Cardiology & Cardiovascular Disease

Hypertension

• Disease of the arteries
    * Consistent elevation of systemic arterial blood pressure
• Blood pressure= systolic/diastolic
    * Systolic= force/contraction 100-120mmHg
    * Diastolic= relaxation 60-80 mmHg
      * High bp → obstruction OR greater pressure when pumping
      * Common disorder that impacts 25% of the population; leads to major risk of atherosclerosis, CHF, and renal failure
• Hypertensive bp → 130/80 or greater
• 2 types of HT: Primary/Essential HT or Secondary HT

Blood Pressures

Essential/Primary Hypertension

• ==MOST COMMON TYPE OF HT==
• Problems lie in the blood vessels
• Genetic and environmental factors; but, don’t know where the problem lies in the gene defects; usually runs in the family
• Affects 92-95% of individuals with HT

→ Risk Factors

• %%Increase in age → wear & tear of heart and blood vessels in age%%
• %%Family history → cultural/lifestyle%%
• %%Race/ethnicity → African Americans at highest risk for hypertension%%
• Sex → males at higher risk
    * All are ESSENTIAL, cannot be changed
• High sodium intake → diet, H2O follows, increase in pressure
• @@Inflammation@@
• @@Obesity/weight gain@@
• Insulin resistance
    * The 3 go hand in hand, diabetes and hypertension are usually seen together
• Dyslipidemia → high cholesterol
• Alcohol, smoking, prolonged/current stress → all cause vasoconstriction -

→ S&S

• ASYMPTOMATIC, NO SYMPTOMS
• Non-specific fatigue
• Malaise
• The body adapts

→ Diagnostics

• CBC

• Kidney panel (BUN/creatinine)

• Lipid profile

• Urinalysis

• EKG

• ECG

• With patients, you would measure a first time, have them come in again and measure again, and then make them come in a final time for 3 measurements in order to rule out hypertension; NEVER treat upon first reading

→ Treatment

• CONSERVATIVE = reducing the risks
    * Lifestyle changes
    * Low sodium diet
    * Weight reduction
    * Exercise
    * Decrease stress
    * Patient education
• Medicines
    * Diuretics → African American community responds well to this treatment
    * ACE inhibitors
    * ARB
    * Calcium channel blockers
    * Beta blockers

→ Complications

• ==HYPERTENSIVE CRISIS== (malignant hypertension)
    * Retinopathy
    * Elevated BP
    * Nephrosclerosis
    * CHF, atherosclerosis, angina, MI
    * CVA
• RAPIDLY PROGRESSES
• 180/>120
• Life-threatening with organ damage
• Don’t respond to medications
• If they do survive, can lead to dialysis or coma

Secondary Hypertension

• Systemic disease that raises peripheral vascular resistance or cardiac output
    * UNCOMMON
• Usually caused by something else (ex: sleep apnea, renal artery stenosis, hypothyroidism)

Coronary Artery Disease (CAD)

• Caused by atherosclerosis
    * Blockage of blood flow
• Narrowing of coronary arteries leads to myocardial ischemia → MI

Atherosclerosis

• Form of arteriosclerosis
• Presence of atheroma (plaque) in the large arteries
    * Cause of atheromas = damage
      * When atheromas break, causes an embolism/thrombus which can lead to a MI
      * Fatty streak is #1 sign of atherosclerosis and CAN be reversed
• Related to diet, exercise, and stress

Risk Factors for Atherosclerosis

• Genetic abnormalities
• Family Hx
• Age
• Males (females protected by estrogen until menopause)
• Hyperlipidemia
• Obesity
• Sedentary lifestyle
• Cigarette smoking
• Diabetes
• Inflammation

Angina Pectoris

• Local, temporary deprivation of the coronary blood supply (O2) to meet myocardial needs → chest pain
    * Blockage (thrombus/embolus)
• Occurs in different patterns

Stable/Classic Angina Pectoris

• Recurrent, intermittent brief episodes of substernal chest pain
• Pressure, heaviness, squeezing, burning or choking sensation
• Triggered by physical or emotional stress
• Lasts 1-5 minutes, relieved by rest or nitroglycerin
• No cell death or necrosis
• Physical exam is often normal in findings

Angina is a warning sign of progression of disease

→ Diagnostics

• CBC
• EKG
• Stress test (treadmill/nuclear)
• ECG
• CT scan & angiography
• Cath lab

→ Treatment

• Relieve symptoms, and slow progression of disease by reducing complications (stop smoking, treat risks)
• Nitroglycerin → decreases the demand for O2, reduces systemic resistance
• Ranolazine → anti-anginal

Acute Coronary Syndromes

• Unstable angina = 1 foot into the heart attack door
    * REVERSIBLE MI
• Myocardial infarction (MI) → acute process that is sudden and extended obstruction of the myocardial blood supply which causes myocardial cell death

Unstable Angina Pectoris

• Reversible myocardial ischemia without necrosis
• Angina at rest
    * More frequent/severe and prolonged
      * Changed from usual pattern of angina
        * Longer in duration
        * Lower in threshold
    * ==DOES NOT RESPOND TO NITRO==
      * Only relieved with time
      * Requires aggressive treatment

Myocardial Infarction (MI)

