Cardiovascular Disorder (1)

Outlines
Arteriosclerosis Hypertension Syncope Shock Heart Failure Cor Pulmonale

Arteriosclerosis; Atherosclerosis
Definition:
Subintimal thickening of medium and large arteries

Pathology and pathogenesis

fatty streak is evolved into fibrous plaque fibrous plaque- smooth m. cells, connective tissues, intra and extracellular lipids

Cardiovascular risk factorsRisk Factors of Atherosclerosis

A. modified:
Dyslipidemias Hypertension Diabetes Mellitus Cigarette Smoking Obesity (BMI>30) Physical inactivity
Chobanian AV et al. The 7th Report of the Joint National Committee on Prevention, Detection, Evaluaation, and Treatment of High Blood Pressure. JAMA 2003:289:2560

B. unmodified:
Age: >55 for men, >65 for women Male gender
Increased risk in men Increased risk in women after menopause

Family history of premature cardiovascular disease

Men<55 or women <65

Risk Factors of Atherosclerosis

Risk factors (emerging)
Homocystinemia Clamydial pneumonia infection

Atherosclerosis
Symptoms/ Signs
Patients are asymptomatic until complications develop Complications: critical stenosis, thrombosis, aneurysm, embolism)
In brain: TIA, stroke In heart: angina pectoris, M.I. In low extremities: intermittent claudication

Diagnosis
Obstruction can be confirmed by Doppler ultrasonography
Doppler ultrasonography : a tech which monitors the moving substance eg. flowing blood, beating heart

Atherosclerosis
Prevention: prevent risk factors Treatment
directed at its complications should be aggressive for patients with established atherosclerosis

*Treatment
Lifestyle changes (diet, smoking, physical activity)
Diet:
Less saturated fat No trans fats More fruits and vegetables More fiber Moderate (if any) alcohol

Regular physical activity (eg, 30 to 45 min of walking, running, swimming, or cycling 3 to 5 times/wk)

Drug treatment of diagnosed risk factors Antiplatelet drugs Possibly statins, ACE inhibitors, -blockers

Hypertension

*Hypertension-Epidemiology
In the US, about 65 million people have hypertension. Only about 70% of these people are aware that they have hypertension, only 59% are being treated, and only 34% have adequately controlled BP. In adults, hypertension occurs more often in blacks (32%) than in whites (23%) or Mexican Americans (23%), and morbidity and mortality are greater in blacks.

Systemic Hypertension
Definition
Hypertension: chronic elevation of BP: > 140/90 mmHg (Isolated) Systolic Hypertension:
systolic BP> 160, diastolic BP< 90

Classification Systolic pressure Normal <120

Diastolic pressure <80

Pre<140 hypertension

<90

Stage 1

<160

<100

Stage 2

>160

>100

Chobanian AV et al. The 7th Report of the Joint National Committee on Prevention, Detection, Evaluaation, and Treatment of High Blood Pressure. JAMA 2003:289:2560

Hypertension Physiology:
Physiologic determinants of arterial pressure: ( BP= CO x TPR)
cardiac output (C.O.) total peripheral resistance (TPR): viscosity, radius of artery, hemotocrit arterial blood volume elasticity of aorta (compliance)

Hemodynamics of blood pressure

Sympathetic hyperactivity
esp. in young Tachycardia & increased CO

Renin- Angiotensin-Aldosterone system (RAS system) PG I2( prostaglandin) & TX A2 ( thromboxan): vasodilatation & vasoconstriction

Pathology
The target organs of hypertension:
Heart:
LVH,CAD

Brain:
cerebrovascular disease, hypertensive encephalopathy

Eye (retina):
arteriosclerosis, exudates, hemorrhage, papilladema

Kidney:
renal arteriosclerosis, renal function impairment

*Etiology & Classification

Primary Hypertension (Essential Hypertension):
85 to 95% of cases Unknown etiology *Between ages 25-55 years Heredity is a predisposing factor
Environmental factors (eg, dietary Na, obesity, stress) seem to affect only genetically susceptible people.

