Systemic pathology 400 (CV path 2) Flashcards
valvular disease
Any heart valve can become stenotic (narrowed) or incompetent/insufficient (doesn’t close properly)
what changes take place long before SSx appear when valves stenose?
Causes hemodynamic changes long before symptoms
do valvular insufficiencies occur simultaneously in multiple valves?
Most often valvular stenosis or insufficiency occurs in isolation in individual valves,
but multiple valvular disorders may coexist
mitral valve and valvular disease
Mitral regurgitation
Mitral stenosis
insufficiency vs stenosis
insufficiency means that your valve doesn’t fully close
stenosis means that your valve is narrowed and doesn’t open fully
opposite but related (?)
mitral regurgitation
incompetency (insufficiency) of the mitral valve (bicuspid) causing backflow (reflux) from the left ventricle into the left atrium
Mitral stenosis
narrowing of the mitral valve impeding blood flow from the left atrium to the left ventricle
valvular disease and AORTIC VALVE
Aortic regurgitation
Aortic stenosis
Aortic regurgitation
incompetency of the aortic valve causing backflow from the aorta into the left ventricle
Aortic stenosis
narrowing of the aortic valve obstructing blood flow from the left ventricle to the ascending aorta
valvular disease etiology / risk factors
rheumatic heart disease
endocarditis
congenital valvular disease
autoimmune disorders
valvular disease – pathogenesis
Abnormalities in valves causes back flow of blood
Back flow of blood overburdens chambers
Overburdening causes hypertrophy of chamber
also related to pathogenesis of valvular disease
HTN (hypertension)
decreased systemic bloodflow (as a result)
valvular disease clinic manifestations, SSx
Angina
Dyspnea
Heart failure
Arrhythmia
Palpitations
Heart murmur
valvular disase Dx, Tx, Px
Echocardiogram, auscultation
Tx:
Valve replacement, medication
Px:
Variable
ischemic heart disease
Major disorders of the heart due to insufficient blood supply
AKA coronary heart disease (CHD) or coronary artery disease (CAD)
—-> MI, angina, cardiac arrest
ischemic heart disease epidemiology
CAD/IHD is the leading cause of death globally
CAD is the most common cause/type of cardiovascular disease
ischemic heart disease pathogenesis
Ischemic heart disease that develops as a result of slowly progressive narrowing of the coronary arteries results in hypoperfusion of myocardium and slowly evolving pump failure (congestive heart failure)
ischemic heart disease pathogenesis 2
Ischemic heart disease can develop due to sudden occlusion of a major coronary artery resulting in an infarct
ischemic heart disease risk factors
Age
Gender
Family history
Ethnicity
Infection
Smoking
High cholesterol
HTN
Alcohol
ischemic heart disease risk factors 2
Diet
Obesity
Physical inactivity
Diabetes
Hormonal status
Medication
Excessive alcohol consumption
Stress
ischemic heart disease clinical manifestations
Variable – depending on rapidity and extent of blockage and which arteries are blocked
can ischemic heart disease be asymptomatic
yes
ischemic heart disease other clinical manifestations and SSx
Asymptomatic
Pain
Angina pectoris
Breathlessness (dyspnea)
Palpitations
Congestive heart failure
MI
Death
ischemic heart disease Dx, Tx
Echocardiogram
Stress test
Tx:
Meds
Surgery
Prevention***
angina pectoris
Type of CAD/IHD
Crushing chest pain, typically precipitated by exercise or strain and relieved by nitroglycerin (stable angina)
angina etymology
“strangling”
angina pectoris caused by
Caused by any condition that alters:
Blood supply to myocardium
Blood requirements of myocardium
(—>circulatory disorders, blood loss)
angina pectoris – pathogenesis
Narrowed or obstructed blood vessels limit blood supply to tissues
When the cardiac workload exceeds oxygen supply to myocardial tissue, ischemia occurs causing temporary chest pain
Chronic stable angina (type)
Classic exertional angina
Preceded by exercise or stress and relieved by rest or nitroglycerin
Predictable and consistent
Prinzmetal’s angina (vasospastic or variant angina) (type)
Symptoms similar to typical angina
Caused by coronary artery spasm
Usually occurs early morning; unrelated to exertion
Decubitus angina (resting angina) (type)
Atypical
Occurs at rest, worse when laying down (decubitus)
Reduced when sitting or standing
More prevalent in women
decubitus etymology
from Latin decumbere ‘lie down’, on the pattern of words such as accubitus ‘reclining at table’.
