week 2 Flashcards
what is the #1 leading cause of death in the us?
cardiovascular disease -coronary heart disease is most common type (~44% of cases)
What is the DASH diet?
- stands for dietary appraoches to stop hypertension and it is used for hypertension and other CVD management
word break down: atherosclerosis
athero = gruel/paste sclerosis = hardening (hardening of vessels)
what is a common pathologic denominator for CVD’s?
atherosclerosis
athero = initially a fatty streak -> mass of fibrofatty paste (atheroma)
- increased endothelial permeability
- excess lipids (cholesterol), fatty streaks, calcium
sclero = hardneing of plaque
- chronic inflammation + platelet aggregation -> thrombus
results of sclero in atherosclerosis?
- narrowing of arterial lumen -> partial occulsion -> total
- increased resistance to flow
- vasospasmic response of damaged intimal smooth muscle lining of artery
what are some risk factors for atherosclerosis?
- HTN, hyper lipidemia (HLD), smoking, obesity, inactivity, M>F
what is the mechanism of impact with atherosclerosis?
- mechanism of impact remains unclear
- it is clear that the endothelial lining is compromised –> plaque build up
- pathophys: lipid deposts –> inflammation –> atheroma –> weakening of arterial walls –> thrombus –> embolus
what is the desirable range for high density lipoprotein (HDL)?
60 mg/dL
men > 40 mg/dL
women > 50 mg/dL
waht is the desirable range for low density lipoproteins (LDL)?
<100mg/dL
triglycerides normal range?
normal: < 150 mg/dL
triglycerides are the body fat storage center for energy source
total cholesterol desired level
< 200 mg/dL
What is the BP formula?
BP = CO x SVR
blood pressure depends on cardiac output (CO) and system vascualr ressitance (SVR)
what is the cardiac output formual
CO = HR x SV
cardiac outout depends on heart rate and stroke volume
what is considered normal BP?
systolic less than 120 AND diastolic less than 80
what is considered elevated BP?
systolic 120-129 AND diastolic less than 80
what is high blood pressure (HTN stage1) range ?
systolic 130-139 OR diastolic 80-90
What range is high blood pressure (HTN stage 2)?
systolic 140 or higher OR diastolic 90 or higher
what is the BP for hypertensive crisis?
systolic higher than 180 AND/OR diastolic higher than 120
What is the BMI range for underweight?
BMI for normal weight?
over weight?
obese (class I)
obese (class II)
obese (class III)
underweight - <18.5
normal - 18.5-24.9
overweight - 25.0-29.9
obese I - 30.0-34.9
obese II - 35.0-39.9
obese III - > 40.0
blood glucose
diabetes mellitus (DM)
what is it?
what does it impair?
what is the result?/ what does it affect?
- insulin deficiency (I) or insulin resitance (II) - pancreatic dysfunction
- impaired ability to regulate glucose levels –> hypo vs. hyperglycemic state
- resultant damage to the blood vessels and nerves
impacts:
- heart function, vision, periphery (neuropathy)
blood glucose
CVD is #1 cause of morbiidity and mortality in those with DM. why?
- endothelial dysfunction
- proinflammatory environment
- macroangiopathies (athreosclerosis) AND microangiopathies (eyes, nerves)
- symptoms are often silent!! - due to diabetic neuropathy of the heart vessels (impacts autonomic system)
What is the cell turn over rate for Hgb A1C (glucose)?
2-3 months
for A1C test
what is the values for
normal:
prediabetes:
diabetes:
N: below 5.7%
PD: 5.7-6.4%
DM: 6.5% or above
what is the ripple effect for atherosclerosis?
↑ LDL + ↑ triglycerides + ↓ HDL = atherosclerosis
What can atherosclerosis lead to?
- CAD (coronary artery disease)
- PAD (peripheral artery disease)
- cerebral artery disease
is atherosclerosis typically localized?
- no; rarely localized
- intially no symptoms -> progression -> multi location accumulation of plaque
What are possible symptoms of atherosclerosis?
think locations - think arteries
coronary: chest pain (CAD)
brain: CVA (certebral arteries)
peripheral: LE intermittent claudication (PAD)
What is coronary artery disease (CAD)?
- umbrella term
- partial obstruction of coronary blood flow
- no significant impact/inhibition to the myocardium
( some tissue perfusion remains, ischemia)
What is coronary heart disease (CHD)?
