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 presente
Historia remota
Revision por sistemas
Factores de riesgo cardiovascular
Antecedentes familiares
Uso de medicamentos terapeuticos
Uso de drogas recreacionales
Examen general
Examen segmentario.

Ll
 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: Cronica:

Edema pulmonar EBOC

Asma Insuficiencia cardiaca
Trauma toracico Fibrosis Intersticial difusa
Neumotorax espontaneo Asma
Embolia Derrame pleural
Neumonia Enf. pulmonar tromboembolica
Sindrome de distress respiratorio Enf. Vascular pulmonar
Derrame pleural Disnea psicogenica
Hemorragea pulmonar Anemia severa
Estenosis traqueal postintubacion
Desordenes de hipersensibilidad.
 Escala de la American Thoracic Society de la disnea

0 no Sin disnea caminando rapido en plano o

moderadamente una pendiente.

4 Leve Disnea camiando rapido en plano o moderadamente

una pendiente.

7 Moderada Disnea a caminar regularmente en plano.

9 Severa Disnea que obliga a detenerse a menos de 100 metros

o al caminar unos pocos minutos.

12 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 debido

a 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 y
de 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 hipotension
postural. 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

Venous ulceration

Varicose veins
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