MED

It

is an organ system that passes nutrients (such as amino acids, electrolytes and lymph), gases, hormones, blood cells, etc. to and from cells in the body to help fight diseases, stabilize body temperature and pH, and to maintain homeostasis.

 This

system may be seen strictly as a blood distribution network, but some consider the circulatory system as composed of the cardiovascular system, which distributes blood,and the lymphatic system, which returns excess filtered blood plasma from the interstitial fluid (between cells) as lymph. While humans, as well as other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves the network of arteries, veins and capillaries), some invertebrate groups have an open cardiovascular system.

 Covered by the pericardium. Has two sides with two chambers. Blood flows through the heart in one direction. Valves control the blood flow. The cardiac conduction system controls the electrical impulses that cause the heart to contract.

 Two

types of fluids move through the circulatory system: blood and lymph. Lymph is essentially recycled blood plasma after it has been filtered from the blood cells and returned to the lymphatic system. The blood, heart, and blood vessels form the cardiovascular (from Latin words meaning 'heart'-'vessel') system. The lymph, lymph nodes, and lymph vessels form the lymphatic system. The cardiovascular system and the lymphatic system collectively make up the circulatory system.

 The

main components of the human cardiovascular system are the heart, blood, and blood vessels.[4] It includes: the pulmonary circulation, a "loop" through the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the rest of the body to provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, which consists of plasma, red blood cells, white blood cells, and platelets. Also, the digestive system works with the circulatory system to provide the nutrients the system needs to keep the heart pumping.

The

heart is a double pump

arterioles veinsvenules capillaries

heartarteries

Heart

as known to be called as Double pump as it consist of double circulation. Coronary circulation. Pulmonary circulation. Systemic circulation

The

pulmonary circulatory system is the portion of the cardiovascular system in which oxygen-depleted blood is pumped away from the heart, via the pulmonary artery, to the lungs and returned, oxygenated, to the heart via the pulmonary vein.

 Systemic

circulation is the circulation of the blood of to all parts of the body except the lungs. Systemic circulation is the portion of the cardiovascular system which transports oxygenated blood away from the heart, to the rest of the body, and returns oxygen-depleted blood back to the heart. Systemic circulation is, distancewise, much longer than pulmonary circulation, transporting blood to every part of the body.

The

coronary circulatory system provides a blood supply to the heart. As it provides oxygenated blood to the heart, it is by definition a part of the systemic circulatory system.

In the human heart there is one atrium and one ventricle for each circulation, and with both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lungs as well as the pulmonary vein which is passed into the strong left ventricle to be pumped through the aorta to the different organs of the body.

The

cardiovascular systems of humans are closed, meaning that the blood never leaves the network of blood vessels. In contrast, oxygen and nutrients diffuse across the blood vessel layers and enters interstitial fluid, which carries oxygen and nutrients to the target cells, and carbon dioxide and wastes in the opposite direction. The other component of the circulatory system, the lymphatic system, is not closed.

Heart

chamber is a general term used to refer to any chambers of the mammalian heart. The heart consists of four chambers: the right and left atrium and the right and left ventricle. The top chambers are connected to the bottom chambers by valves and are separated by the coronary sulcus. The left and right side of the heart are separated by the posterior interventricular sulcus.

Right atrium: Situated in the upper right section of the heart, this chamber receives oxygen-depleted blood from the body from two major veins, the superior vena cava and the inferior vena cava. This chamber then pumps blood through the tricuspid valve into the right ventricle situated below. Right ventricle: Located below the right atrium, this chamber receives oxygen-depleted blood from the right atrium and pumps it through the pulmonary valve and into the lungs via the right and left pulmonary artery. Left atrium: This chamber sits opposite the right atrium and is the upper part of the heart that receives oxygenrich blood from the lungs via the right and left pulmonary veins and pumps it through the bicuspid valve or mitral valve into the left ventricle. Left ventricle: This chamber is the lower part of the heart that receives oxygen-rich blood from the left atrium above it, and pumps it through the aortic valve to be distributed throughout the entire body via the aorta, including to the heart muscle itself through the coronary arteries.