- complete obstruction of coronary blood flow
- permanent damage to myocardium
( tissue perfusion distal to the occlusion is lost –> infarction)
infarction means muscle death
What is a transiet ischemia attack?
brain (partial) obsutrction of cerebral or carotid arteries
- symptom onset that fully resolves within 24hr window
transient = temporary ischemia = lack of O2
What is cerebral vascular accident (CVA)?
brain (complete) obstruction of cerebral or carotid arteries
- symptom onset that extends beyond 24hr window
What are the 3 types of strokes?
- ischemic stroke
- hemorrhagic stroke
- transient ischemic stroke
What is an ischemic stroke?
What could be some causes?
symptoms?
occurs when a blood clot or other blockage prevents blood flow to the brain (lack of O2)
causes:
- atherosclerosis
- blood clot
- emboli
symptoms:
- Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body
- Sudden confusion, trouble speaking, or understanding speech
- Sudden trouble seeing in one or both eyes
- Sudden severe headache
- Dizziness or loss of balance
Emboli: Small pieces of plaque or clots that break off and lodge in the brain’s blood vessel
what is hemorrhagic stroke?
some causes?
symptoms?
occurs when a blood vessel in or around the brain ruptures, causing bleeding into the brain tissue (blood outside its vessel is toxic)
causes:
- High blood pressure
- Aneurysms (weakened areas in blood vessels)
- Arteriovenous malformations (abnormal connections between arteries and veins)
- Trauma to the head,
- Blood clotting disorders.
symptoms:
- Sudden, severe headache
- Nausea and vomiting
- Confusion or loss of consciousness
- Weakness or numbness on one side of the body
- Difficulty speaking or understanding speech
What is transient ischemic stroke?
causes?
symptoms?
“mini-stroke,” is a temporary interruption of blood flow to the brain that causes stroke-like symptoms that typically resolve within 24 hours
causes:
- Blood clots (most commonly)
- Narrowing of blood vessels in the brain (atherosclerosis)
- Other factors, such as heart disease, atrial fibrillation, and smoking
symptoms:
- Sudden numbness or weakness in the face, arm, or leg, usually on one side of the body
- Sudden confusion, difficulty speaking or understanding speech
- Sudden loss of vision in one or both eyes
- Sudden difficulty walking, dizziness, or loss of balanc
What are the types of aneurysms?
- saccular
- fusiform
- pseudoaneurysm
a siteof stenosis or occlusion at the aorta may have a site of pain where?
- bilateral buttock
- thigh and calf claudication
what is claudication
what are S/S?
- aching or burining in leg muscles
- reliably reproduces at a aset distance of walking
- relieved within minutes of rest
- never resent at rest
- not exacerbated by position
if stenosis or occlusion is presesnt at common iliac artery, where is site of pain?
buttock claudication
if stenosis or occlusion of common femoral artery, where is site of pain?
thigh claudication
if stenosis or occlusion of superficial femoral artery, where is site of pain?
- calf claudication
What are the 4 main clinical presentations of coronary heart disease? (CHD)
- sudden cardiac death
- chronic stable angina
- acute coronary sydnrome (ACS)
- cardiomyopathy (CM)
What is sudden cardiac death?
- death within 1 hr of symptom onset (if the person is symptomatic)
what is chronic stable angina?
- predictable (pain with increase demand)
- modification of myocardial demand or taking a vasodilator ↓ s/s
what is acute coronary syndrom (ACS)
- type of ischemia to the heart
- differntiating acute onset of mycardial ischemia
-unstable angina - unpredictable, absence of myocardial demand, unrelieved by vasodilator
two types
- STEMI
- NSTEMI
what is a STEMI?
type of heart attack - ST segment (on ECG ) is elevated
- worst type
what is NSTEMI
type of heart attack
- ST segment (on ECG) without elevation; may see ST segment depression
what is cardiomyopathy (CM)
- any disorder taht imapcts the hearts ability to pump
- common with heart and lung disease
What is angina (pectoris)?
what are symptoms?
absence of or imbalance betwen onxygen supply and mycardial demand
- squeezing, crushing, tightness ;radiating from substernal to jaw and or LEFT UE
- men more commonly present this way… women present with indigestion or back pain more commonly
what is the #1 reason a person seeks medical attention?
angina
What is unstable angina: ACS (acute coronary syndrome)
inadequate myocardial perfusion in the absence of myocardial demand
“a type of chest pain that occurs when the heart muscle does not receive enough oxyge”
what is the onset of unstable angina? symptoms?
