(4) Cardiovascular System and Peripheral Vascular System

What main topics we talk about?

• Cardiovascular risk

• Coronary/Heart Conditions

  • IHD/stable angina

  • ACS/unstable angina, NSTEMI, STEMI

  • Heart Failure

  • Arrhythmia

  • Valvular Disease

• Vascular conditions

  • PAD

  • VTE → DVT / PE

  
  

Cardiovascular risk

Topics mentioned

HTN crisis

dyslipidemia/PREVENT

HYPERTENSIVE CRISIS

• Generally BP ≥180/110 mmHg.

• Both systolic AND diastolic do not have to be above the cutoff.

  • Example: 190/100 can still be considered a hypertensive crisis.

HYPERTENSIVE CRISIS

The distinction you need:

	Target-organ damage?
Markedly elevated BP	NO
Hypertensive emergency	YES

Target organs discussed:

• Heart

• Brain

• Kidneys

• Eyes

• Peripheral vasculature

Markedly elevated BP may be asymptomatic or cause:

• Epistaxis = nosebleed

• Headache

• Anxiety

• SOB

DYSLIPIDEMIA

• Dyslipidemia = abnormal cholesterol/lipids that increase cardiovascular risk.

• Know the pattern

  • ↑ LDL = bad (LDL >100)

  • ↑ triglycerides (TG >150)

  • ↓ HDL = bad (HDL <40)

  • TC >200 mg/dL = total cholesterol

• Patients are usually asymptomatic.

PREVENT CALCULATOR

• estimates future cardiovascular risk (for ASCVD and total CVD)

• Predicts:

  • 10-year risk

  • 30-year risk

PREVENT CALCULATOR

KNOW THE RISK CATEGORIES

10-year PREVENT-ASCVD risk	Category
0 to <3%	Low
3 to <5%	Borderline
5 to <10%	Intermediate
≥10%	High

PREVENT CALCULATOR

Understand what goes into PREVENT

• Person → age, gender

• Pressure → SBP + BP treatment

• Cholesterol → total cholesterol + HDL

• Metabolism → BMI + diabetes

• Kidneys → eGFR

• Habits → smoking

ISCHEMIC HEART DISEASE

topics discuessed

• define

• symptom

• DIAGNOSIS

• risk factors

• FOLLOW-UP

ISCHEMIC HEART DISEASE

define

• IHD = CHD = CAD

  • These mean the same thing in this lecture:

    • Ischemic heart disease

    • Coronary heart disease

    • Coronary artery disease

  • IHD = plaque buildup in the coronary arteries → reduced blood supply/oxygen to the heart → myocardial ischemia (ANGINA)

• BIG PICTURE

  • IHD = chronic disease

  • ACS = acute event happening now

ISCHEMIC HEART DISEASE

risk factors

Smoke, Pressure, Lipids, Sugar

Know the important ones

• Smoking

• HTN

• ↑ LDL

• ↓ HDL

• Diabetes

Other risk factors:

• Obesity

• Physical inactivity

• Family history

• Age

• Insulin resistance

ANGINA

define

• intermittent chest pain from myocardial ischemia.

• pressure/squeezing/crushing, substernal ± radiates left arm/jaw/back; triggered by exertion/stress/cold/after meals

ANGINA

types

	When?	What happens with rest?	Cause
Stable angina	Exertion	Relieved by rest/nitro	Gradual narrowing
Unstable angina	Rest	Not relieved by rest	progressive plaque problem
Prinzmetal	Rest	Requires evaluation	Coronary spasm

IHD

Symptoms

“A-T-E + abnormal heart”

• A = Stable Angina → biggest symptom

• T = Trouble breathing → dyspnea/chest tightness

• E = Exercise tolerance ↓

• Abnormal heart → ECG abnormalities + S3/S4 sounds

NO EDEMA

DISTINGUISHING CHEST PAIN

Condition	Trigger	Relief	Pain
Angina	Exertion/stress	Rest/nitro	Crushing, pressure, squeezing
GI	Food	Antacid	Burning
Musculoskeletal	Movement	Rest/heat/pain medicine	Sharp/sore

IHD DIAGNOSIS

• exercise stress test

• if unable to exercise: pharmacologic stress test

• if test is positive - coronary angiogram

IHD DIAGNOSIS

What does a stress test do?

• exercise → reproduce chest pain + ECG changes → suggests ischemia.

IHD DIAGNOSIS

Coronary angiogram

• Used to locate narrowing/blockage.

• If severe narrowing is found, clinicians may use: Balloon/Stent

IHD FOLLOW-UP

• Watch for angina becoming: More, worse, at rest

• At-rest symptoms suggest progression toward unstable angina.

ACUTE CORONARY SYNDROME

topics discussed

• define

• symptoms

• diagnosis

• labs

IHD =

ACS =

IHD = chronic

ACS = acute

ACUTE CORONARY SYNDROME

define

Types from least → most serious

• Unstable angina

  • → NSTEMI → artery may be almost completely blocked

  • → STEMI - artery may be completely blocked

    • 90-minute door-to-balloon time

ACS PRESENTATION

Use ARISE for ACS:

• A = Angina → severe, not relieved by rest/nitro

• R = Radiates → arm/jaw/back

• I = Ill stomach → nausea/vomiting

• S = SOB + Sweating

• E = Elderly/women/diabetes may present atypically

“Elephant sitting on the chest.”

