Circulatory Diseases and Treatments

Coronary Artery Disease

Coronary ArteriesSupply the heart muscle (myocardium) with

oxygenated blood.

Coronary Artery Disease

• These small vessels can become blocked (occluded). This happens when a blood clot forms on the inner wall of a coronary artery or the narrowing of the lumen (opening within the vessel).

CAD• Usually the result of

atherosclerosis (deposits of fatty compounds on the inner lining of an artery).

• The fatty plaque first causes plugging of the artery.

• Next, the roughened lining may rupture or cause abnormal clotting of the blood leading to a thrombotic occlusion.

CAD

• Blood flow is then decreased (ischemia) or stopped completely.

• Lack of oxygen leads to tissue death (necrosis) of the myocardium. The area of necrosis is called an infarct. (MI=mycardial infarction=heart attack)

MI

Acute Coronary Syndromes (ACSs)• Conditions caused by

myocardial ischemia. (Temporary oxygen insufficiency). MI is when the myocardium is suddenly completely deprived of oxygen.

• Some heart muscle cells die and are replaced by scar tissue.

• Symptoms include angina (chest pain) which may radiate to the neck, jaw, and left arm.

CAD

• Arteriosclerosis is hardening of the arteries. Artery walls become thick and loose their elasticity.

• Can be a result of aging and chronic hypertension.

CAD Causes

• High Blood Pressure• High

Cholesterol/Obesity• Smoking• Diabetes• Genetics has a role• Stress• Aging

CAD Signs and Symptoms

• Angina• SOB (shortness of

breath)• Heart attack (crushing

pain, diaphoresis, nausea, pallor, light headedness.

• Fatigue• Lack of energy

CAD Diagnosis• History (medical past,

symptoms, risk factors). Also current medications, and vital sign recordings, surgeries.

• Physical exam (listen for murmurs, abnormal pulse, skin color and temp, swelling.)

• Vital signs (BP, HR, RR, Temp)

CAD Diagnosis

• EKG/ECG• Chest x-ray• Angiography/Cath lab• Stress test• Echo (EF%)• Normal EF is 50-70%• Average is 58%• Labs: Cardiac Enzymes,

Lipid panels, BNP.

Angiography/Cardiac Catheterization

CAD Treatment

MedicalRestHeart Healthy DietStress ReductionSmoking CessationExerciseControlling Diabetes and

Hypertension

CAD Treatments

Medications• Statin drugs: Cholesterol-

lower drugs. The block the enzyme in the liver responsible for making cholesterol.

• Simvastatin (Zocor)• Atorvastatin (Lipitor)• Rosuvastatin (Crestor)

CAD Treatments (Medication)

Nitrates• Dilate (open) the arteries of

the heart which increases blood flow.

• Nitroglycerin• Isosorbide dinitrate (Isordil)

CAD

• Thrombolytics are clot busting drugs.

• tPA (alteplase)• Urokinase• Streptokinase

• These must be used in first few hours of an MI.

Other medications

• Aspirin is given to help prevent clot formation. It doesn’t break up clots.

• If a patient is intolerant of aspirin (ASA) clopidogrel (Plavix) is prescribed.

• Heparin may be given IV to thin blood and prevent further clot formation. Close monitoring has to be done to watch for bleeding.

• Lovenox (low molecular weight heparin) is widely used now since no blood levels have to be monitored and there is less risk of bleeding. It is given in an injection in the abdomen.

Lovenox

ACE inhibitors (angiotension-converting enzyme)

• Angiotension in a hormone produced by the liver. It causes vasoconstriction which increases blood pressure.

• These medications decrease production of angiotension converting enzyme.

• Captopril• Lisinopril

Beta blockers

• Beta-blockers improve the heart's ability to relax, decrease the production of harmful substances produced by the body in response to heart failure, and slow the heart rate. Over time, beta-blockers improve the heart's pumping ability.

• Beta blockers block beta-adrenergic receptors, preventing adrenaline (epinephrine) from stimulating these receptors.

• Metoprolol• Propranolol• Carvedilol

Calcium Channel Blockers• Blocks the entry of calcium into the

muscle cells of the heart and the arteries. It is the entry of calcium into these cells that causes the heart to contract and arteries to narrow. By blocking the entry of calcium, calcium channel blocker decrease the contraction of the heart and dilate (widen) the arteries. By dilating the arteries, CCBs reduce the pressure in the arteries. This makes it easier for the heart to pump blood, and, as a result, the heart needs less oxygen. By reducing the heart's need for oxygen, CCBs prevent or relieve angina

• Nicardipine (Cardene)• Amlodipine (Norvasc)• Nifedipine (Procardia)• Diltiazem (Cardizem)

CAD Treatments

• Percutaneous Coronary Intervention (PCI).

