Disorders of cardiac function
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Disorders of Cardiac Function. Cardiac Pathology Outline. Blood Vessels Heart I Heart Failure Congenital Heart Disease Ischemic Heart Disease. Ischemic Heart Disease. Myocardial perfusion can ’ t meet demand

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Disorders of cardiac function

Disorders of Cardiac Function


Cardiac pathology outline

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

    • Heart Failure

    • Congenital Heart Disease

    • Ischemic Heart Disease


Ischemic heart disease

Ischemic Heart Disease

  • Myocardial perfusion can’t meet demand

  • Usually caused by decreased coronary artery blood flow (“coronary artery disease”)

  • Four syndromes:

    • angina pectoris

    • acute MI

    • chronic IHD

    • sudden cardiac death


Angina pectoris

Angina Pectoris

  • Intermittent chest pain caused by transient, reversible ischemia

  • Typical (stable) angina

    • pain on exertion

    • fixed narrowing of coronary artery

  • Prinzmetal (variant) angina

    • pain at rest

    • coronary artery spasm of unknown etiology

  • Unstable (pre-infarction) angina

    • increasing pain with less exertion

    • plaque disruption and thrombosis


Myocardial infarction

Myocardial Infarction

  • Necrosis of heart muscle caused by ischemia

  • 1.5 million people get MIs each year

  • Most due to acute coronary artery thrombosis

    • sudden plaque disruption

    • platelets adhere

    • coagulation cascade activated

    • thrombus occludes lumen within minutes

    • irreversible injury/cell death in 20-40 minutes

  • Prompt reperfusion can salvage myocardium


Manifestations of st segment elevation acute myocardial infarction

Manifestations of ST-Segment Elevation Acute Myocardial Infarction

  • Abrupt onset

  • Severe and crushing pain, usually substernal, radiating to the left arm, neck, or jaw

  • Gastrointestinal complaints (nausea and vomiting)

  • Complaints of fatigue and weakness

  • Tachycardia, anxiety, restlessness, feelings of doom

  • Pale, cool, and moist skin


St segment

ST Segment

  • Abnormalities of the ST segment and the T wave represent abnormalities of ventricular repolarization.


Factors determining the extent of an infarct

Factors Determining the Extent of an Infarct

  • Location and extent of occlusion

  • Amount of heart tissue supplied by the vessel

  • Duration of the occlusion

  • Metabolic needs of the affected tissue

  • Extent of collateral circulation

  • Heart rate, blood pressure, and cardiac rhythm


Disorders of cardiac function

Morphologic Changes in Myocardial Infarction


Disorders of cardiac function

Acute Myocardial Infarction


Disorders of cardiac function

MI: day 1, day 3, day 7


Myocardial infarction1

Myocardial Infarction

  • Clinical features

    • Severe, crushing chest pain ± radiation

    • Not relieved by nitroglycerin, rest

    • Sweating, nausea, dyspnea

    • Sometimes no symptoms

  • Laboratory evaluation

    • Troponins increase within 2-4 hours, remain elevated for a week.

    • CK-MB increases within 2-4 hours, returns to normal within 72 hours.


Myocardial infarction2

Myocardial Infarction

  • Complications

    • contractile dysfunction

    • arrhythmias

    • rupture

    • chronic progressive heart failure

  • Prognosis

    • depends on remaining function and perfusion

    • overall 1 year mortality: 30%

    • 3-4% mortality per year thereafter


Disorders of cardiac function

Rupture of papillary muscle after MI


Cardiac pathology outline1

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

    • Heart Failure

    • Congenital Heart Disease

    • Ischemic Heart Disease

    • Hypertensive Heart Disease


Hypertensive heart disease

Hypertensive Heart Disease

  • Can affect either L or R ventricle

  • Corpulmonale is RV enlargement due to pulmonary hypertension caused by primary lung disorders

  • Result: myocyte hypertrophy

  • Reasons for heart failure in hypertension are poorly understood


Disorders of cardiac function

Left ventricular hypertrophy (L) and cor pulmonale (R)


