Monthly Archives: March 2014

Approach to Dyspnea

History taking in Cardiology Contd….

Continuing our discussion on history taking in cardiology today we will form an approach to dyspnoea.

What is Dyspnea?

A consensus statement of the American Thoracic Society defined dyspnea in the following way1:

“Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses.”

The American Thoracic Society (ATS) statement on the mechanisms, assessment, and management of dyspnea, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.

It is one of the most common presentations of a variety of disorders.

What are we looking for when evaluating dyspnea?

In the approach to any symptom we should have a clear understanding of what we are looking for. Among patients who present with undue dyspnoea we are looking for one of the following major conditions:

  1. Respiratory system disease
    1. Asthma
    2. COPD
    3. Interstitial lung disease
    4. Pulmonary hypertension
  2. Cardiac disease
    1. Valvular heart disease
    2. Myocardial dysfunction either systolic or diastolic
    3. Pulmonary hypertension
    4. Pericardial diseases – though they present with symptoms of biventricular dysfunction or predominant right sided heart failure.
  3. Obesity
  4. Anaemia
  5. Deconditioning

Though this list is not complete but for all practical purposes these are the major differential diagnosis.

How to take history of dyspnoea?

General approach to record cardiac history:

In the description of any cardiac symptom you should proceed in a particular order. First describe the baseline (premorbid) functional status of the patient e.g. something like – the patient was able to walk for 5 kms, play golf, do jogging etc. without any symptoms.

Once the baseline functional status is clearly described go for symptoms. Any symptom should be described as ODP i.e. O= onset, D= duration, P= progression.

Describing the history:

  1. Onset of symptoms
  2. Duration of symptoms
  3. Progression (in terms of NYHA class and time to progression). In cardiovascular history always try to quantify symptoms in terms of NYHA class. Because it is the most widely used and validated.
  4. Describe the dyspnea in patient’s language. Try to ascertain that the patient actually has dyspnea. Sometimes the patient may be having predominant fatigue. Some of the common patient expressions of  dyspnea are like-
    • My breathing is shallow.
    • I feel an urge to breathe more.
    • My chest is constricted.
    • My breathing requires effort.
    • I feel a hunger for more air.
    • I feel out of breath.
    • I cannot get enough air.
    • My breath does not go in all the way.
    • My chest feels tight.
    • My breathing requires work.
    • I feel that I am smothering/suffocating.
    • I feel that I cannot get a deep breath.
    • I feel that I am breathing more.
    • My breath does not go out all the way.
    • My breathing is heavy.
    • Other descriptions

The language of dyspnoea can give a clue to the diagnosis e.g.

    1. Chest tightness or constriction is described in  Bronchoconstriction, interstitial oedema (e.g. Asthma, Myocardial ischemia)
    2. Increased work or effort of breathing is the description in – Airways obstruction, neuromuscular disease, reduced chest wall or pulmonary compliance (COPD, moderate to severe asthma, myopathy, pulmonary fibrosis)
    3. Air hunger, need to breathe, urge to breathe is seen in – increased drive to breathe (HF, pulmonary embolism, moderate to severe asthma or COPD)
    4. Rapid, shallow breathing- reduced chest wall or pulmonary compliance       (Interstitial fibrosis)
    5. Suffocating, smothering- Alveolar oedema (Pulmonary oedema)
    6. Heavy breathing, breathing more- Inadequate oxygen delivery to the muscles- Deconditioning

So carefully listen to the language patients use to describe the symptoms.

5. Variation in dyspnea – positional, diurnal or seasonal variation
6. Associated cough. If cough is there – dry or productive
7. Any history of wheezing
8. Haemoptysis
9. Orthopnoea or PND,History of PND is suggestive of cardiac disease. So always carefully ask for PND
10. Finally mention the present functional status of the patient.
Go to the next symptom like chest pain, palpitation , fatigue etc……only after you finish describing dyspnea

Once you are finished with describing the symptom of dyspnoea, formulate a short summary of the symptom. I will give an example of a summary – “patient had dyspnea which was insidious in onset and progressed from NYHA II to III/IV in …..Years, it is associated with h/o orthopnoea/PND, presently he is NYHA III.”

