PT 559 - Cardiovascular Pathology: HTN & CAD

Based off "Cardiovascular Pathology: HTN & CAD" PPT

Pericardium

2 layers w/ space filled w/ pericardial fluid

How does the pericardium remain in place?

Anchored to the diaphragm and great vessels

Myocardium

Contractile layer

Endocardium

Forms inner lining of chambers and valves

R main coronary artery and marginal branches

Supply the R ventricle, SA & AV nodes

Posterior interventricular branch

Supply inferior/posterior L ventricle

L main coronary artery

Supply LAD, anterior & septal aspects of L ventricle, circumflex, & lateral aspect of L ventricle

Modifiable risk factors for CVD

Diet, smoking, activity level, stress, HTN, cholesterol

Non-modifiable risk factors for CVD

Gender, age, family hx

What can cause myocardial ischemia?

DEC supply and INC demand

What causes a DEC supply which could eventually lead to ischemia?

Narrowing vessels, spasms, HTN, lack of collateral circulation, anemia, arrythmias

What causes an INC demand which could eventually lead to ischemia?

Hyperthyroidism, exercise, emotion, digesting a large meal

What is ischemic heart disease?

A lack of O2 that could lead to infarction

Atherosclerosis

Chronic inflammatory condition that leaves deposits of cholesterol on arterial walls triggering an immune reaction

When can someone present with symptoms if they have atherosclerosis?

When 75% of a vessel is occluded

LDL desirable value

<100

HDL desirable value

>45 M or >55 F

Total cholesterol desirable value

<200

Triglycerides desirable value

<150

Risk factors for metabolic syndrome

Waist measurement >40” M or >35” F

HDL: <40 M or <50 F

BP: >130/85

Fasting blood glucose: >100

Triglycerides: >150

Out of the cluster risk factors for metabolic syndrome, how many need to come back positive to consider this ddx?

3 out of 5

How do you diagnose CAD

Cardiac catheterization

ECHO

Stress testing

Heart CT

MRA

Angiogram

Cardiac catheterization

Uses a catheter to look at coronary arteries

ECHO

looks at cardiac anatomy and EF

Stress testing

Sees how well the heart functions and adequately receives blood

Heart CT

3D imaging of the heart anatomy

MRA

Type of MRI that focuses on blood vessels

Angiogram

Shows how blood circulates and uses imaging to look for blockages

Tx of CAD

Risk factor modification (exercise, meds, surgery)

Cardiac rehab

Complementary meds

Angina

Symptom of CAD presenting w/ substernal pain/pressure/tightness that can range from the jaw to epigastric area due to ischemia

How long does an episode of angina last?

Mild to moderate pain lasting b/t 1-3mins but can go up to 20mins

Classic stable angina

Tightness, pressure, indigestion

Can be substernal, neck, arms, cervical, and/or midscap

Develops w/ specific activity

Subsides at rest or w/ nitroglycerin

How do women present w/ angina?

Nausea, indigestion, midscap p!, excessive fatigue

Unstable angina

Accelerating frequency and/or severity

May occur at rest or if it is the first time

Prinzmetal angina

Not associated w/ increased demand

Associated w/ ST segment elevation

Occurs at rest typically in the AM

Pericarditis

Pain at rest, may worsen w/ activity

Not relieved by rest or nitroglycerin

Responds to anti-inflammatory meds

Common post-CABG

Pulmonary/pleuritic pain

Sharp pain changing w/ breathing

Vascular (pulmonary embolism, aortic dissection)

Sudden onset, constant

Pleuritic pain w/ SOB

Gastrointestinal

Prolonged epigastric discomfort

Related to food intake and/or relieved by antacids

How would the body compensate to increase blood supply?

Vasodilate

How would the body decrease demand?

Dec HR and force of contractility

What pharmacological agents help increase blood supply?

Organic nitrates and calcium channel blockers

Organic nitrates

Dec preload and afterload by vasodilating smooth muscle

What is a common example of an organic nitrate used for angina

Nitroglycerin (NTG)

Calcium channel blockers

Dec calcium entry into the heart leading to vasodilation

What pharmacological agent help decrease demand of the heart?

Beta blockers

Beta blockers

Dec HR and contractility

Nitroglycerin procedure

Take one dose

Wait 5 min

If angina is still present, take another dose

Can take a 3rd dose after another 5 mins

When should you call 911 during a NTG procedure?

If pain doesn’t subside after the 1st dose

Myocardial infarction

Death of myocardium from sudden blockage of coronary artery

What are the types of MIs

STEMI and NonSTEMI

STEMI

Occurs in ventricles and causes distinct change in EKG

Non-STEMI

No change in EKG but have elevated biomarkers, still causing cell death

Causes of MI

Drug stimulants

Catecholamine release

Stress

Respiratory infections

Diabetes

What is the most common site of an MI

L coronary artery infarct affecting the LV

Patient presentation of an MI

Crushing chest p! w/ radiation

Pallor

SOB

Sweating

How does a woman present with an MI

Prolonged mid-thoracic pain

Nausea

Anxiety

Complications after an MI

Recurrence of ischemia

Pericarditis

HF

Sudden death

Arrhythmias

What cardiac biomarker is indicative of cardiac damage?