Cardiac pathology outline2

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II


Cardiac pathology outline3

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

    • Heart Failure

    • Congenital Heart Disease

    • Ischemic Heart Disease

    • Hypertensive Heart Disease


Cardiac pathology outline4

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II

    • Valvular Heart Disease

    • Cardiomyopathies

    • Pericardial Disease

    • Tumors


Cardiac pathology outline5

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II

    • Valvular Heart Disease


Valvular heart disease

Valvular Heart Disease

  • Stenosis and/or insufficiency

  • Stenosis: failure to open

  • Insufficiency: failure to close

  • Murmurs

  • Outcome depends on severity and speed of development


Calcific aortic stenosis

Calcific Aortic Stenosis

  • Part of aging process

  • Can occur on normal or congenitally bicuspid valves

  • Results in increased LV pressure, LV hypertrophy, and relative ischemia

  • Angina, CHF, or fainting


Disorders of cardiac function

Calcific aortic stenosis: normal (L) and bicuspid (R) valves


Mitral valve prolapse

Mitral Valve Prolapse

  • Common (5% of adults in US, F>M)

  • Ballooning of mitral leaflets

  • Myxoid/mucoid change within leaflet

  • Pathogenesis unknown

  • Most patients asymptomatic


Disorders of cardiac function

Mitral valve prolapse


Rheumatic valvular disease

Rheumatic Valvular Disease

  • Rheumatic fever: systemic inflammatory disease occurring a few weeks after strep throat

  • Valves (esp. mitral) become scarred

  • Consequence: stenosis (± regurgitation)


Rheumatic fever

Rheumatic Fever

  • Body makes antibody to strep bug that cross-reacts with antigens in heart and joints

  • 2-3 weeks after strep throat, patient gets:

    • migratory polyarthritis

    • pericardial friction rub, arrhythmias

  • Chronic disease can reappear decades later

    • mitral stenosis, left atrial enlargement, thrombi

    • increased risk of infective endocarditis

  • Long term prognosis variable


Disorders of cardiac function

Strep throat

Antibody

production

Antibody cross-reaction

with heart

vegetations

Aschoff body

pericarditis


Disorders of cardiac function

Mitral stenosis with commissural fusion


Disorders of cardiac function

Infective Endocarditis

  • Microbial invasion of heart valves, endocardium

  • Acute endocarditis

    • highly virulent bug attacks normal valve

    • half of patients dead within days to weeks

  • Subacuteendocarditis

    • low virulence bug colonizes abnormal valve

    • slow onset, long course, most recover

  • Symptoms: fever, flu-like symptoms

  • Complications: septicemia, arrhythmias, renal failure, systemic emboli


Infective endocarditis

Invasion of the heart valves and endocardium by a microbial agent

Formation of bulky, friable vegetations and destruction of underlying cardiac tissues

Systemic manifestations

Streptocococci

Enterococci

Haemophilussp.

Actinobacillusactinomycetemcomitans

Cardiobacteriumhominis

Eikenellacorrodens

Kingellakingae

Gram-negative bacilli

Fungi

Infective Endocarditis


Disorders of cardiac function

Infective endocarditis: splinter hemorrhage of nail bed


Cardiac pathology outline6

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II

    • Valvular Heart Disease

    • Cardiomyopathies


Myocardial diseases

Myocardial Diseases

  • Myocarditis

    • Inflammation of the heart muscle and conduction system without evidence of myocardial infarction

  • Primary cardiomyopathies

    • Heart muscle diseases of unknown origin

  • Secondary cardiomyopathies

    • Conditions in which the cardiac abnormality results from another cardiovascular disease, such as myocardial infarction


Cardiomyopathies

Cardiomyopathies

  • Diverse group of disorders in which there is intrinsic myocardial dysfunction

  • Lots of causes; some idiopathic

  • Three groups

    • dilated cardiomyopathy

    • hypertrophic cardiomyopathy

    • restrictive cardiomyopathy


Dilated cardiomyopathy

Dilated Cardiomyopathy

  • Heart dilates, enlarges, and can’t contract well

  • Causes

    • viral

    • alcohol/toxin

    • genetic abnormalities

    • peripartum

  • Slowly progressing CHF

  • 70% of patients dead within 5 years


Disorders of cardiac function

Dilated (L) and hypertrophic (R) cardiomyopathy


Disorders of cardiac function

Sarcomere of cardiac muscle


Restrictive cardiomyopathy

Restrictive Cardiomyopathy

  • Heart wall is stiff; can’t fill during diastole

  • Cause: Idiopathic or secondary to systemic disease (amyloidosis, hemochromatosis, sarcoidosis)

