Heart Examination

You and Dr. Wilson are working in an outpatient practice. Dr. Wilson tells you, “Our next patient, Ms. Yang, is coming in because she had some chest pain. Let’s go find out what is going on.”
You and Dr. Wilson enter the examination room. The patient is a professionally dressed female who looks anxious. She says right away, “I think I may have heart disease. I want an ECG.”
Knowing that you should continue in an open-ended fashion in order to explore the patient’s concerns and beliefs, you ask,
“What leads you to believe that you have heart disease?”
Using the technique you learned for taking a patient’s history, you get the following information.
Her symptoms occurred in the evening last week on 2 different days. The first episode occurred when she and her sister were discussing her mother’s hospice care for congestive heart failure, and it happened again when talking to her best friend about it. She had a mild squeezing chest pain. Initially, the chest squeezing began at a mild 1/10 level and then increased to a moderate discomfort at 3-4/10. It was located in the upper middle of her chest (she put her hand on her upper sternum under the clavicles). It didn’t radiate anywhere. The palpitations felt like her heart was “skipping”, lasted about a minute and the chest squeezing slowly improved in about 5 minutes. She noticed some sweaty palms associated with the palpitations, but she didn’t feel any shortness of breath or lightheadedness. She felt afraid and worried she was going to die. She tried some deep breathing exercises which seemed to help the palpitations go away, but didn’t make the chest squeezing better or worse.
You gather the rest of your history from Ms. Yang.
Past medical history:
• Hypothyroidism
• Gastroesophageal reflux disease
• Post-partum depression after her second and third vaginal deliveries
Surgical history:
• Bilateral tubal ligation
• Appendectomy
Medication:
• levothyroxine 88 mcg PO daily
• omeprazole 20 mg daily
Allergies:
• No known drug allergies
Family history:
• Mother has congestive heart failure; had her first myocardial infarction at age 55
• Father smoked for many years, died at age 50 of laryngeal cancer
• Brother 57 years old, has hypertension and high cholesterol, no myocardial infarctions
• Sister 52 years old in good health
Review of systems:
No change in her hair or skin. Has occasional headaches. Has insomnia, which includes both difficulty falling asleep (she worries and cannot relax enough to fall asleep) and occasional awakenings due to night sweats. Has had some irregular menses and rare hot flashes but no heat intolerance.
Social History:
No tobacco or alcohol, and limits intake of caffeinated beverages. She is Chinese-American, is married, and has three teenage daughters. She says that she and her husband are close, but there has been a lot of stress at home lately between their demanding work schedules as engineers and the kids. Also, she is very stressed about her mother’s deteriorating health and expresses how thankful she is that her sister lives near their mother to take care of her. She becomes tearful when discussing her mother.

You step out of the room to tell Dr. Wilson the additional history you obtained. He asks you for your differential diagnosis. You list dysrhythmias, valvular heart disease, hyperthyroidism, anxiety/panic attack, coronary artery disease (CAD), vasomotor symptoms of menopause, anemia, and drugs. You tell Dr. Wilson that there are a number of things you will look for on physical examination to confirm or refute these diagnostic possibilities:

You and Dr. Wilson perform a physical exam.
Physical exam
Vital signs:
• Temperature is 37 C (98.6 F)
• Pulse is 92 beats/minute
• Respiratory rate is 16 breaths/minute
• Body Mass Index is 23 kg/m2
• Blood pressure is 130/88 mmHg
• Weight is 61 kg (135 lbs)
General: Ms. Yang is alert and sitting up comfortably, but she appears anxious and is fidgeting.
Integument: No lesions. There is no hair loss.
Head, eyes, ears, nose, and throat (HEENT): Conjunctivae are pale pink. Pupils are equal, round, and reactive to light. No lid lag noted. No adenopathy noted. Thyroid is palpable without enlargement, tenderness or masses noted.
Pulmonary: Breath sounds clear and equal bilaterally with no rales or rhonchi.
Musculoskeletal: No tenderness found on palpation of the chest wall.
Cardiovascular: No carotid bruits appreciated. Heart is regular in rate and rhythm. Clear S1 is heard at mitral and tricuspid areas, clear S2 is heard at pulmonic and aortic areas; no splitting or murmurs heard; no audible S3 or S4. No rubs.
Abdomen: Nontender, nondistended. Normal active bowel sounds. No masses or organomegaly.
Neurologic: Coordination and accuracy of movement equal bilaterally in upper and lower extremities. No tremor . Deep tendon reflexes 2+ bilaterally.
You determine that except for her anxious demeanor, Ms. Yang has a normal physical exam.
Dr. Wilson reassures Ms. Yang that her physical exam findings are normal. He tells her that he agrees with her request for an electrocardiogram because it could help detect a possible rhythm disturbance.

A few minutes later, the nurse finds you and Dr. Wilson in his office and hands you the electrocardiogram (ECG) shown on this page. Dr. Wilson comments,
Dr. Wilson asks you what laboratory tests you want to assess Ms. Yang.
Dr. Wilson gives you some information.
You know that females may present with symptoms that differ from the classic symptoms of heart disease. Ms. Yang has a family history of CAD with her mother having an MI at 55 years, consistent with premature CAD. Her East Asian ancestry may add one possible risk-enhancing factor.
Dr. Wilson asks you what else do you need to calculate Ms. Yang’s risk of CAD. You decide that in order to evaluate this further you want Ms. Yang’s cholesterol to assess her risk. Dr. Wilson had also checked a cholesterol panel with the other labs.

