Lecture 10 - (Additional Lecture) Alterations in the Cardiovascular System (Part 2)

What are the diseases categories we go over? (I cateogorized)

• Artheral & vascular disease

• Coronary & ischemic heart disease

• Valvular & endocardial disease

• Pericardial disease

• Heart Failure

What are the Artheral & Vascular diseases?

• Atherosclerosis

• peripheral artery disease

Atherosclerosis

• Definition/why it matters:

• Major outcomes: (IGNORE)

• progression:

• Common contributors:

• Treatment focus: (IGNORE)

• Definition/why it matters: plaque → narrowed vessel → ↓ perfusion/occlusion

• Major outcomes: reduced perfusion, stroke, coronary disease

• progression: slow; often no early symptoms

• Common contributors:

  • LIFESTYLE: poor diet, sedentary lifestyle, smoking,alcohol, excess cholesterol intake

  • MEDICAL REASONS: dyslipidemia, diabetes, hypertension,

• Treatment focus

  • risk-factor reduction: improve diet, exercise, stop nicotine/smoking, control alcohol

  • Procedures: angioplasty with stent placement

    • Heparin-coated stent idea: local blood-thinning effect → helps prevent local clot formation after opening the vessel

Peripheral Artery Disease

• What it is

• Higher risk: (IGNORE)

• Key symptom:

• Treatment (IGNORE)

Peripheral Artery Disease

• What it is: atherosclerotic plaque in arteries that perfuse limbs, especially lower extremities

• Higher risk: diabetes, smoking

• Key symptom: intermittent claudication

  • Pain with walking/movement due to brief interruption of blood flow

• Treatment

  • improve flow + prevent clotting + lipid control

  • lipid control

  • exercise

What are the Coronary & ischemic heart disease?

• coronary artery disease/myocardial ischemia/acute coronary syndromes

• myocardial infarction

• Angina/Transient Myocardial Ischemia

Coronary Artery Disease, Myocardial Ischemia, Acute Coronary Syndromes

• Big concept:

• Path sequence

• Most common cause:

• Risk factors

• what is the disease message name?

• Big concept: imbalance between oxygen delivery and oxygen demand in the myocardium

• Path sequence

  • Low oxygen delivery vs demand → ischemia

  • Prolonged ischemia → infarction

• Most common cause: atherosclerosis

• Risk factors

  • Nonmodifiable: age, family history, male sex earlier risk (women increase after menopause)

  • Modifiable: (SAME AS ATHEROSCLEROSIS RISK FACTORS)

    • poor diet, sedentary lifestyle, smoking

    • dyslipidemia, diabetes, hypertension,

• what is the disease message name? “Disease of excess” message: occasional unhealthy choices aren’t the issue; consistent excess over years is

Transient Myocardial Ischemia and Angina

• Transient Myocardial Ischemia Definition:

• Angina definition

• Transient Myocardial Ischemia Definition: coronary blood supply cannot meet myocardial oxygen/nutrient demands

• Angina definition = chest pain due to ischemia

Types of Angina

• Stable angina

  • Predictable and reproducible (can be triggered at a certain exertion level or stress test)

• Unstable angina

  • Unpredictable, not reproducible, can happen randomly

  • More concerning than stable angina

• Silent ischemia

  • No chest pain or detectable symptoms

Myocardial Ischemia Treatments (JUST LOOK AT MY TREATMENT NOTES IN ONENOTE) LOOK AT YELLOW ANSWER

• Restore Flow → nitrates (vasodilators), CCBs, stents,

• Lower Demand → beta blockers, sodium channel blockers

• Prevent Clot → statins, aspirin (antiplatelet), anticoagulants

• Gene and stem therapy was discussed as emerging and expanding, but the core tested treatment themes are restoring flow, lowering demand, and preventing clotting

Acute Coronary Syndromes

• Definition:

• Can cause:

• Major complications:

• Treatment priorities (IGNORE)

• Definition: sudden obstruction of coronary vessels due to thrombus over ruptured plaque

• Can cause: unstable angina → rapid ischemia → MI

• Major complications: BIG AND SCARY: dysrhythmias, congestive heart failure, sudden death

