Intro to cardiology

Kim Altavesta
MassBay Community College
Paramedic Program
Fall 2011

Objectives
1. Discuss the incidence, prevalence, and
risk factors associated with heart
disease
2. Introduce specific diseases under the
umbrella of heart disease
3. Explain prevention and treatment
strategies

What is Cardiology?
 Cardiology from Greek καρδίᾱ, kardiā,
"heart"; and -λογία, -logia
 Medical specialty dealing with disorders
of the heart
 The field includes diagnosis and
treatment of congenital heart defects,
coronary artery disease, heart failure,
valvular heart disease and
electrophysiology

http://en.wikipedia.org/wiki/File:Apikal4D.gif

Synchronization of Ventricular Contraction is
Facilitated by Rapidly Conducting Purkinje
Fibers
Johannes Evangelista Purkinje
1787 - 1869
From Garrison FH. History of Medicine.
Philadelphia. Saunders, 1929
Purkinje System of the Left Ventricle
From Wenckebach KF, Winterberg H.
Die Unregelmäsige Herstäigkeit.
Leipzig. Wilhelm Engelmann, 1927.
Left
Bundle
Branch
Anterior
Fascicle
Posterior
Fascicle
Purkinje
Network

Slow Pulse and Syncope
Hippocrates
467 - 377 BCE
Richards DW. JAMA. 1968; 206:377-378.
Robert Adams
1791 – 1875
Willius FA, Keys TE,
Cardiac Classics.
“[He had] remarkable
slowness of the pulse,
which generally ranged at
the rate of 30 in a minute
[and] not less than twenty
apoplectic attacks… When
they attacked him, his
pulse would become even
slower than usual …”
Dublin Hosp Reports.
1827;4:353-453.
“[The combination] of
permanently slow pulse
[and] cerebral attacks of an
apoplectic nature, though
not followed by paralysis,
[is] a very curious and…
special combination of
symptoms.”
Dublin Quart J Med Sci.
1846;2:73-45.
“Those who frequently feel
very faint die suddenly from
no discernable cause.”
Aphorisms II:41 tr. P.B. Katz
William Stokes
1804 - 1878
St. Louis, Mosby, 1941.

Luigi Galvani 1737-1798
“I… applied the point of the scalpel [A] first to one and then the other
[nerve], while at the same time one of the assistants produced a spark [B]…
Violent contractions were induced in the individual muscles of the limbs…”
Galvani L. De viribus electricitatis in motu musculari commentarius.
De Bononiensi Scientarium et Atrium Instituto atque Academia Commentarii. 1791;7:363-418.
(Tr. Acierno LJ. The History of Cardiology. London, Parthenon 1994)
Muscular Contraction in Frogs Can Be
Induced By Electrical Impulses
A
B

Giovanni Aldini 1762-1834
(Nephew and assistant of Galvani who studied the effects of
electrical stimulation on the bodies of executed criminals)
Electrical Impulses Can Stimulate
Human Hearts to Contract
Figure from Aldini J.
Essai Théoretique et
Experimental pour
le Galvanisme.
Paris, Fournier Fils.
1804.
“Upon Galvanic stimulation, the heart [of an executed criminal]… which
possessed a great deal of vitality, was immediately very visibly contracted.”
Aldini J. General Views on the Application of Galvanism to Medical Purposes.
London, J. Callow, 1819

Hugo van Ziemessen and his
electrical stimulator.
Schechter DC. NY State J Med.
1972;72:395.
Catherina Serafin
after removal of
an enchondroma
of her chest wall.
van Ziemessen H.
Arch Klin Med.
1882;30:270.
Sphygmic responses to pacing by repetitive
electrical stimuli applied through the skin
directly over a human heart.
Intrinsic beats: Paced beats:
Onset of Cessation of
Electrical Stimulation Electrical Stimulation
Electric Shock Can Pace the Human
Heart

