4.3 Cardiovascular Diseases

4.3 Cardiovascular Diseases

Quick Answer: Cardiovascular vignettes dominate Part II red-flag testing. Crushing chest pressure with diaphoresis suggests acute MI; tearing pain radiating to the back suggests aortic dissection; exertional pressure relieved by rest suggests stable angina; orthopnea and edema suggest heart failure. Chiropractors must recognize these impressions and refer before any high-velocity cervical or thoracic manipulation.

Cardiovascular Screening in Chiropractic Offices

Every new patient encounter is an opportunity to screen blood pressure, pulse rhythm, and cardiovascular risk. General Diagnosis (19% of Part II) tests whether you can form the correct clinical impression from a short case and choose appropriate action — continue care, co-manage, or emergency referral. Cardiovascular disease kills more Americans than any other cause; missed MI and dissection in chiropractic settings carry catastrophic malpractice exposure. Part II rewards systematic reasoning, not memorized buzzwords alone.

Hypertension

Hypertension is sustained elevation of blood pressure — generally ≥130/80 mmHg per current ACC/AHA guidelines for staging, with treatment thresholds depending on risk category. Most patients are asymptomatic; "headache from high blood pressure" is uncommon except in hypertensive emergency.

Chiropractors should measure BP on intake and periodically thereafter. White coat hypertension and masked hypertension remind you that one reading is not definitive, but repeated elevated readings warrant medical follow-up.

Hypertensive emergency (severe BP with acute end-organ damage — encephalopathy, MI, pulmonary edema, aortic dissection, acute kidney injury) requires emergency reduction. Hypertensive urgency is severe BP without acute end-organ damage — needs prompt outpatient management, not emergency department care unless symptoms suggest otherwise.

Impression: untreated hypertension increases stroke, MI, heart failure, and renal disease risk. Chiropractic manipulation is not contraindicated in well-controlled hypertension without other red flags, but poorly controlled BP (commonly above 180/110) warrants medical clearance before HVLA, especially cervical.

Chest Pain: Cardiac vs Musculoskeletal

Chest pain is the classic Part II discriminator. Build the impression from quality, timing, associated symptoms, and risk factors.

Acute myocardial infarction (MI) — occlusion of coronary artery with myocardial ischemia:

• Quality: crushing, pressure, heaviness — patient may say "elephant on chest"
• Duration: typically more than 20 minutes, not relieved by rest or nitroglycerin alone
• Radiation: left arm, jaw, neck, epigastrium
• Associated: diaphoresis, nausea, dyspnea, sense of doom
• Risk factors: age, male sex, diabetes, smoking, hyperlipidemia, family history
• Action: emergency medical services activation — time to reperfusion determines mortality

Stable angina — fixed coronary stenosis limiting flow during exertion:

• Predictable chest pressure with activity, relieved by rest within 5 minutes
• Same exertion level triggers similar symptoms
• Responds to nitroglycerin
• Impression: chronic ischemic heart disease, medical management and activity prescription

Unstable angina / NSTEMI — intermediate acuity:

• Rest pain or increasing frequency/severity (crescendo pattern)
• May lack ST elevation on ECG but still requires emergency evaluation
• Part II may present "new chest pain at rest in a diabetic patient" — answer is unstable angina or NSTEMI, not costochondritis

Musculoskeletal chest pain (costochondritis, rib strain):

• Reproducible with palpation or specific movement
• No diaphoresis, no dyspnea disproportionate to activity
• No radiation pattern typical of cardiac ischemia
• Vital signs stable

When the stem includes diaphoresis plus crushing pain plus risk factors, the cardiac impression wins even if the patient also has thoracic spine tenderness.

Aortic Dissection and Other Vascular Emergencies

Aortic dissection — tear in the aortic intima with blood tracking in the media:

• Sudden severe tearing or ripping pain, maximal at onset
• Radiation to the back between the scapulae
• Blood pressure differential greater than 20 mmHg between arms
• Pulse deficit in a limb if branch vessel involved
• Associated with Marfan syndrome, bicuspid aortic valve, hypertension, cocaine use
• Impression: emergency — CT angiography diagnosis; beta-blockade and surgical or endovascular repair

Dissection is an absolute contraindication to cervical and thoracic HVLA. A patient with acute severe back and chest pain after chiropractic adjustment should be evaluated for vascular catastrophe — Part II may test recognition that dissection mimics musculoskeletal pain.

