Important Clinical Conditions
McTimoney College of Chiropractic
FTE Year 4
Manchester
Michael Verouden
1
, Cardiovascular (14)
Region CVS
Condition Angina Pectoris (Stable Angina)
Description Blockade of coronary artery leads to reduced coronary circulation (partial occlude)
Trigger: Physical Exertion / Extreme Emotion / Eating a heavy meal / Exposure to cold (4
E)
Can caused by: Commonly atheroma, sometimes coronary artery spasm / embolus
Reversible: No necrosis or tissue damage
Epidemiology Men 45-65
Presentation Central diffuse constrictive chest pain (may be a vague barely troublesome ache)
May rapidly become a severe intense precordial crushing sensation
Pain may refer to left shoulder, arm, neck or upper back (occasionally refer to right arm)
Dyspnoea
Symptoms relieved within 5 mins by resting or nitrates
Testing Blood Pressure: Hyper or Hypotension (look for extremes) Pulse: Tachy or Bradycardia
Apical Impulse: Lateralisation (Cardiomegaly) / Double bounce (Cardiomyopathy) /
Absent 🕿Ventricular Tachycardia due to ↓ Stroke Volume)
Percussion: Cardiomegaly
Auscultation: 3rd or 4th heart sound (potential gallop rhythm)
History Taking: Chest discomfort / Sx precipitated by trigger / Alleviated by rest
ECG Stress Test +/- and Imaging +ve: Confirmation of diagnosis
Coronary Angiography: Assess feasibility of PCI/ CABG
Treatment Increase Awareness / Conservation Management:
● Identification of hypertension patient
● Alert any changes in pattern of triggers 🡺 high risk
● Referral for assessment of severity of arterial disease and medical management
Pharmacological: Antiplatelet / Statin / Beta Blocker / ACEI / CCB / Nitro-glycerine
Region CVS
Condition Unstable Angina
Description Acute obstruction of a coronary artery without myocardial damage
Outcome based on the location of obstruction
Epidemiology Men 45-65
Presentation New onset / rapidly worsening angina
Angina on minimal exertion or at rest with absence of myocardial damage
Prolonged Angina at rest (> 20mins)
2
,Testing Pulse: Tachy/Bradycardia, Arrhythmia
Blood Pressure: Hypo/Hypertension
Temperature: Fever?
Palpation:
● Apical Impulse: Diffuse/Lateralised
● Peripheral Extremities: Cool/Cold, ↓Peripheral pulse, Pallor/Cyanosis
Auscultation: 4th Heart Sound / Soft 1st heart sound or 3rd heart sound, Crepitus in lungs
Observation: Possible raised jugular venous pulse (Dependent on area of damage
Require Urgent Referral
ECG: Changes within 10mins of presentation, Possible elevated ST segment
Blood Test:
● Inflammatory Biomarker (↑ESR/CRP)
● Cardiac Biomarker (-ve in unstable angina) ↑ c Troponin / cCreatine Kinase (Dx for
MI)
Immediate Coronary angiography: Indicated unless administration of fibrinolytics
Other imaging: Echocardiography, CXR
Treatment Pre-Hospital Care
O2, Aspirin and Nitrates
Transport to appropriate secondary care unit
1st 12-24 hours post admission to cardiac unit
O2, anti-platelets, anti-anginal, anti-coagulants, antiemetics, analgesics (IV morphine)
Fibrinolytics for STEMI if appropriate
Thrombolysis alteplase (synthetic tissue plasminogen activator)
Coronary Angioplasty
Reperfusion therapy (PCI/ CABG)
Post discharge
Rehabilitation and chronic medical management of CAD
Region CVS
Condition Myocardial Infarction (MI)
Description Acute obstruction of a coronary artery with myocardial damage
Outcome based on the location of obstruction
Epidemiology Men 45-65
Presentation Sx occur at rest with evidence of myocardial ischaemia or not relieving at rest
May refer to left arm / Neck / Throat / Jaw / Shoulder / Epigastrium
Dyspnoea
Anxiety
Diaphoresis
Nausea / Vomiting
Syncope / Collapse
3
, Male 🡺 increase prevalence of Acute MI
● Chest Pain, Diaphoresis and left arm radiation
Female 🡺 increase incidence of Atypical Presentation
● Indigestion, Nausea / Vomiting, Neck / Jaw or Back Pain, Right Shoulder / Arm
Radiation / Rales (small/clicking bubbling sounds on inhale) on lung auscultation /
Pulmonary Oedema (CXR)
Testing Pulse: Tachy/Bradycardia, Arrhythmia
Blood Pressure: Hypo/Hypertension
Temperature: Fever?
