knowt logo

Cardiology & Cardiovascular Disease

Hypertension

  • Disease of the arteries

    • Consistent elevation of systemic arterial blood pressure

  • Blood pressure= systolic/diastolic

    • Systolic= force/contraction 100-120mmHg

    • Diastolic= relaxation 60-80 mmHg

      • High bp → obstruction OR greater pressure when pumping

      • Common disorder that impacts 25% of the population; leads to major risk of atherosclerosis, CHF, and renal failure

  • Hypertensive bp → 130/80 or greater

  • 2 types of HT: Primary/Essential HT or Secondary HT

Blood Pressures

Blood Pressure Category

Systolic (mmHg)

Diastolic (mmHg)

Normal

< 120

< 80

Elevated (Pre-hypertension)

120-129

< 80

High blood pressure STAGE 1

130-139

80-89

High blood pressure STAGE 2

140 >

90 >

Hypertensive crisis (emergent)

180 >

120 >

Essential/Primary Hypertension

  • MOST COMMON TYPE OF HT

  • Problems lie in the blood vessels

  • Genetic and environmental factors; but, don’t know where the problem lies in the gene defects; usually runs in the family

  • Affects 92-95% of individuals with HT

→ Risk Factors

  • Increase in age → wear & tear of heart and blood vessels in age

  • Family history → cultural/lifestyle

  • Race/ethnicity → African Americans at highest risk for hypertension

  • Sex → males at higher risk

    • All are ESSENTIAL, cannot be changed

  • High sodium intake → diet, H2O follows, increase in pressure

  • Inflammation

  • Obesity/weight gain

  • Insulin resistance

    • The 3 go hand in hand, diabetes and hypertension are usually seen together

  • Dyslipidemia → high cholesterol

  • Alcohol, smoking, prolonged/current stress → all cause vasoconstriction -

→ S&S

  • ASYMPTOMATIC, NO SYMPTOMS

  • Non-specific fatigue

  • Malaise

  • The body adapts

→ Diagnostics

  • CBC

  • Kidney panel (BUN/creatinine)

  • Lipid profile

  • Urinalysis

  • EKG

  • ECG

  • With patients, you would measure a first time, have them come in again and measure again, and then make them come in a final time for 3 measurements in order to rule out hypertension; NEVER treat upon first reading

→ Treatment

  • CONSERVATIVE = reducing the risks

    • Lifestyle changes

    • Low sodium diet

    • Weight reduction

    • Exercise

    • Decrease stress

    • Patient education

  • Medicines

    • Diuretics → African American community responds well to this treatment

    • ACE inhibitors

    • ARB

    • Calcium channel blockers

    • Beta blockers

→ Complications

  • HYPERTENSIVE CRISIS (malignant hypertension)

    • Retinopathy

    • Elevated BP

    • Nephrosclerosis

    • CHF, atherosclerosis, angina, MI

    • CVA

  • RAPIDLY PROGRESSES

  • 180/>120

  • Life-threatening with organ damage

  • Don’t respond to medications

  • If they do survive, can lead to dialysis or coma

Secondary Hypertension

  • Systemic disease that raises peripheral vascular resistance or cardiac output

    • UNCOMMON

  • Usually caused by something else (ex: sleep apnea, renal artery stenosis, hypothyroidism)

Coronary Artery Disease (CAD)

  • Caused by atherosclerosis

    • Blockage of blood flow

  • Narrowing of coronary arteries leads to myocardial ischemia → MI

Atherosclerosis

  • Form of arteriosclerosis

  • Presence of atheroma (plaque) in the large arteries

    • Cause of atheromas = damage

      • When atheromas break, causes an embolism/thrombus which can lead to a MI

      • Fatty streak is #1 sign of atherosclerosis and CAN be reversed

  • Related to diet, exercise, and stress

Risk Factors for Atherosclerosis

  • Genetic abnormalities

  • Family Hx

  • Age

  • Males (females protected by estrogen until menopause)

  • Hyperlipidemia

  • Obesity

  • Sedentary lifestyle

  • Cigarette smoking

  • Diabetes

  • Inflammation

Angina Pectoris

  • Local, temporary deprivation of the coronary blood supply (O2) to meet myocardial needs → chest pain

    • Blockage (thrombus/embolus)

  • Occurs in different patterns

Stable/Classic Angina Pectoris

  • Recurrent, intermittent brief episodes of substernal chest pain

  • Pressure, heaviness, squeezing, burning or choking sensation

  • Triggered by physical or emotional stress

  • Lasts 1-5 minutes, relieved by rest or nitroglycerin

  • No cell death or necrosis

  • Physical exam is often normal in findings

Angina is a warning sign of progression of disease

→ Diagnostics

  • CBC

  • EKG

  • Stress test (treadmill/nuclear)

