Ischemic Cardiovascular Conditions & other Vascular Pathologies

How does an infarction look on an ECG?

ST elevation.... the S doesn't return to baseline and stays up into the T-wave

What is complete lack of blood flow and 100% blockage of O2 called?

infarction

What does ischemia look like on an ECG?

S-T segment depression as the S doesn't go up to baseline after QRS complex

When a tissue is deprived of blood flow, and still receives some oxygen, what is this called?

ischemia

What are the layers of the coronary arteries?

outer = adventitia

middle = media

inner = intima

Describe the outer layer of the coronary arteries

adventitia

-provides support for the artery

-houses the vessels that furnish the middle layer

Describe the middle layer of the coronary arteries

media

-smooth msucle cells

-responsible for making luminal diameter adjustments based on required blood flow (aka vasoconstriction & dilation)

What is a vasospasm?

vessel constriction in an abnormal way that can cause a decrease in blood flow

T or F: Adequate tissue perfusion is when the demand is less than the supply

False; when supply = demand

When there is inefficient perfusion, what is this called?

ischemia

When does myocardial perfusion primarily occur?

during periods of muscle relaxation (diastole)

T or F: Most of cardiac muscle gets perfused during ventricular diastole

True

What can happen to perfusion if diastolic BP is too high or too low?

can cause issues with perfusion into the heart due to the differences in pressure gradients

What is the major driving force of moving blood into the myocardial tissue?

diastolic blood pressure

T or F: Systolic BP is a major determinant of myocardial blood flow

False

What are collateral arteries?

Connections between two branches of arteries that is caused by constant use & pressure of the coronary arteries which increases its size & strength

T or F: Collateral arteries can create a solid bypass around a blocked coronary artery

True

What is atherosclerosis?

-disease which causes progressive hardening and narrowing of the coronary, cerebral, and peripheral arteries (in the intima and endothelial walls)

-atherosclerotic plaque is composed of lipids and thrombus

What aspect of SV is affected if the aorta has atherosclerosis?

after load

What does atherosis mean?

building up of lipid blockages

Describe how lipids build up and create blockages in the body

-cluster of monocytes found in areas where lipids accumulate to them (foam cells)

-fatty streak = foam cells and smooth muscle cells

-fatty streak gets so large that endothelium is stretched and begins to separate, exposing the intima

-platelets bunch and a thrombus forms

Where does atherosclerosis most often happen?

can happen in any artery, but most often in arterioles with small lumens

What does sclerosis mean? How does this occur with artery disease?

reduction in blood vessel compliance

-due to fatty streak lesion that creates scar tissue which increases collagen and destroyed elastin

T or F: Destruction of elastin in the arteries will cause less compliance

True

What are the types of angina?

typical and prinzmetal

T or F: It is normal for a healthy athlete to experience typical angina during sport performance

False

T or F: Typical angina is abnormal

true

When does typical angina occur?

with exercise or activity

What does an ECG look like with angina?

ST segment depression

What occurs within the heart during typical angina?

not getting enough blood due the the body's inability to get the heart more blood

What is atypical angina?

chest pain at rest; pt is not doing activity or exercise to induce this

How does atypical angina occur?

significant amount of blockage, and body having trouble getting blood back to the heart due to the buildup of plaque

T or F: Typical and atypical angina are caused by an increase workload demand by the heart that cannot be kept up with

False; only typical angina because the increased workload comes from the activity/exercise the pt is doing

T or F: Atypical angina is caused by vasospasms

False

T or F: Typical angina is caused by vasospasms

False

What is prinzmetal angina?

AKA variant angina; angina typically at rest, early morning, not associated with exercise

What does the ECG look like for prinzmetal angina?

ST segment elevation (infarction)

How is prinzmetal angina relieved?

nitroglycerin or other vasodilators

What is the cause of prinzmetal angina?

atherosclerosis; the endothelial layer is damaged and there is lesion into the smooth muscle, causing the artery to spasm....spasm causes infarction

T or F: Prinzmetal is a type of atypical angina

True

What type of angina results from vasoospsms of the artery?

prinzmetal

What are the AHA risk factors for heart and CV disease?