Each

heart chamber includes valves vital to the efficiency of the circulatory system. These valves open to allow the blood to flow in the right direction into, within, or out of the heart, and close to prevent the backflow of blood. There are four main valves that allow the chambers of the heart to carry out their function efficiently and they relax and contract during a heartbeat.

The

Tricuspid Valve The Mitral Valve

The

tricuspid valve is located between the right atrium and the right ventricle. Blood passively fills the right atrium during diastole phase of the right atrium. When the right atrium is in systole phase, the contraction forces this valve open, thereby forcing any additional deoxygenated blood into the ventricle.

 The

semi-lunar pulmonary valve is located between the right ventricle and the pulmonary trunk. During ventricle systole, the pressure within the chamber will increase until the valve is forced open. Deoxygenated blood can thereby be carried through the pulmonary arteries to each lung. This valve is named because the shape resembles half-moon pockets. When the ventricle relaxes, the pressure within the chamber decreases and blood fills these pockets causing them to close.

The

mitral valve is located between the left atrium and the left ventricle. Similar to the tricuspid valve, during the atrium's systole phase, the valve is forced open to allow the oxygenated blood from the lungs to enter into the left ventricle.

 The

semi-lunar aortic valve is located at the exit of the aorta and the left ventricle. The function of this valve mirrors that of the semi-lunar pulmonary valve, with one exception. Once the pressure in the left ventricle falls back during relaxation phase, oxygenated blood will fill up in the cusps of the semi-lunar aortic valve eventually causing them to close. This blood is what supplies the right and left coronary arteries which distribute blood to the muscle tissues of the heart.

 The

two ventricles are separated by a septum into the left ventricle and the right ventricle. The ventricles of the heart are muscular chambers because they are responsible for propelling blood out of the heart.The left ventricle is the thickest of the four chambers because it is the final chamber that oxygenated blood must be pumped through before it is distributed throughout the body via the circulatory system. The ventricles are also larger in size compared to the atria.

The

blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and the tissues; and the veins, which carry blood from the capillaries back toward the heart.

There

are various kinds of blood vessels: Arteries Veins Capillaries

(from the Greek artria, "windpipe, artery"are blood vessels that carry blood away from the heart. This blood is normally oxygenated, exceptions made for the pulmonary and umbilical arteries. The EABV (Effective Arterial Blood Volume) is that ICF fluid which fills the arterial system. Further divided in to smaller units known as Arterioles.
Arteries

The

anatomy of arteries can be separated into :Gross anatomy Microscopic Anatomy.

The

arterial system of the human body is divided into systemic arteries, carrying blood from the heart to the whole body, and pulmonary arteries, carrying blood from the heart to the lungs.

 The

outermost layer is known as the tunica externa formerly known as "tunica adventitia" and is composed of connective tissue. Inside this layer is the tunica media, or media, which is made up of smooth muscle cells and elastic tissue. The innermost layer, which is in direct contact with the flow of blood is the tunica intima, commonly called the intima. This layer is made up of mainly endothelial cells. The hollow internal cavity in which the blood flows is called the lumen.

In

the circulatory system, veins (from the Latin vena) are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart.

general, veins function to return deoxygenated blood to the heart, and are essentially tubes that collapse when their lumens are not filled with blood. The thick outermost layer of a vein is made of connective tissue, called tunica adventitia or tunica externa. Deeper are bands of smooth muscle called tunica media, which are, in general, thin, as veins do not function primarily in a contractile manner. The interior is lined with endothelial cells called tunica intima.

Superficial

veins :- Are those whose course is close to the surface of the body, and have no corresponding arteries Deep veins :-Are deeper in the body and have corresponding arteries.

Communicating

veins :-(or perforator veins) are veins that directly connect superficial veins to deep veins. Pulmonary veins :-The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart. Systemic veins:- Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart

Arteries Transport blood away from the heart Transport blood away from the heart. Carry Oxygenated Blood (except in the case of the Pulmonary Artery). Do not have valves (except for the semilunar valves of the pulmonary artery and the aorta).

Veins Transport blood towards the heart. Carry De-oxygenated Blood (except in the case of the Pulmonary Vein). Transports blood under lower pressure (than arteries). Have valves.