  • ECG

  • CT scan & angiography

  • Cath lab

→ Treatment

  • Relieve symptoms, and slow progression of disease by reducing complications (stop smoking, treat risks)

  • Nitroglycerin → decreases the demand for O2, reduces systemic resistance

  • Ranolazine → anti-anginal

Acute Coronary Syndromes

  • Unstable angina = 1 foot into the heart attack door

    • REVERSIBLE MI

  • Myocardial infarction (MI) → acute process that is sudden and extended obstruction of the myocardial blood supply which causes myocardial cell death

Unstable Angina Pectoris

  • Reversible myocardial ischemia without necrosis

  • Angina at rest

    • More frequent/severe and prolonged

      • Changed from usual pattern of angina

        • Longer in duration

        • Lower in threshold

    • DOES NOT RESPOND TO NITRO

      • Only relieved with time

      • Requires aggressive treatment

Myocardial Infarction (MI)

  • Heart attack

  • Atherosclerosis most common cause

    • Thrombus from atheroma may obstruct artery; size and location determines damage

  • The irreversible death (necrosis) of heart muscle secondary to prolonged lack of O2 supply (ischemia)

    • Occurs when coronary artery is totally obstructed → necrosis

→ S&S

  • Severe chest pains

    • Intense lasting for 30-60 minutes

  • Radiating pain to neck, shoulder, jaw, and LEFT arm

  • Levine sign → clenched fist over the heart (seen mainly in women)

  • Epigastric → belly pain, not life threatening but MI can mask as belly pain

  • Nausea & vomiting from pain as a sympathetic response

  • Diaphoresis

  • Dyspnea → SOB

  • Fatigue & malaise

→ Diagnostics

  • TROPONIN LEVELS

    • CK-MB isoenzymes if troponin test not an option

  • CBC

  • Comprehensive metabolic panel

  • Lipid profile

  • 12 Lead EKG

    • ST segment depression, T wave inversion or ==ST segment elevation ==

  • ECG

  • CT/MRI (waste of time & $$)

  • Angiography

→ Treatment

  • Oxygen therapy to reduce cardiac demand

  • Aspirin

  • Nitroglycerin → vasodilator

  • Morphine → relieves pain, lowers stress, vasodilates blood vessels which increases blood flow

  • ACE inhibitors

  • Beta blockers

  • Calcium channel blockers

  • Thrombolytic agents

  • Tissue plasminogen activator (once cleared for use)

  • Statins

  • Angioplasty & stents (only when troponin levels are not lowering)

  • Coronary artery bypass surgery

  • External counter pulsation (ECP)

→ Complications

  • Sudden death

  • Cardiogenic shock

  • CHF

  • Rupture of necrotic heart tissues/cardiac tamponade (increases mortality or CVA risk)

  • Thromboembolism causing a CVA w/LVMI

Prinzmetal Angina

  • Vasospasms

  • Angina occurs at rest during sleep, and occurs in clusters

  • Does not develop during treadmill tests

  • No evidence of cardiac diseases or atherosclerotic heart disease

  • Occurs in younger people

  • More often seen in females than males

→ Pathophysiology

  • Reduced nitric oxide availability

  • Imbalance of sympathetic and parasympathetic systems

  • Increased alpha-adrenergic receptors activity

→ Treatment

  • Nitroglycerin (acute attacks)

  • Calcium channel blockers (maintenance)

Heart Failure

  • Inability of the heart to pump enough blood to meet the body’s needs → inadequate perfusion of tissues

    • Less filling of the heart (diastole)

    • Insufficient stroke volume (systole)

  • Can be left or right sided heart failure

Functional

  • Systolic dysfunction: inability to generate adequate cardiac output to perfuse tissues; EF <40%

  • Diastolic dysfunction: decreased compliance of left ventricle, abnormal relaxation

  • High output (other diseases cause heart to fail)

  • Both pumps fail = biventricular failure

→ LEFT SIDED HF

Left sided HF = Lungs

  • CONGESTIVE HEART FAILURE (CHF)

  • Most common type of HF

  • Low cardiac output

  • Dyspnea (pulmonary congestion/edema)

  • “Left HF is a disease with symptoms”