- onset typically at night or the early mornings
symptoms: - chest discomfort: severe pain that worsens with activity attempts (duration >20 min)
What is some past medical history (PMH) seen with chronic stable angina?
- acute deterioration of chronic/known disease
- rupturing of plaque in a known arterial lcoation of partial occlusion –> total occlusion –> MI
- hemodynamic instability (atypical vital signs changes)
- activity the pt is typically engaged in now casues symptom-onset
What is prinzmetal (variant) angina?
what would you see symptoms?
what population is it seen in?
sudden vasospasic response to cold temps, stress, smoking
-time of day (late night or morning)
- absence of myocardial demand
- pain is not as severe
- younger population
- can return to activites later in teh day (rest and or Rx relief)
unstable angina: signs and symptoms
- sudden onset at rest
- time of day (waking pt up from sleep)
- extremely severe chest pain
- previous chronic angina hx
if occurs in outpt clinic send to urgent care
this is a medical emergency, cannot return to activites !!
angina? what are some differential diagnosis to assess for (Rule out/in)
MSK chest wall pain:
pulmonary chest pain:
GI pain:
MSK chest wall pain: reproduceable on palpation (muscle soreness)
pulmonary chest pain: breathing-pattern dependent
GI pain: meal dependent; relieved by medication
if it ends up being none of these…then we can start worrying and ruling in heart
What are the most common warning signs of heart attack?
- uncomfortable pressure, fullness squeezing or pain in the cetner of the chest (prolonged)
- pain that spreads to the throat, neck, back, jaw, shoulders or arms
- chest discomfort with lightheadedness, dizziness, sweating, pallor, nausea or dyspnea
- prolonged symptoms unrelieved by antacids, nitroglycerin or rest
what are atypical, less common warning signs of heart attack (especially for women)
- unusual chest pain (quality, location, burning, heaviness; left chest)
- stomach or abdominal pain
- continuous midthoracic or interscapular pain
- continuous neck or shouldr pain
- isolated righ bicceps pain
- pain releved by antacids; pain unrelieved by rest or nitroglycerin
- nausea and vomiting; flu-like manifestation without chest pain/discomfort
- unexplained intense anxiety, weakness or fatigue
- breathlessness, dizziness
NSTEMI: ACS
- non-ST segment elevation myocardial infarction
- no “Q” on the EC: poit incident
- ECG will show ST depression
- indicating ischemia (partial occlusion)
- non transmural (involving only subendocardial layer)
STEMI: ACS
- ST -segment elevation myocardial infarction
- ST elevation seen on ECG
- indicating MI (total occlusion)
- sometimes called a “Q- wave STEMI” : post-infarct
- transmural infarction
(involving full or near full thickness of myocardium layer)
12 lead ECG taht captures different angles of the heart
determine which coronary artery has been injured/infarcted
inferior?
- right coronary A.
12 lead ECG taht captures different angles of the heart
determine which coronary artery has been injured/infarcted
anterior and lateral
left main artery
12 lead ECG taht captures different angles of the heart
determine which coronary artery has been injured/infarcted
anterior
left a. descending
12 lead ECG taht captures different angles of the heart
determine which coronary artery has been injured/infarcted
lateral
circumflex
left ventricular sparing goes with stemi or nstemi?
nstemi
left ventricular remodeling goes with stemi or nstemi?
stemi
what are the 3 types of troponin?
C/T/I
troponin I/T is primarily used for
troponin - gold standard for cardiac biomarkers
myocardial-specific damage and definitive diagnosis
- normally bind to actin filament of striated muscle, in the presence of injury, released into blood stream
What is the normal troponin level?
waht is peak onset of T? of I?
<.2 ng/mL
peak onset: T: 3-4 hrs I:4-6 hrs
> 0 = muscle damage
when looking at patients troponin levels what is a PT looking for?
looking for a downtrend (ideally 3 total reads)
What is brain natriuretic pepetide (BNP) used for?
- used for CHF
- increase in response to increased heart chamber pressure
what is c-reactive protein used for?
