Lecture 3: Cardiac Pathology & Pharmacology Flashcards
Fatty deposits (plaque) accumulate inside the artery wall: called what?
Atherosclerosis
Where does arthosclerosis start?
Tunica intima
Which layer of arteries is responsible for inflammatory responses?
Tunica Intima
You get plaque buildup which causes a tear in the tunica intima and causes an inflammatory response
What is an ischemia?
Reduction of blood flow (not complete blockage)
What diliniates myocardial infarction and ischemia?
Ishcemia is a partal blackage while infarction is complete
KNOW: Atherosclerosis causes progressive hardening and narrowing of the coronary, cerebral, and peripheral arteries
* **Its very systemic
* If you have cornary artery disease or likely have cerebral / peripheral artery disease as well (because its a systemic disease) **
KNOW: Atherosis (paste) = the fatty streak
* Consists of lipid-laden macrophages (foam cells) and smooth muscle cells
Sclerosis definition
Hardening
Does atherosclerosis indecrease or decrease blood vessel compliance?
Decreases
KNOW: Progressive hardening / narrow in atherosclerosis comes from that inflammatory response. You have those fibroblasts that are in the tunica intimia, and in order to repair itself it keeps lying down more collagen, which leads to the hardening, essentially forming a fibris cap of thrombi over advanced plaqyes that have developed on the endothelial lining
The thrombus can block the entire artery or break of
7 Recommendations for reducing the risk of coronary artery disease and cardiovasclar disease
1) Avoid cigarette smoking
2) Engage in appropriate PA
3) Maintain ideal body wt
4) Eat a healthy diet
5) Manage BP
6) Manage cholesterol
7) Manage fasting blood glucose
KNOW: Emerging risk factors for cardiovascular disease:
1) Lipid-releated biomarkers; lipoprotein(a) and high lopoprotein-associated phospholipase A2
2) Inflammatory markers; interleukin-6, C-reactive protein, and others
3) kidney related biomarkers; microalbuminuria
4) Air pollution
5) Mediastinal radiation (think cancer radiation)
6) Human immunodeficiency viral infection (HIV) - causes increase radiation
7) Elevated homocysteine levels
8) Abdominal sleep (increased infllamation)
I think really anything that causes increase inflammatory response
Atherosclerosis typically persents in one of four ways
1) Sudden cardiac death (typically from ventricular tachycardia –> ventricular fibriliation –> quivering of ventricle and not pumping enough blood out into body)
2) Chronic stable agina
3) Acute cornary syndrome (ACS)
* unstable angina
* ST-segment elevation myocardial infarction (STEMI)
* Non-STEMI
4) Cardiac muscle dysfunction
What is angina
Not enough blood to supply metabolic demands
Substernal pressure anywhere from epigastric area to jaw
Squeezing tightness or crushing
Imbalance in supply and demand of myocardial O2
How are angina symptoms controlled? (2)
Reducing the intensity of EX and taking sublingual nitroglycerin
angina that has a well established onset (I get over this HR and it starts) is called
Chronic stable angina
What is the most common syptom of acute coronary syndrome?
Chest discomfort for greater than 20 minutes
NOTE: its basically chest pain (kind of an umbrella term for lots of things)
Whats dangerous stable or unstable angina
unstable
Patient starts to have new chest pain 30 seconds into working out. What is this?
unstable angina
KNOW: Acute myocardial infarction can be STEMI or non STEMI
transient ischemic attack = stroke
aneurysm = outpocket of wall
KNOW: Coronary Artery disease = when atherosclerosis hits coronary arteries
Order of anginia that occurs w/ coronary artery disease
Unstable anginia –> resting anginia –> new onset anginia
Coronary Artery Disease causes elevation of what thing?
Troponin 1
What is peripheral vascular disease?
Atherosclerosis of arteries AND veins
issue to getting blood there
Where is PVD most common?
Extremities (legs mostly)
Why is someone w/ cornoary artery disease likely to also have peripheral vascular disease (PVD)
Because atherosclerosis (which causes both) is typially systemic
Arterial Occlusive Disease = Peripheral vascular disease
What is arteriosclerosis?
Atherosclerosis of arterioles
What do symptomes of acute coronary syndrome signify?
Acute mycardial infarction, as a result of insufficient supply to cardiac muscle
symptoms indicate whats coming
What is angina pectoris?
Chest pain
Is Angina Pectoris a symptom or a disaese? (Test)
Angina Pectoris is a symptom not a disease
What kind of ischemia is angina?
Transient ischemia of cardiac m
Its ischemia that omes and goes
Does angina cause damage to cardiac muscle
No
KNOW: Angina can be one of the first warning signs that there is a cardiac issue
4 causes of angina Test
1) Demand of myocardium > blood supply = ischemia (not enough blood flow) –> happens w/ EX because you need more blood supply to the heart
* With angina, the vessels narrow, meaning you have an increased demand on that tiny space it can get through but a decreased supply
2) Increase O2 needs to myocardium
3) Decreased blood flow to heart
4) Increased CO
Anginia equivalents (things that arent chest pain but indicate a coronary issue) TEST
1) Shortness of breath
2) Nausea
3) Fatigue
4) Diaphoresis - excessive sweating
5) Pain other htan chest
EX: someone exercising and sweating perfusly for the amount of EX they’re doing. Well that could indicate an angina equivalents, especially if that have any kind of cardiovascular issues in the past.
Exertional angina is also known as
Stable angina (comes on w/ EX)
TEST What do you do for someone with exertional (stable) angina that it comes on when they start exercising.
