PATH CH9 CARDIOVASCULAR

Main Ideas

100

Describe the anatomy and flow of blood through the 4 chambers of the heart.

Blood low in O2 flows >Sup/Inf vena cava> Right atrium>Tricuspid valve>Right ventricle>Pulmonary artery>Lungs>Blood rich in O2 flows >Pulmonary vein> left atrium>Bicuspid valve>   left ventricle> Aorta> Body

200

Common signs and symptoms of cardiac pathologies.

• Chest, neck, arm pain/discomfort

• Palpitations

• Dyspnea

• Cardiac syncope

• Vasovagal syncope

• Cough
• Cyanosis

300

Describe the effects of aging on the CV system

• Reduction in Function

  • Development of cardiac fibrosis

  • Reduction in calcium transport across membranes

  • Lower capillary density

  • Decreased adrenaline response

  • Impaired autonomic reflex control of heart rate (BP and HR control)

• Fit and healthy adults, the heart will:

  • Pump less blood to the skin

  • Work harder under the same circumstances

• Disease may have greater impact than CV function than aging

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  • Heart disease begins earlier than formerly expected

    • Early findings in adolescents of cholesterol deposits in vessels

• Cardiovascular disease

  • Most common cause of hospitalization and death in the older population

• Effects of aging have less relevance at rest but considerable consequences during cardiac events

400

List the common causes of angina pectoris

chest pain or discomfort occurring when heart muscle does not get enough oxygen

• Can start behind the sternum

• May be mistaken for indigestion

• Can feel tight and can radiate

500

Describe the types of angina pectoris

Stable angina

• Exertional - predictable levels of physical or emotional stress and responds promptly to rest or nitroglycerin

• No pain at rest

• Location, duration, intensity, and frequency of chest pain are consistent over time

    Unstable angina

• Preinfarction angina

• Unpredictable and not relieved by rest

    Post-infarction angina

• After MI when residual ischemia triggers an episode

600

Management of angina

• Short acting sublingual nitroglycerine

• Vasodilators: beta blockers

• Calcium channel blockers: limit heart rate and contraction of heart

700

List common gender differences in the CV system

Coronary Artery Disease: leading cause of death and a significant cause of morbidity among women in the US

• Women and minorities were underrepresented in studies conducted on heart disease

• In general, patients with smaller bodies and smaller arteries have a higher mortality rate after CABG

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  • Women may have CAD and microvessel disease - just opening the artery may not be sufficient

    Coronary microvascular dysfunction

• Tiny blood vessels to the heart become constricted - reducing blood flow

• “Stealth” heart disease

• May not show up on classic angiograms

• Classic signs of reduced blood flow may not be present    

800

Explain the condition of Ischemic heart disease

AKA: Coronary Artery Disease (CAD) - coronary arteries carry O2 blood to the myocardium; one of the arteries become narrowed or blocked, areas of the heart muscle supplied by that artery do not receive sufficient O2 and become ischemic/injured = infarction may result

    Modifiable Risk Factors

• Cigarette smoke (leading cause)

• Tobacco products (increase HR and BP)

• Elevated cholesterol levels

• Hypertension

• Obesity (heart has to work harder)

• Physical inactivity

• Impaired glucose metabolism

• Psychological factors and emotional stress

• Moderate alcohol consumption

    Non-Modifiable Risk Factors

• Increasing age

• Gender

• Family history

• Ethnicity

• Social determinants of health

900

Medical Management of Ischemic heart disease

• Prevention is the ultimate goal

  • Begins slowly in adolescence and develops slowly

• Controlling cholesterol before atherosclerosis (thickening and hardening of arteries) has a chance to do damage

• Exercise and physical activity

  • Moderate intensity for 30 mins on most days of the week

  • Independent of weight loss - significant beneficial effects on risk factors

  • One intervention with the ability to influence the greatest number of risk factors

    Surgery

• Angioplasty: open an occluded artery without opening the chest using inflated balloon

• CABG: taking a portion of a vessel from the chest or leg and grafting it on the coronary artery