- inflammatory presence
waht is coagulation profile used for?
reference point for VTE (venous throboembolism - deadly)
what does electrolyte values tell us?
Na+, K+, BUN/creatinine, albumin
Na+ = impaired cognition
K+ = dysrhythmias
BUN/creatinine = kidney function
albumin = liver function
what are some possible post myocardial complications?
- decreased cardiac output CMD (coronary microvascular dysfunction)
- pulmonary edema (CHF)
- arrythmias
- wall motion abnormalities
- ventricular remodeling
- multi-system complications (circulation, endocrine, RAS system, natriuetic peptides, adrenal cortex, renal
what is a PT’s role in various cardiac diseases including post myocardial infarction
- recognition of 12 lead ECG changes : can indicate what part of heart is damaged
- resting and exertional vitals
- monitor tropinin trends (want to see a down trend)
- communication with MD (POC, surgical intervention, PT clearance)
- post-op (hemodynamic stability (BP), post op precaution)
what type of HTN is considered the silent killer? waht are some symptoms to look for?
primarily asymptomatic
- even with critically elevated levels
- common symptom: headache, dizziness
- prehypertension (1 in 3 adults)
ex: if they are seeing spots when going upstairs
what are some secondary complicatiosn of HTN?
what are the effects of them?
- onset or exacerbation of atherosclerosis
- CHF
- CVA
- aneurysms
- PVD
effects:
- decreased LV compliance (stiff ventricle) –> LA enlargement –> pulmonary congestion –> CHF
- dysrhythmia risks –> decreased SV; increased clotting ris k
SV = stroke volume LA - left atrium LV = left ventricle dysrhthmias= afib
What are the different types of HTN?
6 of them
- isolated systolic HTN (>130 sBP)
- isolated diastolic HTN (> 80 dBP)
- white coat: MD elevated
- masked: non MD elevated
- pseudo HTN: calcified BV secondary to age (falsely elevated, ABI >1.30)
- hypertensive crisis
HTN: treatment
primary goal now?
lifestyle modifications
- weight management
- diet
- NA+ restriction
+ aerobic exercise - education (PT’s role)
HTN: treatment
secondary goal?
-pharmaceutical management (HTN stage specfic)
- complience (med) managment (PTS play a major role here)
- combine with exercise –> lower prescription dosage
What is an absolute contra indication for exercise in BP?
SBP > 250 mmHg or
DBP > 115mmHg
what is a relative contraindication for exercise with blood pressure?
SBP: > 200 mmHg
or
DBP: > 100mmHg
- speak to MD prior to commencing TX (for example if they ahd a stroke a BP this high may be okay)
permissive hypertension?
Permissive hypertension is a medical strategy that allows for a temporarily higher blood pressure in certain situations. It is used in acute ischemic stroke (brain attack) to optimize blood flow to the affected area of the brain and improve outcomes
exercise guidelines:
orthostatic hypotension?
SBP: drop > 20 mmHG
or
DBP: drop > 10mmHg
- positional sensitivity (may be symptomatic may be asymptomatic)
common to see post op
wait 2 minutes of laying down or standing up before taking BP
exercise guidelines:
exertional hypotension?
- drop in SBP > 10 mmHG with exertion
terminate exercise, allow pt to rest, monitor vitals, notify MD or RN
what is peripheral arterial disease (PAD)?
atherosclerosis of LE arteries - peripheral circulation
what are teh 4 subjective gradation of claudication discomfort for PAD?
I: initial dicomforrt (established but minimal)
II: moderate discomfort but attention can be diverted
III: intesne pain (attention cannot be diverted)
IV: excruciating and unbearable pain
What is the classic sign of intermittent claudication of PAD?
pain with activity (increast lactic), relief almost immediately from rest
what is a sign of complete obstruction in PAD?
pain with activity, unrelieved by rest; skin changes, tissue necrosis, risk of limb amputation secondary to gangrenous foot
what are some additional signs/symptoms seen with PAD?
- cold distal extremities (if not enough blood flow tissues wont be healthy)
- muscular atrophy
- rubor dependency
- hairless, shiny extremiteis
- thickned nail beds
- poor/delyaed wound healing
- decreased pulses
- impaired sensation
what is a capillary refill test?
what is normal?
