

       Elevated intrathoracic pressure

Pressure on SVC

Pleural effusion (massive)

       Fluid overload (IV)

       Growths (or obstructive lesions) in right heat :

Tumour or thrombus iRA

TR or TS

        Hyperdynamic states (besides Anaemia)

And also due to



Cor pulmonable (anoxic)

Disease of liver



Graves disease

Heat and

Pregnancy, Pagets disease

 Cardiac murmurs

            I. Innocent

               Systolic ejection



               Supine position best for auscultation

               Supraclavicular or sternal border

               Single S2 during expiration while standing

                Satisfactory ECG and CXR

           II. Physiological




Pulse pressure wide


Pectus excavatum (severe)

Straight back syn.

           III. Relative  

(a)  Dilatational : All 4 valve sites

(b)  Flow :

 IV.     Organic

               1. Systolic

(a) Ejection

Obstructive,Aortic / Pulmonary,Supravalvar,Valvar,Infravalvar

Increased now                   AR

Complete heart block

Post valvular                     Systemic hypertension

Pulmonary hypertension

50/50 murmur


           (b) Pansystolic  

A-V valve incompetenc : MR, TR

L or R shunt : VSD, PDA.

             (c) Late systolic



Mitral chorda or papillary muscle abnormality

           2. Diastolic

Obstruction at A-V                 MS, TS. Mid or late


Reg. across                          AR, TS. Early

Semilunar valves

Increased flow

across A-V valves                             (Ref. functional murmurs)

       3. Continuous

Innocent               :         Venous hum

Mammary suffle

Uterine suffle

Pathological          :         5 pairs

PDA, Aortopulmonary septal defect

Pul. atresia, Fallots triad

Pul. AV fistula, systemic AV fistula

Pul. arterial stenosis, coarctation

Rupture of sinus of Valsalva into RA or

RV, rupture of aortic aneurysm into rt. heart or pul. artery.

Ejection Systolic Murmur


Aortic Stenosis : valvular, subvalvular and supra valvular

Increased flow; Aortic regurgitation

Bicuspid aortic valve

Aortic root dilatation (aortitis, aneurysm, hypertension, idiopathic)


Pulmonary stenosis

Increased pulmonary blood flow (ASD, VSD)

Pulmonary hypertension

Early Systolic Murmur

Acute MR / TR-, TR in absence of pulmortary hypertension   Small VSD

Large VSD with pulmonary hypertension

Late Systolic Murmur

Mitral valve prolapse

Papillary muscle dysfunction.

Holosystolic Murmur

Mitral regurgitation

Tricuspid regurgitation


Early Diastolic Murmur

Aortic regurgitation

Pulmonary regurgitation

Mitral Mid Diastolic Murmur

Mitral valve obstruction (MS, ball valve thrombus, atrial myxoma, cortiatriatum, valve vegetations)

Patent Ductus Arteriosus (PDA), VSD (increased flow across MV)

Tricuspid Mid Diastolic Murmur

Tricuspid stenosis

Right atrial tumor


Anomalous pulmonary venous connections

Continuous Murmurs

         (i) Left to right shunt

Patent Ductus Arteriosus (PDA)

Aorto-pulmonary septal defects

Coronary A-V Fistula

Anomalous left Coronary artery

ASD with mitral setnosis

Rupturned Sinus of Valsalva

Palliatie surgical shunts VSD + AR

         (ii) Other pathologic causes

Pulmonary artery branch stenosis

Bronchial collateral

Intercostal AV fistula

Proximal coronary artery stenosis

         (iii) Nonpathologic

Cervical venous hum

Mammary suffle.

Characteristics of a Venous Hum

1.     Best heard when sitting up

2.     More common on right side

3.     Increases during inspiration

4.     Louder in diastole

5.     Maximal with head turned away

6.     Abolished by finger pressure over internal jugular vein

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