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Common Diseases of the heart
- 1. Diseases of the Heart
- 8. Major Determinants of Disease • Most heart disease is the result of atherosclerotic obstruction of the coronary arteries • Congestive heart failure is mechanical failure of the heart to eject blood delivered to it • Metabolic or autoimmune disease may cause heart muscle or valve damage • High blood pressure accelerates atherosclerosis & most other cardiac disease • Cardiac valves are one-way gates for blood flow & are susceptible to obstruction & regurgitation • Cardiac valves are susceptible to infection • Abnormal embryonic development of the heart produces significant cardiac anatomic malformations • Abnormal heartbeat patterns (arrhythmias) can cause cardiac dysfunction or death & can complicate any heart condition
- 9. Arrhythmias • Mechanically inefficient • CO decreases • Potentially fatal • Caused by • myocardial ischemia • MI • electrolyte imbalance • stress • caffeine • drugs, especially stimulants • congenital defects in the electrical network • Normal rhythm is ~ 70 beats/min • bradycardia is < 60 beats/min • tachycardia is > 100 beats/min
- 10. • Premature atrial contractions • extra atrial beats • common in healthy people • not harmful • due to • stress • lack of sleep • caffeine • some drugs • Atrial flutter • rapid, regular atrial rhythm • ~ 300 beats/min • Atrial fibrillation • rapid, irregular atrial rhythm • AV node filters out alot • decreased CO
- 11. • Each year heart disease accounts for about 1/3 of deaths in the US, most of which are associated with coronary artery atherosclerosis. If cerebrovascular disease, vascular complications of diabetes, & other vascular diseases are included, the figure is over 40%. After age 40 the lifetime risk for developing symptomatic coronary artery disease is 50% in men & 40% in women.
- 12. Heart Block • Atrial signal is delayed & cannot cross into the ventricle • Common cause is anatomic abnormalities • Can also be caused by digitalis • 1st degree • delay of signal but no missed ventricular beats • 2nd degree • delay long enough to cause missed ventricular beats • 3rd degree • total block of atrial signal • decreased CO
- 14. • Premature ventricular contractions • occur in healthy people • chest palpitations & anxiety • Ventricular tachycardia • spontaneous, regular beating at > 120 beats/min • decreased CO • Ventricular fibrillation • extremely rapid & irregular • negligible CO
- 15. Congestive Heart Failure • CHF • Heart unable to eject volume of blood delivered to it • Endpoint for • coronary atherosclerosis • HTN • valve disease • cardiomyopathy • congenital cardiac malformation • Affects about 1% of Americans • ½ die within 5 years
- 16. • Most common cause is cardiac muscle damage usually due to CAD • Less commonly due to valve defects • Heart tries to compensate for either of these by increasing HR & force of contraction & through cardiac muscle hypertrophy
- 17. • In L ventricular failure, low CO causes systemic hypoperfusion & pulmonary venous congestion • In R ventricular failure, low CO causes systemic venous congestion • The most common cause of R heart failure is L heart failure • The low CO of L heart failure reduces renal blood flow which stimulates the renin-angiotensin-aldosterone system
- 18. • R & L ventricles can fail independently but usually fail together • 2 components to uncompensated failure • forward failure • low ventricular output • backward failure • venous congestion
- 19. L Heart Failure • L ventricle dilates • Forward component • decreased blood flow to organs • Backward component • blood backs up into L atrium & lungs • pulmonary edema • dyspnea
- 20. R Heart Failure • R ventricle dilates • Forward component • decreased blood flow to lungs • Backward component • systemic venous congestion • congestion of liver, spleen • edema in feet & legs • ascites • Usually not by itself but found in combination with pulmonary HTN • known as cor pulmonale
- 21. Etiology • L heart failure • damaged cardiac muscle • HTN • valve disease • cardiomyopathy • R heart failure • L heart failure • pulmonary HTN • lung disease • valve disease • congenital heart disease involving L to R shunt
- 23. Coronary Artery Disease • CAD • Almost all from atherosclerotic narrowing or complete obstruction • Depending on the degree & character of the obstruction • angina pectoris • MI • sudden cardiac death • chronic ischemic heart disease with CHF
- 24. Epidemiology • Begins in the crib • Risk factors • age • high LDL • low HDL • HTN • smoking • fatty diet • sedentary lifestyle • diabetes • familial history • Average patient • overweight • diet high in saturated fat • big belly • little exercise • high cholesterol • has diabetes or HTN