- non arterial or venous specific
- quick assessment of peripheral perfusin
normal: is < 2-3 second capillary refill
what is ankle brachial index (ABI)
gold standard!
- assess peripheral arterial occlusion presence and severity
- SBP LE/SBP UE * take the higher of the two pressures
what is normal values for ABI?
noraml > .9-1.0
abnormal <0.9 or > 1.3
severe < .5
What does rubor dependency assess?
whats the set up/what are you looking for?
tissue coloration changes
start: supine with LE elevated >45°
- observe for pale/painful limb during ~1 min elevation
- quickly transition elevated limb to dependent position (like hanging from plinth)
- observe for rapid return of blood flow in limb
arterial insufficiency = presence of dee pred limb discoloration > 30 sec dependent position
What is venous filling time assess?
set up/observation?
asesses arterial > capillary > venous efficiency
- from supine, limb(s) transition to elevation > 45°
- maintain ~ 1 min, draining blood from extremity
- transition limb(s) to dependent position
- record venous reful time
normal: < 15 sec
- tourniquet on leg
What are appropriate exercise guidelines for PAD?
- walk!
- start with 5 minutes (less if necessary)
- alternate with resting periods
- increase exercise duration; decerasing rest periods as able
- encourage wB activites over NWBing, unless tolerance is low
- use claudication scale (for reassessment during TX)
educate!! - foot hygiene; sensory assessment; assess shoes ; integument
What is venous insufficiency?
secondary valve incompetence orobstruction; decrease muscle pump contribution
what are some risk factors for venous insufficency/disease
age, prolonged standing/sitting, smoking
*initially may not have any symptoms
What are some symptoms of venous insufficiency?
dull ache, limb heaviness, tingling, itching
What are the types of venous insufficiency
- chronic venous insufficiency
- varicose v.
- spider v.
- venous stasis ulcers (wounds)
how does chronic venous insufficiency manifest?
- skin changes: hemosiderin staining, swelling, wounds
hemosiderin looks like rusty brown spots on the skin
what are some classic sign of venous stasis ulcers?
- start on medial ankle
- beefy
- red
- irregular borders
- severe exudate
What are the two types of venous disease?
- venous thromboembolism (VTE)
- deep vein thrombosis (DVT)
primarily LE > UE
What is the virchow’s triad?
the virchows triad are 3 known characteristics that show high risk of thrombosis… they are:
- hypercoagulability
- venous stasis
- endothelial injury
What are syptoms of virchows triad?
- unilateral limb swelling, palpable cord, redness, warmth
pathophys of venous disease (VTE, DVT)
- breaks away from throbsis -> emboli -> lodges within pulmonary a. –> more likely to occur with proximal LE DVT
what are some symptosm of VTE or DVT
- rapid onset of dyspnea
- pleuritic (sharp) chest pain
- decrease SpO2, tachycardia
- life threatening - if clot is massive, RVF and acardiac arrest –> death within minutes
cannot get O2 to lungs as they are blocked
RVF = right ventricular failure
What is the normal venous filling time when assessing trendelenburg?
< 30 seconds
What is trendelenburg test?
- assesses valvular competence (rule out/in retrograde flow)
- from supine, limb is extended to 90°
- blood from venous system is emptied
- tourniquet functions to occlude venous flow
- pt transitiosn to standindg (watch for OTH s/s)
- normal venous filling = <30 sec
- superficial filling with tourniquet in palce = incompetent communicating veins
- additional filling after tourniquet is removed = incompetent saphenous valves
is the patient at high risk for VTE?
if yes - what interventions to decrease risk?
if no ?
yes:
1. enoucrage mobiilty and PA
2. use of mechanical compression
3. consult w/ physician about medication
4. provide edu on VTE prevention
no:
encourage mobility and PA
what are the different anticoagulants (blood thinners)?
- LMWH (low molecular weight heparin) (lovenox)
- fondaparunix (atrixtra)
- UFH
- NOAC (noval oral anticoagulants (Apixaban)
- coumadin (warfarin)
INR - standardized number of prothrobin; checks how well blood is clotting
what is the normal blood clotting range?
what is the therapeutic range?
normal: <1.1
VTE therapeutic range: 2-3
What is the primary function of a inferior vena cava (IVC) filter?