Palpation:
Apical Impulse: Diffuse/Lateralised
Peripheral Extremities: Cool/Cold, ↓Peripheral pulse, Pallor/Cyanosis
Auscultation: 4th Heart Sound / Soft 1st heart sound or 3rd heart sound, Crepitus in lungs
Observation: Possible raised jugular venous pulse (Dependent on area of damage
Require Urgent Referral
ECG: Changes within 10mins of presentation, Possible elevated ST segment
Blood Test:
Inflammatory Biomarker (↑ESR/CRP)
Cardiac Biomarker (-ve in unstable angina) ↑ c Troponin / cCreatine Kinase (Dx for MI)
Immediate Coronary angiography: Indicated unless administration of fibrinolytics
Other imaging: Echocardiography, CXR
Treatment Pre-Hospital Care
O2, Aspirin and Nitrates
Transport to appropriate secondary care unit
1st 12-24 hours post admission to cardiac unit
O2, anti-platelets, anti-anginal, anti-coagulants, antiemetics, analgesics (IV morphine)
Fibrinolytics for STEMI if appropriate
Thrombolysis alteplase (synthetic tissue plasminogen activator)
Coronary Angioplasty
Reperfusion therapy (PCI/ CABG)
Post discharge
Rehabilitation and chronic medical management of CAD
Region CVS
Condition Congestive/Chronic Heart Failure (HF)
Description Inability of heart pumping to maintain adequate systemic tissue perfusion
Epidemiology Common in ages 60+, more common in females and family history
4
McTimoney College of Chiropractic
FTE Year 4
Manchester
Michael Verouden
1
, Cardiovascular (14)
Region CVS
Condition Angina Pectoris (Stable Angina)
Description Blockade of coronary artery leads to reduced coronary circulation (partial occlude)
Trigger: Physical Exertion / Extreme Emotion / Eating a heavy meal / Exposure to cold (4
E)
Can caused by: Commonly atheroma, sometimes coronary artery spasm / embolus
Reversible: No necrosis or tissue damage
Epidemiology Men 45-65
Presentation Central diffuse constrictive chest pain (may be a vague barely troublesome ache)
May rapidly become a severe intense precordial crushing sensation
Pain may refer to left shoulder, arm, neck or upper back (occasionally refer to right arm)
Dyspnoea
Symptoms relieved within 5 mins by resting or nitrates
Testing Blood Pressure: Hyper or Hypotension (look for extremes) Pulse: Tachy or Bradycardia
Apical Impulse: Lateralisation (Cardiomegaly) / Double bounce (Cardiomyopathy) /
Absent 🕿Ventricular Tachycardia due to ↓ Stroke Volume)
Percussion: Cardiomegaly
Auscultation: 3rd or 4th heart sound (potential gallop rhythm)
History Taking: Chest discomfort / Sx precipitated by trigger / Alleviated by rest
ECG Stress Test +/- and Imaging +ve: Confirmation of diagnosis
Coronary Angiography: Assess feasibility of PCI/ CABG
Treatment Increase Awareness / Conservation Management:
● Identification of hypertension patient
● Alert any changes in pattern of triggers 🡺 high risk
● Referral for assessment of severity of arterial disease and medical management
Pharmacological: Antiplatelet / Statin / Beta Blocker / ACEI / CCB / Nitro-glycerine
Region CVS
Condition Unstable Angina
Description Acute obstruction of a coronary artery without myocardial damage
Outcome based on the location of obstruction
Epidemiology Men 45-65
Presentation New onset / rapidly worsening angina
Angina on minimal exertion or at rest with absence of myocardial damage
Prolonged Angina at rest (> 20mins)
2
,Testing Pulse: Tachy/Bradycardia, Arrhythmia
Blood Pressure: Hypo/Hypertension
Temperature: Fever?