Electric Shock Can Pace the Human
Heart… a young woman, a chronic morphine eater, was admitted to the Ste.-Anne asylum, Paris.
[when] deprived of her daily dose of morphine she had a sudden attack of syncope, the pulse was
almost imperceptible, and her face was blue - almost black-blue…
We practiced rhythmic [electrical] excitations [and] as the excitations were being repeated, it
was astonishing to see the accompanying change in color of the patient’s face; the dark blue
color changed to pale, then to almost natural color; at the end of the thirty seconds of rhythmic
excitations, the patient took a spontaneous breath, opened her eyes, and said: “Oh, I feel so cold
in my back.” The cold she felt was the wet cotton of the electrodes… with our method we cause
artificial heart beats, as well as artificial respirations, to take place…”
Robinovitch LG. J Ment Path. 1907-1909;8:180.
Disposition of electrodes
favored by Robinovitch who
laid stress on exclusion of
the brain from electric field.
Schechter DC. NY State J Med.
1972;72:395.
“Cathode”
“Anode”

Paul Zoll
http://www.bidmc-
cardiology.com/images/dummy.jpg
Paul Zoll and an Early Pacemaker
Electrocardiogram from a man with complete heart block and an
idioventricular rate of 38/min. : External pacemaker impulses.
“During the first few hospital days the ventricular rate
was between 30 and 40 beats per minute. At noon on the 6th
hospital day, episodes of prolonged asystole with syncope
and convulsions began… and electric shocks [from the
external pacemaker] were employed… Constant ventricular
responses to the electrical stimuli were observed in the
electrocardiograms.
For 3 days the electrical stimulator was turned on for
repeated episodes of ventricular standstill… [After] a
persistent spontaneous idioventricular rate of 44 per minute
appeared that was adequate to maintain satisfactory
cerebral and peripheral blood flow… the electrical
stimulator was turned off… No further episodes of
syncope or asystole occurred…
[Two days later] his blood pressure remained stable at
110/70… no neurologic or other ill effects of the 5 days
of ventricular standstill and external electrical stimulation
were evident.”
New Engl J Med. 1952;247:768.

1774: “Electricity Restored Vitality”
“Sophia Greenhill, on Thursday last, fell out of a… window [and was]
to all appearance dead. The surgeons at Middlesex Hospital, and the
Apothecary, declared that nothing could be done for the child.
Mr. Squires tried the effects of electricity.
… upon transmitting a few shocks through the thorax, he perceived
a small pulsation; after a few minutes the child began to breathe with
great difficulty, and after some time she vomited. A kind of stupor…
remained for several days, but, by the proper means being used,
her health was restored.”
Registers of the Royal Humane Society of London. London, Nichols & Sons, 1774-1784.
(Cited by Acierno LJ. The History of Cardiology. London, Parthenon 1994).
Electric Shock Can Restart
Stopped Human Hearts

Electric Shock Can Restart
Stopped Human Hearts
1872: Electric Shock Can Reverse
Chloroform-Induced Cardiac Arrest
“I had operated on a small boy for stone, under chloroform. The operation
was over… when Mr. Webster called after me to say the pulse had stopped.
On turning around I found the boy deadly pale and pulseless, and his
breathing stopped. The galvanic battery was in the theatre ready for use
and it was instantly applied. After a few seconds, both pulse and breathing
returned, and the patient entirely recovered.
… The last five cases here related can leave no doubt as to the fact that
galvanism saved life in each of them; that the pulsations of the heart stopped
in an instant, and were instantly restored by this agent.
… [galvanic stimulation is] the most powerful agent known to restore animation
when [the heart beat] is suspended by chloroform… to be successful it must
be ready for instantaneous use – on that depends its success… when
galvanism is employed… one pole should be applied to the neck, and
the other over the ribs at the left side”
Green T. On death from chloroform; its prevention by galvanism. Br Med J. 1872;1:551-553.

“With the electrodes applied directly to the heart, currents of 0.4 ampere for five
seconds will cause fibrillation and currents of 0.8 ampere or more will stop fibrillation…
Following the countershock the ventricles are quiescent for a brief period.
When contractions begin they are very feeble but quickly increase in vigor and
the circulation is reestablished if fibrillation has not continued for long. If fibrillation
has lasted for two minutes or more, spontaneous recovery of effective beats will not
follow. Under these circumstances cardiac massage may be of signal benefit.”
Hooker DR, Kouwenhoven WB, Langworthy OR. Am J Physiol. 1933;103:444-454.
ECG Documented Reversal of Ventricular
Fibrillation by Electric Shock in Dogs
Normal ECG Ventricular fibrillation
Pause following countershock Recovery
1 2
3 4