Troponin I (TNI)

When should you treat someone that has elevated TNI levels

Once TNI levels DEC, need to wait for TNI to peak

What are the goals when managing an MI

Reperfusion, control pain, limit necrosis, prevent complications

Treatment options for an MI

Antiplatelet therapy, anticoagulant therapy, nitrates, O2, early reperfusion, meds

What are the types of percutaneous coronary intervention (PCI)

Percutaneous transluminal coronary angioplasty (PTCA, angioplasty)

Coronary stenting

Atherectomy

Percutaneous transluminal coronary angioplasty (PCTA)

Balloon tipped catheter to compress the lesion outward toward the wall of the artery, often combined with stenting

Coronary stenting

Metal cage that holds compressed lesions against vessel wall to limit re-occlusions

Atherectomy

Cutting and excising of atheroma

Pros of CABG over PCI

Dec risk of re-occlusion, subsequent revascularization procedure, mortality rate

Better long term outcome and if there are additional pathologies

Where are vascular grafts harvested from?

Internal mammary artery (IMA)

Radial artery

Saphenous vein

What are post CABG considerations?

Sternal precautions and anemia

What sternal precautions are there that a PT should be aware about?

Dec ROM to limit stretching or tearing of sternal incision

No resistance testing so the pt won’t hold their breath

What can impact total peripheral resistance (TPR)

Blood viscosity, arterial wall elasticity, and sympathetic response

Activation of sympathetic NS

INC CO, vasoconstriction

Elastin replaced by fibrous tissue → INC resistance

DEC tissue perfusion

Renin-angiotensin system activation

Vasoconstriction → DEC blood flow to kidneys → renin → angiotensinogen → angiotensin I & II → INC sodium & water retention → INC BP bc of INC blood volume

What is happening with HTN?

Pressure overload on LV → LV hypertrophy

LV can’t relax → diastolic dysfunction

Backflow into LA

Supply and demand of myocardium is altered

Symptoms of HTN

Silent → dizziness, DEC exercise tolerance and sleep disordered breathing

Who’s at risk for HTN?

DM, stroke, CAD, aortic aneurysm, PAD, obesity, renal failure, alcoholism, high stress

Why are there so many classes of meds for HTN?

Due to the many influences on BP

What influences BP

Baroreceptors, TPR, kidneys, humoral factors, relationship b/t CO and TPR

Diuretics

Target kidneys to INC formation and excretion of urine b/c it DEC overall fluid volume

Adverse effects of diuretics

Fluid depletion, electrolyte imbalance, orthostatic HTN

What PT considerations are there when working with someone on diuretics?

S/s of hyponatremia and hypokalemia

Preventing orthostatic HTN

Urinary incontinence/frequent urination

S/s of dehydration

NSAIDs make drug less effective

Key diuretics to know

Hydrochlorothiazide (HCTZ)
Furosemide (Lasix)

Bumetanide (Bumex)

Spironolactone (Aldactone)

Sympatholytic drugs

Beta-adrenergic blockers

Alpha-adrenergic blockers

Pre-synaptic adrenergic neurotransmitter depletors

Centrally acting drugs

Ganglionic blockers

What is something to keep in mind if our pt. has a repiratory dysfunction and is on a non-selective beta blocker?

They may experience bronchoconstriction

What PT considerations are there when working with someone on beta blockers?

Commonly used and well tolerated

Depression, fatigue, GI disturbances

Worsen glucose control in those w/ diabetes

Monitor HR response w/ RPE and vitals

May see bronchoconstriction in those w/ respiratory conditions

Key beta blockers to know

Lopressor

Coreg

Tenormin

Toprol

Alpha blockers

Act on smooth muscle

DEC BP due to DEC TPR

Improve lipid profiles and glucose metabolism

Adverse effects of alpha blockers

Reflex tachycardia and orthostatic HTN

What other sympatholytic drugs are there?

Presynaptic adrenergic inhibitors

Centrally acting agents

Ganglionic blockers

Presynaptic adrenergic inhibitors

Inhibit release of NE → DEC cardiac excitability

Adverse effects of presynaptic adrenergic inhibitors

Bradycardia, N/V, diarrhea

Centrally acting agents

Inhibit sympathetic discharge → DEC sympathetic response to heart and peripheral vasculature

Adverse effects of centrally acting agents

Dry mouth and dizziness

Ganglionic blockers

Block synaptic transmission at autonomic ganglia → DEC sympathetic activity

Used in HTN crisisA

Adverse effects of ganglionic blockers

GI upset, vision problems, urinary retention

Vasodilators

Act on smooth muscle to DEC TPR

Used in HTN crisis

Adverse effects. of vasodilators

Reflex tachycardia, dizziness, orthostatic HTN, weakness, INC hair growth

Key vasodilators to know

Hydralazine

Nitroprusside

Types of renin-angiotesnin system inhibitors

ACE inhibitors

Angiotensin II blockers

Direct renin inhibitor

Calcium channel blockers

Block calcium entry into vascular smooth muscle → inhibit contraction → vasodilates and DEC TPR

Used cautiously b/c of MIs in certain populations