• Treatment priorities

  • restore perfusion fast + stop clots + reduce demand

Acute Coronary Syndromes

why unstable angina can come and go?

transient vessel occlusion or vasoconstriction at plaque site; perfusion returns before major necrosis

Myocardial Infarction

• Definition (What it is):

• Core concept (Why it matters):

• Effects? (LOOK AT YELLOW)

• Definition (What it is): prolonged ischemia → irreversible myocyte necrosis

• Core concept (Why it matters): cardiac myocytes do NOT regenerate → permanent loss of functional muscle

• Effects:

  • Post-reperfusion effect: myocardial stunning (temporary dysfunction after blood flow returns) (stunning dysfunction)

  • Chronic ischemia adaptation: hibernating myocardium (survives by chronic lowering activity/contractility) (hibernating activating)

  • Long-term structural changes: remodeling after MI (scar + hypertrophy + reduced function)

What are the main topics we talk about MI?

• MI and Angiotensin II

• MI Detection

• MI Emergency Priorities

How are Angiotensin II and MI connected?

• body senses low output and tries to “fix” pressure/flow

• Effects

  • Vasoconstriction + fluid retention → increases preload and workload → strains the injured heart

  • Contributes to hypertrophy and remodeling

How MI is Detected?

• ECG: ST-segment elevation can indicate MI, but many patients will NOT show ST elevation

• Biomarkers

  • Troponin I: gold standard and most specific

    • Rises/peaks a few hours after MI

  • Others: CPK-MB, LDH, myoglobin, creatinine (less specific) (IGNORE FOR NOW)

  • Why biomarkers rise: damaged myocytes release intracellular contents into blood

• False positives

  • Heavy exercise in prior 48 hours can elevate some muscle markers and confuse interpretation

MI Emergency Priorities

• “Minutes mean muscle”

• Immediate steps

  • Get to hospital ASAP

  • Supplemental oxygen

  • Aspirin

  • Hospital therapies may include thrombolytics, antithrombotics, anticoagulants, vasodilators, and intervention in cath lab

• Possible complications

  • Dysrhythmias

  • Heart failure

  • Cardiogenic shock

  • Pericarditis

  • Ventricular aneurysm

What are the Valvular & endocardial disease?

• valvular heart disease

  • 4 to know:

    • Mitral stenosis

    • Mitral regurgitation

    • Aortic regurgitation

    • Tricuspid regurgitation

  • Mitral valve prolapse

  • Acute Rheumatic Fever and Rheumatic Heart Disease

Valve disease can result from…

 altered pressure ranges and remodeling

Valvular & endocardial disease

important terms to know

• Stenosis: narrowed opening → impairs filling or emptying

• Regurgitation: valve doesn’t seal → backflow

Valvular & endocardial disease

Murmurs

characteristic sounds can help identify which valve is abnormal

Valvular & endocardial disease

Which direction blood flow is blocked/leaks for each:

• Mitral stenosis: LA → LV impaired

  • Treatment: repair or replacement

• Mitral regurg: LV → LA backflow

  • Treatment: repair or replacement

• Aortic regurg: aorta → LV backflow during diastole

  • Treatment: vasodilators and inotropic agents may delay surgery; replacement when needed

• Tricuspid regurg: right-sided backflow/volume overload → systemic venous congestion→ right-sided HF

Valvular & endocardial disease

Mitral valve prolapse

• the valve leaflets bulge backward into the atrium.

• Often asymptomatic

• Treatment: none or beta blockers

Valvular & endocardial disease

Acute Rheumatic Fever and Rheumatic Heart Disease

• Cause:

• Findings:

• Treatment:

• Cause: delayed immune response after group A strep; antibodies cross-react with heart tissue

• Findings: murmur/carditis, polyarthritis, subcutaneous nodules, chorea, rash (IGNORE FOR NOW-JUST YELLOW)

• Treatment: antibiotics (often 10 days; some need prolonged prophylaxis)

What are the Pericardial disease?

• pericardial effusion

• pericarditis

Pericardial disease

Pericardial effusion

• what is it?