  • Symptoms: shortness of breath, peripheral edema

  • Treatment: not often helpful

  • 70% of patients dead within 5 years


Hypertrophic cardiomyopathy

Hypertrophic Cardiomyopathy

  • Massively hypertrophied L ventricle can’t fill

  • Cause: mutation in a sarcomereprotein gene

  • Symptoms: atrial fibrillation, CHF, arrhythmia, sudden death

  • Treatment: drugs to promote ventricular relaxation or surgical excision of part of septum

  • Prognosis: about 4% of patients die each year


Treatment of cardiomyopathy

Treatment of Cardiomyopathy

  • Treatment depends on the type

    • Medication

    • Implanted pacemakers

    • Defribillators

    • Ventricular assist devices

    • Ablation

    • The goal of treatment is often symptom relief, and some patients may eventually require a heart transplant.


Cardiac pathology outline7

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II

    • Valvular Heart Disease

    • Cardiomyopathies

    • Pericardial Disease


Pericardial disease

Pericardial Disease

  • Pericarditis

    • secondary (MI, radiation, pneumonia) or primary (infectious)

    • atypical chest pain

    • dangers: tamponade, chronic fibrosis

  • Pericardial effusion

    • serous (CHF), serosanguinous (aortic dissection), chylous (lymphatic obstruction)

    • outcome depends on stretchiness of pericardial sac

    • slow = asymptomatic; sudden = catastrophic


Disorders of cardiac function

Acute pericarditis


Cardiac pathology outline8

Cardiac Pathology Outline

  • Blood Vessels

  • Heart I

  • Heart II

    • Valvular Heart Disease

    • Cardiomyopathies

    • Pericardial Disease

    • Tumors


Definition and functions of the pericardium

Definition and Functions of the Pericardium

  • Definition

    • A double-layered serous membrane surrounding the heart

  • Functions

    • Isolates the heart from other thoracic structures

    • Maintains its position in the thorax

    • Prevents it from overfilling

    • Contributes to coupling the distensibility between the two ventricles during diastole; they both fill equally


Types of pericardial disorders

Types of Pericardial Disorders

  • Pericardial effusion

    • The accumulation of fluid in the pericardial cavity

  • Cardiac tamponade

    • Slow or rapid compression of the heart due to accumulation of fluid, pus, or blood in pericardial sac


Pericarditis

Pericarditis

  • An acute inflammatory process of the pericardium

    • Can be acute, chronic, or constrictive

    • May be due to autoimmune disease, infection, Rheumatic fever

    • Difficulty breathing, swelling of legs and ankles, dry cough, fatigue, anxiety, chest pain


Types of pericardial disorders cont

Types of Pericardial Disorders (cont.)

  • Constrictive pericarditis

    • A disorder caused by inflammation of the pericardium

    • Eventual thickening, scarring and contracture of the pericardium occurs causing it to be less elastic.

    • This prevents the pericardium from stretching and results in reduced filling of the chambers of the heart.

    • This reduces the amount of blood pumped by the heart and causes blood to back up behind the heart, resulting in symptoms of heart failure.

    • Constrictive pericarditis may be life threatening if untreated.


Clinical manifestations

Clinical Manifestations

  • Acute pericarditis is based on clinical manifestations

    • ECG, chest radiography, and echocardiography

    • Friction rub

  • Chronic pericarditis

    • No pathogen identified

    • Autoimmune disorders


Cardiac tumors

Cardiac Tumors

  • Most common: metastatic

    • heart is a rare site of metastasis

    • lung cancer, lymphoma most common

  • Primary tumors uncommon

    • most are benign

    • most common: myxoma


Disorders of cardiac function

Cardiac myxoma


Coronary circulation

Coronary Circulation

  • Left main coronary artery

  • Left anterior descending artery

  • Circumflex branch

  • Right coronary artery

  • Posterior descending artery


Coronary heart disease

Coronary Heart Disease

  • Impaired coronary blood flow that may cause:

    • Angina

    • Myocardial infarction or heart attack

    • Cardiac arrhythmias

    • Conduction defects

    • Heart failure

    • Sudden death

    • http://www.youtube.com/watch?v=22bDs8teiZA


Question

Question

  • Which of the following conditions will result in pathological changes arising from pulseless electrical activity?

