Cardiac Pathophys

Risk Factors for Developing CVD: Modifiable

Hypertension, dyslipidemia, smoking, alcohol, diabetes, obesity, lifestyle

Risk Factors for Developing CVD: Non-Modifiable

increasing age, family history, genetics, sex-related biological factors

Common Types of Cardiovascular Disease

coronary artery disease, cerebrovascular disease, peripheral arterial disease, heart failure, arrhythmias (congenital heart disease, heart value disease)

Atherosclerotic Cardiovascular Diseases (ASCVD)

1. Coronary artery disease

2. Cerebrovascular disease

3. Peripheral arterial disease

ASCVD’s account for _% of cardiovascular deaths

75

Development and Progression of Atherosclerosis

1. Healthy artery

2. Endothelial dysfunction and activation

3. Inflammation begins

4. Foam cell formation (fatty streak)

5. Plaque growth and apoptosis

6. Thrombosis

The Atherosclerotic Cardiovascular Continuum

1. Risk Factors

2. Endothelial Dysfunction

3. Atherosclerosis

4. Myocardial Infarction

5. Heart Failure, Arrhythmias

6. Sudden Cardiac Death

Atherosclerotic Cardiovascular Continuum Risk Factors

Hypertension, dyslipidemia, diabetes, smoking, obesity, family history, sedentary lifestyle

Atherosclerotic Cardiovascular Continuum Endothelial Dysfunction

Inflammation, oxidative stress, impaired nitric oxide production, increased vascular permeability

Atherosclerotic Cardiovascular Continuum Atherosclerosis

lipid accumultion, plaque formation, vessel remodeling, progressive narrowing

Atherosclerotic Cardiovascular Continuum Myocardial Infarction

plaque rupture/erosion, thrombosis, acute vessel occlusion, myocardial ischemia & necrosis

Atherosclerotic Cardiovascular Continuum Heart Failure, Arrhythmias

Ventricular dysfunction, electrical instability, structural changes, reduced cardiac output

Atherosclerotic Cardiovascular Continuum Sudden Cardiac Death

malignant arrhythmia, pump failure, hemodynamic collapse

Atherosclerotic Cardiovascular Continuum Risk Factors Prevention

address risk factors & promote healthy habits

Atherosclerotic Cardiovascular Continuum Endothelial Dysfunction Prevention

prevent & reduce vascular injury

Atherosclerotic Cardiovascular Continuum Atherosclerosis Prevention

slow progression & stabilize plaque

Atherosclerotic Cardiovascular Continuum Myocardial Infarction Prevention

rapid recognition & restore blood flow

Atherosclerotic Cardiovascular Continuum Heart Failure, Arrhythmias Prevention

managing complication & prevent worsening

Atherosclerotic Cardiovascular Continuum Sudden Cardiac Death Prevention

identity high risk & prevent events

Hypertension (HTN)

BP is persistently too high, increasing stress on the heart, blood vessels, and kidneys

Hypertension Risk Factors Non-modifiable

increasing age, family history

Hypertension Risk Factors Modifiable

obesity, smoking, excess alcohol use, stress, sedentary lifestyle

Hypertension Secondary Causes

obstructive sleep apnea, kidney disease, medications, thyroid adrenal gland disorders, tumors

What determines blood pressure?

Cardiac output x peripheral resistance

Cardiac output

the amount of blood the heart pump per minute

Peripheral resistance

resistance that blood encounters as it flows through the vessels

Heart rate

beats per minute

Stroke volume

amount of blood pumped per beat

Volume

amount of blood in the circulation

Viscosity

thickness of the blood

Vessel

diameter & elasticity of blood vessels

Cardiac Output factors

heart rate, stroke volume

Peripheral Resistance

volume, viscosity, vessel

Renin-Angiotensin-Aldosterone System (RAAS)

1. Low blood pressure or low blood volume triggers the system

2. Kidney releases renin

3. Renin converts angiotensinogen (from livers) to angiotensin I

4. ACE (in lungs) converts angiotensin I to angiotensin II

5. Angiotensin II causes 2 major effects

1. Angiotensin II 2 major effects

1. Vasoconstriction: increase peripheral resistance → raises blood pressure

2. Aldosterone release: adrenal gland signals kidneys to retain sodium & water → increases blood volume and blood pressure

What stage does aldosterone release inhibit?

