Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Coronary Heart Disease, Myocardial Infarction, and Heart Failure, A Review of the Basics.ppt
1. Coronary Heart Disease,
Myocardial Infarction,
and Heart Failure
Provided Courtesy of Nutrition.com
Review Date 12/13
G-0967
A Review of the Basics
2. Defining Heart Disease
Heart disease is a broad term used to describe a
range of diseases that affect your heart, such as:
• Coronary heart disease (CHD)
• Atherosclerosis
• Myocardial infarction (MI)
• Heart failure (formerly called congestive heart
failure)
3. Risk Factors for CHD
and MI
• Smoking
• High intake of alcohol
• Obesity
• Sedentary lifestyle
• Diabetes
• Hypertension
4. Risk Factors for CHD
and MI (cont’d)
• More than 34 years of age for males and
55 years of age for females (risk increases after
menopause)
• Family history—genetics
• Hypertension
• Stress
• Chronic kidney disease
5. Risk Factors for CHD
and MI (cont’d)
• High low-density lipoprotein (LDL) cholesterol
• Low high-density lipoprotein (HDL) cholesterol
• Left ventricular hypertrophy
6. Risk Factors
for Heart Failure
• Obesity
• Hypertension
• Overweight or obesity
• Ischemic heart disease
• Changes in cardiovascular structure, such as
diseases to the heart valves or muscle
7. Coronary Heart
Disease: An Overview
• Blood flow to the vessels surrounding the
heart is blocked
• The major underlying cause of CHD is
atherosclerosis or a buildup of plaque in
the arteries
8. Plaque Development
• Many factors speed up plaque development:
̶ Elevated cholesterol and triglyceride levels
̶ Hypertension
̶ Infection that initiates the inflammatory response
̶ Elevated iron levels—carry free radicals that damage lining
̶ Elevated homocysteine level
̶ Cigarette smoking
̶ Diabetes
̶ Obesity
̶ Oxidized (LDL) levels
9. The Atherosclerotic
Process
• Buildup of smooth muscle cells, macrophages,
and lymphocytes
• Smooth muscle cells form a matrix of
connective tissue
• Lipid and cholesterol accumulates in the matrix
10. The Atherosclerotic
Process (cont’d)
• Lipid deposits and other materials (including
cellular waste, fibrin, and calcium) build up and
form a plaque
• After injury, platelets adhere to the arterial wall
and release growth factors, which promote
lesion development
11. Coronary Heart Disease
Development
• Steps to development of CHD:
̶ Fatty streaks form, often in people younger than
30 years of age
̶ People are asymptomatic during this first stage of CHD
̶ Plasma LDL enters the injured endothelial wall and
forms a plaque that sometimes is prone to rupture
̶ Acute, complicated lesions with rupture and either
nonocclusive or occlusive thrombus form (occlusive
form often results in MI and sudden death)
̶ Hemorrhage into plaque produces thrombi—thrombus
formation with arterial lumen initiated
12. Coronary Heart Disease
Development (cont’d)
• Steps to development of CHD (cont’d):
̶ Progressive narrowing of lumen
̶ Insufficient blood flow to myocardium (ischemia) results
̶ Chest pain or angina pectoris occurs
13. Signs and Symptoms of
Coronary Heart Disease
• Chest pain
• Hypertension
• Increased pulse
• Increased respiration
• Dyspnea on exertion
• Pallor of skin
• Light-headedness with exertion
• Diminished peripheral pulses
• Intermittent claudication—cramping of the lower
extremities
15. Angina Pectoris:
An Overview
• Chest pain caused by myocardial ischemia from
reduced blood flow and/or reduced oxygen supply
to the myocardium
• Angina is a warning sign that a heart attack (MI)
may occur
16. Angina Pectoris:
An Overview (cont’d)
• Aerobic metabolism switches to anaerobic
metabolism:
̶ Lactic acid buildup
̶ Release of histamine, bradykinins, and enzymes, which
stimulate nerve fibers in the myocardium, sending pain