Record symptoms/vital and continue on w/ EX (maybe at a lower intensity)
TEST Do you continue EX w/ unstable angina?
Stop EX immediately.
NOTE: It could turn into stable angina, or it could lead to a myocardial infarction, we just dont know at this point. Needs to be tracked before we feel comfortable continuing EX.
TEST The question is essentially going to be diliniating between stable vs unstable angina, then your course of action.
Most common cause of angina?
What often triggers it?
Coronary artery disease (when artherosclerosis hits the coronary arteries)
Often triggered by EX or any kind of exertion because, exertion causes increased blood supply through a decreased area.
Remember, angina is just chest pain. However, it is typically caused by atherosclerosis. Name the different causes of angina
* How it happens w/ vessels
* How it happens w/ circulation
* How it happens w/ blood factors
Vessels: Atherosclerosis, hypertension, cardiomyopathy, CAD
Circulation: Arrhythmias, coronary spasms, aortic stenosis, hypotension, bleeding (trauma)
Blood factors: Anemia, hypoxia, polycythemia (wasnt really covered)
TEST a pt w/ chest pain doesnt always have angina. Know the differential diagnosis charts and be able to dilinate them out.
Probs focus mostly on s/s
pleural rub = sound w/ stethascope
RR = respiratory rate
TEST Reasons to stop or modify EX: - With CV Hx or angina
1) New onset of easily provoked chest pain (unstable angina)
2) Increasing episodes/intensity /duration of angina (unstable angina)
3) Discomfort elsewhere in the upper body
4) Syncope, dizziness, light-headedness
5) Severe sydden dyspnea (difficult breathing)
6) Severe fatigue or muscle pain
7) Nausea or vomiting
8) Back pain during exercise - further investigate if they’ve had cardiac risk factors that could be leading to this
9) Bone/joint pain or discomfort during or after EX
10)
TEST Symptoms of angina (15)
1) Temporary squeezing
2) Burning
3) Pressure
4) Heartburn
5) Indigestion
6) Chocking
7) Pallor (think turning blue_
8) Cyanosis
9) Cold
10) Moist skin
11) >6 arrhythmias (palpations or irregular beats) per hour
12) Oxygen saturation <90%
13) Resting HR 130 beats/mm (because heart rate trying to get CO back up)
14) Fall in systolic BP with increase workload (10 mmHg or more)
15) Rise in systolic BP > 250 mmHg or diastolic > 115 mmHg
** If you have any of the above + angina, discontinue exercise**
Angina scale
Will ECG be normal or abnormal with angina?
Normal, angina isnt affecting the electrical part unless its actually stopping the heart
For documentation what is our mnuemonic / fill in
OLDCART
* Onset
* Location
* Duration
* Charactersitics
* Accompanying symptoms
* Radiation
* Treatment
Drugs used to treat angina pectoris (4)
- Organic Nitrates = first line of defense
- Beta-Adrenergic Blockers
- Calcium Channel Blockers
- Anticoagulants
typically prescribed when you have something else + angina, however, you typically have angina + another pathology going on thats leading to angina
* Remember, angina is a symptom, not a pathology
What is the MOA for Organic Nitrates?
Dilate peripheral blood vessels, decreasing peripheral resistance so the afterload is decreased, making it easier for the heart to pump into the systemic vascular supply
How are organic nitrates typically administered and how long does it take to see affects?
Adminustred sublingally
Therapeutic effects within 2 minutes
What effect does the sublingual adminstration of organic nitrates spare the patient?
First pass effect
when taken orally it goes through GI system and into liver which breaks down medication
Sublingually, it just disolves and goes right into blood system, which is why its much faster than taking orally
Adverse effects and why nitro
Primary: HA, dizziness, orthostatic hypotension
* This is because the blood vessels are dilated, so, HA because increased BF, and dizziness / hypotension because blood pressure cannot be maintained w/ diliated vessels
Nausea is another possible side effect
NOTE: Transdermal is another possible application (patch on skin), however, isnt recommend because they can build a tolerance
* This is typically for people who need it all the time
Why would you want to sit a patient down before adminsitration of organic nitrates?
Because vasodilation causes hypotension, which can lead to them falling and causing some injury
TEST Sublingual organic Nitrates should be kept how
* Discard after how long?
* how many till you call 911
In OG bottle
* ROOM temp, no direct light
* Discard after 3 months
should be in original glass bottle, O2 starts breaking it down along w/ sunlight
Super important to discard after 3 months because if they have angina they need this medication to work
If they have adminstered 3 than call 911
What do Beta blockers do?
* How do they work?
Block beta-1 receports on the myocardium (act as antagonists)
Block HR and force on contractions, which decreases the workload of the heart and demand of O2
Beta blockers suffix
olol
What do selective beta blockers target?
What do non-selective beta receptors target?
Selective = Beta 1 receptors on the heart
* 1 heart –> targets the heart
Non-selective = block both beta 1 and beta 2 receptors
* 2 Lungs –> targets the lungs
TEST Patient taking non-selective betablockers is experienceing brochoconstriction, how can this be fixed?
Put them on selective beta blockers that only target the heart
go back to slide 35 and recap here
KNOW: If beta blockers are taken daily they will blunt HR/BP, so you can’t use BP/HR to see how they’re responding to EX. Going to have to use RPE scale (increased subjectivity)
Calcium channel blockers suffix
* 2 exceptions
End in Pine
Diltiazem
Verepamil