Heart

is composed of three layers that are as follows:Pericardium Epicardium Endocardium

Pericardium

is a tough double layered membrane which covers the heart. The space between the two layers of it is filled with a pericardium fluid which protects the heart from any kind of external jerk or shock.

Epicardium

describes the outer layer of heart tissue (from Greek; epiouter, cardium heart). When considered as a part of the pericardium, it is the inner layer, or visceral pericardium, continuous with the serous layer.

The

endocardium is the innermost layer of tissue that lines the chambers of the heart. Its cells are embryologically and biologically similar to the endothelial cells that line blood vessels.

Cardiac

muscle (heart muscle) is a type of involuntary striated muscle found in the walls and histological foundation of the heart, specifically the myocardium.

Automaticity Conductivity Contractility Excitability

 Automaticity

is a characteristic unique to cardiac muscle and refers to the heart's ability to generate its own signal to contract. Rather than receiving input from the central nervous system, at rest the heart relies on pacemaker cells located in the right upper chamber to spontaneously generate electrical signals, which lead to the rhythmic contractions known as heartbeats. The rate of the heartbeat is based on how long it takes the pacemaker cells to fire, reset and fire again.

In order to transmit the electrical signal that is generated in the upper right quadrant of the heart to the rest of the myocardium, the muscle fibers must be able to conduct electricity. Cardiac muscle has the ability to pass the electrical signal from one fiber to the next until it has spread throughout the entirety of the heart. Once each fiber has been given the signal, the heart will contract as a whole. Contracting in this fashion allows for a significant amount of force to be generated by the two lower chambers of the heart, which will allow blood to be delivered to the lungs and throughout the whole body. Without conductivity, each muscle fiber would need to have its own pacemaker and would likely disrupt the synchronicity, rhythm and efficiency of myocardial contractions.

Contractility

is the ability of the heart to generate tension, or produce force, in order to eject blood from the heart. It is, in essence, the physical expression of the electrical signals initiated by the pacemaker cells and passed throughout the heart muscle.

Although

cardiac muscle can generate its own electrical signal, the pacemaker cells fire at a very steady rate. Because of this, any increases in heart rate have to be governed by an external stimulus. The heart's ability to respond to an additional stimulus and change its rate of contraction is known as excitability.

Cardiac

cycle is consist of following phases:Systole (0.3 sec) Diastole (0.5 sec) One systole and one diastole together forms a cardiac cycle.

Blood

volume is the volume of blood (both red blood cells and plasma) in the circulatory system of any individual.

stroke

volume (SV) is the volume of blood pumped from one ventricle of the heart with each beat. Stroke volume is an important determinant of cardiac output, which is the product of stroke volume and heart rate.

Cardiac

output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. An average resting cardiac output would be 5.6L/min for a human male and 4.9L/min for a female.

Total

peripheral resistance (TPR) is the sum of the resistance of all peripheral vasculature in the systemic circulation. Vasculature throughout the entire body can be thought of as two separate circuits one is the systemic circulation, while the other is the pulmonary circulation. TPR should not be confused with Pulmonary Vascular Resistance (PVR), which is the resistance in the pulmonary circulation.

Stroke

Volume (SV) = EDV ESV Ejection Fraction (EF) = (SV / EDV) 100% Cardiac Output (Q) = SV HR Cardiac Index (CI) = Q / Body Surface Area (BSA) = SV HR/BSA HR is Heart Rate, expressed as BPM (Beats Per Minute)

 The

sounds of the heart are caused by the closing of the valves. The lub sound- quieter, longer, lower pitched- caused by the bicuspid and tricuspid valves closing. The dub sound- louder, shorter, higher pitched- caused by the semi lunar valves closing. A heart murmur is an abnormal sound of the heart. It is usually an indication of damaged valves.

 Blood

pressure is the blood pressing against the blood vessel walls. It is measured by a sphygmomanometer. The pressure varies along the circuit decreasing from artery to arteriole to capillary to venule to vein. Pressure is highest at the start of the artery and lowest at the entrance to the atrium. Blood pressure is much higher in the aorta than in the pulmonary artery.

The

measures of a persons blood pressure it taken at a large artery in the upper arm. It is the pressure need to stop blood flow in this artery and is measured at diastole and systole. Standard healthy readings are 80 mm Hg diastolic, 120 mm Hg systolic. People with a diastolic number at or above 95 have hypertension (high blood pressure). It is usually caused by blockages in the arteries.