2. Kidney release renin

Normal Systolic BP

120 mm Hg

Normal Diastolic BP

80 mm Hg

Systole

Contraction

Diastole

Relaxation

Systolic BP

Highest arterial pressure, occurs when ventricles contract & eject blood, influenced by stroke volume & arterial stiffness

Diastolic BP

Lowest arterial pressure, occurs when ventricles relax & fill, influenced by vascular resistance & arterial recoil

Diagnosis of Hypertension

1. Average of 2 or more bp readings on 2 or more separate occasions

2. Confirmed using out of office or home bp

3. Using an automated oscillometric device

Steps to improve BP accuracy

1. No conversation

2. Support arm at heart level

3. Put cuff on bare arm

4. Use correct cuff size

5. Support feet

6. Keep legs uncrossed

7. Have empty bladder

8. Support back

ASA BP Categories (Systolic-Diastolic): Normal

<120 and <80

ASA BP Categories (Systolic-Diastolic): Elevated

120-129 and <80

ASA BP Categories (Systolic-Diastolic): Stage 1 HTN

130-139 or 80-89

ASA BP Categories (Systolic-Diastolic): Stage 2 HTN

>140 or >90

ASA BP Categories (Systolic-Diastolic): Pregnancy-related HTN

typically >140-90

Hypertensive Emergency: Severe BP Elevations (Systolic-Diastolic)

>180 and/or >120

Hypertensive Emergency=

severe BP elevation and acute target-organ damage

Acute target-organ damage:

Myocardial infarction, heart failure, stroke, acute kidney injury

Assessing BP Control in Patients with HTN, BP goal:

<130/80

Is 126/72 at goal?

yes

is 126/88 at goal?

no

Dyslipidemia

Abnormal circulating lipoproteins can promote cholesterol deposition within arterial walls, resulting in atherosclerosis

Dyslipidemia Risk Factors

Genetics, family history, obesity, smoking, alcohol, diabetes, high saturated fat/trans fats diets, kidney disease, liver disease

Cholesterol

Waxy, fat-like substance used to make cell walls and hormones

Triglycerides (TG)

Type of lipid used for energy storage

Lipoprotein

Moves TG and cholesterol through blood inside a hydrophilic shell

Types of Lipoproteins

Chylomicron, VLDL (very low-density lipoprotein), IDL (intermediate-density lipoprotein), LDL (low-density lipoprotein), HDL (high-density lipoprotein)

What is the driver of Atherosclerosis?

ApoB-100

Coronary Artery Disease (CAD) & Ischemic Heart Disease: Problem

Atherosclerotic narrowing or obstruction limits blood flow to the heart muscle

Ischemia

heart muscle cells do not enough oxygen and nutrients because blood flow through a stenotic artery is reduced

Ischemia is a _ problem

functional

Stenosis is a _ problem

structural

Ischemia overview

reduced blood flow → reduced oxygen delivery

Angina defintion

chest pain or discomfort that happens when the heart muscle does not get enough oxygen-rich blood

Angina is a _ signal

sensory

Common Angina symptoms:

tightness, pressure, squeezing, heartburn/ingestion, chest discomfort that spreads to the jaw, teeth, shoulder, arm or back

Angina symptoms for women:

nausea, dyspnea, palpitations, referred pain, symptoms that resemble a panic attack

Other Angina symptoms;

dizziness, weakness, gas, upset stomach, sweating, pale skin, feeling of impending doom

What are the types of Ischemic Heart Disease

Stable angina, unstable angina, NSTEMI (NSTE-ACS), STEMI (STE-ACS)

What are the types of acute coronary syndrome (ACS)

stable angina, NSTEMI, STEMI

What is the coronary plaque status for an unstable angina?

plaque rupture

What is the coronary plaque status for a NSTEMI?

plaque rupture

What is the coronary plaque status for a STEMI?

plaque rupture

What is the artery occlusion status for an stable angina?

narrowing or partial

What is the artery occlusion status for an unstable angina?

partial

What is the artery occlusion status for a NSTEMI?

partail

What is the artery occlusion status for a STEMI?

complete

What is the ECG status for an unstable angina?

normal

What is the ECG status for an NSTEMI?

normal or minor ST changes

What is the ECG status for an STEMI?

ST elevation

Does an unstable angina cause an injury or infarction?

no

Does an NSTEMI cause an injury or infarction?

yes

Does an STEMI cause an injury or infarction?

yes

Does an unstable angina have cardiac biomarkers?

normal

Does an NSTEMI have cardiac biomarkers?

elevated

Does an STEMI have cardiac biomarkers?

elevated

Is a stable angina a medical emergency?

no

Is a unstable angina a medical emergency?

yes

Is a NSTEMI a medical emergency?

yes

Is a STEMI a medical emergency?

yes

High Probability of Cardiac Chest Pain

central, pressure, squeezing, gripping, heaviness, tightness, exertional/stress-related, retrosternal

Low probability cardiac chest pain

sharp, fleeting, shifting, pleuritic, positional

What are the 5 anatomical approach to assessing chest pain?

1. Cardiac

2. Pulmonary

3. Gastrointestinal (GI)

4. Musculoskeletal (MSK)

5. Psychogenic/Neurogenic

What are the anatomical approach examples of the cardiac category?

ACS, angina, pericarditis

What are the anatomical approach examples of the pulmonary category?

PE, pneumonia/infection, malignancy

What are the anatomical approach examples of the GI category?

GERD, cholecystitis, pancreatitis