Palpation:
● Apical Impulse: Diffuse/Lateralised
● Peripheral Extremities: Cool/Cold, ↓Peripheral pulse, Pallor/Cyanosis
Auscultation: 4th Heart Sound / Soft 1st heart sound or 3rd heart sound, Crepitus in lungs
Observation: Possible raised jugular venous pulse (Dependent on area of damage
Require Urgent Referral
ECG: Changes within 10mins of presentation, Possible elevated ST segment
Blood Test:
● Inflammatory Biomarker (↑ESR/CRP)
● Cardiac Biomarker (-ve in unstable angina) ↑ c Troponin / cCreatine Kinase (Dx for
MI)
Immediate Coronary angiography: Indicated unless administration of fibrinolytics
Other imaging: Echocardiography, CXR
Treatment Pre-Hospital Care
O2, Aspirin and Nitrates
Transport to appropriate secondary care unit
1st 12-24 hours post admission to cardiac unit
O2, anti-platelets, anti-anginal, anti-coagulants, antiemetics, analgesics (IV morphine)
Fibrinolytics for STEMI if appropriate
Thrombolysis alteplase (synthetic tissue plasminogen activator)
Coronary Angioplasty
Reperfusion therapy (PCI/ CABG)
Post discharge
Rehabilitation and chronic medical management of CAD
Region CVS
Condition Myocardial Infarction (MI)
Description Acute obstruction of a coronary artery with myocardial damage
Outcome based on the location of obstruction
Epidemiology Men 45-65
Presentation Sx occur at rest with evidence of myocardial ischaemia or not relieving at rest
May refer to left arm / Neck / Throat / Jaw / Shoulder / Epigastrium
Dyspnoea
Anxiety
Diaphoresis
Nausea / Vomiting
Syncope / Collapse
3
, Male 🡺 increase prevalence of Acute MI
● Chest Pain, Diaphoresis and left arm radiation
Female 🡺 increase incidence of Atypical Presentation
● Indigestion, Nausea / Vomiting, Neck / Jaw or Back Pain, Right Shoulder / Arm
Radiation / Rales (small/clicking bubbling sounds on inhale) on lung auscultation /
Pulmonary Oedema (CXR)
Testing Pulse: Tachy/Bradycardia, Arrhythmia
Blood Pressure: Hypo/Hypertension
Temperature: Fever?
Palpation:
Apical Impulse: Diffuse/Lateralised
Peripheral Extremities: Cool/Cold, ↓Peripheral pulse, Pallor/Cyanosis
Auscultation: 4th Heart Sound / Soft 1st heart sound or 3rd heart sound, Crepitus in lungs
Observation: Possible raised jugular venous pulse (Dependent on area of damage
Require Urgent Referral
ECG: Changes within 10mins of presentation, Possible elevated ST segment
Blood Test:
Inflammatory Biomarker (↑ESR/CRP)
Cardiac Biomarker (-ve in unstable angina) ↑ c Troponin / cCreatine Kinase (Dx for MI)
Immediate Coronary angiography: Indicated unless administration of fibrinolytics
Other imaging: Echocardiography, CXR
Treatment Pre-Hospital Care
O2, Aspirin and Nitrates
Transport to appropriate secondary care unit
1st 12-24 hours post admission to cardiac unit
O2, anti-platelets, anti-anginal, anti-coagulants, antiemetics, analgesics (IV morphine)
Fibrinolytics for STEMI if appropriate
Thrombolysis alteplase (synthetic tissue plasminogen activator)
Coronary Angioplasty
Reperfusion therapy (PCI/ CABG)
Post discharge
Rehabilitation and chronic medical management of CAD
Region CVS
Condition Congestive/Chronic Heart Failure (HF)
Description Inability of heart pumping to maintain adequate systemic tissue perfusion
Epidemiology Common in ages 60+, more common in females and family history
4