Bernard Lown
http://www.hno.harvard.edu/gazette/
1999/02.11/photos/lown2.200x236.gif
Bernard Lown and an Early Cardioverter
“All 9 episodes of ventricular tachycardia were
successfully reverted with a single synchronized
DC discharge… a normal sinus mechanism was
observed in each patient within 2 to 3 seconds.”
Lown B et al. JAMA. 1962;182:548.
Shock applied by an
external defibrillator

Michel Mirowski and the Implantable
Defibrillator
Michel Mirowski
http://www.webapps.jhu.edu/n
amedprofessorships/professor
“A laboratory model of an automatic defibrillator has been
designed, developed, and tested successfully on dogs…
For use outside the hospital, this device might be
implanted on a permanent basis in selected patients
with coronary heart disease identified as belonging
to high-risk population.”
Mirowski M et al. Arch Int Med. 1970;126:158.
Shock applied automatically
by an implanted defibrillator

Why is heart disease such a
problem?
 2005 survey
 92% recognized chest pain as a symptom of
a heart attack
 Only 27% were aware of all major
symptoms and knew to call 911 when
someone was having a heart attack
Source: www. cdc.gov

Why is it relevant to EMS?
 About 47% of sudden cardiac deaths
occur PREHOSPITAL
 This suggests that many people with heart
disease don't act on early warning signs
 Even more of your patients will be living,
breathing cardiac patients
 Assessment and early management is key

Incidence, Morbidity & Mortality
 Since 1900, cardiovascular disease has
been the #1 killer in the United States
every year except 1918
 Claims as many lives each year as the next
seven leading causes of death combined
 Nearly 62,000,000 Americans have at
least one type of cardiovascular disease

 In 2006
 631,636 people died of heart disease
 Heart disease caused 26% of deaths—more
than 1/4—in the United States

 Heart disease is the leading cause of
death for both men and women
 Half of the deaths due to heart disease in
2006 were women
 Coronary heart disease is the most
common type of heart disease
 In 2005, 445,687 people died from coronary
heart disease

 Every year
 715,000 Americans have a MI/yr
○ 525,000 have 1st MI
○ 190,000 have another MI (2nd, 3rd…)
 Strokes and heart attacks are among the
leading causes of long-term chronic disability.
 Up to 90 percent of all cases of impotence are
now known to be directly related to vascular
insufficiency

Economics
 2010
 Heart disease will cost the United States
$316.4 billion
○ This total includes the cost of health care
services, medications, and lost productivity
(>$129 billion)
 2001
 Nationwide cost for all cardiovascular
disease was $300 billion
 Heart disease the cost was $109 billion and
Stroke, $28 billion

Cardiovascular Diseases
Coronary Heart Disease
Prevalence (Percentage) 3.8% 2007 BRFSS Data Sources: BRFSS -
Behavioral Risk Factor Surveillance System; CDC.
Mortality (Rate per 100,000) 157.5 2006 Vital Records Data Sources: Vital Records -
Vital Records; National Center for Health Statistics, CDC.
Acute Myocardial Infarction (Heart Attack)
Heart Failure
Stroke
Mortality (cerebrovascular disease)
(Rate per 100,000)
56.9 2006 Vital Records Data Sources: Vital Records -
Ischemic stroke mortality (Rate per 100,000) 2.7 2006 Vital Records Data Sources: Vital Records -
Hemorrhagic stroke mortality
(Rate per 100,000)
8.4 2006 Vital Records Data Sources: Vital Records -
Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA,
2010.http://www.cdc.gov/dhdsp/.

Risk Factors
Hypertension
Prevalence (Percentage) 25.1% 2007
BRFSS Data Sources: BRFSS -
Medication (Percentage) 61.7% 2007
Cholesterol Abnormalities
High total cholesterol prevalence (18+)
(Percentage)
32.5% 2007
Screening prevalence (18+) (Percentage) 82.2% 2007
Diabetes
Obesity
Smoking
Physical Inactivity
Fruit and Vegetable
Prevalence 5+ fruits and vegetables per day
(Percentage)
27.7% 2007
Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA,
2010.http://www.cdc.gov/dhdsp/.