• Coronary stents: stent in place to maintain an open vessel

1000

Explain the pathophysiology and treatment of hypertension (HTN)

• BP is the force exerted against the wall of the arteries

  • Systolic pressure: when heart contracts

  • Diastolic pressure: when heart is relaxed

    • Normal:  <120 and <80

    • Elevated:  120-129 and <80

    • High: 130-139 or 80-89

    • High stage 1: >140 or >90

    • Crisis: >180 and/or >120

• BP regulated by 2 factors

  • Blood flow (determined by cardiac output) and peripheral vascular resistance (diameter of vessels)

• Prolonged HTN - elastic tissue is replaced by fibrous tissue; thickened artery wall has greater resistance to flow of blood

• Prevention

  • Annual BP check

  • Physical activity/exercise

  • Weight control

  • Limitations on salt and alcohol intake

1100

Explain what occurs in a myocardial infarction

• Myocardium receives blood from 2 large coronary arteries and their branches

  • 1 or more of these vessels may become occluded

  • Most common site = left ventricle (chamber of the heart with the greatest workload)

    • Common cause: clot of the anterior descending branch of the left coronary artery

• Zone of infarction: cells die where they have been deprived of O2

• Zone of injury: area surrounding infarction, less damage, may return to normal

• Caused by ischemic and injured myocardial tissues

1200

Clinical manifestations of a myocardial infarction (MI)

• Sudden sensation of pressure (crushing chest pain - can radiate to the arm, throat, neck and back)

• Pallor

• SOB

• Profuse perspiration

• Mid-thoracic pain

• Abdominal pain and nausea

• In women:

  • Chronic unexplained fatigue

  • SOB - sometimes in the middle of the night

1300

Explain the symptoms of congestive heart failure (CHF)

CHF Compensatory mechanisms

First: failing heart attempts to maintain normal output of blood by enlarging to hold a greater volume of blood

• Short term improvement

• Contractility muscle decreases

    Second: Nervous system increases the stimulation of cardiac muscle

• Increase in pumping, mass, strength

• Hypertrophy leads to increased need for O2

    Third: Kidney compensation

• Water retention = increase blood volume, exacerbates edema

• Expanded blood volume increases the load on an already compromised heart

Compensated CHF: combined efforts of the 3 mechanisms achieve a normal level of cardiac output

Decompensated CHF: mechanisms are no longer effective and the disease progresses to the final stages of impaired heart function

• Can range from mild to life-threatening fluid overload

• Symptoms usually develop gradually so many people do not recognize or report the symptoms

1400

Medical management and exercise conditions of CHF

Medical management

• Diet and exercise

• Sodium restricted diet

• Limited fluid intake

• Pharmacotherapy:

• 
  

  • Reduce hearts workload

  • Increase muscle strength and contraction

  • Decrease kidney compensation response

• Medications

• 
  

  • ACE inhibitors: increase renal blood flow and decrease vascular resistance - enhance diuresis

  • Diuretics: control fluid buildup

  • B-blockers: act on cardiac tissue to reduce contraction and rate

Exercise considerations

• Monitor vital signs before, during, and after exercise

• Monitor for decreasing BP

• Monitor for dyspnea - aerobic capacity is likely impaired

• Low RPE - light to somewhat hard

• Exertional dyspnea - should not exceed a rating of mild

• American College of Sports Medicine

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  • Moderate intensity

  • 40-60% VO2 max

  • 2-6 minute bouts

  • 2 mins of rest

  • Gradually increase intensity and duration

  • Individual goals and expected outcomes in mind

  • Avoid exercise taking vasodilator medication

1500

Explain the electroconductive pathway through the heart and how an arrhythmia occurs

Electroconductive pathway:

• HR and rhythm is regulated by the SA node

• Signal travels through the conduction system

  • Through walls of atria

  • Down to AV node

  • Walls of ventricles

Main Ideas

100

How to treat rhythmic arrhythmia 

• Treatments

  • Cardioversion: normal rhythm returns spontaneously (AF)

  • Defibrillator: electrical method (VF)

  • Pacemaker: implants designed to replace the heartbeat (heart block)

200

Explain how DVT and pulmonary embolism is formed

Formation: DVT typically occurs when a blood clot forms in a deep vein, often in the legs. These veins are responsible for returning deoxygenated blood back to the heart.