Multiple factors are probably involved in sustaining elevated BP

Secondary Hypertension
Renal Artery Stenosis Coarctation of Aorta Pheochromocytoma: catecholamineproducing tumor Hyperaldosteronism: tumor or hyperplasia in zona glomerulosa Other Causes: oral contraceptive usage, Cushings syndrome

Coarctation of Aorta
Aortic coarctation causes low blood pressure and low blood flow in the arteries that branch off below the narrow spot; high blood pressure occurs in the arteries that branch off closer to the heart. As a result, aortic coarctation often leads to high blood pressure in the upper body and arms (or one arm) and low blood pressure in the lower body and legs.

Symptoms/ Signs
Primary hypertension:
Asymptomatic until complications in target organs

Severe hypertension
Dizziness, flushed face, headache, fatigue, nervousness, blurred vision

Approach to the patient with hypertension

History Physical Examination: leg & arm BP Laboratory work-up:
BUN, Cr, CXR, renin, aldosterone

Primary hypertension: repeatedly elevated BP Exclude secondary hypertension

Treatment-Lifestyle modification

*Life-style modification
regular aerobic physical activity at least 30 min/day most days of the week weight loss to a body mass index of 18.5 to 24.9 smoking cessation a diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat content; dietary sodium [Na+] of < 2.4 g/day (< 6 g NaCl); and alcohol consumption of 1 oz/day in men and 0.5 oz/day in women. In stage 1 (mild) hypertension with no signs of target-organ damage, lifestyle changes may make drugs unnecessary.
(the National Heart Lung and Blood Institute's Dietary Approaches to Stop Hypertension)

Treatment-Drugs
Antihypertensive drug therapy: systolic BP remains > 140 mm Hg or diastolic BP remains > 90 mm Hg after 6 mo of lifestyle modifications, antihypertensive drugs are required.
See attachment

*Malignant hypertension
Severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys).
Diastolic pressure>120mm-Hg Associated with encephalopathy or nephropathy with papilledema Clinical manifestations
BP is elevated, often markedly (diastolic > 120 mm Hg). CNS symptoms include rapidly changing neurologic abnormalities (eg, confusion, transient cortical blindness, hemiparesis, hemisensory defects, seizures). Cardiovascular symptoms include chest pain and dyspnea. Renal involvement may be asymptomatic, although severe azotemia due to advanced renal failure may produce lethargy or nausea.

*Malignant hypertension
Diagnosis is by BP measurement, ECG, urinalysis, and serum BUN and creatinine measurements. Treatment is immediate BP reduction with IV drugs (eg, nitroprusside, blockers, hydralazine). Hypertensive emergencies, requiring aggressive and immediate treatment.
Damage is rapidly progressive and often fatal.

*Malignant hypertension
Diastolic pressure>120mm-Hg Associated with encephalopathy or nephropathy with papilledema Clinical manifestations
Encephalopathy:
headache, seizure,

Retinopathy
visual disturbance

Deteriorating renal function Cardiac decomposition:

CHF, angina

Syncope (Fainting)
Definition:
transient loss of consciousness due to reduced cerebral blood flow

Causes of Syncope
I. Disorders of vascular tone or blood volume
1.Vasovagal (vasodepressor) syncope
Excessive vagal tone Precipitated by unpleasant physical or emotional stimuli Preceded by vagal activity: nausea, yawning, visual blurring, weakness, sweating Occur in upright; e.g. fainting to needling

I. Disorders of vascular tone or blood volume (cont.)

2.Postural (orthostatic) hypotension
Caused by hypovolemic or venous pooling Occurs while standing up suddenly
E.g. UGI bleeding, ectopic pregnancy rupture E.g. after prolonged bed rest or severe varicose vein E.g. standing without moving in healthy person

3.Carotid sinus hypersensitivity

Rubbing carotid sinus, causing elevated BP in carotid sinus, resulting in reduced HR & slow AV conduction

Causes of Syncope
II. Cardiovascular disorders
1.Cardiac arrhythmias
Bradyarrhythmias : digitalis, beta-blocker Tachyarrhythmias

2. Other cardiopulmonary etiologies: myocardial infarction

III. Cerebrovascular disease

Vertebrobasilar insufficiency

IV. Other disorders that resemble syncope:

1.Metablic: hypoglycemia, DM with peripheral neuropathy 2.Psychogenic: hyperventilation syndrome
CO2 decrease, vasoconstriction, blood flow decrease