Blood

pressure = Cardiac output x

TPR
It

is evident from the formula that any increase in the cardiac output or in the total peripheral resistance would result in the increase in the blood pressure.

High

blood pressure is often referred to as "the silent killer." Most people with high blood pressure (also known as hypertension) don't have any high blood pressure symptoms, since the effects are occurring inside the body.

Relationship between BP & CV risk is linear (i.e no threshold)

Most people have normal BP levels.

Most MIs & strokes occur in individuals with normal levels of BP

Hypertension risk factors

Concurrent conditions
Asthma Gout Pregnancy

Clues to 2o HT
Symptoms Drugs Signs

Other CV risk factors

Lipids Smoking Diabetes Exercise

Target organ damage

Heart Brain Eyes Kidneys

Non-pharmacological/ lifestyle Pharmacological

SBP BP Classification mmHg*

DBP mmHg

Lifestyle Drug Modification Therapy* *

and Encourag No e <80 Prehypertens 120-139 or 80Yes No ion 89 Stage 1 Yes Single 140-159 or 90Hypertension Agent 99
Normal Stage 2 Yes Combo 160 or Hypertension 100 *Treatment determined by highest BP category; **Consider
treatment for compelling indications regardless of BP
JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

<120

Flow-mediated vasodilation (FMD)

Measures that lower blood pressure:

q q q q q

weight salt intake alcohol consumption physical exercise fruit & vegetable consumption

Measures to reduce cardiovascular risk:

q q q q

Stop smoking saturated fat, poly- & mono-unsaturates oily fish consumption total fat intake
BHS Guidelines 2010

1200

Total number of individuals affected

Non-fatal events Fatal events T=treatment C=control

1000 800 600 400 200

C T C T

Stroke % reduction in odds 38% SD 4

CHD 16% SD 4

All vascular deaths

All other deaths

Brit Med Bull2009;50:272-98

The ideal Antihypertensive ?

No contraindications q Inexpensive q Effective in Mono therapy. q Simple once daily dosage q Prevents / reverses target organ damage q Improves mortality / morbidity q No side-effects or adverse metabolic effects q Combinable with other drugs q Genetically targeted
q

Diuretic Calcium-channel blocker Beta-blocker

q q

ACE-inhibitor Angiotensin receptor blocker (Alpha-blocker)

Most hypertensive will need 2 drugs to control BP Drug combinations may be synergistic

ACE inhibitor (AII antagonist) or -blocker Calcium antagonist One drug: Two drugs: C Diuretic

A B

Younger, non-black A or B Older, black C or D (A or B) + (C or D)

Three drugs: (A or B) + C + D

Heart HR

Veins Stroke Volume Arteries SVR

Veins

Mechanism: inhibit Na/K pumps in the distal tubule Examples:

Hydrocholorthiazide 12.5-25 mg daily Chlorthalidone 12.5-50 mg daily

Thiazides

Effective first line agent and provides synergistic benefit As single agent more effective if CrCl >30 ml/min Compelling indications: HF, High CAD risk, Diabetes, Stroke, ISH

Veins

Mechanism: inhibit aldosterones effect at the receptor, reducing Na and water retention Examples:
Spironolactone 25 mg daily

Thiazides Loops Aldosterone Ant.

Can provide as much as 25 mmHg BP reduction on top of 4 drug regimen in resistant hypertension Monitor SCr and K Compelling indications: HF
Am J Hypertension. 2003; 16:925-930.