NO EDEMA

ACS LABS

• ↑ cardiac enzymes:

  • Troponin

  • CK-MB

ACS DIAGNOSIS

• ECG + cardiac enzymes

  • if they suggest ACS: coronary angiogram

HEART FAILURE

topics discussed

• define

• symptoms

• diagnostics

• labs

• follow-up

• HEART FAILURE CLASSES

HEART FAILURE

define

• heart cannot pump/fill effectively

• top 2 causes:

  • Ischemic heart disease

  • MI

HEART FAILURE

symptoms

• Orthopnea/PND

• Peripheral/pitting edema

• Assess fluid overload: JVD/HJR

• Dyspnea with exertion

• pulmonary edema / crackles / S3 gallop

Orthopnea

• SOB when lying flat.

• Needs multiple pillows to sleep.

Paroxysmal nocturnal dyspnea — PND

• wakes suddenly because of SOB

• needs to sit upright.

NYHA HEART FAILURE CLASSES

Class	What causes symptoms?
I	Nothing
II	moderate activity
III	daily activities
IV	rest

PITTING EDEMA

• Press over top of foot for about 5 seconds and release:

  • Normal: skin returns immediately

  • Pitting edema: indentation remains.

JVD vs. HJR

• JVD (JUGULAR VENOUS DISTENSION): assess at about 45°; >4 cm above the sternal angle = abnormal/JVD

• HJR (HEPATOJUGULAR REFLEX): press over the liver/upper abdomen while watching the jugular vein

  • Stays elevated = positive HJR → fluid overload

  • Drops back down quickly = negative HJR

• Big picture: both are ways to assess fluid overload in heart failure.

HEART FAILURE LABS

• BNP >100 pg/mL → prompts further evaluation for heart failure

• NT-proBNP

  • <50 years → >450

  • 50–75 years → >900

  • >75 years → >1800

HEART FAILURE DIAGNOSIS

• Main heart failure diagnostic = Echocardiogram (ECHO) ⭐

  • ECHO evaluates:

    • Ventricle size

    • Valve function

    • Wall motion

    • Ejection fraction (EF)

      • HFrEF = EF ≤40% (reduced)

      • HFpEF = EF ≥50% (preserved)

• Chest X-ray can show:

  • enlarged heart

  • pulmonary edema

  • pleural effusion

HEART FAILURE FOLLOW-UP

• daily weight

  • 3–5 lb/week or 1 lb/day repeatedly → worsening fluid overload/HF

Arrhythmia

• Symptom:

  • irregular rhythm

  • Abnormal heart rate alone ≠ necessarily arrhythmia

  • palpitations (“flutter/butterfly”)

• Holter/Zio = portable ECG for arrhythmias that come and go.

Valvular heart disease

• Stenosis = stiff/narrow valve → trouble OPENING

• Insufficiency/Regurgitation = valve doesn't CLOSE → blood leaks backward

• Main clue = MURMUR (unique!)

• Diagnostic = ECHO

PAD

topics discussed

• main facts

• severe/worsened form of PAD

• Assessment

• ABI

PAD

main facts

• Atherosclerotic plaque in peripheral arteries → ↓ blood flow

• 2 biggest risk factors = smoking + diabetes

• Main symptom: Pain with exercise relieved by rest = intermittent claudication = Think: stable angina of the legs

PAD

Severe/worsened form of PAD

Pain at rest = critical limb ischemia → serious

PAD

assessment

• ↓ peripheral pulses/2+ pulse = normal

• ↑ capillary refill time = poor arterial blood flow

• You can recognize cool/pale/cyanotic skin, hair loss, ulcers/gangrene

PAD

ABI

• ABI = ankle systolic BP ÷ brachial systolic BP

• Gold standard for PAD screening/diagnosis

• Lower ABI = worse PAD.

ABI	Meaning
1.0–1.29	Normal
0.91–0.99	Borderline
≤0.90	PAD
0.4–0.9	Mild PAD
<0.4	Severe PAD

VTE

• VTE = umbrella term → DVT + PE

• Biggest risk factor for another VTE = previous VTE.

DVT

topics discussed

• main facts

• testing

• follow up

DVT

main facts

• Unilateral/ONE-sided: swollen + warm + painful leg

• HF edema usually bilateral

• Estrogen replacement - BIGGEST R/F! (i think)

DVT

testing

• D-dimer → if positive → duplex ultrasound (commonly used for diagnosis)

• Venography = called gold standard, but invasive/not routinely used

DVT

follow-up

• Anticoagulants prevent more clotting; body breaks the clot down over time (resolution-can take

• Highest recurrence risk = first 90 days

• Warfarin → monitor INR.

PE

topics discussed

• main facts

• testing

PE

main facts

• PE = clot travels to lungs

• Main things to recognize: dyspnea + chest pain

• Massive PE can cause ↓ O₂, hypotension/cyanosis and shock.

PE

testing

• D-dimer first, then usually spiral CT or V/Q scan

• Pulmonary angiography = gold standard but too invasive for routine use