- prevens floating clot from circulating to the lungs
- ” clot trapper” placed by vascular surgeon
only protects against Pulmonary embolism (PE); not DVT’s
draw the mind map for algorithm for mobilizing patients with known LE DVT
start with is the patient anticoagulated?
if yes - what about each type of anticoagulate?
if no, then what?
non-invasive DVT assessment tool:
the wells decision tool - less than what means DVT unlikely? more than what means DVT is likely?
<2 = DVT unlikely
=/> 2 DVT likely
homan’s sign
DVT
- passive
- supine
- dorsiflex the foot and squeeze the calf
- (+): increase pain at the posterior leg or calf = throbophelebitis
this test has a low SP and SN…but if the calf is really swollen, really hard and painful you can typically tell
cardiomyopathy (CM) leads to ?
CHF
- multiple etiologies can lead to CHF, but the underlying cause is CM
HTN, CAD, PE, age, dysrhythmias can also lead to CHF
What is considered the disease of the heart muscles?
cardiomyopathy
- impaired myocardial cell function –> contraction and relaxation dysfunction
problems with the heart muscles can lead to heart failure
what are the 3 main classifications of cardiomyopathy?
- dilated
- hypertrophic
- restrictive
What is dilated DCM? (dilated cardiomyopathy)
is it a systolic or diastolic dysfunction?
“flaccid heart”
- mitochondrial dysfunction –> impaired pumping mechanism –> increased vole and chamber pressure –> chronid dilation –> impaired contraction
systolic dysfunction (HFrEF)
- the heart is capable of filling but cannot effectively contract to empty chamber
- EF will not be preserved (EF<40%)
- chambers are chronically stretched out
what is hypertrophic CM?
is it a systolic or diastolic dysfunction?
” stiff heart”
- intact myocardial mitochondrial function
- genetic changes occur –> septal wall thickening
- impaired filling due to hypertrophic myocardial environment –> increased LV pressures –> increased LA pressure –> increased pulmonary pressures
- rapid ventricular filling, empyting, high EF, decreased filling time
diastolic dysfunction (HFpEF)
- heart is capable of contracting but filling time is limited
- EF is preserved (>50%) - volume sparing
What is restrictive CMD? (cardiomyopathy)
- similar to hypertrophic CMD (diastolic dysfunction), except walls are more rigid not thickened.
RARE
What is the defintion of congestive heart failure (CHF)
according to AHA:
heart failure is the inabililty of the heart to meet the demands of the tissues, which resulted in symptoms of fatigue or dyspnea on exertion progressing to dyspnea at rest
ppl with CHF can live for many many years! some symptoms can even improve with exercise
What is the pathophysiology of CHF?
7 steps
- myocardial injury
- CM (cardiomyopathy)
- impaired ventricular contraction and/or relaxation
- decreased CO (cardiac output)
- multi- system compensatory strategies to improve pump function
- only results in continued deleterious outcomes
- primary c/o dyspnea
during CHF there are a multi system compensatoroy strategies to improve pump functions. talk about those
think sympathetic nervous system, renin angiotensin aldosterone system
- SNS attempts to increase inotropic and chronotropic effects; ↑ vasoconstriction
- RAAS system is activated –> angio II (systemic and renal vasoconstriction); aldosterone (retain Na+ and H2O; releasing K+) > fluid retention (edema) think about salting a snail
- SNS releases catecholamines –> beta- adrenergic de-sensitivity -> further reduction in inotropic and chronotropic effects
inotropic = strength of heart contractions chronotropic = heart rate
What is the presentation of right sided heart failure?
- think SWELLING
- fatigue
- ↑ peripheral venous pressure
- enlarged liver and spleen
- may be secondary t ochronic pulmonary problems
- distended jugular veins
- anorexia and compaints of GI distress
- swelling in hands and fingers
- dependent edema
right side of heart goes out to lungs
What is the presentation of left sided heart failure?
- paroxysmal nocturnal dyspnea
- elevated pulmonary capillary wedge pressure (can back up into lungs)
- pulmonary congestion
- restlnessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- fatigue
- cyanosis
L side of heart goes out to peripheral body
What is the main cause of right sided heart failure?
LEFT SIDED HEART FAILURE
- Left sided heart failure can cause blood to build up on the left side of the heart.
- the build up of blood raises the pressrue in the blood vessels that carry blood from your heart to yoru lungs
= pulmonary hypertension