I hope this discussion is useful to you. Any suggestion, comments or correction is most welcome.

Dr. Anupam Jena
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Reference:

1.         Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine 2012;185:435-52.

 

History taking in Cardiology

History taking in any branch of medicine is the single most important exercise. Most clinical books open with the idea of history taking. In the initial part of medical training students sometimes fail to understand the importance of history taking. But as we go higher in our training we understand the importance of history gradually.

Why a good history is important?

A good history gives the diagnosis, or a list of differential diagnosis in most of the cases. Then you can channelize your investigations in that direction. Another practical need is for facing your clinical assessments and exams. The more you learn of a subject the more you understand about the history. History taking is a difficult job for the beginner. The skill improves with your knowledge in a field of medicine. These posts on “history taking in cardiology” will be an honest attempt by me to discuss the beauty and depth of history taking in cardiology.

How to take history in cardiology?

It is always safer to follow the standard format of history taking.

Patient particulars:

  1. Name
  2. Age
  3. Sex
  4. Address
  5. Educational status of the patient
  6. Occupation
  7. History given by self or parents/relatives
  8. If history given by relatives what do you think of the reliability of information given

When presenting your case in exams make this part of presentation sound like well-articulated sentences, e.g. the patient mr./mrs x.. ,is  a 55… years old male/female. He/she is a resident of y.. he is educated upto … and he/she works as ….history has been given by self/relative.

Make your presentation in a calm and composed manner, don’t sound haphazard and disorganized.

Presenting Complains:

Write the presenting complains in the proper chronological order. All of you might be aware of the chronological order in which symptoms are written. Usually the longest duration symptoms are mentioned first, followed by the second and so on.

Then comes history of present illness (HOPI)

In HOPI you should try to be systematic and proceeding in a well-directed manner. Now is the time to elaborate your presenting complains. It’s like what you want to keep as your diagnosis and differential diagnosis you talk more about them.

Those points we will discuss subsequently.

Basically history of present illness is analysis of symptoms.

What are symptoms of cardiovascular disease?

The presenting symptoms of cardiovascular disorders are

  1. Dyspnoea
  2. Chest pain
  3. Palpitation
  4. Fatigue
  5. Presyncope/Syncope/dizziness
  6. Pedal edema
  7. Neck pulsations
  8. Cyanosis
  9. Murmur
  10. Chest bulging, stunted growth, cyanotic spell – in paediatric cases

We will discuss about these symptoms one by one and how to analyse them

Past history:

Past history should include information about relevant diseases and conditions like diabetes mellitus, hypertension, bronchial asthma, tuberculosis, and other past medical and surgical conditions. In Indian setup history of rheumatic fever and treatment for same like penicillin prophylaxis should be sought.

Family history (Socio-economic history):

Is very important for cardiovascular diseases.

Personal history:

It includes questions about diet, addictions and substance abuse, etc.

Treatment history:

Ask about all previous investigations, drugs taken, procedures done

Summary of the entire history

Analysis of history

Differential diagnosis from history

Then proceed to physical examination

I will describe each component of the above outline in my subsequent posts

So keep reading. Any feedback or suggestion is welcome

Thank you

DR. ANUPAM JENA
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Heart Disease in Women

Heart Disease in Women

This topic will cover important and unique issues related to cardiovascular diseases in women. I will simplify it as much as I can. The problem of women’s heart is complex. Feed-backs or follow-up comments are welcome.

Is Heart disease really important for females?