impulses to the central nervous system
17. Angina Pectoris:
An Overview (cont’d)
• Other causes of decreased oxygen supply to the
myocardium:
̶ Congestive heart failure
̶ Congenital heart defects
̶ Pulmonary hypertension
̶ Left ventricular hypertrophy
̶ Cardiomyopathy
̶ Severe hypertension
̶ Narrowing of the aortic valve
18. Angina Pectoris:
An Overview (cont’d)
• Other causes of decreased oxygen supply to the
myocardium (cont’d):
̶ Leakage of the aortic valve
̶ Ventricle wall thickening
̶ Atheroma leading to arterial narrowing
• Silent ischemia—decreased oxygen supply with no
pain
19. Causes of Increased
Oxygen Demand
• Causes of increased oxygen demand on the
myocardium:
̶ Anemia
̶ Exercise
̶ Thyrotoxicosis
̶ Substance abuse, particularly cocaine
̶ Hyperthyroidism
̶ Emotional stress
20. Four Types of Angina
• Stable:
̶ Caused by specific amount of activity
̶ Predictable
̶ Relieved with rest and nitrates
• Unstable:
̶ Pain occurs with increasing frequency, severity, and
duration over time
̶ Unpredictable
̶ May occur at rest
̶ High risk for MI
21. Four Types of Angina
(cont’d)
• Prinzmetal’s (variant):
̶ Has no identified cause
̶ May occur at same time of day
̶ May intensify or worsen over time
̶ Is usually caused by coronary artery spasm
• Angina decubitus:
̶ Occurs when a person is lying down with no cause
̶ Occurs because gravity redistributes body fluids
22. Signs and Symptoms
of Angina
• Pressure or heaviness in chest beneath
breastbone—women are likely to have unusual
types of chest discomfort
• Pain may occur down shoulder or inside of arms,
or in the throat, jaw, or teeth
• Stomach pain, especially after eating
• Sweating
23. Signs and Symptoms
of Angina (cont’d)
• Light-headedness
• Hypotension
• Pulse changes
• Indigestion
24. Treatment of Angina
• Antianginals (nitroglycerin)
• Antiplatelets (aspirin)
• ACE inhibitors
• Beta-blockers
• Calcium channel blockers
• Thrombolytic therapy (if thrombi are the cause)
• Oxygen administration
• Percutaneous transluminal coronary angioplasty or
coronary artery bypass graft to prevent MI
25. Myocardial Infarction:
An Overview
• Death of cells in the myocardium, usually related
to prolonged or severe ischemia
• Necrosis, tissue damage, and sometimes death
results
• Cause of MI include:
̶ Sudden onset of ventricular fibrillation
̶ Embolus (most common cause)
̶ Thrombosis
̶ Atherosclerotic occlusion
̶ Prolonged vasospasm
26. Myocardial Infarction
Progression
• Cellular injury occurs from lack of oxygen:
̶ If prolonged, will lead to cell death
• Scar replaces muscle, but cannot contract or
conduct impulses:
̶ Location of damage is determined by which artery is
blocked
• Damage begins at subendocardial level:
̶ Will progress to the epicardium within 1 to 6 hours
27. Myocardial Infarction
Progression (cont’d)
• Damaged cells lead to decreased contractility:
̶ Less blood ejected by left ventricle with each beat
̶ Decreased blood pressure
̶ Decreased tissue perfusion
28. • Pain, typically in middle of chest, radiating to
jaws, arms (usually the left), abdomen, and/or
shoulders, and lasting 20 minutes:
̶ Possible to have no pain or atypical pan (particularly
in females)
̶ Sudden onset of pain, not associated with activity
Myocardial Infarction:
Signs and Symptoms
35. Heart Failure:
An Overview
• Inability of the heart to pump sufficiently to meet
metabolic needs, leading to decreased tissue
perfusion as a result of decreased cardiac output
• Acute or chronic
• Left sided or right sided
• Systolic or diastolic
36. Causes of Heart Failure
• Hypertension
• MI
• Cardiomyopathies
• Congenital heart disease
• Valve disorders
• Side effect of medication or alcohol
37. Types of Heart Failure
• Systolic dysfunction:
̶ Heart contracts with less force and cannot pump out as
much blood to the rest of the body as normal
̶ Blood accumulates in the ventricles and veins
• Diastolic dysfunction:
̶ Heart is stiff and does not relax after contracting
̶ Heart does not allow as much blood to enter its
chambers from the veins, and the blood accumulates in
the veins
38. Types of Heart Failure
(cont’d)
• Left sided:
̶ More common
̶ Fluid backs into lungs
̶ Signs and symptoms include:
•Fatigue
•Activity intolerance
•Dizziness
•Syncope
•Dyspnea
•Coughing
•Pulmonary crackles
•Tacycardia
• urine output
•Shortness of breath
when lying down
39. Types of Heart Failure
(cont’d)
• Right sided:
̶ Caused by pulmonary hypertension or right ventricular
infarction
̶ Fluid backs into rest of body, with abdominal organ
congestion and peripheral edema
̶ Signs and symptoms include:
•Lower extremity edema
in the ambulatory
•Sacral edema in the
bedridden
•Liver engorgement and right
upper quadrant pain
•Anorexia and nausea
•Jugular venous distension
40. Types of Heart Failure
(cont’d)
• Biventricular (signs and symptoms of both left and
right heart failure):
̶ Signs and symptoms include:
•All symptoms of right and
left heart failure
•Dyspnea at rest
•Hepatomegaly and
splenomegaly
•Abdominal pressure
•Ascites
•Anorexia
•Nausea and vomiting
• digestion and absorption of
nutrients
•Dysrhythmias
•Cardiogenic shock or acute
pulmonary edema
41. Cardiac Cachexia
• 10% to 15% of patients with heart failure
develop cardiac cachexia
• Loss of 6% of nonedematous body weight
over 6 months
• Concurrent loss of cardiac muscle mass as a
result
42. Cardiac Cachexia
(cont’d)
• Many other metabolic changes:
̶ Increased catabolic catecholamines
̶ Tumor necrosis factor is increased, contributing to
a lower body mass index and catabolic state
44. Treatment of Coronary
Heart Disease (cont’d)
• Antibiotics, if necessary
• Iron supplementation, if necessary
• Supplemental oxygen
• Nitrates
• Beta-blockers
• Anticoagulants
45. References
Academy of Nutrition and Dietetics. Nutrition Care Manual ®
[by subscription]. Nutrition Care Manual Web site.
www.nutritioncaremanual.org. Accessed December 1, 2013.
Cleveland Clinic. Acute myocardial infarction. Cleveland Clinic Center of
Continuing Education Web site.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/
cardiology/acute-myocardial-infarction/. Accessed
December 1, 2013.
Cleveland Clinic. Heart failure. Cleveland Clinic Center for Continuing
Education Web site.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/
cardiology/heart-failure. Accessed December 1, 2013.
46. References (cont’d)
Raymond JL, Couch SC. Medical nutrition therapy for cardiovascular
disease. In: Mahan, LK, Escott-Stump S, Raymond JL. Krause’s Food and
the Nutrition Care Process. 13th ed. St Louis, MO: Elsevier Saunders;
2012:742-781.
The Merck Manual for Health Care Professionals. Cardiovascular
disorders. Merck Manuals Web site.
http://www.merckmanuals.com/professional/cardiovascular_disorders.ht
ml. Accessed December 1, 2013.
What is angina? National Heart, Lung, and Blood Institute Web site.
http://www.nhlbi.nih.gov/health/health-topics/topics/angina/. Accessed
December 1, 2013.
Editor's Notes
Coronary heart disease involves the narrowing of small vessels that oxygenate the heart muscle.
Myocardial infarction (MI), also known as ischemia, is the main form of heart disease responsible for cardiovascular disease deaths.
Heart failure is a condition in which the heart cannot provide adequate blood flow to the rest of the body, causing fatigue, shortness of breath, and fluid retention.
Note to presenter: Systolic and diastolic are defined on a later slide.
Treatment varies depending on symptoms and comorbidities.