-smoking

-physical inactivity

-obesity

-suboptimal diet

-hypotension

-elevated total cholesterol (high LDL, low HDL)

-DM

-family hx

-age

-gender (male and females after menopause)

-stress

T or F: Smoking increases HDL

False; lowers it

What is the number one risk factor for developing chronic heart disease?

lack of physical activity

Do men or women engage in a more sedentary lifestyle

women

An obese person is more likely to develop chronic heart disease if the adipose tissue is located where?

abdomen

The AHA recommends how much sodium intake?

1500mg per day

The AHA recommends how much sugar/sweetened drinks?

36oz per week

What is the principle influence for increased cholesterol in the blood?

intake of saturated fats

An HDL level below what number is considered a CV risk factor?

below 35 mg/dL

Triglycerides above what number is considered a risk factor for CV disease?

above 150 mg/dL

What is the best CV disease predictor of total risk when taking blood?

total cholesterol to HDL ratio

--ratio greater than 4.5 increases risk of developing atherosclerosis

T or F: You ideally want a low total cholesterol to HDL ratio

True

A total cholesterol to HDL ratio of what value is indicative of increased atherosclerosis risk?

4.5

Does dietary cholesterol affect total blood cholesterol levels?

Not as much as saturated fat does

Fasting glucose levels should be less than what?

100 mg/dL

A higher blood glucose levels will have what effect on HDL and LDL?

decrease HDL and increase LDL production

T or F: High cholesterol and HTN are highly genetic, thus family history is important to consider risk factors for CV disease

True

T or F: When an individual has an MI, women are at more risk of mortality than men

True

What are the average ages for initial MI for men and women?

men 64.7yo

women 72.2yo

Why is stress a CV risk factor? what does it do?

increased stress stimulates the sympathetic NS in "fight or flight" mode; increases levels of platelet secreted proteins

What happens to the heart when a pt experiences sudden cardiac death?

-ventricular tachycardia and ventricular fibrillation

-ventricles are contracting so fast, that when the atria are contracting, blood can't get into the ventricles; therefore no blood flow is getting out of the heart / to the body

How is sudden cardiac death treated?

immediate use of an AED or arrival to the ER quickly

What is chronic stable angina?

chest pain resulting from inadequate O2 supply to myocardial tissue with activity

What is the double product / rate pressure product?

value which pts with chronic stable angina can calculate to not exceed the functional supply/demand of O2 in the heart during exercise

-SBP x HR

What is the calculation for rate pressure product?

SBP x HR

How is the rate pressure product upper limit established?

pt exercises, then once they begin to have chest pain, take SBP and HR. This product of the two is the value that shouldn't be exceeded during proceeding exercise bouts to limit the chest pain the pt experiences

What are the most common warning signs of a heart attack?

-uncomfy pressure, pain, squeezing in center of chest (prolonged)

-pain that spreads to throat, neck, back, arms

-chest discomfort with lightheadedness or dizziness

-pallor, nausea, sweating

-prolonged sx NOT relieved by nitroglycerin or antacids

What are the less common sx of an MI that women are likely to experience?

-unusual chest pain, stomach pain

-isolated R bicep pain

-flulike manifestations

-breathlessness, dizziness

-unexplained intense anxiety, weakness, fatigue

"impending doom"

What factors may contribute to unstable angina?

-atherosclerotic plaque rupture in an already partially blocked artery

-dynamic obstruction (coronary vasoconstriction)

-tachycardia, causing Mi

T or F: Unstable angina occurs with exercise

False

T or F: Unstable angina occurs at rest

True

What is another name for variant angina?

Prinzmetal angina

Pericarditis related chest pain is described as how?

pain at rest or activity; not relieved with rest; doesn't respond to vasodilators (bc no vasospasm is happening); responds to anti-inflammatory meds; most common after CABG

How is a pulmonary dx type of chest pain described?

sharp in nature with changes in breathing; decreased or abnormal breath sounds

How is GI related chest pain described?

usually related to food intake, and can happen with GERD or peptic ulcer; relieved with antacids

What does STEMI stand for and what does it involve?