The answer is YES ABSOLUTELY. Diseases of the heart are the leading causes of death and suffering in women. Every 1 in 3 female deaths is caused by heart disease. This amounts to more deaths from heart disease than from stroke, lung cancer and breast cancer combined. About half of these deaths (1 in 6) are caused by coronary artery disease (coronary artery = arteries supplying blood to heart muscles). A 40 years old female has a life time risk of development of cardiovascular disease of about 32%. The life time risk of heart failure is more in females than males, every 1 in 6 women is at risk of developing heart failure, whereas every 1 in 9 males is at risk of developing heart failure. Now I hope the problem of cardiovascular diseases in women is well understood. There is a need to be vigilant about your heart.

Heart disease in women:

Risk factors are the conditions or diseases which increase the chances of having heart disease (you can read more about risk factors under patient information page). The major risk factors of having coronary artery disease in females are same as in males. They are:

  1. Hypertension
  2. Diabetes mellitus
  3. High blood cholesterol
  4. Smoking
  5. Obesity
  6. Family history of coronary artery disease.

There are important differences in the manner in which these risk factors are tackled in women as compared to men.

Hypertension is 15% more common in females than males. Diabetes mellitus is as common in females as in males if not higher. Similarly elevated blood cholesterol in females is as common as in males. Obesity is more common in females than males. The things which are unique to women are that

  1. They are less likely to receive adequate treatment for these risk factors
  2. Guideline recommended treatment is used to a lesser extent in females
  3. Females are more likely to discontinue treatment
  4. They adopt life style modifications like regular walking, less often.

All these factors make females uniquely susceptible to coronary artery disease.

It has been seen that even after a heart attack there is delay in seeking medical attention. The response to treatment of heart attack is also less favourable in females.

In conclusion, the idea of writing this article is to create an awareness that women are equally or sometimes more prone for cardiovascular disease than men. They experience less symptoms which leads to delay in seeking medical attention. Even after medical consultation they are more likely to be undertreated and less likely to comply with medications. So it is high time that medical professionals and patients take notice of these facts and act accordingly

What to do ?

The following measures help to reduce the morbidity and mortality of cardiovascular diseases in women

1. Regular checking of blood sugar for diabetes

2. Regular checking for BP

3. Life style modification like – regular physical exercise, weight control, low salt intake

4. Consult your doctor for any symptoms

5. Regular intake of medicines

Thank you

Dr. Anupam Jena

 

 

A Hole In The Heart

Hole in the heart – Common cardiac problems in children

Many a times parenrs are told that the kid has a hole in the heart. What does a hole in the heart mean? Parents have many doubts and apprehensions about what actually that hole in the heart mean. Sometimes this term is used as a general term to suggest many diseases. Common problems which present as hole in the heart are:

  1. ASD – Atrial septal defects
  2. VSD – Ventricular septal defects
  3. PDA – Patent ductus arteriosus
  4. Multiple combinations of these defcts and other defects

Usually such diseases are treatable and completely correctible. I will explain these diseases or defects briefly and in a patient friendly language.

Normally our heart has two atria (left and right), two ventricles (left and right), two great arteries (aorta & pulmonary artery) and four valves (mitral, aortic, tricuspid & pulmonary). A hole in the heart can be a result of problems in one of these structures.

ASD (Atrial Septal Defects):

The left and the right atria are separated by the inter-atrial septum (IAS). When there is incomplete development of the IAS it results in ASD. An ASD can be an isolated problem or it may be associated with other cardiac problems. Isolated ASDs are completely correctible. Some ASDs are closed by percutaneous devices by cardiac catheterization and some are corrected by open surgery. (Details of device closure are available under cardiac interventions)

VSD (Ventricular septal defect):

The left and right ventricle are separated by inter-ventricular septum. When there is defect in the inter-ventricular septum it is known as VSD. VSD results in blood abnormally flowing from left to the right ventricle. There are four types of VSD and there are three sizes of VSD (small, moderate and large). The treatment and outcome depends on the type of VSD. Some VSDs close spontaneously while some VSDs need to be closed either by surgery or by devices. (Details of device closure are available under cardiac interventions)

PDA (Patent ductus arteriosus):

Normally in fetal life (inside mother’s womb) the aorta and the pulmonary artery are communicated by the ductus arteriosus. This ductus closes after birth. In case of some children this might remain open abnormally which is called patent ductus arteriosus. All PDAs need to be closed. Small PDAs can be closed by devices while large PDAs need surgery. (Details of device closure are available under cardiac interventions).