3.Seizures

Approach to the patient with syncope

History:
the position of patient at time of syncope, in particular situation

Laboratory findings:
blood sugar, ECG, echocardiogram, hematocrit

Treatment
Postural hypotension & vasovagal syncope: horizontal posture Treat underlying causes:
Vasovagal syncope: avoid situation Orthostatic hypotension: rise slowly Volume depletion: Bradyarrhythmia: pacemaker

Prognosis
Depends on causes

Shock
Definition: a state of inadequate blood flow or perfusion of peripheral tissues to sustain life Resulting from:
Inadequate C.O. or misdistribution of peripheral blood flow , associated with hypotension and oliguria

Classification of shock
Hypovolemic shock:
Hemorrhage Volume depletion Internal sequestration: the blood from systemic circulation to a nonfunctional area

Cardiogenic shock:
Myopathic Arrhythmic

Classification of shock (cont.)

Extracardiac obstructive shock:
Pericardial tamponade Tension pneumothorax

Vasodilatory shock: relatively inadequate intravascular volume (vasodilation)

Sepsis Anaphylaxis ( systemic vasodilatation)

Symptoms/ Signs of Shock

Mentation:
letharge, confusion, somnolence

Hands & feet: cold, moist, cyanotic, pale Pulse: weak, rapid ( unless terminal bradycardia) Breathing: tachypnea, hyperventilation ( apnea in terminal ) B.P.: <90mmHg or unobtainable Urine output< 30ml/hr

Hyperdynamic syndrome
A cluster of S/S which signals the onset of septic shock ( early stage of septic shock) Characterized by shaking chills, rapid rise in temperature, flushing of skin, gallop pulse, alternating rise & fall B.P.

Treatment of Shock
First Aid:
Keep warm, leg raised Stop hemorrhage

Supportive treatment
Dopamine or norepinephrine O2

Carefully monitor Treat underlying causes:

Hypovolemic shock: restore intravascular volume Vasodilatory shock: fluid resuscitation with normal saline, vasopressor drugs, antibiotics Cardiogenic shock: improving cardiac performance

Prognosis of Shock
Depending on the cause Untreated shock: fatal Cardiogenic shock due to M.I., septic shock: high mortality

The Heart
www.youtube.com/watch?v=D3ZDJg FDdk0&feature=related

Congestive Heart Failure

Definition: a condition that the heart is unable to pump sufficient blood for metabolizing tissues The heart is unable to perform its function Physiology
Preload: end-diastolic volume ( venous return) Afterload: the load to resist ventricular contraction

Heart FailurePrevalence
Both the incidence and prevalence of heart failure increase with the age Incidence:
Over 65 years, incidence is 11/1,000 men per year and 5/1,000 women per year

Prevalence:
Over 65 years, prevalence is 40/1,000 men and 30/1,000 women
( Cowie MR et al. The epidemioology of heart failure. Eur Heart J 1997;18:208-225)

Classification and Etiology of Congestive Failure

Left ventricular failure
Coronary artery disease Hypertension Cardiomyopathy Congenital heart disease

Right ventricular failure

Prior LV failure: pulmonary vein pr., pulmonary a hypertension Volume overload: eg. over-transfusion, polycythemia

Functional Classification of Heart Disease

Class I
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or anginal pain

Class II:
Slight limitation of physical activity. Ordinary physical activity results in symptoms

Class III
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms

Class IV
Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest
New York Heart Association

Symptoms/ Signs of Congestive Heart Failure

LV failure:
Fatigue on exertion Dyspnea Intolerance to cold Pulmonary rales

RV failure:
Fullness in neck (jugular vein distention) Hepatomegaly, Peripheral edema

Acute pulmonary edema

Life threatening Acute LV failure acute pulmonary v. hypertension S/S:
extreme dyspnea deep cyanosis tachypnea

Laboratory findings
EKG: LV hypertrophy, QRS wave deeper & taller CXR: cardiomegaly Echocardiography

Treatment of Congestive Heart Failure

1.Decrease cardiac workload:
decrease physical activity

2.Control excess fluid retention:

Dietary Na restriction Diuretics

Other medications
Vasodilators Digoxin ACE inhibitors

Refractory HF: heart transplantation

Symptom relief: diuretics, nitrates, digoxin Long-term management, improved survival:

ACE inhibitors, -blockers, aldosterone receptor blockers, angiotensin II receptor blockers (ARBs)