→ S&S

  • Restlessness

  • Confusion

  • Orthopnea

  • Tachycardia

  • Exertional dyspnea

  • Fatigue

  • Cyanosis

  • Tachypnea

  • Blood-tinged sputum

  • Cough/crackles/wheezes

  • Paroxysmal nocturnal dyspnea

→ RIGHT SIDED HF

Right sided HF = Rest of the body

  • Most common cause is LEFT SIDED HF

  • Inability of the right ventricle to provide adequate blood flow at a normal venous pressure

  • “Right HF is a disease with signs”

→ S&S

  • Pedal edema

  • Fatigue

  • “Pitting” edemas

  • Ascites

  • Enlarged liver & spleen

  • Increased venous pressure

  • May be secondary to chronic pulmonary problems

  • Distended jugular

  • Weight gain

  • Anorexia/complaints of GI distress

  • Dependent edema

→ High-Output HF

  • Normal heart function, something caused an increased demand, the heart can’t keep up

  • Inability of the heart to supply the body with nutrients, despite adequate blood volume and normal/elevated myocardial contractility

  • Causes include: severe anemia, hyperthyroidism, septicemia, and beriberi (B12 deficiency)

Shock

  • Cardiovascular system fails to perfuse tissues adequately

  • Manifestations often include feeling weak, cold, hot, nauseated, dizzy, confused, afraid, thirsty, SOB, hypotension, tachycardia, increased respiratory rate

Hypovolemic = acute trauma

  • Loss of blood or plasma

    • Blood vessels ⬇️

    • Blood pressure ⬇️

    • Heart workload ⬆️

  • Caused by hemorrhage, burns, dehydration, peritonitis, pancreatitis

Cardiogenic = heart at fault

  • Decreased pumping capability of the heart

  • Caused by MI of left ventricle, cardiac arrhythmia, pulmonary embolus

Vasogenic = nervous system at fault

  • Vasodilation owing to loss of sympathetic and vasomotor tone

  • Caused by pain and fear, spinal cord injury, hypoglycemia (insulin shock)

Anaphylatic = immune response

  • Systemic vasodilation and increased permeability owing to severe allergic reaction

  • Caused by insect stings, drugs, nuts, and shellfish

Septic/Endotoxic = immune but by gram-negative organisms

  • Vasodilation owing to severe infection, often gram negative bacteria

  • Caused by virulent microorganisms or multiple infections

Hypertension

  • Disease of the arteries

    • Consistent elevation of systemic arterial blood pressure

  • Blood pressure= systolic/diastolic

    • Systolic= force/contraction 100-120mmHg

    • Diastolic= relaxation 60-80 mmHg

      • High bp → obstruction OR greater pressure when pumping

      • Common disorder that impacts 25% of the population; leads to major risk of atherosclerosis, CHF, and renal failure

  • Hypertensive bp → 130/80 or greater

  • 2 types of HT: Primary/Essential HT or Secondary HT

Blood Pressures

Blood Pressure Category

Systolic (mmHg)

Diastolic (mmHg)

Normal

< 120

< 80

Elevated (Pre-hypertension)

120-129

< 80

High blood pressure STAGE 1

130-139

80-89

High blood pressure STAGE 2

140 >

90 >

Hypertensive crisis (emergent)

180 >

120 >

Essential/Primary Hypertension

  • MOST COMMON TYPE OF HT

  • Problems lie in the blood vessels

  • Genetic and environmental factors; but, don’t know where the problem lies in the gene defects; usually runs in the family

  • Affects 92-95% of individuals with HT

→ Risk Factors

  • Increase in age → wear & tear of heart and blood vessels in age

  • Family history → cultural/lifestyle

  • Race/ethnicity → African Americans at highest risk for hypertension

  • Sex → males at higher risk

    • All are ESSENTIAL, cannot be changed

  • High sodium intake → diet, H2O follows, increase in pressure

  • Inflammation

  • Obesity/weight gain

  • Insulin resistance

    • The 3 go hand in hand, diabetes and hypertension are usually seen together

  • Dyslipidemia → high cholesterol

  • Alcohol, smoking, prolonged/current stress → all cause vasoconstriction -

→ S&S

  • ASYMPTOMATIC, NO SYMPTOMS

  • Non-specific fatigue

  • Malaise

  • The body adapts

→ Diagnostics

  • CBC

  • Kidney panel (BUN/creatinine)

  • Lipid profile

  • Urinalysis

  • EKG

  • ECG

  • With patients, you would measure a first time, have them come in again and measure again, and then make them come in a final time for 3 measurements in order to rule out hypertension; NEVER treat upon first reading