Unstable angina (progressive or crescendo angina)
Residual ischemia triggers angina
Unpredictable
Angina Pectoris, Dx, Tx
Dx:
History
Clinical manifestation
Angiogram
Tx:
Medications to treat symptoms or underlying conditions
MYOCARDIAL INFARCTION
Development of ischemia with resultant necrosis of myocardial tissue
MI is due to
Due to occlusion of a coronary artery
Anterior descending branch of left coronary artery (50%)
(LAD – LEFT ANTEIROR DESCENDING)
Right coronary artery (30-40%)
Left circumflex artery (15-20%)
Myocardial Infarction – risk factors
same as for CAD
Age
Gender
Family history
Ethnicity
Infection
Smoking
High cholesterol
HTN
Alcohol
Diet
Obesity
Physical inactivity
Diabetes
Hormonal status
Medication
Excessive alcohol consumption
Stress
MI – death occurs in what percentage of cases?
Death occurs in 25% of cases due to arrhythmia (ventricular fibrillation), heart block, pump failure, asystole (cardiac arrest)
can MI be asymptomatic?
Symptoms are variable but can be asymptomatic (rarely)
MI SSx
Can also include crushing pericardial pain, syncope, pallor, SOB, cold sweating, fatigue, referred pain (left arm), heartburn, nausea
syncope recall
temporary loss of consciousness caused by a fall in blood pressure.
Syncope, commonly known as fainting or passing out, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery.
It is caused by a decrease in blood flow to the brain, typically from low blood pressure
MI Dx
Diagnosis includes clinical history, clinical manifestation, ECG,
blood tests (troponin or CK/CPK)
note ck test, cpk test, troponin test
Healthcare providers sometimes use a creatine kinase (CK) test to help diagnose a heart attack, though not very often
CK testing used to be a common test for heart attacks, but healthcare providers now use another test, called troponin, which is better at detecting heart damage.
The creatine phosphokinase (CPK) isoenzymes test measures the different forms of CPK in the blood. CPK is an enzyme found mainly in the heart, brain, and skeletal muscle.
MI Tx
Treatment – medications, surgery
Resuscitation must be immediate or death will occur
MI can lead to
Can lead to
cardiac arrest,
cardiogenic shock,
multisystem organ failure (brain, kidneys),
myocardial rupture (cardiac aneurysm),
mural thrombi
MI prevention
Prevention includes minimizing risk factors
Congestive Heart Failure
A condition in which the heart is unable to pump sufficient blood to supply the body’s needs
Failure can occur on left or right, but predominantly affects the left
Can be chronic or acute
CHF, epidemiology
Common complication of ischemic heart disease and hypertension
500,000 new cases per year in US
Most common cause of hospitalization in the elderly
Increasingly common
MOST COMMON CAUSE OF HOSPITALIZATION
IN ELDERLY
CONGESTIVE HEART FAILURE
CHF pathogenesis
“Failing” heart keeps working, but is less effective
Inability to pump blood out of heart decreases blood returning to the heart
where is edema common in CHF
Edema, especially in LE (dependent edema)
dependent edema define
Dependent edema is specific to parts of the body that that are influenced by gravity, such as your legs, feet, or arms.
Edema may be a side effect of medications for conditions such as high blood pressure or diabetes.
why is edema common in lower extremity in CHF
esp because of gravity
CHF pathogenesis (continued)
Inability to pump blood out of heart increases blood in the chambers and lungs
SOB, especially in recumbent position
CHF — what is the result involving kidney response?
Decreased peripheral blood flow causes kidney to release renin
—> End result = increased blood volume
—> Heart can’t keep up = more edema and HTN
what does renin do?
The renin-angiotensin-aldosterone system is a series of reactions designed to help regulate blood pressure.
When blood pressure falls (for systolic, to 100 mm Hg or lower), the kidneys release the enzyme renin into the bloodstream.
CHF — What then happen to left ventricle?
Left ventricle pumps harder to try to get more blood to tissues, leading to left ventricular hypertrophy
resulting in (which adverse effect involving the coronary arteries?)
Coronary arteries cannot meet demand of overworked heart
which can result in?
Can lead to ischemia, angina, and/or MI
how can this entire cycle be classified?
Positive feed back loop
why positive feedback loop?
the more it becomes challenging to send blood to periphery (hypoperfusion)
the more renin-angiotensin-aldosterone pathway attempts to regulate BP (INCREASE BLOOD VOLUME)
The more blood volume increases, the more edema and HTN
= The more heart can’t keep up (has to work harder)
= the more left ventricle hypertrophy
= the more difficult it is to circulate blood
and so on
CHF Tx
Diet, exercise, and lifestyle modifications
Medications
CHF Px
Poor
Cor Pulmonale
Cor pulmonale is right ventricular hypertrophy
secondary to a lung disorder.
Right ventricular heart failure follows.
Cor Pulmonale Etiology (Chronic)
Chronic cor pulmonale is usually caused by COPD.
(Chronic Obstructive pulmonary disorder)
Cor Pulmonale Etiology (Acute)
Acute is caused by pulmonary embolism
COPD
“Chronic obstructive pulmonary disease (COPD) is a common lung disease causing restricted airflow and breathing problems. It is sometimes called emphysema or chronic bronchitis.”