- 25. Causes of Coronary Ischemia • Partial obstruction • usually stable plaques • coronary vasospasm • Complete obstruction • usually an unstable plaque
- 26. Angina Pectoris • Distinctive sensation caused by myocardial ischemia • Described as • smothering • pressing • aching • heaviness • May radiate to • jaw • shoulder • arms • upper abdomen • May have dyspnea & sweating • Stable angina • rises & falls smoothly over a few minutes • rest & medication helps • usually precipitated by exertion or emotion • Unstable angina • caused by platelets aggregating on a plaque • may herald an impending MI • new onset, intensification, nocturnal, prolonged • need intervention • Unremitting angina • does not fluctuate • no relief • due to MI
- 27. Myocardial Infarction • MI • Area of necrosis caused by ischemia • Most common cause of death in industrialized nations • Most initiated by plaque disruption & accompanying thrombosis • Size of infarct determined by vessel involved • Age of infarct determined by gross & microscopic findings • coagulative necrosis early • development of granulation tissue • mature scar
- 28. • Nearly ½ of all infarcts involve anterior descending • About 1/3 involve the R coronary artery • The rest involve the circumflex artery
- 29. • Deepest muscle is last supplied & 1st to die • subendocardial infarct • In 3-6 hours, can enlarge to involve the full thickness of the ventricular wall • transmural infarct
- 30. • Anatomic complications • Infarct papillary muscles • Release of substances from necrotic muscle that attracts platelets & WBCs to form mural thrombus
- 32. Chronic Myocardial Ischemia • Elderly • Usually have CHF • Ventricles dilated, thin-walled, & flabby • May lead to heart failure
- 33. Sudden Cardiac Death • Death within 1 hour of onset of symptoms • About ½ of all cardiac deaths • Most common cause of instantaneous death in industrialized society • Most due to electrical malfunction • asystole • ventricular fibrillation
- 34. Hypertensive Heart Disease • L ventricular hypertrophy • Stiff myocardium • susceptible to infarction • reduced compliance & stroke volume • increases diffusion distance • Predisposed to atherosclerosis • End result is often CHF, MI, or arrhythmias
- 36. Causes • Inflammation & infection • Syphilitic aortitis • Myxomatous degeneration of the mitral valve • Ruptured mitral valve chordae tendineae • Massive L ventricular dilation
- 40. Calcific Aortic Stenosis • Age-related degenerative changes • Fibrosis, calcification, deformity • Have • systolic murmur • L ventricular hypertrophy • angina • syncope
- 41. MitralValve Prolapse • Most common valve disease • “floppy” valve • Cause unknown • Late systolic murmur & mid-systolic click • Most patients asymptomatic
- 42. NoninfectiveThrombotic Endocarditis • Vegetations of platelets & fibrinous material • No microbes in lesions but susceptible to microbial colonization • Linked to • cachexia • DVT • hypercoagulable blood • malignancies • May embolize
- 43. Infective Endocarditis • Almost always caused by bacterial infection • L-sided valves most commonly affected • Vegetations containing microbes • May embolize • Greatest hazard is erosion & perforation of the valve • Usually affects previously disease valves • Staphylococcus more dangerous than Streptococcus or Enterococcus
- 44. Myocarditis • Usually due to virus • coxsackie A or B • Most resolve without therapy but a few cases proceed to CHF
- 45. Cardiomyopathies • Primary • Intrinsic disease of cardiac muscle • Cause usually unknown • Secondary • Associated with • ischemic heart disease • HTN • infections • valvular disease • congenital abnormalities
- 46. Dilated Cardiomyopathy • Hypertrophy, dilation, & low ejection fraction • Cause usually unknown • Heart is flabby & weak • All chambers dilated
- 47. Hypertrophic Cardiomyopathy • About ½ the cases are genetic • Sudden death in children & young adults during or immediately after exertion • Myocardium is stiff • Diastolic filling incomplete
- 48. Restrictive Cardiomyopathy • Stiff, noncompliant ventricle which fills incompletely during diastole • Systole not forceful • Usual outcome is CHF
- 49. Congenital Heart Disease • One of most common congenital abnormalities • 8 in 1000 live births • Cause usually unknown • Defects develop in 1st 10 weeks • Malrotation defects • Expansion defects • Septal defects
- 51. Malformations with Shunts • Most common • May cause pulmonary HTN & R heart failure
- 57. Malformations with Obstruction to Flow • Embryonic vessels fail to expand properly • Coarctation of the aorta • high BP in arms but low BP in legs • low blood flow to kidneys • 50% of cases also have PDA
- 58. Pericardial Disease • Pericarditis • usually viral infection • atypical chest pain • friction rub • Pericardial effusion • may occur in noninflammatory conditions • hemopericardium