Using the Pooled Cohort Equation risk calculator, you estimate Ms. Yang’s 10-year ASCVD risk and determine she has a 2.1% chance of developing a first ASCVD event in the next 10 years and tell this to Dr. Wilson.
Dr. Wilson states “That’s right, 2% over 10 years says Ms. Yang is low-risk for ASCVD by the ASCVD Pooled Cohort Equation calculator.”
You ask, “So even though Ms. Yang has an elevated cholesterol and LDL, she is at low risk for ASCVD in the next 10 years?”
Dr. Wilson responds, “Using this model of assessment. However, up to 20% of heart attacks in females occur in those without any of the major risk factors.”
He continues, “Even though Ms. Yang has a low calculated risk for ASCVD in the next 10 years, we still need to work to reduce Ms. Yang’s risk factors for ASCVD with diet and exercise. According to the 2018 AHA/ACC cholesterol guidelines, with her LDL greater than 160 mg/dl, a statin at a moderate dose could be recommended. However, according to the 2022 USPSTF guideline on statin use for primary prevention of cardiovascular events, a statin would not be recommended until she had a 7.5% risk, so we will have to discuss it with her and make a shared decision.”
Although Ms. Yang appears to be at low risk for ASCVD at this time, you are concerned that her palpitations were associated with squeezing chest pain could be a symptom of CAD. Several pieces of information that you are aware of support this concern:
Dr. Wilson tells you, “Models used to identify symptoms of acute coronary syndrome (ACS) have been consistently based on data primarily from males. Increasing evidence indicates that the majority of females with CAD present differently from males. This lack of a good model makes it harder to identify presenting symptoms as prodromal to ACS in females.”
You recall that anxiety or panic disorder is on your differential diagnosis as a cause for Ms. Yang’s symptoms. Dr. Wilson reminds you that “stress” is a vague, shorthand designation for psychosocial pressures associated with increased vulnerability to illness, and yet the term “stress” (or “stressors”) can be helpful in talking about these important issues with patients, and stress can cause or contribute to Acute stress affects the cardiovascular, nervous, and endocrine systems. Chronic stress has been linked to increased risk of CAD and adverse cardiac events.Together you and Dr. Wilson review stressors in Ms. Yang’s life:
• Mother in hospice for her terminal congestive heart failure
• Demanding, high-pressure profession
• Going through menopause
• Three teenage daughters
What do you think most likely caused Ms. Yang’s chest squeezing and palpitations?”
“Could she have had a pulmonary embolism?”

Score > 4: PE likely. Consider diagnostic imaging.
Score 4 or less: PE unlikely. Consider D-dimer to rule out PE.
Ms, Yang’s score is zero, indicating low risk of PE
Dr. Wilson tells you, “The question now is to make a decision about Ms. Yang’s risk for cardiac disease. We know that her Pooled Cohort Equation 10-year risk of ASCVD is 2.1%. But, if we entertain the idea that her squeezing chest pain and palpitations may be an anginal equivalent, we would consider an exercise stress test (EST) as the next step. Let’s explore this.”
“The clinician’s interpretation of the patient’s symptoms is part of the ‘art’ of medicine,” explains Dr. Wilson. “Based on her history, physical, lab work, and what I know of the patient; my assessment is that Ms. Yang’s symptoms are not cardiac in origin and that she has chest discomfort and palpitations are due to panic attacks. With her female gender and her age, her pretest probability of CAD is low.”
He continues, “If we consider Ms. Yang to be low risk for CAD, exercise stress testing would be associated with a higher risk of a false-positive result. It is not necessary or cost-effective to order every test listed in the textbook, especially when the pretest probability is low. This is where the clinician makes the call about the appropriate use of resources. Also, remember that some testing carries its own risk, such as radiation or pursuing invasive testing (catheterization) based on a false-positive result. I believe that EST would not be indicated for Ms. Yang.”
Dr. Wilson agrees, “A panic attack could explain her symptoms. But we don’t want to forget that patients with panic disorder can have heart disease, too. And emotional stress can precipitate cardiac events. She really does have a lot going on in her life. Let’s have her complete a screening questionnaire for panic disorder and then go talk to her.”
Mrs. Yang answers positively to the questions on the Patient Health Questionnaire for Panic Disorder. You and Dr. Wilson return to the exam room to talk with Ms. Yang. She asks:
“Do you think I have heart disease, like my mother?”
Ms. Yang says, “I feel better knowing where I stand concerning my cardiac risk. Also, I have heard of panic attacks and I wondered if that was what was happening to me.” What do you suggest?
Dr. Wilson says, “I am concerned that you have a lot of stressful things happening in your life. Having a panic attack can be frightening but can also be a call to address the stressors in your life that you can modify. At this time, I would like to encourage you to take the time to think about how you might reduce both your physical and mental stress. In addition, it is important to get adequate sleep and regular moderate physical exercise.”
One week later you are pleased to see Ms. Yang has returned for her scheduled appointment.
When you visit with her, she tells you that she has done a lot of thinking since she last saw you.
She has decided to take several days off work to be with her mother. Also, she tells you that she has been talking with her husband about improving their diet and doing more things together.
She has started exercising during the past week.
She has been taking the statin and notes no side effects.
She has had no further palpitations or fast heart rate episodes.
She says, “Just knowing that my palpitations were stress-related and not a heart attack takes a huge worry off me. And I am happy that I have a medication that can decrease my heart disease risk.”
Ms. Yang tells you that she knows she eats out too often and is ready to modify her diet. She would also like to become more physically fit.
You recommend several resources.
You ask Ms. Yang to do a 24-hour dietary recall. Based on her responses, you decide that she has a high carbohydrate and high fat diet and make some specific recommendations to improve her diet.