“Chronic obstructive pulmonary disease (COPD) is a chronic disease characterized by shortness of breath, cough and sputum production”
Cor Pulmonale Pathogenesis
Pulmonary disorders lead to hypertension in pulmonary artery
—> Blood backs up in RV
RV dilates and hypertrophies
RV fails
Cor Pulmonale clinical manifestations
Dyspnea
Exertional fatigue
Heart murmurs
Lower Extremity edema
can Cor Pulmonale be asymptomatic?
yes
Why lower extremity edema in Cor Pulmonale
since Right side is congested blood becomes held back in veins
esp as a result of gravity, lower extremity is most often affected
Cor Pulmonale Dx
History
Examination
ECHO
Cor Pulmonale, Tx
Medications
Pulmonary Embolism
The occlusion of one or more pulmonary arteries by thrombi that originate elsewhere,
typically in the large veins (DVT) of the lower extremities or pelvis, break free of the vessel, and circulate to the lungs.
pulmonary embolsim is cause of
acute cor pulmonale
pulmonary embolism etiology and risk factors (DVT)
DVT – iliofemoral (50%), deep calf veins (5%), subclavian vein (20%)
pulmonary embolism etiology and risk factors
Immobility
Surgery
Pregnancy
pulmonary embolism more risk factors / etiology
LE fractures
Malignancy
more risk factors PE
Blood stasis
Endothelial injury
Hypercoagulable states
other risk facotrs PE
Previous PE
more
CHF
CHD (CAD)
COPD
Obesity
Smoking
Catheterization
Oral contraceptives
HRT
Neurological disability
can pulmonary embolism be asymptomatic
yes
other clnical manifestations of pulmonary embolism
Cardiac arrest
Dyspnea
Chest pain
Apprehension
Cough
Tachypnea
Rales
Tachycardia
Fever
Hemoptysis
Edema
Murmur
Cyanosis
rales
“to rattle”
an abnormal crackling or rattling sound heard upon auscultation of the chest, caused by disease or congestion of the lungs.
Pulmonary embolism, Dx, Tx, Px
Dx:
History and S&S
Rule out other pathologies
Imaging as a last resort
Tx:
Medications
Variable
—> Mortality ranges from 0.5% if treated early to 25% if untreated
Dysrhythmia
Aka – arrhythmia
Disturbance of heart rate or rhythm
Caused by an abnormal rate of electrical impulse generation, abnormal conduction of electrical signal, tissue death
can arrhythmia be caused by tissue death
yes
arrhythmia classification
via speed
via location
Classified according to
origin (atria or ventricles)
and speed (slow or fast)
..
Tachycardia – HR > 100
Bradycardia – HR < 60
..
what does clinical significance of arrhythmia depend on?
Clinical significance
depends on effects
on cardiac output and BP
Atrial fibrillation (arrhythmia)
Fibrillation - rapid, uncoordinated heart beats
The most common chronic arrhythmia
Rapid, involuntary irregular muscle contraction of atrial myocardium
potential result of atrial fibrillation
Blood remains in atria after contraction
—> Ventricles don’t fill properly
Heart races but blood flow diminishes
important note about last semester notes
( NOTE THAT IN LAST SEMESTER’S NOTES, ATRIAL FIBRILLATION NOT CONSIDERED A SERIOUS EMERGENCY, B/C VENTRICLES STILL FILLED PASSIVELY DESPITE DYNSFUNCTIONING ATRIAL CONTRACTION)
atrial fibrillation SSx
S&S: asymptomatic, SOB (dyspnea), palpitations, fatigue, death (rare)
can atrial fibrillation be asymptomatic
yes
what does atrial fibrillation usually occur secondary to
Usually occurs secondary to heart disease
ventricular fibrillation
Electrical phenomena that results in involuntary, uncoordinated muscular contractions of the ventricular muscle
Frequent cause of cardiac arrest
Treatment includes depolarizing the muscle
note
ventricular fibrillation considered a much more serious medical emergency b/c absence of ventricle’s pumping capability leads to quick hypoperfusion of vital organs
whereas the ventricles can still fill passively in the absence of the pumping capability of the atria
Heart block (AV block)
Interruption in passage of impulses through the heart’s electrical system
May occur because SA (node??) misfires or because impulses are not transmitted properly
1st vs 2nd vs 3rd degree heart block
With first-degree heart block, you might not need treatment.
With second-degree heart block, you may need a pacemaker if symptoms are present or if Mobitz II heart block is seen.
With third-degree heart block, you will most likely need a pacemaker.
“Key Points. There are 3 degrees of AV block: first, second, and third. First- and second-degree blocks are partial and third-degree block is complete. First-degree AV block is rarely symptomatic and no treatment is required.”
heart block causes
Can be caused by heart disease or increased heart meds
Can cause fatigue, dizziness, fainting
Treatment includes meds or pacemaker
paroxysmal tachycardia
An abnormally rapid heart rate that begins and ends suddenly
Ectopic Beats
An electrical activation of the heart that originates outside the SA node.