→ Treatment

  • CONSERVATIVE = reducing the risks

    • Lifestyle changes

    • Low sodium diet

    • Weight reduction

    • Exercise

    • Decrease stress

    • Patient education

  • Medicines

    • Diuretics → African American community responds well to this treatment

    • ACE inhibitors

    • ARB

    • Calcium channel blockers

    • Beta blockers

→ Complications

  • HYPERTENSIVE CRISIS (malignant hypertension)

    • Retinopathy

    • Elevated BP

    • Nephrosclerosis

    • CHF, atherosclerosis, angina, MI

    • CVA

  • RAPIDLY PROGRESSES

  • 180/>120

  • Life-threatening with organ damage

  • Don’t respond to medications

  • If they do survive, can lead to dialysis or coma

Secondary Hypertension

  • Systemic disease that raises peripheral vascular resistance or cardiac output

    • UNCOMMON

  • Usually caused by something else (ex: sleep apnea, renal artery stenosis, hypothyroidism)

Coronary Artery Disease (CAD)

  • Caused by atherosclerosis

    • Blockage of blood flow

  • Narrowing of coronary arteries leads to myocardial ischemia → MI

Atherosclerosis

  • Form of arteriosclerosis

  • Presence of atheroma (plaque) in the large arteries

    • Cause of atheromas = damage

      • When atheromas break, causes an embolism/thrombus which can lead to a MI

      • Fatty streak is #1 sign of atherosclerosis and CAN be reversed

  • Related to diet, exercise, and stress

Risk Factors for Atherosclerosis

  • Genetic abnormalities

  • Family Hx

  • Age

  • Males (females protected by estrogen until menopause)

  • Hyperlipidemia

  • Obesity

  • Sedentary lifestyle

  • Cigarette smoking

  • Diabetes

  • Inflammation

Angina Pectoris

  • Local, temporary deprivation of the coronary blood supply (O2) to meet myocardial needs → chest pain

    • Blockage (thrombus/embolus)

  • Occurs in different patterns

Stable/Classic Angina Pectoris

  • Recurrent, intermittent brief episodes of substernal chest pain

  • Pressure, heaviness, squeezing, burning or choking sensation

  • Triggered by physical or emotional stress

  • Lasts 1-5 minutes, relieved by rest or nitroglycerin

  • No cell death or necrosis

  • Physical exam is often normal in findings

Angina is a warning sign of progression of disease

→ Diagnostics

  • CBC

  • EKG

  • Stress test (treadmill/nuclear)

  • ECG

  • CT scan & angiography

  • Cath lab

→ Treatment

  • Relieve symptoms, and slow progression of disease by reducing complications (stop smoking, treat risks)

  • Nitroglycerin → decreases the demand for O2, reduces systemic resistance

  • Ranolazine → anti-anginal

Acute Coronary Syndromes

  • Unstable angina = 1 foot into the heart attack door

    • REVERSIBLE MI

  • Myocardial infarction (MI) → acute process that is sudden and extended obstruction of the myocardial blood supply which causes myocardial cell death

Unstable Angina Pectoris

  • Reversible myocardial ischemia without necrosis

  • Angina at rest

    • More frequent/severe and prolonged

      • Changed from usual pattern of angina

        • Longer in duration

        • Lower in threshold

    • DOES NOT RESPOND TO NITRO

      • Only relieved with time

      • Requires aggressive treatment

Myocardial Infarction (MI)

  • Heart attack

  • Atherosclerosis most common cause

    • Thrombus from atheroma may obstruct artery; size and location determines damage

  • The irreversible death (necrosis) of heart muscle secondary to prolonged lack of O2 supply (ischemia)

    • Occurs when coronary artery is totally obstructed → necrosis

→ S&S

  • Severe chest pains

    • Intense lasting for 30-60 minutes

  • Radiating pain to neck, shoulder, jaw, and LEFT arm

  • Levine sign → clenched fist over the heart (seen mainly in women)

  • Epigastric → belly pain, not life threatening but MI can mask as belly pain

  • Nausea & vomiting from pain as a sympathetic response

  • Diaphoresis

  • Dyspnea → SOB

  • Fatigue & malaise

→ Diagnostics

  • TROPONIN LEVELS

    • CK-MB isoenzymes if troponin test not an option

  • CBC

  • Comprehensive metabolic panel

  • Lipid profile

  • 12 Lead EKG

    • ST segment depression, T wave inversion or ==ST segment elevation ==

  • ECG

  • CT/MRI (waste of time & $$)