Indicators Data Year Data Source
Cardiovascular Diseases
Coronary Heart Disease
Behavioral Risk Factor Surveillance System;
CDC.
Mortality (Rate per 100,000) 165.0 2006
Vital Records Data Sources: Vital Records -
Vital Records; National Center for Health
Statistics, CDC.
Acute Myocardial Infarction (Heart Attack)
CDC.
Statistics, CDC.
Signs and symptoms (Percentage) 12.4% 2005
CDC.
Rehabilitation (Percentage) 19.7% 2007
CDC.
Heart Failure
Statistics, CDC.
Stroke
CDC.
Mortality (cerebrovascular disease)
(Rate per 100,000)
75.1 2006
Statistics, CDC.
Ischemic stroke mortality
(Rate per 100,000)
3.4 2006
Statistics, CDC.
Hemorrhagic stroke mortality
(Rate per 100,000)
11.8 2006
Statistics, CDC.
Signs and symptoms (Percentage) 21.0% 2005
CDC.
Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.

Risk Factors
Hypertension
Medication (Percentage) 78.7% 2007
Cholesterol Abnormalities
High total cholesterol
prevalence (18+)
(Percentage)
35.0% 2007
Screening prevalence (18+)
(Percentage)
75.8% 2007
Diabetes
Obesity
Smoking
Physical Inactivity
Fruit and Vegetable
Prevalence 5+ fruits and
vegetables per day
(Percentage)
20.8% 2007
Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.

What is Heart Disease?
 A general term that covers a number of
diseases which affect the heart
 Coronary artery disease
 Heart failure
 Angina
 #1 killer in the United States

What Causes Heart
Disease?
 Atherosclerosis
 fatty deposits of cholesterol
 Hypertension
 High blood pressure

Coronary Artery Disease
 Occurs when the coronary arteries that
supply the heart muscle become blocked
 Ischemia or infarct result
 Partially blocked
 Angina
 Fully blocked
 myocardial infarction

Myocardial Infarction
 Symptoms may be diverse- NOT JUST
CHEST PAIN
 uncomfortable pressure, fullness, squeezing
pain, pain spreading to the shoulders, neck
and arms.
 Chest discomfort and light headedness
 Anxiety/nervousness
 Paleness or pallor
 Increased and/or irregular heart rate
 Feeling of impending doom

Congestive Heart Failure
 Fits under the description of heart
disease.
 Does not mean the heart has failed,
simply means the heart is not doing an
efficient job.
 It results from an injury or a reduction of
function of the heart muscle.
 Can be due to arteriosclerosis,
hypertension, myocardial infarction,
rheumatic fever or birth defect.

Congestive Heart Failure
 The right side of the heart collects the
blood returning from the body and sends it
to the lungs.
 If it is failing, the blood backs up into the
veins, and there are signs of edema.
 The left side of the heart receives the blood
from the lungs and pumps it out into the
body. If it is failing the blood is not pumped
effectively.

Stroke
 Blood vessel in the brain becomes blocked by
atherosclerosis- the tissue supplied by the
artery dies.
 Embolus – which is a traveling blood clot.
 Every 53 seconds, someone in the United
States has a stroke
 A death from a stroke takes places every
three minutes

Symptoms of Stroke
 Sudden numbness or weakness of the
face, arm or leg, especially on one side
of the body.
 Sudden confusion, trouble speaking, or
understanding.
 Sudden trouble seeing in one or both
eyes.
 Sudden trouble walking, dizziness, loss
of balance or coordination.

Symptoms of Stroke
 Sudden severe headache with no known
cause.
 If you have any of these symptoms you
need immediate medical attention!

• In 1948, under the direction of the National Heart Institute
• now known as the National Heart, Lung, and Blood Institute or
NHLBI
• The Framingham Heart Study became a joint project of the
National Heart, Lung and Blood Institute and Boston University.
• At the time, little was known about the general causes of heart
disease and stroke, but the death rates for CVD had been
increasing steadily since the beginning of the century and had
become an American epidemic.
• The objective of the Framingham Heart Study was to identify the
common factors or characteristics that contribute to CVD by
following its development over a long period of time in a large group
of participants who had not yet developed overt symptoms of CVD
or suffered a heart attack or stroke.
Framingham Heart Study