300

Medical management of a DVT 

• Primary prevention

  • Early mobilization

  • Prophylactic use of anticoagulants

  • Elastic stockings

  • Pneumatic pressure devices (mimic calf pump)

• Ambulation after adequate anticoagulation therapy has been administered if symptoms and condition permit

400

Describe how orthostatic hypotension occurs

Orthostatic hypotension: significant drop in blood pressure when standing from sitting or laying down

• Normal response - standing results in force of gravity causing venous pooling lower limbs

  • Compensatory mechanisms: increased HR, increased vascular resistance

• Orthostatic hypotension - the body cannot compensate, loss of cerebral blood flow which may result in fainting

• During supine → standing transition

  • Drop of >20 mmHg in systolic BP

  • Drop of >10 mmHg in diastolic BP

  • May see HR increase as well

• Causes

  • Aging

    • Postural reflexes are slowed

    • Cardiac output decreases

  • Vasoactive HTN drugs

500

Describe the different types of aortic aneurysms and where they occur

Aneurysms: abnormal stretching in the wall of vessel or chamber

• Types:

  • Thoracic aortic aneurysm - above the diaphragm

  • Abdominal aortic aneurysm - below the diaphragm

• May be asymptomatic initially then results in:

• 
  

  • Persistent vague, substernal, back and neck pain

• Rupture - tearing of the vessel walls with bleeding into the thoracic or abdominal cavity

• May be identified by palpation of imaging

• Medical screening questions are critical

600

BP regulated by 2 factors

Blood flow (determined by cardiac output) and peripheral vascular resistance (diameter of vessels)

700

• _____ pressure: when heart contracts

• _____ pressure: when heart is relaxed 

Systolic

Diastolic

800

What is the most common site of a Myocardial infarction and why?

Most common site = left ventricle (chamber of the heart with the greatest workload)

900

Compensated CHF: combined efforts of the 3 mechanisms achieve a normal level of cardiac output

First: failing heart attempts to maintain normal output of blood by enlarging to hold a greater volume of blood

• Short term improvement

• Contractility muscle decreases

Second: Nervous system increases the stimulation of cardiac muscle

• Increase in pumping, mass, strength

• Hypertrophy leads to increased need for O2

Third: Kidney compensation

• Water retention = increase blood volume, exacerbates edema

• Expanded blood volume increases the load on an already compromised heart

Definitions

100

Causes of cardiac related chest pain

Ischemia, MI, pericarditis, endocarditis, aortic dissection

200

• Irregular, fast or ‘extra’ heart beat

• Occur with arrhythmias/dysrhythmias

• Associated symptoms

• Light-headedness, syncope

• Can be benign

• Caffeine, anxiety, exercise

• Severe condition

• CAD, cardiomyopathy, complete heart block, ventricular aneurysm

Palpitations

300

• Shortness of breath (SOB)

• Can be cardiovascular, pulmonary, or due to trauma, fever, medications, or obesity

• Dyspnea on exertion (DOE): dyspnea with mild exertion

• Orthopnea - breathlessness which occurs with recumbency - relieved with sitting upright

• 
  

  • Can occur day or night

Dyspnea

400

• Fainting (mild form = light-headedness)

• Reduced O2 to the brain when the heart’s pumping ability is compromised

• Causes

• 
  

  • Arrhythmias, orthostatic hypotension, aortic dissection, CAD

Cardiac syncope

500

• Very strong parasympathetic response that leads to vasodilation throughout the body

  • As a response to emotional distress, heart rate slows and vessels dilate leading to hypotension and cerebral hypoperfusion = fainting