  • Angiography

→ Treatment

  • Oxygen therapy to reduce cardiac demand

  • Aspirin

  • Nitroglycerin → vasodilator

  • Morphine → relieves pain, lowers stress, vasodilates blood vessels which increases blood flow

  • ACE inhibitors

  • Beta blockers

  • Calcium channel blockers

  • Thrombolytic agents

  • Tissue plasminogen activator (once cleared for use)

  • Statins

  • Angioplasty & stents (only when troponin levels are not lowering)

  • Coronary artery bypass surgery

  • External counter pulsation (ECP)

→ Complications

  • Sudden death

  • Cardiogenic shock

  • CHF

  • Rupture of necrotic heart tissues/cardiac tamponade (increases mortality or CVA risk)

  • Thromboembolism causing a CVA w/LVMI

Prinzmetal Angina

  • Vasospasms

  • Angina occurs at rest during sleep, and occurs in clusters

  • Does not develop during treadmill tests

  • No evidence of cardiac diseases or atherosclerotic heart disease

  • Occurs in younger people

  • More often seen in females than males

→ Pathophysiology

  • Reduced nitric oxide availability

  • Imbalance of sympathetic and parasympathetic systems

  • Increased alpha-adrenergic receptors activity

→ Treatment

  • Nitroglycerin (acute attacks)

  • Calcium channel blockers (maintenance)

Heart Failure

  • Inability of the heart to pump enough blood to meet the body’s needs → inadequate perfusion of tissues

    • Less filling of the heart (diastole)

    • Insufficient stroke volume (systole)

  • Can be left or right sided heart failure

Functional

  • Systolic dysfunction: inability to generate adequate cardiac output to perfuse tissues; EF <40%

  • Diastolic dysfunction: decreased compliance of left ventricle, abnormal relaxation

  • High output (other diseases cause heart to fail)

  • Both pumps fail = biventricular failure

→ LEFT SIDED HF

Left sided HF = Lungs

  • CONGESTIVE HEART FAILURE (CHF)

  • Most common type of HF

  • Low cardiac output

  • Dyspnea (pulmonary congestion/edema)

  • “Left HF is a disease with symptoms”

→ S&S

  • Restlessness

  • Confusion

  • Orthopnea

  • Tachycardia

  • Exertional dyspnea

  • Fatigue

  • Cyanosis

  • Tachypnea

  • Blood-tinged sputum

  • Cough/crackles/wheezes

  • Paroxysmal nocturnal dyspnea

→ RIGHT SIDED HF

Right sided HF = Rest of the body

  • Most common cause is LEFT SIDED HF

  • Inability of the right ventricle to provide adequate blood flow at a normal venous pressure

  • “Right HF is a disease with signs”

→ S&S

  • Pedal edema

  • Fatigue

  • “Pitting” edemas

  • Ascites

  • Enlarged liver & spleen

  • Increased venous pressure

  • May be secondary to chronic pulmonary problems

  • Distended jugular

  • Weight gain

  • Anorexia/complaints of GI distress

  • Dependent edema

→ High-Output HF

  • Normal heart function, something caused an increased demand, the heart can’t keep up

  • Inability of the heart to supply the body with nutrients, despite adequate blood volume and normal/elevated myocardial contractility

  • Causes include: severe anemia, hyperthyroidism, septicemia, and beriberi (B12 deficiency)

Shock

  • Cardiovascular system fails to perfuse tissues adequately

  • Manifestations often include feeling weak, cold, hot, nauseated, dizzy, confused, afraid, thirsty, SOB, hypotension, tachycardia, increased respiratory rate

Hypovolemic = acute trauma

  • Loss of blood or plasma

    • Blood vessels ⬇️

    • Blood pressure ⬇️

    • Heart workload ⬆️

  • Caused by hemorrhage, burns, dehydration, peritonitis, pancreatitis

Cardiogenic = heart at fault

  • Decreased pumping capability of the heart

  • Caused by MI of left ventricle, cardiac arrhythmia, pulmonary embolus

Vasogenic = nervous system at fault

  • Vasodilation owing to loss of sympathetic and vasomotor tone

  • Caused by pain and fear, spinal cord injury, hypoglycemia (insulin shock)

Anaphylatic = immune response

  • Systemic vasodilation and increased permeability owing to severe allergic reaction

  • Caused by insect stings, drugs, nuts, and shellfish

Septic/Endotoxic = immune but by gram-negative organisms

  • Vasodilation owing to severe infection, often gram negative bacteria

  • Caused by virulent microorganisms or multiple infections