Cardiovascular Diseases

1. Cardiovascular Diseases Introduction to Human Diseases Chapter 12

2. Review of Cardiovascular Anatomy • Atria (right and left) • Ventricles (right and left) • Valves • Tricuspid, pulmonic, mitral, aortic • Regurgitation or insufficiency, stenosis • Systole • Diastole

3. Review of CV Anatomy • Myocardium • Epicardium & endocardium • Coronary arteries • Left mainstem • Left anterior descending • Left circumflex • Right coronary artery

4. Review of CV Anatomy • Aorta • Arteries, arterioles • Capillaries • Venules, veins • Vena cava (inferior and superior)

5. Reye’s Syndrome • Non-inflammatory encephalitis & hepatic failure associated with: • Mitochondrial dysfunction, often due to mitochondrial toxin (aspirin most commonly) • First described in Australia in 1963 • Peak ages: 5-14 YOA, average = 7 YOA • Peak incidence 1979-80: 555 cases • 2 or fewer cases/year since 1994

6. Reye’s Syndrome • Develops within 3 weeks after viral illness • Strong association with aspirin use • S/S: altered consciousness & mood, abnormal liver tests, high serum ammonia level, cerebral edema, abnormal CSF (lymphocytes)

7. Reye’s Syndrome • Mortality: 20% • Down from 50% • Usual cause of death: • Cerebral edema • Common neurological impairment in survivors

8. Acute Rheumatic Fever (ARF) & Rheumatic Heart Disease (RHD) • Disease caused by recent Group A streptococcal infection (usually URI) • Well-known and described since 1800’s and earlier • Decreased incidence & mortality over last few decades, due to: • Antibiotic Rx of strep infections • Changes in subtypes & virulence of strep

9. ARF & RHD • Some genetic susceptibility involved also • Sore throat is commonest URI • Average age: 5-15 YOA • 60% with ARF eventually develop RHD • Usually cause of morbidity is cardiac disease • Diagnosis via: • Known strep infection previously • Plus two major criteria

10. ARF & RHD • Major criteria • Carditis (40%) • Murmur, CHF, valvular disease, pericarditis, cardiomegaly • Migratory polyarthritis (75%): large joints • Subcutaneous nodules (10%) • Erythema marginatum rash (5%) • Chorea (Syndenham’s chorea) (5-10%) • Abnormal purposeless movements of face and upper extremities

11. ARF & RHD • Treatment: • Antibiotics for strep, anti-inflammatories, steroids

12. Carditis • Pericarditis • Myocarditis • Endocarditis

13. Pericarditis • Inflammation of pericardium • Acute or chronic • Etiologies: • Infection (most common), metastases, ARF, uremia, trauma, idiopathic, associated with autoimmune diseases

14. Pericarditis • S/S: atypical chest pain, effusion, abnormal pulse & BP, dysrhythmias and EKG changes • Treatment: • Pericardiocentesis, possibly surgery • Antiinflammatories, antibiotics, etc.

15. Myocarditis • Inflammation of the myocardium & conducting system • Acute or chronic • S/S: fever, fatigue, pain, less specific • Etiology: viral infection, alcohol, toxins, drugs or radiation therapy • Treatment: variable

16. Endocarditis • Inflammation of endocardial membrane lining the valves and chambers • Typically infectious (bacterial) • Group A nonhemolytic strept • During bacteremic episodes (surgery, IVDA) • Structurally abnormal valves are most susceptible • Causes vegetations • These may embolize to other areas

17. Endocarditis • S/S: highly variable, often long-standing illness with fever, fatigue, new murmur • Testing: echocardiogram & blood cultures • Treatment: • Long-term antibiotics • Occasional valve surgery

18. Valvular Disease • Types • Improper valve closure • Incompetance, regurgitation, insufficiency • Allows backward flow of blood into previous chamber • Narrow valve opening • Stenosis • Blood is more slowly pumped out of the chamber prior to the stenotic valve, higher pressure there