Frequently heart defects are combined and complex problems are associated with these septal defects. Those are more complex disorders which I can clarify for a particular patient.

In conclusion : I want you to understand that “A hole in the heart” is not always dangerous, though it signifies heart disease and needs evaluation and treatment.

If you have any queries feel free to ask (under ask your queries). If you like it, please leave a comment

Thank you

Heart Problems In Children

 Heart problems in children are more varied and complex than in adults as they suffer from a group of diseases called congenital heart diseases (Cardiac defects present since birth) as well as from many diseases seen in adults. Children with congenital heart disease pose a significant health problem. The severity of congenital heart disease range from simple defects to various complex diseases. A significant proportion of the untreated children with congenital heart disease actually die before reaching adolescence. But the good news is many of children’s heart diseases are completely treatable by early and effective therapy.

These days the advent of fetal echocardiography has enabled us to know about the structure and function of the developing heart of the fetus. Fetal echocardiography can diagnose important heart diseases in fetus making it possible to take adequate precautionary measures.

It is important to know about the symptoms of heart disease in children so that unnecessary delay in seeking medical attention can be avoided. I will explain about the symptoms.

Symptoms of heart disease in children

 The important symptoms of heart disease include

  1. Cyanosis: it means bluish discoloration of lips, tongue, finger tips and toes. Sometimes cyanosis is mild and inapparent to the eye, but the child would be obviously blue while crying. Cyanosis is usually associated with serious cardiovascular diseases. Never ignore any cyanosis seen in a child and you should immediately consult your doctor.
  2. Difficulty in breathing: In small children suffering from heart disease, there will be fast breathing. The child has difficulty with taking feeds, gets fatigued easily
  3. Excessive Sweating may be seen
  4. Growth retardation: reduced weight and height for age
  5. Frequent respiratory Infections : pneumonias can occur
  6. Exercise intolerance: unable to perform at par with other children
  7. Loss of consciousness may be seen in more serious conditions.

It is important to understand that these are common symptoms , but there can be atypical presentations also. So if you suspect anything is abnormal with your child visit a pediatric cardiologist.

Types Of Heart Problems In Children

Common types of heart problems in children are

  1. “ A hole in the heart” meaning usually – atrial septal defect, ventricular septal defect and patent ductus arteriosus. Anyone interested can read about these defects in my other posts.
  2. Stenosis(blockage) of a valve
  3. Cyanotic congenital heart diseases
  4. Acquired heart diseases- which affect in later parts of life.
  5. Many complex anomalies are there which I am not describing here.

To conclude this post – childrens are at risk for heart disease some are serious. Timely diagnosis and treatment are of vital importance.

Thank you. Please leave a comment

Dr. Anupam Jena

Palpitation

What is palpitations? 

Why it’s important?

Palpitation is the abnormal awareness of one’s own heartbeat. Normally you are not aware of your heart beat, the heart just goes on beating in the background sustains our lives. When you become aware of your heart beats its palpitation. Of course you can always feel the heart beats by putting a palm on the chest. Palpitation can be normal or abnormal, like everyone experiences palpitation after running, during anxiety or emotional excitement etc. the demarcation between normal and abnormal is sometimes diminished in cardiac symptoms – like palpitation can be a normal finding but undue palpitation is abnormal. What is means that it’s ok to have palpitation after running but if you are having palpitation while doing your routine activities then it is abnormal.

Palpitation can be a symptom of a wide variety of conditions starting from acute anxiety to serious heart diseases. Many non-cardiac diseases can also produce palpitation like anemia, hyperthyroidism etc.