• Types of (Ballon Angioplasty, Stents)

CAD Treatments

• Stent: tube placed in an artery to keep it open.

CAD Treatments• Coronary Artery Bypass Graft• Surgical procedure in which one

or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient’s own arteries and veins located in the chest (thoracic), leg (saphenous) or arm (radial). The graft goes around the blocked artery (or arteries) to create new pathways for blood to flow to the heart.

Hypertension

• Abnormally high blood pressure.

• Often called the “silent killer” because it often goes unrecognized until complications arise.

Causes of Hypertension

• High Sodium Intake• Age• Race• Obesity• Genetics• Kidney Failure• Lack of Exercise• Diabetes • Smoking

Signs and Symptoms of Hypertension

• Headache• Dizziness• Nausea• Blurred vision• Chest pain• Shortness of breath• Flushing• Nose bleeds

Diagnosis of Hypertension

• Blood pressure readings. Several visits (to avoid “white coat” syndrome. Home journaling. Size does matter (in blood pressure cuffs).

• Lab work (Lipid panels, Chemistry, CBC)• Urinalysis (most patients with kidney problems

have hypertension).• ECG• Echo

Treatment of Hypertension• Lifestyle changes: low

sodium, low fat diet; smoking cessation, exercise, stress reduction, weight loss.

• Medications: Diuretics (water pills), Beta blockers, ACE inhibitors, Calcium channel blockers.

• Treat underlying problem.

Congestive Heart Failure

• Progressive decrease in the ability of the heart to contract.

• Things get “congested.”

Causes of CHF

• Diseases that damage the heart or cause “heart fatigue.” (CAD, MI, infection, valve defects, hypertension, etc).

Signs and Symptoms of CHF• Edema (ankle)• Weight gain• Neck vein distention• Enlargement of spleen• Fluid in the lungs (sounds

“wet”)/pulmonary edema (frothy bloody sputum)/pleural effusions

• Shortness of breath

Diagnosis of CHF

• Assessment• CXR• BNP• ECG• Echo

Treatment of CHF

• Lifestyle changes (smoking cessation, heart healthy diet, exercise)

• LOWER SALT INTAKE• Fluid restriction• ACE inhibitors• Beta blockers• Diuretics• Oxygen (for SOB)

• Thoracentsis• Pericardi0centsis

Pericardiocentsis

Thoracentsis

Arrthymias

• An abnormal heart rhythm.

• Causes an abnormal heart beat.

Too Fast = Tachycardia

Too Slow = Bradycardia

Fibrillation = quivering

Heart Block (Junctional) Impulse from AV junction is blocked

Causes of Arrthymias

• MI• Electrolyte imbalance• Drugs• Electrical Shock• Congenital• Idiopathic

Signs and Symptoms of Arrthymias

• Palpitations• Dizziness• Irregular Pulse• Shortness of breath• Weakness• Fatigue• Chest pain

Diagnosis of Arrthymias

• ECG• Lab work (chemistry

sets)• Stress Tests• Holter monitor

Treatment of arrthymias

Tachycardia

• Treat cause• Medications• Ventricular tachycardia

may need CPR

Bradycardia

• Medications• Epinephrine• Pacing (Implanted,

transcutaneous, and transvenous)

Fibrillation

• Cardioversion• Medication• Treat underlying cause

AICD (Automated Implantable Cardiac Defibrillation)

Cardioversion

Congenital Heart DiseaseFetal Circulation

Fetal Heart Development

Congenital Heart Defects

• Structural problems with the heart, which are present at birth. They result when a mishap occurs during heart development soon after conception

Septal Defects

• Most common congenital heart defects.• An opening in the septum that separates the right

and the left side. This allows for mixing of oxygenated and deoxygenated blood. This can stress the heart as it compensates for lower oxygen levels.

• Left side of heart has greater pressures than right side. If there is a defect blood is generally shunted from left (oxygenated) to right (deoxygenated).

Cyanosis

• If the pressure becomes greater in the right side of the heart, blood may be shunted from right to left causing cyanosis (blue color in the tissues).

• Deoxygenated blood is now being pumped out to the body.

Cyanotic Heart Defect

ASDAtrial-Septal Defect

VSDVentricular-Septal Defect

PDA

Transposition of the Arteries

Signs and Symptoms of Congenital Heart Disease

• Loss of healthy skin color• Pale gray or blue skin color (cyanosis)• Rapid breathing• Swelling in the legs, abdomen or areas around the eyes• Shortness of breath during feedings, leading to poor

weight gain• Easily becoming short of breath during exercise or activity• Easily tiring during exercise or activity• Built-up fluid in the heart or lungs• Swelling in the hands, ankles or feet

Diagnosis of Congenital Defects

• Echo• CXR• Cath• Pulse Ox• ECG

Treatment

• Cath• Surgery• Cardiac Transplant• Medications to reduce heart workload

Aneurysms

• A weakening in the wall of a blood vessel.