19. Valvular Disease • Any valve may be involved • S/S: murmurs (grades I through VI), dilation of various cardiac chambers • Most commonly affected valves: • Mitral and Aortic

20. Mitral Valve Disease • Mitral insufficiency & mitral stenosis • Left atrial enlargement • Etiology: ARF, mitral valve prolapse (MVP), left heart failure • Testing: Echocardiography • S/S: murmur, CHF, fatigue, dyspnea • Treatment: medical or surgical

21. Aortic Valve Disease • Aortic insufficiency or aortic stenosis • Both can cause left ventricular dilation, hypertrophy, or failure • Etiology: ARF, syphilis, endocarditis, HTN, congenital malformations • S/S: murmur, syncope, angina, fatigue, CHF • Testing: echocardiogram • Treatment: medical or surgical

22. Hypertensive Heart Disease • Hypertension: over 140/90 on at least 3 separate occasions • Hypertensive Cardiac Disease: • Type of heart disease that is due to the longterm effect on the heart of pumping against higher than normal pressure in the systemic circulation • Types of hypertension: • Essential • renovascular

23. Hypertension • Higher risk of HTN: • Sedentary, obese, African-Americans, high salt and fat diet, genetics, older age, smokers, oral contraceptive users • S/S: may be asymptomatic • Dizziness, headaches, fatigue, shortness of breath, tinnitus • Treatment: medications • Diuretics, beta-blockers, vasodilators, calcium channel blockers, also low salt diet

24. Hypertension • Common disease of middle-aged and older people • Only about 1/3rd of hypertensive patients have well-controlled BP on treatment • Those with good BP control are almost always on multiple meds, usually 3.

25. Coronary Artery Disease (CAD) • Narrowing of coronary arterial lumens by plaque, causing myocardial ischemia due to decreased blood flow • Increased plaque risk: • Older age, heredity, hyperlipidemias, DM, HTN, smoking • More common in males, in post menopausal females and geriatrics

26. CAD • S/S: chest pain (angina), shortness of breath, fatigue • Testing: EKG, stress tests, cardiac catheterization • Treatment: medical (nitroglycerin, other vasodilators, lipid-lowering meds) or surgical (angioplasty or CABG-bypass grafting)

27. Angina Pectoris • Chronic or recurrent chest pain due to myocardial ischemia • Substernal pressure, squeezing, tightness • Associated symptoms: • Nausea, diaphoresis, radiation of pain to shoulder or jaw • Worsened by exertion or activity • Improved with rest, oxygen, nitroglycerin

28. Myocardial Infarction (MI) • Emergency condition of major/total coronary artery occlusion leading to severe myocardial ischemia or necrosis (cell death) • Almost always due to lumen occlusion by clot forming on a ruptured plaque • Cardiovascular disease is the #1 cause of death in the US

29. MI • S/S: same as for plaque formation • HTN • DM • Hyperlipidemias • Smoking • Obesity • Sedentarism • Past history of CAD or family hx of CAD

30. MI • S/S: Chest pain most commonly (like angina) • Dyspnea, fatigue, nausea, diaphoresis • Right or left shoulder or arm pain • Jaw pain • Epigastric pain, indigestion • Syncope (fainting), palpitations, sudden death

31. MI • Testing: EKG, cardiac enzymes (blood tests) • Treatment: • Angioplasty, cardiac catheterization • Coronary artery bypass grafting (CABG) • Medical treatment • Nitroglycerin, beta-blockers, lipid-lowering meds, aspirin and other anticoagulants • Fibrinolytics (thrombolytics) “clot buster” meds

32. MI • Complications: • Ventricular fibrillation: fatal dysrhythmia, most common cause of sudden death • Congestive heart failure • Cardiogenic shock • Ventricular septal rupture • Papillary muscle rupture