Vasovagal syncope

600

• Usually associated with pulmonary conditions

  • Can be pulmonary complication of a cardiovascular condition

  • Left ventricular dysfunction with resulting pulmonary edema presenting as cough with aggravated by exercise

  • Dry and hacking

  • Hemoptysis: productive, frothy, blood tinged sputum with pulmonary edema

Cough

700

• Bluish discoloration of the lips, nail beds, fingers, toes

  • Inadequate blood oxygen levels

• Cyanosis

800

• Hallmark of right ventricular failure

• Usually bilateral and dependent

  • Jugular venous distention

  • Abdominal distension - ascites

• Peripheral edema

900

• Cramping or leg pain

• Brought about by consistent amount of exercise or activity

  • Result of peripheral vascular disease

  • Most functionally debilitating of symptoms

• Claudication (leg pain)

1000

Chest pain or discomfort occurring when heart muscle does not get enough oxygen

Angina pectoris

1100

coronary arteries carry O2 blood to the myocardium; one of the arteries become narrowed or blocked, areas of the heart muscle supplied by that artery do not receive sufficient O2 and become ischemic/injured = infarction may result

Ischemic heart disease

AKA: Coronary Artery Disease (CAD)

1200

Persistent elevation of systolic BP >130mmHg, diastolic BP >80mmHg (or both) measured on 2 separate occasions

Hypertension

1300

• Development of ischemia with resultant necrosis of myocardial tissue

• Any prolonged obstruction depriving the heart muscle of O2 can cause MI

• Risk factors are same as CAD

• Occur more frequently in the early morning hours

Myocardial infarction (MI)

1400

 condition in which the blood is unable to pump sufficient blood to supply the body’s needs; caused by inadequate pump performance; backup of blood into the pulmonary veins = pulmonary congestion

• Left ventricular failure = CHF

• Right ventricular failure = cor pulmonale

• Common complication of ischemic and hypertensive heart disease

• CHF may develop after an MI

Congestive heart failure (CHF)

1500

When heart is extensively damaged, cardiac enlargement occurs, heart cannot completely eject blood from the left ventricle

Cardiomyopathy

Definitions

100

Disturbance of heart rate (normal 60-100 x/minute)

• Tachycardia - >100 bpm

  • Increased sympathetic stimulation

• Bradycardia - <60 bpm

  • Normal in well-trained athletes

Rate Arrhythmia

200

 variations from the normal rhythm

• Dangerous as they reduce cardiac output - perfusion of the brain and myocardium can be impaired

  • Ventricular fibrillation: non-coordinated muscular contractions of ventricular muscle

  • Heart block: irregular rate caused by an interruption in the passage of impulses through the heart’s electrical system; treated with medication and pacemakers

  • Atrial fibrillation: blood remains in the atria after they contract and ventricles do not fill properly; prone to blood clots

Rhythmic Arrhythmia

300

partial or complete occlusion of a vein by a thrombus (clot)

• Inflammatory reaction in the wall of the vein

• Common complication after surgical procedures or CVA

• Clinical manifestation of DVT may take up to 4 weeks

  • May be asymptomatic; dull ache, tight feeling, pain in calf

Venous thrombosis

400

embolus has traveled via the venous system into the heart then travels into a pulmonary artery and occludes it

Pulmonary embolism 

500

intermittent episodes of small artery constriction to the extremities

• Causes temporary pallor and cyanosis of the digits and changes in skin temperature

  • Cold temperature

  • Strong emotion

Raynaud’s disease

600

Narrowing that prevents the valve from opening fully; chamber behind the narrow valve must work harder

Stenosis

700

Regurgitation; valve does not close properly

Valve insufficiency

800

A significant drop in blood pressure when standing from sitting or laying down

Orthostatic hypotension

900

• open an occluded artery without opening the chest using inflated balloon

Angioplasty

1000

 taking a portion of a vessel from the chest or leg and grafting it on the coronary artery

CABG

1100

• ______ - >100 bpm

  • Increased sympathetic stimulation

• ______ - <60 bpm

  • Normal in well-trained athletes

Tachycardia

Bradycardia