Among heart diseases palpitations is caused by two types of conditions:

  1. Disturbances of heart rhythm
  2. Diseases affecting the cardiac structures like – valves, heart muscles etc.

Palpitation due to rhythm abnormalities occur intermittently, are sudden in onset and may terminate on it’s own or need treatment. Palpitation due to heart disease can also present during exertion, and in more advanced conditions may be present at rest.

Sometimes palpitation can be associated with a feeling of light-headedness and blackening of vision and may lead to frank fainting attacks. Many cardiac diseses like aortic valve diseases , pulmonary hypertension can lead to palpitation and syncope. When the heart is dilated like in some patients with heart failure it can lead to palpitation.

Most commonly many of us sometimes feel like missing a beat or palpitation which are usually caused by premature atrial or ventricular contractions.

The message is – “don’t ignore a palpitation.” Always consult your doctor . it  may turn out to be a minor problem or no problem at all  , but it is better than unknowingly denying a serious problem

Thank you

Dr. Anupam Jena

Chest Pain

CHEST PAIN to HEART ATTACK

not too far

 Its alarming to have a chest pain. It bothers us too often, that we sometimes tend to ignore it. So today I decided to tell a few things in brief about chest pain that everybody should know. This post is intended for general health information and not for self-treatment.

As we already know there are many structures inside the chest like- ribs,muscles ,lungs, food pipes, heart etc. So pain in chest can arise from any of these structures, but each structure usually has some typical characteristics of pain which helps to determine the presumed site of origin. For example when chest pain is due to muscles/bones then there may be some local pain on touching or pressing; in case of lung the pain will be associated with breathing difficulty, cough and expectoration. Similarly when pain arises from the food pipes there will be associated symptoms like – difficulty in swallowing, nausea, vomiting. But the most alarming and serious chest pain is the one arising from heart.

The heart is basically made up of muscles and like any other muscle in the body it needs blood supply. Blood supply to the heart is done by coronary arteries.   There are two occasions when cardiac pain can occur, either it is due to reduced blood supply to the heart due to blockage in the coronary arteries, or due to excessive demand of the heart like thickening of heart muscles. Chest pain arising from the heart is called ANGINA. Angina has a typical character – it is felt as a heaviness, squeezing sensation, tightness or heaviness in the centre of the chest which is often also felt in left arm, jaw,neck, shoulder or back. It is precipitated by physical exertion , emotional excitability and is relieved by rest. Sometimes pain can be more severe and longer lasting when it indicates something more sinister like an heart attack.

If someone feels a chest pain which is bothering him/her then medical attention should be sought. Like I said in the beginning – this article is for general health information and any chest pain needs evaluation by a doctor and prompt and proper treatment.

Thank you

DR. ANUPAM JENA

DIABETES AND HEART DISEASE

Diabetes and heart disease are closely related. Before discussing the heart problems in diabetes we will see what is diabetes mellitus. Diabetes mellitus is basically persistent elevation of blood sugar level due to inability to produce sufficient insulin or failure to respond appropriately to insulin. International guidelines define diabetes as fasting plasma glucose ≥ 126mg/dL or nonfasting plasma glucose ≥ 200mg/dL, or glycosylated hemoglobin ≥ 6.5%. Diabetes affects more than 200 million persons worldwide and by 2030 this figure will rise to >400 million persons.

HEART DISEASE IN DIABETES

Cardiovascular disease (CVD) remains the principal cause of suffering and death in diabetes. Diabetes causes widespread disease in heart and blood vessels like

1. Coronary artery disease- involvement of blood vessels of heart

2. Carebrovascular disease- involves the blood vessels of brain causing stroke

3. Peripheral vascular disease – involves blood vessels of limbs and aorta , may lead to loss of limbs

4. Heart failure

Coronary artery disease in diabetes:

Diabetes increases the risk of coronary artery disease manifold increasing the risk of having myocardial infarction (heart attack) and angina (chest pain). The level of increasing blood sugar directly influences the development and progression of CAD. Currently CAD is the principal cause of mortality in diabetes. People with diabetes are more likely to have severe coronary artery disease like involvement of multiple coronary arteries.