• Treatment:

• what is it? Fluid in pericardial sac increases pressure on the heart

• Treatment: pericardiocentesis

Pericardial disease

Pericarditis

• what is it?

• Symptoms: (LOOK AT YELLOW ONLY)

• Causes: (SKIP)

• Treatment:

• what is it? Inflammation of pericardial sac; can scar/calcify → restrict motion of heart

• Symptoms: exercise intolerance, dyspnea on exertion, fatigue; can resemble right-sided HF with increased systemic venous pressure

• Causes: infections, radiation, neoplasms, autoimmune disease, drugs, post-cardiac injury (SKIP FOR NOW)

• Treatment: anti-inflammatory drugs; surgery if severe scarring/calcification

What is dyslipidemia?

Lipoproteins

Dyslipidemia

Lipoproteins you must know:

HDL = “good”

LDL/VLDL = “bad” in risk terms

Dyslipidemia

LDL/VLDL role

• Role: delivers cholesterol to tissues

• High LDL over time → endothelial inflammation/injury → vessel narrowing → atherosclerosis risk

Dyslipidemia

HDL role

• Role: reverse cholesterol transport to liver for removal or conversion

• Also helps remove cholesterol from arterial walls

• High HDL suggests the system is clearing cholesterol well

How the heart muscle changes in size, shape, and function over time (normal vs abnormal)? basically causes cardiac remodeling

• cardiomyopathies

• athletic heart

cardiomyopathy =

remodeling problem

What are the type of cardiomyopathy?

Dilated cardiomyopathy

Hypertrophic cardiomyopathy

Restrictive cardiomyopathy

dilated cardiomyopathy

• what happens?

• Symptoms: (SKIP)

• Treatment theme:

• what happens? enlarged chambers → weak systolic pump → systolic HF

• Symptoms: cluster (dyspnea/fatigue/edema)

• Treatment theme: reduce volume + improve pumping + treat cause

Hypertrophic cardiomyopathy

• Pattern:

• Symptoms (SKIP)

• Treatment theme: (SKIP)

• Pressure overload hypertrophy concept (SKIP)

• Pattern: thick myocardium (sometimes obstructive/inherited)

• Symptoms cluster (chest pain, syncope, palpitations; HF-type symptoms)

• Treatment theme: reduce demand/HR + sometimes procedures/ICD

• Pressure overload hypertrophy concept (HTN/valve disease → thickening) + perfusion issue at high HR

Restrictive cardiomyopathy

• Collagen/fibrosis makes myocardium stiff → impaired filling → can progress to right-sided HF

Athletic heart

• what is it?

• Clinical clue:

• patterns?

• what is it? Physiologic remodeling: chamber size increases with proportional mild wall thickening

• Clinical clue: resting HR decreases over months of training due to increased stroke volume

• patterns?

  • Runner pattern: more chamber enlargement

  • Weight training pattern: more wall thickening (but far less than pathologic hypertrophy)

Heart failure syndromes

•  systolic vs diastolic failure

•  right- vs left-sided failure

Heart Failure

• Core concept:

• Congestive heart failure:

• Core concept: pump failure → backup (lungs vs body) + fluid leaks

• Congestive heart failure = left-sided heart failure

Which type of heart failure is life-threatening?

• left-sided because pulmonary edema is life-threatening

• Right-sided HF is generally more manageable

Systolic heart failure

• what is it?

• Symptoms: (LOOK AT YELLOW ONLY)

• Treatment themes (SKIP)

• what is it? reduced pumping/CO

• Symptoms: dyspnea, fatigue, orthopnea, edema

• Treatment themes - reduce preload/afterload + improve outcomes

Diastolic heart failure

• what is it?

• Symptoms:

• Treatment: (SKIP)

• what is it? Preserved ejection fraction with impaired relaxation and filling

• Symptoms: dyspnea on exertion, fatigue

• Treatment: control BP/workload + exercise training

Right-sided vs left-sided heart failure

• Right-sided HF: systemic venous congestion signs

• Left-sided HF: pulmonary congestion/pulmonary edema signs

• Left-sided HF can eventually lead to right-sided HF