Cardiovascular Disorder (1)

8/4/2019 Cardiovascular Disorder (1)

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Cardiovascular Disorder (1)


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Outlines

ArteriosclerosisHypertension

SyncopeShockHeart Failure

Cor Pulmonale


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Arteriosclerosis; Atherosclerosis

Definition:Subintimal thickening of medium andlarge arteries

Pathology and pathogenesisfatty streak is evolved into fibrousplaque

fibrous plaque - smooth m. cells,connective tissues, intra and extra-cellular lipids


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Cardiovascular risk factorsRiskFactors of Atherosclerosis

A. modified:DyslipidemiasHypertensionDiabetes MellitusCigarette SmokingObesity (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


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B. unmodified:Age: >55 for men, >65 for womenMale gender

Increased risk in menIncreased risk in women aftermenopause

Family history of prematurecardiovascular diseaseMen


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Risk Factors of Atherosclerosis

Risk factors (emerging)HomocystinemiaClamydial pneumonia infection


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Atherosclerosis

Symptoms/ SignsPatients are asymptomatic untilcomplications developComplications: critical stenosis, thrombosis,aneurysm, embolism)

In brain: TIA, strokeIn heart: angina pectoris, M.I.In low extremities: intermittent claudication

DiagnosisObstruction can be confirmed by Dopplerultrasonography

Doppler ultrasonography : a tech which monitorsthe moving substance eg. flowing blood, beatingheart


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Atherosclerosis

Prevention: prevent risk factorsTreatment

directed at its complicationsshould be aggressive for patientswith established atherosclerosis


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*Treatment

Lifestyle changes (diet, smoking, physical activity)Diet:

Less saturated fatNo trans fatsMore fruits and vegetablesMore fiberModerate (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 factorsAntiplatelet drugsPossibly statins, ACE inhibitors, -blockers


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Hypertension


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*Hypertension-Epidemiology

In the US, about 65 million people havehypertension.Only about 70% of these people are

aware that they have hypertension, only59% 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%), andmorbidity and mortality are greater inblacks.


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Systemic Hypertension

DefinitionHypertension: chronic elevation of BP:> 140/90 mmHg(Isolated) Systolic Hypertension:

systolic BP> 160, diastolic BP< 90


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Classification Systolicpressure

Diastolicpressure

Normal


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Hypertension Physiology:

Physiologic determinants ofarterial pressure:( BP= CO x TPR)

cardiac output (C.O.)total peripheral resistance (TPR):viscosity, radius of artery, hemotocrit

arterial blood volumeelasticity of aorta (compliance)


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Hemodynamics of bloodpressure

Sympathetic hyperactivityesp. in youngTachycardia & increased CO

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


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Pathology

The target organs of hypertension:Heart:

LVH,CAD

Brain:cerebrovascular disease, hypertensiveencephalopathy

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

Kidney:renal arteriosclerosis, renal function impairment


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*Etiology & ClassificationPrimary Hypertension (EssentialHypertension):

85 to 95% of cases Unknown etiology*Between ages 25-55 yearsHeredity is a predisposing factor

Environmental factors (eg, dietary Na,

obesity, stress) seem to affect onlygenetically susceptible people.

Multiple factors are probably involvedin sustaining elevated BP


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Secondary HypertensionRenal Artery StenosisCoarctation of AortaPheochromocytoma: catecholamine-producing tumorHyperaldosteronism: tumor or

hyperplasia in zona glomerulosaOther Causes: oral contraceptiveusage, Cushings syndrome


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Coarctation of Aorta

Aortic coarctation causes low bloodpressure and low blood flow in thearteries that branch off below the

narrow spot; high blood pressure occurs in the arteries that branch offcloser to the heart. As a result, aorticcoarctation often leads to high bloodpressure in the upper body and arms(or one arm) and low blood pressurein the lower body and legs.
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Symptoms/ Signs

Primary hypertension:Asymptomatic until complications intarget organs

Severe hypertensionDizziness, flushed face, headache,fatigue, nervousness, blurred vision

A h h i i h


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Approach to the patient withhypertension

HistoryPhysical Examination: leg & armBPLaboratory work-up:

BUN, Cr, CXR, renin, aldosterone

Primary hypertension: repeatedlyelevated BPExclude secondary hypertension


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Treatment-Lifestyle modification


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Treatment-Drugs

Antihypertensive drug therapy:systolic BP remains > 140 mm Hgor diastolic BP remains > 90 mmHg after 6 mo of lifestylemodifications, antihypertensivedrugs are required.

See attachment


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*Malignant hypertension

Severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys).Diastolic pressure>120mm-HgAssociated with encephalopathy or nephropathy withpapilledemaClinical 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 severeazotemia due to advanced renal failure may producelethargy or nausea.


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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.


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Diastolic pressure>120mm-HgAssociated with encephalopathy ornephropathy with papilledema

Clinical manifestationsEncephalopathy:headache, seizure,

Retinopathyvisual disturbance

Deteriorating renal functionCardiac decomposition:

CHF, angina


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Syncope (Fainting)

Definition:transient loss of consciousness dueto reduced cerebral blood flow


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Causes of SyncopeI. Disorders of vascular tone orblood volume

1.Vasovagal (vasodepressor)syncope

Excessive vagal tonePrecipitated by unpleasant physical oremotional stimuliPreceded by vagal activity: nausea,yawning, visual blurring, weakness,sweatingOccur in upright; e.g. fainting to needling


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I. Disorders of vascular tone orblood volume (cont.)