Veins

Mechanism: Direct venodilation by release of nitric oxide Examples:

Isosorbide dinitrate 10 mg TID IMDUR 30 mg daily

Thiazides Loops Aldosterone Ant. Nitrates

In renal patients with resistant hypertension addition to 3-4 drug regimen may help get patient to goal Provide 8h nitrate free interval daily Compelling indications: Angina

Veins

Mechanism: Inhibit vasoconstriction by inhibiting synthesis or blocking action of angiotensin II; provides balanced vasdilation Examples:
Enalapril 2.5-40 mg daily BID Lisinopril 5 40 mg daily Irbesartan 150-300 mg daily Losartan 25-100 mg Daily - BID

Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB

Monitor: SCr, K Compelling indications: HF, post-MI, High CAD risk, Diabetes, CKD, Stroke

Heart

Mechanism: Competitively inhibit the binding of catecholamines to betaadrenergic receptors Examples:

Atenolol 25-100 mg PO daily Metoprolol 25 -100 mg PO daily or BID Carvedilol 6.25-25 mg PO BID

Beta Blockers

Monitor: HR, Blood Glucose in DM Not contraindicated in asthma or COPD but use caution Compelling indications: HF, post-MI, High CAD risk, Diabetes

Heart

Mechanism: false neurotransmitters reduce sympathetic outflow reducing sympathetic tone Examples:
Clonidine 0.1-0.6 mg PO BID-TID; patch Methyldopa, Guanabenz, Guanfacine

Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine

Monitor: HR Side effects often limiting: Dry mouth, orthostasis, sedation Clonidine patch can be useful in elderly patients with labile blood pressure

Arteries

Mechanism: Decrease calcium influx into cells of vascular smooth muscle Examples:
Amlodipine 2.5-10 mg PO daily

Dihydropyridine CCBs

Felodipine2.5-10 mg PO daily Do not use immediate release nifedipine

Monitor: Peripheral edema, HR (can cause reflex tachycardia) Good add on agent if cost is not an issue

Arteries

Mechanism: Direct vasodilation of arterioles via increased intracellular cAMP Examples:

Hydralazine 20-400 mg BID-QID Minoxidil 2.5-40 mg PO daily-BID

Dihydropyridine CCBs Hydralazine Minoxidil

Monitor: HR (can cause reflex tachycardia), Na/Water retention Hydralazine is an alternative in HF if ACEI contraindicated Consider minoxidil in refractory patients on multi-drug regimens

Arteries

Mechanism: Inhibit peripheral postsynaptic alpha1 receptors causing vasodilation Examples:

Terazosin 1 20 mg daily Doxazosin 1 16 mg daily

Dihydropyridine CCBs Hydralazine Minoxidil Alpha1 Blockers

Cause marked orthostatic hypotension, give dose at bedtime Consider only as add on therapy Can be beneficial in patients with BPH

< 140/90 mmHg . except in those with diabetes or chronic renal disease < 130/80 mmHg

Topic Contents
Structure and functions of vascular endothelial cell. The endothelial dysfunction. The oxidant- stress induced endothelial dysfunction. How to assess endothelial functions. Summary

 Historically viewed as a passive vascular lining.

 Many

important roles to maintain vascular homeostasis:

Vascular tone regulation VSMC proliferation Inflammatory responses Haemostasis

It

produces and releases vasoactive, thromboregulatory and growth factor subst ances.

Endothelial cell functions

ntaining the vascular tone: Vasodilation and Vasoconstr

Tousoulis, et al., Heart 2005; 91: 353-358.

Functional targets action/Mediators

Physiological

Haemostasis Prothrombotic Antithrombotic PAI-1 PGI2, TPA

Calles-Escandon and Cipolla, Endocrine Rev 2001; 22: 36-52.

 Factors affecting vascular tone and structure

Xanthine oxidase, NADP/NADPH oxidase uncoulpled eNOS

NO bioavailability

general term that covers a number of diseases which affect the heart, including coronary artery disease, heart-failure and angina. Heart Disease is the number one killer in the. Three major reasons of the heart diseases in the world populations are as follows:-

HURRY

WORRY

CURRY

Hypertension Coronary

Artery disease.

Angina (Myocardial Ischemia)

Heart Attack (Myocardial Infarction)

Heart

Failure Arrhythmias

Atherosclerosis

is a specific form of arteriosclerosis (thickening & hardening of arterial walls) affecting primarily the intima of large and medium-sized muscular arteries and is characterized by the presence of fibrofatty plaques or atheromas. The term atherosclerosis is derived from atheroma (meaning porridge) referring to the soft lipid-rich material in the centre of atheroma, and sclerosis (scarring) referring to connective tissue in the plaques.