  • A. Pericardial effusion

  • B. Cardiac tamponade

  • C. Pericarditis


Disorders of cardiac function

Answer

  • Pericardial effusion

  • B. Cardiac tamponade: Cardiac tamponade is the result of restricted movement of the muscle and will inhibit ventricular contraction. The conduction is intact, but there will be little or no SV.

  • Pericarditis


The evaluation of coronary blood flow and myocardial perfusion

The Evaluation of Coronary Blood Flow and Myocardial Perfusion

  • ECG

    • Changes in pattern or orientation of wave forms

  • Echocardiogram

    • M-mode, two-dimensional, Doppler, and esophageal

  • Exercise stress testing

    • Motorized treadmill and bicycle ergometer

  • Nuclear cardiovascular imaging methods

    • Myocardial perfusion imaging, infarct imaging, radionuclide angiocardiography, and positron emission tomography


Classification of coronary heart disease

Classification of Coronary Heart Disease

  • Chronic ischemic heart disease

    • Chronic stable angina

    • Silent myocardial ischemia

    • Variant or vasospastic angina


Acute coronary syndromes acs

Acute coronary syndromes (ACS)

  • Represent the spectrum of ischemic coronary disease

  • Ranges from unstable angina through myocardial infarction

  • Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer

  • Pain elsewhere in the body, such as the left upper arm or jaw (referred pain

  • Nausea

  • Vomiting

  • Shortness of breath (dyspnea

  • Sudden, heavy sweating (diaphoresis)


Types of angina

Types of Angina

  • Chronic stable angina

    • Associated with a fixed coronary obstruction that produces a disparity between coronary blood flow and metabolic demands of the myocardium

  • Stable angina

    • The initial manifestation of ischemic heart disease in approximately half of people with CHD


Populations affected by silent myocardial ischemia

Populations Affected by Silent Myocardial Ischemia

  • Persons who are asymptomatic without other evidence of CHD

  • Persons who have had a myocardial infarct and continue to have episodes of silent ischemia

  • Persons with angina who also have episodes of silent ischemia


Non pharmacologic treatment of angina

Non-pharmacologic Treatment of Angina

  • Smoking cessation in persons who smoke

  • Stress reduction

  • Regular exercise program

  • Limiting dietary intake of cholesterol and saturated fats

  • Weight reduction if obesity is present

  • Avoidance of cold or other stresses that produce vasoconstriction


Anti platelet and anticoagulant therapy

Anti-platelet and Anticoagulant Therapy

  • Aspirin

    • The preferred anti-platelet agent for preventing platelet aggregation in persons with CHD

    • Inhibits synthesis of prostaglandin and thromboxaneA2


Anti platelet and anticoagulant therapy cont

Anti-platelet and Anticoagulant Therapy (cont.)

  • Platelet receptor antagonists

    • Target a single step in the aggregation process

    • Block the receptor involved in the final common pathway for platelet adhesion, activation, and aggregation

    • Treat acute coronary syndrome


Determinants of acs acute coronary syndrome status

Determinants of ACS (Acute Coronary Syndrome) Status

  • Persons with an ACS are routinely classified as low risk or high risk for infarction based on

    • Presenting characteristics

    • ECG variables

    • Serum cardiac markers

    • Timing of presentation


Causes of unstable angina

Causes of Unstable Angina

  • Atherosclerotic plaque disruption

  • Platelet aggregation

  • Secondary hemostasis


Characteristics of pain associated with unstable angina

Characteristics of Pain Associated With Unstable Angina

  • The pain has a more persistent and severecourse and is characterized by at least one of threefeatures:

  • It occurs at rest (or with minimal exertion) usually lasting more than 20 minutes (if not interrupted by nitroglycerin).

  • It is severe and described as frank pain and of new onset.

  • It occurs with a pattern that is more severe, prolonged, or frequent than previously experienced.


