Systemic effects of cardiovascular disease Flashcards

1
Q

Learning objectives

A

Revise thrombosis
• Seeing Disease section 6 to revise thrombosis https://sway.office.com/kyen3WcSyrK6jWrb
Define cardiac failure
• Appreciate the differences between the following pairs of terms:
– acute and chronic cardiac failure;
– systolic and diastolic cardiac failure; – right and left ventricular failure
• Describe the causes of left and right ventricular failure
– Describe the clinical effects of left and right ventricular failure

• Distinguish between pulmonary and systemic hypertension
• Be aware of B-natriuretic peptide BNP
• Describe the causes of systemic hypertension
– Describe the end-organ effects of systemic hypertension
• Describe the causes of pulmonary hypertension
– Describe the end-organ effects of pulmonary hypertension

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2
Q

Define cardiac failure

A

• Failure of the heart to pump sufficient
blood, and deliver sufficient oxygen, to satisfy
metabolic demands
• Results in under-perfusion which may cause fluid retention and increased blood volume

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3
Q

Discuss acute and chronic cardiac failure

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• Acute heart failure
– rapid onset of symptoms, often with definable cause e.g. myocardial infarction
• Chronic heart failure
– slow onset of symptoms, associated with, for
example, ischaemic or valvular heart disease
• Acute-on-chronic heart failure
– chronic failure becomes decompensated by an acute event

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4
Q

Discuss systolic cardiac failure

A
Systolic failure
• Failure of the pump to move blood in systole
• Reduced ejection fraction
• Reduced ventricular contraction
Causes
• Myocardial ischaemia
• Myocardial infarction
• Myocardial scarring
• Myocarditis
• Drugs eg alcohol, anti-cancer cytotoxics, cocaine
• Muscular disorders eg DMD
Effects
• Reduced cardiac output
• Feedback to atria and right side of heart
• Pulmonary oedema then
• Peripheal oedema
Treatment
• Support - what else?
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5
Q

Discuss diasystolic cardiac failure

A
Diastolic failure
•Failure of ventricular wall to relax
•Restrictive, stiff ventricle
•Reduced ventricular filling leads to reduced blood for systole •Elevated end diastolic pressure
Causes
•Scarring plus most causes of systolic •Infiltrative disease eg amyloid
Effects
•None
•Pulmonary and peripheral oedema •Response to exercise
•Tachycardia and pulmonary acute oedema
Treatment
•Reduce AV conduction – what else?
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6
Q

Describe the causes of left and right ventricular failure

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• Coronary heart disease
• Hypertension
• Cardiomyopathies-Familial/genetic or non-familial/non-genetic (including acquired, e.g. Myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassified
• Drugs-beta-Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents
• Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic)
• Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma
• Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia
• Infiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue
disease
• Others Chagas’ disease, HIV infection, peripartum cardiomyopathy, end- stage renal failure

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7
Q

Discuss left ventricular failure

A
  • Particularly resulting from hypertensive and ischaemic heart failure
  • Causes pulmonary oedema, with associated
  • symptoms
  • Leads to pulmonary hypertension and, eventually, right ventricular failure
  • Combined left and right ventricular failure often called ‘congestive’ cardiac failure
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8
Q

Right ventricular

A
Common causes
• Secondary to left ventricular failure
• Related to intrinsic lung disease
• ‘Cor pulmonale’ due to pulmonary hypertension
• Primary pulmonary hypertension
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9
Q

scuss key features of the clinical examination inpatients with failure

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• Appearance -alertness, nutritional status, weight
• Pulse rate -rhythm, and character
• Blood pressure -systolic, diastolic, pulse
pressure
• Fluid overload -jugular venous pressure
• Peripheral oedema -(ankles and sacrum),
hepatomegaly, ascites
• Respiratory rate, crackles, effusion (transudate)
• Apex displacement, gallop rhythm, third heart sound, flow murmurs suggesting valvular dysfunction

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10
Q

Discuss clinical features of heart failure

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• “Forward” failure
– Reduced perfusion of tissues
– Tends to be more associated with advanced failure
• “Backward” failure
– Due to increased venous pressures
– Dominated by fluid retention and tissue congestion