Most

commonly affected arteries by atherosclerosis include large and medium sized arteries like aorta, coronary, popliteal and cerebral arteries. Major complications resulting from ischemia due to atherosclerosis include myocardial infarction leading to heart attacks and cerebral infarction leading to strokes. Less common complications include peripheral vascular disease,

Most

commonly affected arteries by atherosclerosis include large and medium sized arteries like aorta, coronary, popliteal and cerebral arteries. Major complications resulting from ischemia due to atherosclerosis include myocardial infarction leading to heart attacks and cerebral infarction leading to strokes. Less common complications include peripheral vascular disease,

Atherosclerosis

is the cause of more than half of all deaths in the western industrialized nations. Incidence progressively increasing in developing nations too in an epidemic proportion over the last few decades due to fast changing lifestyles. Deaths from myocardial infarction (20-25 % of all deaths) are mostly related to underlying atherosclerosis. Cardiovascular disease related to

Major risk factors 1) Major Constitutional risk factors: i. Age ii. Sex iii. Genetic factors iv. Familial and racial factors 2) Major Acquired risk factors: i. Hyperlipidaemia ii. Hypertension iii. Diabetes mellitus iv. Smoking

Minor Risk Factors: 1. Environmental influences 2. Obesity 3. Hormones: Oestrogen deficiency, oral contracep. 4. Physical inactivity 5. Stressful life

HYPERLIPIDAEMIA Hypercholesterolaemia has directly proportionate relationship with atherosclerosis and IHD because: The atherosclerotic plaques contain cholesterol and cholesterol esters largely derived from the lipoproteins in the blood. The lesions of atherosclerosis can be induced in experimental animals by feeding them cholesterol-rich diet. beneficial effect on reducing the risk of IHD

Individuals with hypercholesterolemia due to various causes such as diabetes mellitus, myxoedema, nephrotic syndrome and familial hypercholesterolaemia have increased risk of developing atherosclerosis and IHD. Populations having hypercholesterolaemia have higher mortality from IHD. Dietary regulation and administration of cholesterol-lowering drugs have

Mevalonate Pathway..

CHOLESTEROL

LDL

HDL

Bad Cholesterol (Results in CVD)

Good form of cholesterol (Improves Cardiovascular functions

Myocardial

Ischemia
when the blood flow

Myocardial ischemia occurs the coronary arteries.

demands of the heart exceed the blood supplied by

The leading cause of myocardial ischemia is:

a) b) atherosclerosis or blockage of coronary arteries due to the accumulation of lipid plaques and/or thrombus .

mia : Inadequate blood flow to a tissue or part of the b

Pathophysiology of myocardial ischemia: Under conditions of rest, myocardial oxygen supply and delivery of nutrients through the coronary arteries should match the metabolic requirements of the heart. When the metabolic needs of the heart increase, the coronary blood flow must increase accordingly. The myocardial oxygen balance is affected by several factors that :
a)

will increase the oxygen and nutrient demand of the myocardium as: exercise, stress and cold. will increase coronary blood flow as cardiac metabolites and nitric oxide.

b)

Myocardial Ischemia
Pathophysiology of myocardial ischemia:
With age and progressive occlusion of coronary arteries, smaller collateral vessels may begin to carry a greater proportion of blood and provide an alternate means of perfusion for an area of myocardium. These collateral blood vessels may run parallel to the larger coronary arteries and be connected to other small coronary vessels by vascular connections called anastomoses. Development of collateral circulation may reduce or delay the occurrence of symptoms from myocardial ischemia until the blockage is very progressed. The presence of extensively developed collateral circulation might also explain why many older individuals often survive serious heart attacks when younger individuals, who have not yet developed collateral circulation, often do not.

Myocardial

Ischemia

Manifestation of myocardial ischemia: Angina pectoris

It is the major symptom of myocardial ischemia. Angina pectoris most commonly presents as pain, pressure or a burning sensation in the area of the sternum.

There are three types of Angina pectoris 1. Classic or exertional angina:

Pain is precipitated by increased workload on the heart. May be caused by exercise, emotions, stress and cold exposure. Symptoms may remain stable for a number of years or progress in severity.