ST-elevation myocardial infarction

-happens as a result of a complete blockage in a coronary artery

-MI occurs

What does Non-STEMI stand for? what does it involve?

non-ST elevation myocardial infarction

-happens when a coronary artery is partially blocked, severely reducing blood flow

-non-stemi heart attack might occur

How do you tell if an MI has occurred or not?

blood work, looking at troponin

Will a non-STEMI show up on an ECG?

no

How are STEMI and non-STEMIs treated?

clot busting medication (fibrinolytics or thrombolytics) given within 30m of attack

mechanical/surgical means with stents, angioplastys, or percutaneous coronary intervention (PCI)

T or f: Some hospitals cannot do PCI

True

If a pt cannot get to a PCI hospital within how many minutes, what happens instead with their impending doom of a heart attack they are having?

within 90 minutes; otherwise, given clot busting medication

What is the negative effect of utilizing clot busting medications?

poses a bleeding risk elsewhere within the body

What is PCI?

percutaneous coronary intervention

What is coronary calcium scan? What do the results say?

-CT used to detect calcium deposits in the coronary arteries

-higher score suggests higher chance of significant narrowing in the coronary arteries and higher risk of future heart attack

What are causes for MI other than atherosclerosis?

trauma, congenital, metabolic disease, vasospasms, electrolyte imbalance, stress,drugs

What does medical management of acute coronary syndrome involve?

-quick recognition, so care is received within 60-90m

-#1 goal is reperfusion: restoring blood flow to the heart via aspirin, anticoagulants, administering O2, controlling cardiac pain

-preventing complications to tissue

What are some complications with STEMI and non-STEMIs afterwards?

-hypokinesis (reduced strength of contraction)

-akinesis (no contraction if cells died)

-dyskinesis (abnormal movement during contraction)

-hyperkinesis often in non-infarcted areas due to increased sympathetic NS compensating for infarcted tissue

T or F: Hyperkinesis is often a result of a STEMI and will occur in the cells that have died

False; will occur in the cells surrounding the ones that died to make up for them via compensation

What happens if a pt's LV has 15-24% damage after an MI?

-decreased SV

-possible s&s of heart failure

-lower stroke volume leads to lower aortic presssure and subsequently a reduction in coronary perfusion pressure

What happens if the LV. is 25-39% damaged following an MI?

s&s of heart failure are seen

What happens if the LV has 40% or more damage following an MI?

likely death

What are some complications post-MI that are seen, most often within the fifrst 24-48hr post-MI?

-ventricular tachycardia

-artial flutter/fib

-second or third degree AV block

-persistent sinus tachycardia (above 100bpm)

-persistent systolic hypotension (below 90mmHg)

-pulmonary edema

-persistent angina

-depression & anxiety

T or F: Pts without complications post-MI have lower morbidity rates

True

What is a general difference between flutters and fibrillations?

flutters = heart beats in a quivering manner

fib = heart vibrates during contractions; is worse than flutter

What is the difference between ventricular tachycardia and sinus tachycardia?

ventricular = when ventricles are beating too fast without the atrium beating fast as well

sinus = whole heart is beating fast

What happens to the physical properties of the ventricles after a STEMI?

ventricular remodeling, changes in shape, size, and thickness in both the infarcted and non-infarcted areas

What is ventricular remodeling? What are factors that affect this remodeling?

-changes in shape, size, thickness of infarcted and non-infarcted myocardium

factors that influence remodeling are:

-size of infarct

-efficiency of the artery that was infarcted

--> decreased blood flow = poor remodeling; increased blood flow = increased scar formatino and improved remodeling

The pt prognosis post MI is dependent upon what?

-amount of complications

-infarct size

-presence of disease in other coornary arteries

-LV function (most important!!!)