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11
Q

Discuss B-natriuretic protein

A
  • BNP is one of of the natriuretic peptide hormone family, produced by ventricular muscle. It is a stress response protein that increases in heart failure.
  • ANP produced in atrial muscle
  • CNP from large blood vessels
  • DNP present in blood probably originates from heart
  • Vessel dilatation
  • Natriuresis
  • Modulation angiotensin and aldosterone
  • Reduction in blood pressure
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12
Q

Systemic hypertension

A

• Common

• Classification
– Primary vs secondary (based on cause)
– Essential vs accelerated (based on clinical presentation)
– (be aware of the previous use of the term “essential” hypertension)

• Definition
– Persistent raised blood pressure above 140/90 mmHg (Framingham, Multiple Risk Factor Intervention Trial –both suggest systolic pressure more important in determining cardiovascular risk)

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13
Q

Why is understanding hypertension

A

• Hypertension is a major risk factor for: – Cardiovascular disease
– Ischaemic heart disease
– Accelerated atherosclerosis
– Alzheimer type dementia?
• Important preventable cause of premature disease and death in developed and developing countries.

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14
Q

Discuss the epidemiology of hypertension

A
  • Hypertension is often symptomless, so screening is vital -before damage is done.
  • About 30% of people aged 45-54 years have blood pressure (BP) that is at least 140/90 mm Hg.
  • About 70% of people aged 75 years or older have BP that is at least 140/90 mm Hg
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15
Q

Discuss normal ranges of bp

A

• Optimal 120/80 mm Hg
– Normal <130/<85 mm Hg
– High normal 130-139/85-89 mm Hg (labelled ‘pre- hypertension’ in the USA)
• Hypertension
– Mild hypertension Grade 1 140-159/90-99 mm Hg
– Moderate hypertension Grade 2 160-179/100-109 mm Hg – Severe hypertension Grade 3 180/110 mm Hg
• Isolated systolic hypertension – Grade 1 140-159/<90 mm Hg – Grade 2 160/<90 mm Hg

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16
Q

Discuss systemic hypertension

A
  • 90% Primary (“essential” ,idiopathic)

* 10% Secondary

17
Q

Discuss causes of secondary hypertension

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• Renal disease
– 75% are from intrinsic renal disease: e.g. Glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic
pyelonephritis or polycystic kidneys.
– Approximately 25% are due to renovascular disease -most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease

• Endocrine disease
– Cushings disease,
– Conns disease,
– phaeochromocytoma,
– acromegaly,
– hyperparathyroidism

• Others
– coarctation,
– pre-eclampsia and hypertension in pregnancy

• Drugs and toxins,
– alcohol,
– cocaine,
– ciclosporin, tacrolimus,
– erythropoietin,
– adrenergic medications,
– decongestants containing ephedrine
– herbal remedies
– liquorice
18
Q

Describe the end-organ effects of systemic hypertension

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Essential
• Slow changes in vessels and heart with chronic end-organ dysfunction

Accelerated
• Rapid changes in vessels with acute end- organ dysfunction

19
Q

Discuss the heart

A

• Left ventricular hypertrophy
– Fibrosis
– Arrhythmias

• Coronary artery atheroma
– Ischaemic heart disease

• Cardiac failure

20
Q

Discuss the kidney

A

• Nephrosclerosis
– Drop-out’ of nephrons due to vascular narrowing
– Proteinuria
– Haematuria

  • Chronic renal failure
  • Acute renal failure associated with malignant hypertension

• Acceleration of atherosclerosis
• Intimal proliferation and hyalinisation of
arteries and arterioles
• Malignant hypertension – fibrinoid necrosis

21
Q

Discuss Brain

A

Atherosclerosis Ischaemia and TIA Infarct Haemorrhage

22
Q

Describe the causes of pulmonary hypertension

A

• Increased pulmonary vascular resistance
• Diffuse lung disease, for example COPD
• Elevated left atrial pressure e.g. left ventricular failure, mitral valve stenosis
• Recurrent pulmonary emboli
• Primary pulmonary hypertension (unknown
cause) - genetics
• Left-right shunts e.g. ASD, VSD

23
Q

Describe the end-organ effects of pulmonary hypertension

A
  • Pulmonary arteries
  • Heart
  • Treat underlying cause, give symptomatic relief, transplant