Myocardial

Ischemia

There are three types of Angina pectoris 2. Unstable angina

Angina that occurs at rest. Also referred to as pre-infarct angina since it is usually associated with extensive blockage of coronary arteries. Coronary blood flow does not meet the needs of the heart even at rest. Requires intensive treatment and evaluation.

3. Variant angina (vasospastic angina, Prinzmetals angina)

Caused by vasospasm of the coronary arteries. Usually associated with coronary artery disease but may result from excess sympathetic activity. Frequently occurs at night, at rest or during minimal exercise. May be precipitated by stress, cold exposure or smoking.

Silent ischemia
is a particularly dangerous form of myocardial ischemia as there is a lack of clinical symptoms, i.e., ischemia without angina. Usually diagnosed by exercise stress testing or Holter monitoring

Myocardial Ischemia
Diagnosis of myocardial ischemia:
1. Electrocardiograph 2. Holter monitoring 24 ambulatory electrocardiograph 3. Stress testing with electrocardiograph 4. Nuclear imaging 5. Cardiac catheterization

Myocardial Ischemia
Rationale for treatment of myocardial ischemia:
Treatment of myocardial ischemia and the resulting angina can involve two strategies: 1. Increase coronary blood flow by dilating coronary arteries. 2. Reduce cardiac workload by reducing heart rate and/or force of contraction

Myocardial Ischemia
Treatment of myocardial ischemia:
The treatment regimen may include : 1. nonpharmacologic treatment 2. pharmacologic therapies. Nonpharmacologic treatment
Pacing of physical activity. Avoidance of stress (emotional, physiologic, cold). Reduction of risk factors for ischemic heart disease, (hyperlipidemia, obesity, hypertension, diabetes, smoking, etc.)

Treatment of myocardial ischemia: Pharmacologic treatment Organic Nitrates

Mechanism of action: Dilate coronary arteries and increase myocardial blood flow. Dilate peripheral arteries and reduce afterload. Dilate peripheral veins and reduce preload. Examples Amyl nitrate, nitroglycerine, isosorbide dinitrite Route of administration : Inhalation, sublingual, oral, transdermal, intravenous Long-acting forms such as isosorbide dinitrite used for prophylaxis of angina Short-acting forms such as sublingual nitroglycerin may be used during angina attacks Major adverse effects :include headache, hypotension. Tolerance may develop rapidly.

Treatment of myocardial ischemia: Pharmacologic treatment -Adrenergic blockers

Mechanism of action:
Block myocardial -adrenergic receptors. Reduce heart rate and cardiac output (reduced myocardial workload and oxygen demand). Examples of -Adrenergic Receptor Antagonists : May be selective (atenolol), or 1 nonselective and blockers (propranolol) 1 2 Major adverse effects : include bradycardia, reduced cardiac output, pacemaker depression and bronchoconstriction with nonspecific drugs

Treatment of myocardial ischemia: Pharmacologic treatment Calcium channel blockers

Mechanism of action: Block calcium channels in vascular smooth muscle. Dilate coronary arteries and increase myocardial blood flow. Dilate peripheral arteries and reduce afterload. Examples: Dihydropyridines (nifedipine), verapamil, diltiazem Dihydropyridines have greater specificity for relaxing vascular smooth muscle Verapmail and diltiazem have greater effects on cardiac pacemaker tissues Major adverse effects include headache, hypotension, reflex tachycardia; risk of heart block of cardiac failure particularly with verapamil or diltiazem Also used for hypertension and arrhythmia

Afterload :The force that the contracting heart must generate to eject blood. Affected by peripheral vascular resistance and arterial pressure.

Treatment of myocardial ischemia: Pharmacologic treatment Aspirin

Prevent platelet aggregation. Use for prophylaxis of blood clots particularly in unstable angina.

Treatment of myocardial ischemia: Surgical treatment

Coronary angioplasty
Uses a balloon catheter to open occluded blood vessels Usually performed under local anesthetic 5% mortality, high rate of vessel re-occlusion Use of metal stents in opened vessel reduces rate of occlusion

Coronary artery bypass graft

Revascularization procedure in which a blood vessel is taken from elsewhere in the body and surgically sutured around a blocked coronary artery May involve multiple (one to five) blood vessels Re-occlusion of transplanted vessel is possible

Safe And Fit

Lives Long