Abdominal aortic aneurysm (AAA) rupture presents with sudden abdominal or back pain, hypotension, and pulsatile abdominal mass in at-risk older male smokers. Emergency surgery. Palpation of the abdomen in elderly smokers with back pain should be gentle and purposeful.

Heart Failure

Heart failure — the heart cannot pump adequately to meet metabolic needs (HFrEF with reduced ejection fraction) or fills poorly due to stiff ventricle (HFpEF).

Left-sided failure symptoms:

• Dyspnea on exertion progressing to orthopnea (dyspnea lying flat — sleeps on pillows)
• Paroxysmal nocturnal dyspnea (PND) — wakes gasping after 1–2 hours of sleep
• Pulmonary crackles, S3 gallop on exam

Right-sided failure symptoms:

• Peripheral edema, jugular venous distension (JVD), hepatomegaly
• Often secondary to left failure or pulmonary hypertension

Clinical impression clues on Part II: elderly patient with progressive dyspnea, bilateral ankle edema, weight gain from fluid retention, and inability to lie flat. This is not lumbar stenosis causing walking limitation — though both may coexist.

Chiropractic care for musculoskeletal complaints in stable heart failure requires medical co-management, avoidance of fluid overload exacerbation, and no aggressive manipulation during acute decompensation (pulmonary edema).

Arrhythmias

Atrial fibrillation (AF) — chaotic atrial activity with irregular ventricular response:

• Irregularly irregular pulse on palpation
• May be asymptomatic or cause palpitations, dyspnea, fatigue
• Stroke risk from atrial thrombus — anticoagulation (warfarin, DOACs) common
• Impression matters before cervical HVLA: anticoagulated patients have higher bleeding risk including vertebral artery and soft tissue hematoma

Atrial flutter — sawtooth pattern, often regular or irregular ventricular response.

Ventricular tachycardia — wide-complex tachycardia, hemodynamic compromise — emergency.

Bradycardia — syncope, fatigue; may need pacemaker.

Part II may give pulse irregularity without other symptoms — impression is AF, next step medical evaluation and stroke risk stratification (CHA₂DS₂-VASc), not cervical adjustment.

Valvular Heart Disease (Recognition Level)

Part II tests basic murmur associations at recognition level:

Infective endocarditis — fever, new murmur, Janeway lesions, Osler nodes, Roth spots — antibiotics and surgery; manipulation contraindicated during active infection.

Peripheral Vascular Disease and DVT

Peripheral artery disease (PAD) — exertional leg pain (claudication) relieved by rest, absent hair, cool skin, diminished pulses. Ankle-brachial index below 0.90 supports impression. Distinguish from neurogenic claudication (spinal stenosis) — PAD claudication is vascular (better with spine flexion, worse with leg use), stenosis is neurogenic (better leaning forward, shopping cart sign).

Deep vein thrombosis — unilateral calf swelling, warmth, Homan sign historically (not relied upon). Risk factors overlap with PE. Anticoagulation before manipulation if DVT suspected.

Risk Stratification Before Manipulation

Before cervical HVLA, consider:

1. Blood pressure — uncontrolled hypertension
2. Anticoagulation — bleeding risk
3. Recent cardiac event — MI within weeks, unstable angina
4. Severe aortic pathology — known aneurysm, dissection symptoms
5. Active heart failure decompensation — pulmonary edema
6. Carotid disease — recent stroke, vertebrobasilar symptoms

Part II correct answers often align with referral or modified technique when cardiovascular impression is unstable, even if the chief complaint is neck pain.

Electrocardiogram Clues (Recognition)

You are not interpreting full ECGs on Part II, but associations appear:

• ST elevation — acute STEMI, emergency reperfusion
• ST depression, T-wave inversion — ischemia, NSTEMI
• Atrial fibrillation — no P waves, irregular RR
• Left ventricular hypertrophy — strain pattern in chronic hypertension
• Prolonged QT — drug toxicity risk (torsades)

When a vignette states "ECG shows ST elevation in leads V2–V4," the impression is anterior STEMI regardless of whether the patient also has T6 tenderness.

Integrating Cardiovascular Impression with Chiropractic Care

Stable, medically managed cardiovascular disease does not exclude chiropractic care — many patients with well-controlled hypertension, stable angina, or compensated heart failure benefit from exercise advice, posture correction, and gentle mobilization. The Part II skill is knowing which presentation is stable versus acute. Acute coronary syndrome, dissection, decompensated heart failure, and symptomatic arrhythmia are referral emergencies. Stable chronic disease is co-management territory with documented clearance and technique modification when warranted.