Basis for diagnosis of unstable angina

Basis for Diagnosis of Unstable Angina

  • Pain severity and presenting symptoms

  • Hemodynamic stability

  • ECG findings

  • Serum cardiac markers


Involvement of heart muscle in an infarct

Involvement of Heart Muscle in an Infarct

  • Transmural infarcts

    • Involves the full thickness of the ventricular wall

    • Occur when there is obstruction of a single artery

    • Associated with atherosclerosis involving major coronary artery


Subendocardial infarcts

Subendocardial infarcts

  • Involves the inner one third to one half of the ventricular wall

  • Occur more frequently in the presence of severely narrowed but still patent arteries


Medical management following infarct

Medical Management Following Infarct

  • Thrombolytic therapy

    • The use of drugs to break up or dissolve blood clots, which are the main cause of both heart attacks and stroke.

  • Revascularization interventions

    • Coronary artery bypass grafting (CABG)

    • Percutaneous coronary intervention (PCI)

    • Atherectomy

  • Cardiac rehabilitation programs


Question1

Question

  • Which type of angina is brought about by exercise or stress?

  • A. Stable

  • B. Unstable


Disorders of cardiac function

Answer

  • A. Stable: Stable angina does not present as a problem until there is an increase in workload.

  • Unstable


Manifestations of rheumatic fever

Manifestations of Rheumatic Fever

  • Acute stage

    • History of an initiating streptococcal infection

    • Involves mesenchymal connective tissue of the heart, blood vessels, joints, and subcutaneous tissues

  • Recurrent phase

    • Extension of the cardiac effects of the disease

  • Chronic phase

    • Permanent deformity of the heart valves


Fetal blood flow

Fetal Blood Flow

  • Parallel rather than in series

  • Right ventricle delivering most of its output to the placenta for oxygen uptake

  • Left ventricle pumping blood to the heart, brain, and primarily upper body

  • Umbilical vein and two umbilical arteries

  • Foramen ovale

    • Allows blood to enter the left atrium from the right atriumDuctusarteriosus

    • A shunt connecting the pulmonary artery to the aortic arch


Cyanosis and shunting

Cyanosis and Shunting

  • Defects that increase resistance to aortic outflow increase left-to-right shunting.

  • Defects that obstruct pulmonary outflow increase right-to-left shunting.

  • Crying, defecating, or stress of feeding may increase pulmonary vascular resistance and cause an increase in right-to-left shunting.

  • Resulting cyanosis


Factors affecting postnatal pulmonary vascular development

Factors Affecting Postnatal Pulmonary Vascular Development

  • Prematurity

  • Alveolar hypoxia

  • Lung disease

  • Congenital heart defects


Types of congenital heart defects

Types of Congenital Heart Defects

  • Patent ductusarteriosus

  • Atrial septal defects

  • Ventricular septal defects

  • Endocardial cushion defects

  • Pulmonary stenosis

  • Tetralogy of Fallot

  • Transposition of the great vessels

  • Coarctation of the aorta

  • Kawasaki disease


Question2

Question

  • Which of the following might result in the development of a cardiomyopathy?

  • A. Valvularstenosis

  • B. Valvularregurgitation

  • C. MI

  • D. Ischemia

  • E. All the above


Disorders of cardiac function

Answer

  • A. Valvularstenosis

  • B. Valvularregurgitation

  • C. MI

  • D. Ischemia

  • E. All the above: Any of these conditions can contribute to the development of a cardiomyopathy.


Kawasaki disease

Kawasaki Disease

  • Vasculitisin the small vessels; progresses to involve some of the larger arteries

  • Immunologic in origin

    • Acute phase: fever, conjunctivitis, rash, involvement of the oral mucosa, redness and swelling of the hands and feet, and enlarged cervical lymph nodes

    • Subacute phase: defervescence and desquamation

    • Convalescent phase: complete resolution of symptoms until all signs of inflammation have disappeared after about 8 weeks


Signs and symptoms of childhood congenital heart disease

Signs and Symptoms of Childhood Congenital Heart Disease

  • Symptoms associated with altered heart action

  • Heart failure

  • Pulmonary vascular disorders

  • Difficulty in supplying the peripheral tissues with oxygen and other nutrients


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