• It will cause local dilation.

• Most common in the abdominal aorta and brain.

• The danger in aneurysms is they may increase in size and could rupture.

Causes of Aneurysms

• The force of blood pushing against the walls of an artery combined with damage or injury to the artery’s walls can cause an aneurysm.

• Examples: Aging, smoking, hypertension.

Signs and Symptoms of Aneurysm

• Typically none.• If in the brain, may exhibit stroke like

symptoms.

Diagnosis of AneurysmsImaging Studies

• X-ray• Ultrasound• CT• MRI• Angiography

Treatment

• Surgical repair• Medications to lower blood pressure and relax

vessels (most common are beta blockers and calcium channel blockers)

Valve Disorders

• Valves maintain unidirectional (one way) flow of blood through the heart. If it isn’t working correctly, blood may flow the wrong way.

• Valve disorders include stenosis (narrowing) and prolapsed (insufficiency).

Causes of Valve Problems

• Congenital• Vegetations caused by Rheumatic Fever or

Endocarditis

Signs and Symptoms

• SOB• Weakness• Palpitations• Edema• Weight gain• Chest pain

Diagnosis

• Murmur on auscultation• Echo• Cath• MRI

Treatment

• If severe enough, valvular replacement

• Heart medications

Carditis

• Inflammation of the heart

Pericarditis

Myocarditis

Endocarditis

Causes of Carditis

• Infections (viral and bacterial)• Lupus

Signs and Symptoms

• Chest pain• SOB (shortness of breath)• Fatigue• Edema

Diagnosis of Carditis

• History• ECG• CXR• Echo

Treatment of Carditis

• Antibiotics• Cardiocentesis (for effusions)

Cardiogenic Shock

• Inadequate pumping of blood due to low blood pressure.

• “Global hypoperfusion”• Decreased pumping

ability of the heart.

Causes

• Massive MI

Signs and Symptoms

• Decreased urine output (oliguria)

• Altered mental status (AMS)

• Hypotension• CHF symptoms

Diagnosis

• Assessment• Echo• Labs: CBC, CE, Lactate• ECG

• Serial lactate measurements are useful markers of hypoperfusion and are also used as indicators of prognosis. Elevated lactate values in a patient with signs of hypoperfusion indicate a poor prognosis; rising lactate values during resuscitation leads to a very high mortality rate.

Treatment

• Fluid resuscitation• Hemodynamic support• Vassopressors• Inotropic support• IABP (intra-aortic

balloon pump)• Left ventricular assist

devices

IABP

LVAD (left ventricular assist device)

Peripheral Vascular Disease

PVD

• Narrowed arteries reduce blood flow to your limbs.

• When you develop peripheral artery disease (PAD), your extremities — usually your legs — don't receive enough blood flow to keep up with demand.

PVD Thrombosis

• Formation of blood clots on blood vessel walls. Caused by slow blood flow. Because blood flows more slowly in veins, it is more common to develop a clot there.

Thrombosis

• More likely to occur where there is turbulent blood flow, such as around a heart valve.

• Increased viscosity also leads to clot formation (like dehydration, polycythemia, or high platelet counts).

Embolus

• If a thrombus breaks free, it becomes an embolus.

• An embolus typically will lodge in the coronary arteries, lung, or brain vessels.

Causes of PVD• High cholesterol• Diabetes• Heart disease (coronary artery disease)• Hypertension• Kidney disease involving hemodialysis• Smoking• Polycythemia• Dehydration• Stasis• High Platelet Counts• Arrhythmias

Signs and Symptoms

• Claudication• Numbness• Coolness in extremity• Pain • Bruit• Weak or absent pulse• Slow wound healing• Clubbing• Decreased blood pressure in the extremity

Diagnosis

• Physical Exam• Lab Tests: CBC, Lipid Panels• Angiography of the arteries in the legs • Blood pressure measured in the arms and legs

for comparison • Doppler Ultrasound• CT• MRI

Treatment• Balance exercise and rest.• Smoking cessation• Reduce weight• Heart health diet• Aspirin or Plavix• Statin drugs• Pain medication• Angioplasty• Stents• Bypass• Amputations

Phlebitis

• Inflammation of a vein. (usually deep veins of the leg)

• Caused by infection, injury, poor circulation, and obesity.

Thrombophlebitits

Phlebitis

Clubbing

Gangrene