• ^^Heart attack^^
• Atherosclerosis most common cause
    * Thrombus from atheroma may obstruct artery; size and location determines damage
• The irreversible death (necrosis) of heart muscle secondary to prolonged lack of O2 supply (ischemia)
    * Occurs when coronary artery is totally obstructed → necrosis

→ S&S

• Severe chest pains
    * Intense lasting for 30-60 minutes
• Radiating pain to neck, shoulder, jaw, and LEFT arm
• $Levine sign$ → clenched fist over the heart (seen mainly in women)
• Epigastric → belly pain, not life threatening but MI can mask as belly pain
• Nausea & vomiting from pain as a sympathetic response
• Diaphoresis
• Dyspnea → SOB
• Fatigue & malaise

→ Diagnostics

• TROPONIN LEVELS
    * CK-MB isoenzymes if troponin test not an option
• CBC
• Comprehensive metabolic panel
• Lipid profile
• 12 Lead EKG
    * ST segment depression, T wave inversion or ==ST segment elevation ==
• ECG
• CT/MRI (waste of time & $$)
• Angiography

→ Treatment

• Oxygen therapy to reduce cardiac demand
• Aspirin
• Nitroglycerin → vasodilator
• Morphine → relieves pain, lowers stress, vasodilates blood vessels which increases blood flow
• ACE inhibitors
• Beta blockers
• Calcium channel blockers
• Thrombolytic agents
• Tissue plasminogen activator (once cleared for use)
• Statins
• Angioplasty & stents (only when troponin levels are not lowering)
• Coronary artery bypass surgery
• External counter pulsation (ECP)

→ Complications

• Sudden death
• Cardiogenic shock
• CHF
• Rupture of necrotic heart tissues/cardiac tamponade (increases mortality or CVA risk)
• Thromboembolism causing a CVA w/LVMI

Prinzmetal Angina

• Vasospasms
• Angina occurs at rest during sleep, and occurs in clusters
• Does not develop during treadmill tests
• No evidence of cardiac diseases or atherosclerotic heart disease
• Occurs in younger people
• More often seen in females than males

→ Pathophysiology

• Reduced nitric oxide availability
• Imbalance of sympathetic and parasympathetic systems
• Increased alpha-adrenergic receptors activity

→ Treatment

• Nitroglycerin (acute attacks)
• Calcium channel blockers (maintenance)

Heart Failure

• Inability of the heart to pump enough blood to meet the body’s needs → inadequate perfusion of tissues
    * Less filling of the heart (diastole)
    * Insufficient stroke volume (systole)
• Can be left or right sided heart failure

Functional

• Systolic dysfunction: inability to generate adequate cardiac output to perfuse tissues; EF <40%
• Diastolic dysfunction: decreased compliance of left ventricle, abnormal relaxation
• High output (other diseases cause heart to fail)
• Both pumps fail = biventricular failure

→ LEFT SIDED HF

==L==eft sided HF = ==L==ungs

• CONGESTIVE HEART FAILURE (CHF)
• Most common type of HF
• Low cardiac output
• Dyspnea (pulmonary congestion/edema)
• “Left HF is a disease with symptoms”

→ S&S

• Restlessness
• Confusion
• Orthopnea
• Tachycardia
• Exertional dyspnea
• Fatigue
• Cyanosis
• Tachypnea
• Blood-tinged sputum
• Cough/crackles/wheezes
• Paroxysmal nocturnal dyspnea

→ RIGHT SIDED HF

==R==ight sided HF = ==R==est of the body

• Most common cause is LEFT SIDED HF
• Inability of the right ventricle to provide adequate blood flow at a normal venous pressure
• “Right HF is a disease with signs”

→ S&S

• Pedal edema
• Fatigue
• “Pitting” edemas
• Ascites
• Enlarged liver & spleen
• Increased venous pressure
• May be secondary to chronic pulmonary problems
• Distended jugular
• Weight gain
• Anorexia/complaints of GI distress
• Dependent edema

→ High-Output HF

• Normal heart function, something caused an increased demand, the heart can’t keep up
• Inability of the heart to supply the body with nutrients, despite adequate blood volume and normal/elevated myocardial contractility
• Causes include: severe anemia, hyperthyroidism, septicemia, and beriberi (B12 deficiency)

Shock

• Cardiovascular system fails to perfuse tissues adequately
• Manifestations often include feeling weak, cold, hot, nauseated, dizzy, confused, afraid, thirsty, SOB, hypotension, tachycardia, increased respiratory rate

Hypovolemic = acute trauma

• Loss of blood or plasma
    * Blood vessels ⬇️
    * Blood pressure ⬇️
    * Heart workload ⬆️
• Caused by hemorrhage, burns, dehydration, peritonitis, pancreatitis

Cardiogenic = heart at fault

• Decreased pumping capability of the heart
• Caused by MI of left ventricle, cardiac arrhythmia, pulmonary embolus

Vasogenic = nervous system at fault

• Vasodilation owing to loss of sympathetic and vasomotor tone
• Caused by pain and fear, spinal cord injury, hypoglycemia (insulin shock)

Anaphylatic = immune response

• Systemic vasodilation and increased permeability owing to severe allergic reaction
• Caused by insect stings, drugs, nuts, and shellfish

Septic/Endotoxic = immune but by gram-negative organisms

• Vasodilation owing to severe infection, often gram negative bacteria
• Caused by virulent microorganisms or multiple infections