Patients with decreased cardiac output secondary to heart failure may become mentally confused and disoriented. Such symptoms also may be due to hypoxia, to drugs that are invariably prescribed for such patients, and to renal or hepatic failure.2 A completed stroke may be caused by a lacunar infarct, cerebral hemorrhage, cerebral arterial thrombosis, or a cerebral embolus (see Chap. 89). A transient cerebral ischemic attack is commonly due to an embolus. The embolus may originate in an atheromatous ulcer in the carotid artery system or the aortic arch; be related to infective endocarditis, a recent MI, atrial fibrillation, or clots on a prosthetic valve; or originate in the leg veins and pass through a patent foramen ovale to the brain (see Chap. 89).
The patient with cardiogenic shock or with a severe tachyarrhythmia who also has considerable intracranial or extracranial vascular disease may develop such severe cerebral hypoxia that coma occurs. Hypoxic encephalopathy may follow cardiac resuscitation and occasionally occurs after cardiopulmonary bypass for cardiac surgery. A cerebral abscess may occur in patients with congenital heart disease and a right-to-left shunt.2
FEVER, CHILLS, AND SWEATS
Patients with rheumatic fever usually do not have chills. Chills are common in patients with bacterial endocarditis. Symptoms of fever, chills, or sweats in any patient with a heart murmur should lead one to suspect infective endocarditis (see Chap. 73). A history of valvular heart disease is not a prerequisite for a diagnosis of endocarditis, since previously normal valves become infected. A history of recent dental work, genitourinary surgery, or illicit drug use increases the suspicion of infective endocarditis. Fever may accompany pericarditis. Myalgia, chills, and fever on rare occasions may be related to MI, presumably because of some form of immunologic response to the necrotic myocardial tissue. An intracardiac tumor (myxoma) may produce systemic symptoms in the absence of infection. Low-grade fever in a patient with heart failure may be a sign of pulmonary emboli.2 A profuse "cold sweat" mediated by sympathetic discharge often accompanies early stages of acute MI. Excessive sweating may occur in patients with severe aortic regurgitation. Diaphoresis is often a sign of congestive heart failure in infants.
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