Design
•The researchers recruited 5,209 men and women between the ages of
30 and 62 from the town of Framingham, Massachusetts
• began the 1st round of physical exams and lifestyle interviews that they
would later analyze for common patterns related to CVD development
• the subjects have continued to return to the study every 2 years for a
detailed medical history, physical examination, and laboratory tests
•1971
• enrolled a 2nd generation
•5,124 of the original participants' adult children and their
spouses - to participate in similar examinations.
• 1994
•1st Omni cohort of the Framingham Heart Study was enrolled
reflecting a more diverse community of Framingham
•April 2002
• 3rd generation of participants
•the grandchildren of the Original Cohort.
•In 2003
• 2nd group of Omni participants was enrolled

Unchangeable Risk
Factors
 Age
 the older you get, the greater the chance
 Sex
 males have a greater rate even after women pass
menopause
 Race
 minorities have a greater chance
○ Why?
 Family history
 if family members have had CHD, there is a greater
chance
 PMH
 other diseases such as Diabetes Mellitus can
increase chances.

Race of Ethnic Group % of Deaths
African Americans 25.8
American Indians or Alaska
Natives
19.8
Asians or Pacific Islanders 24.6
Hispanics 22.7
Whites 27.5
All 27.2
cdc.gov

Changeable Risk Factors
 Hypertension
 Serum cholesterol
 Obesity
 Diabetes Mellitus
 Physical Inactivity
 Cigarette Smoking
 Alcohol Intake
 Are all these controllable?

Cholesterol
 Cholesterol serves a vital function in the
body
 Component of the nerve tissue of the brain
and spinal cord as well as other major
organs.
 Frequently measured to promote health
and prevent disease
 A major component of the plaque that
clogs arteries

Types of Cholesterol
Lipoproteins- 4 main classes
 Chylomicrons
 Very low density lipoproteins (VLDL)
 Low Density Lipoprotein (LDL)
 High Density Lipoprotein (HDL)

Good vs. BAD
 LDL is known as bad cholesterol. It has
a tendency to increase risk of CHD.
 LDL’s are a major component of the
atherosclerotic plaque that clogs
arteries.
 Levels should be <130

Good vs. BAD
 HDL is known as the good cholesterol.
 It helps carry some of the bad
cholesterol out of the body.
 It does not have the tendency to clog
arteries.
 Levels should be >35.
 High levels of HDL >60 can actually
negate one other risk factor.

The Facts About Fat
 Certain fats are essential for good
nutrition and health.
 Fats provide essential fatty acids which
the body can’t manufacture.
 Act as insulators to maintain body
temperature.
 Improve the palatability of food and
promote digestion.

The Facts About Fat
 Provide the greatest energy output per
gram of any food source. ( 9 cals)
 Carry fat soluble vitamins- A,D,E, and K.

Obesity
 People who are obese have 2 to 6 times
the risk of developing hypertension.
 Location of the body fat is significant.
 Pears of apples?

Diabetes Mellitus
 At any given cholesterol level, diabetic
persons have a 2 or 3 x higher risk of
atherosclerosis!
 Insulin is required to maintain adequate
levels of lipoprotein lipase, an enzyme
needed to break down bad cholesterols.

Physical Inactivity
 Increasing physical activity has been
shown to decrease blood pressure.
 Moderate to intense physical activity for
30-45 minutes on most days of the week
is recommended.

Cigarette Smoking
 Causes an increase in blood pressure
 Usually have lower levels of HDL
 Within 1 year of quitting, CHD risk
decreases, within 2 years it reaches the
level of a nonsmoker.

Alcohol Consumption
 In small amounts it acts as a vasodilator
 Good! 1-2 drinks
 In large amounts it acts as a
vasoconstrictor
 BAD! 3-4 drinks
 This is a very fine line!

How can You Stop CVD?
 Diet and Nutrition
 Exercise
 In other words, control the controllable
risk factors!

After the disease starts:
Cardiac Catherization/Angioplasty
(PCTA)
In the Unites States each year,
> 900,000 angioplasties
>121,000 carotid endarterectomies
Coronary Artery Bypass Surgery
(CABG)
Medical Management- Drug therapies

Conclusion
 Cardiovascular disease is the number
one killer
 It is highly preventable and controllable
with diet and exercise
 One of most common medical
emergencies and most critical to
identify and treat aggressively in the
field!

What’s Next
 Anatomy and Physiology of the
Cardiovascular System
 Cardiac Assessment

Intro to cardiology

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