33. Congestive Heart Failure • Impaired cardiac ability to pump leads to backing up of blood in the pulmonary circulation and fluid in the alveoli • Right and left-sided heart failure • Acute or chronic • Left-sided heart failure may eventually lead to right sided heart failure

34. Congestive Heart Failure (CHF) • Left-sided failure: • Left ventricle fails to pump efficiently • Blood backs up into the left atrium and then the pulmonary circulation, eventually filling the alveoli • S/S: rales in lungs, dyspnea, orthopnea

35. Heart Failure • Right-sided Heart Failure: • Failure of the right ventricle to pump effectively • Blood backs up into the right atrium, then the vena cava, and systemic veins • Extra fluid in the liver and spleen • hepatosplenomegaly • Fluid in the feet and distal legs • Pedal edema

36. Heart Failure • Treatments: • Diuretics, control of HTN, oxygen, meds to enhance contractility (digitalis, etc), beta-blockers, etc.

37. Cardiac Arrest • Cessation of all cardiac activity • Pulseless • Apneic • No other signs of life • No movement, cough, attempts at breathing, pupillary activity

38. Cardiac Arrest • Numerous causes • Everyone will eventually have a cardiac arrest • Most common arrythmias involved: • Ventricular fibrillation • Ventricular tachycardia • Asystole (flatline)

39. Cardiac Arrest • Treatment: • CPR*** • Oxygen administration • Defibrillation or pacemaker (varies with the dysrhythmia)*** • Antiarhythmic medicines • ***these are most likely to be lifesaving

40. Blood Vessel Diseases • Arteries • Aneurysms • Arteriosclerosis/Atherosclerosis • Veins • Thrombophlebitis • Varicose Veins

41. Aneurysms • Local dilation of a blood vessel wall • Usually arteries • May also occur in ventricular walls • Types of aneurym: • Saccular (like a sac off one side of vessel) • Fusiform (symmetric dilation of vessel) • Dissecting (separation of layers of the vessel by leaking blood under pressure)

42. Aneurysm • Types (according to location) • Abdominal aorta • Severe, tearing abdominal pain, shock • Thoracic aorta • Severe, tearing thoracic pain, shock, MI-like symptoms and EKG possible • Peripheral arteries

43. Aneurysms • Complications: • Leaking or rupture • Thrombus formation in aneurysm, possible embolism • Treatment: various surgeries

44. Arteriosclerosis/Atherosclerosis • Arteriosclerosis • Diffuse thickening of walls of small arteries & arterioles with loss of elasticity • Atherosclerosis • Lipid, cholesterol, & other debris formation as plaques on endothelial layers of arteries • Begins in 20’s in some places • Commonly affect cerebral & coronary arteries and aorta • Often asymptomatic for decades

45. Atherosclerosis • Treatment: • Vasodilators • Lipid-lowering meds and diet changes • Endarterectomy (removal of plaque and part of endothelium) • Most commonly done in internal carotid and large peripheral arteries of leg.

46. Thrombophlebitis • Vein inflammation with clot formation • Partial or complete vein obstruction • Usually in an extremity • Usually leg • May be superficial or deep • Superficial: conservative treatment • Deep: anticoagulants

47. Thrombophlebitis • Risk factors: • Trauma, turbulent blood flow (endothelial injury), infection, chemical irritation, prolonged immobility, oral contraceptive or other hormone treatment, smoking

48. Varicose Veins • Dilated, superficial veins • Most commonly in legs • Etiology: • usually conditions that cause venous stasis • Populations affected: • Females, over age 50, obese

49. Varicose Veins • Treatment: • Pressure stockings • Variation of exercise • Avoidance of prolonged standing, etc • Sclerosing agents (injection) • Stripping and ligation (surgical)

50. Anemias • Condition of abnormal RBC or hemoglobin deficiency • Types: • Iron deficiency • Folic acid (folate) deficiency • Pernicious anemia (vitamin B12 deficiency) • Aplastic anemia • Sickle cell anemia