2.Postural (orthostatic) hypotensionCaused by hypovolemic or venous poolingOccurs while standing up suddenly

E.g. UGI bleeding, ectopic pregnancy rupture

E.g. after prolonged bed rest or severe varicosevein

E.g. standing without moving in healthy person

3.Carotid sinus hypersensitivityRubbing carotid sinus, causing elevated BP incarotid sinus, resulting in reduced HR & slow AVconduction


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Approach to the patient withsyncope

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

Laboratory findings:blood sugar, ECG, echocardiogram,hematocrit


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Treatment

Postural hypotension & vasovagalsyncope: horizontal postureTreat underlying causes:

Vasovagal syncope: avoid situationOrthostatic hypotension: rise slowlyVolume depletion:Bradyarrhythmia: pacemaker


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Prognosis

Depends on causes


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ShockDefinition:a state of inadequate blood flow orperfusion of peripheral tissues tosustain life

Resulting from:Inadequate C.O. or misdistribution ofperipheral blood flow , associatedwith hypotension and oliguria


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Classification of shockHypovolemic shock:

HemorrhageVolume depletionInternal sequestration: the blood fromsystemic circulation to a non-functional area

Cardiogenic shock:

MyopathicArrhythmic


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Classification of shock (cont.)

Extracardiac obstructive shock:Pericardial tamponadeTension pneumothorax

Vasodilatory shock: relativelyinadequate intravascular volume(vasodilation)

SepsisAnaphylaxis ( systemic vasodilatation)


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Symptoms/ Signs of Shock

Mentation:letharge, confusion, somnolence

Hands & feet: cold, moist, cyanotic, pale

Pulse: weak, rapid ( unless terminalbradycardia)Breathing: tachypnea, hyperventilation( apnea in terminal )B.P.:


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Hyperdynamic syndrome

A cluster of S/S which signals theonset of septic shock ( early stageof septic shock)Characterized by shaking chills,rapid rise in temperature, flushingof skin, gallop pulse, alternatingrise & fall B.P.


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Treatment of ShockFirst Aid:

Keep warm, leg raisedStop hemorrhage

Supportive treatmentDopamine or norepinephrine

O2Carefully monitorTreat underlying causes:

Hypovolemic shock: restore intravascular

volumeVasodilatory shock: fluid resuscitation withnormal saline, vasopressor drugs,antibioticsCardiogenic shock: improving cardiacperformance


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Prognosis of Shock

Depending on the causeUntreated shock: fatalCardiogenic shock due to M.I.,septic shock: high mortality


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The Heart

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Congestive Heart Failure

Definition:a condition that the heart is unable to pumpsufficient blood for metabolizing tissues

The heart is unable to perform its functionPhysiology

Preload: end-diastolic volume ( venous return)Afterload: the load to resist ventricularcontraction

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Heart Failure-Prevalence

Both the incidence and prevalence of heartfailure increase with the ageIncidence:

Over 65 years, incidence is 11/1,000 men peryear and 5/1,000 women per year

Prevalence:Over 65 years, prevalence is 40/1,000 men and30/1,000 women

( Cowie MR et al. The epidemioology of heart failure. Eur Heart J 1997;18:208-225)

Classification and Etiology of


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Classification and Etiology ofCongestive Failure

Left ventricularfailure

Coronary arterydiseaseHypertensionCardiomyopathyCongenital heartdisease

Right ventricularfailure

Prior LV failure:pulmonary vein pr.,

pulmonary ahypertensionVolume overload: eg.over-transfusion,polycythemia

F i l Cl ifi i f H


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Functional Classification of HeartDisease

Class INo limitation of physical activity. Ordinary physicalactivity does not cause undue fatigue, dyspnea, oranginal pain

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

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

Class IVUnable to engage in any physical activity withoutdiscomfort. Symptoms may be present even at rest

New York Heart Association

S / Si


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Symptoms/ Signsof Congestive Heart Failure

LV failure:Fatigue on exertionDyspnea

Intolerance to coldPulmonary rales

RV failure:

Fullness in neck (jugular veindistention)Hepatomegaly,Peripheral edema


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Acute pulmonary edema

Life threateningAcute LV failure acute pulmonaryv. hypertensionS/S:

extreme dyspneadeep cyanosistachypnea


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Laboratory findings

EKG: LV hypertrophy, QRS wavedeeper & tallerCXR: cardiomegalyEchocardiography

T f C i H


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Treatment of Congestive HeartFailure

1.Decrease cardiac workload:decrease physical activity

2.Control excess fluid retention:Dietary Na restrictionDiuretics

Other medicationsVasodilatorsDigoxinACE inhibitors

Refractory HF: heart transplantation


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Symptom relief: diuretics, nitrates,digoxinLong-term management, improvedsurvival:

ACE inhibitors, -blockers, aldosteronereceptor blockers, angiotensin II receptor

blockers (ARBs)


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Cardiovascular Disorder (1)