Heart failure in diabetes:

The most common causes of heart failure are coronary artery disease and hypertension which go hand in hand with diabetes. Presence of diabetes increases the risk of heart failure by 3 to 5 times and also worsens the outcome of treatment

WHAT TO DO?

Reading all these things are frightening but don’t worry there are ways to counter these problems

PREVENTING HEART DISEASE IN DIABETES

The risk of heart disease in diabetes is reduced significantly by the following measures

1. Strict control of blood sugar:

The first and foremost aspect of preventing heart disease in diabetes is control of blood sugar. Proper control is blood sugar reduces the risk of Heart disease

2. Strict control of BP:

Hypertension is present in ~70% of individuals with diabetes. Hypertension increases heart disease in diabetes. So strict control of blood pressure is mandatory. Many antihypertensives like ACE inhibitors ( ramipril, enalaprol) and ARB (losartan, telmisartan) have cardio protective and kidney protective action.

3. Treatment of coronary artery disease by medication , cardiac intervention / surgery reduces morbidity and mortality risk

4. Life style modifications like

– Cessation of smoking

– Regular brisk walking for > 40 minutes per day atleast five days in a week

– Restricting salt intake , fatty foods and increasing consumption of vegetables and fruits  reduce the risk of heart disease

You can find out about the cardiovascular effects of drugs used in diabetes under the ” medications” menu

Information about choosing between percutaneous cardiac intervention vs surgery is available under ” intervention” menu.

Thank you.

Dr. Anupam Jena

Risk Factors for Heart Disease

In the understanding of any disease one of the most important part is the understanding of risk factors or what are the things that makes us more vulnerable to a particular disease. In relation to heart disease there are some well-defined risk factors. It is important to understand that many new and novel risk factors are emerging. Some of the risk factors can be controlled while some are non-modifiable like age, family history , genetics etc. Presently the concept of predisposition to heart disease is changing and the current models consider multifactorial causation, the meaning of which is that many factors interact among themselves to cause disease. Nevertheless there are a few traditional risk factors which cause the majority of heart disease, which are:

  1. Diabetes Mellitus
  2. Hypertension – High Blood Pressure
  3. Smoking
  4. Elevated blood Cholesterol
  5. Family history of heart disease

These risk factors are responsible for around 80% of heart diseases. Even though many new and novel risk factors are coming up, these five factors are responsible for the majority of coronary artery diseases. Effective treatment of the first four of the above can reduce the risk of heart disease. You can’t do much about positive family history.

The old saying can’t be overemphasized- “Prevention is better than cure”.

Act when time is there. Take responsibility for your health.

In my next posts we will discuss about the risk factors and the benefit of proper treatment of them.

Thank you all and keep reading

Dr. Anupam Jena

Welcome to the Heart of Cardiology

Your place for ONLINE CARDIAC CONSULTATION  AND INFORMATION ABOUT HEART DISEASES

Cardiovascular diseases are the biggest threats in today’s world and they kill more number of people than other diseases. Cardiovascular problems are preventable and effectively treated when interventions are done early and effectively. The importance of the old saying “Knowledge is Power” can’t be more than when it comes to deciding about one’s own health. This is the age of information and you have every right to be informed correctly about your health issues. The idea behind this site is to provide up-to-date information related to all issues in Cardiovascular Health.

This site provides information related but not limited to the following topics

  1. Risk factors for heart disease and effective control of then
  2. Common symptoms of heart disease and how to identify then early
  3. Heart diseases associated with other medical problems
  4. Heart problems in young children
  5. All information related to Cardiac procedures
  6. A section for medical students about important topics in cardiology
  7. Answers to your specific questions

And many more

Its all about taking responsibility for your health.

Thank you

Dr. Anupam Jena