Systemic effects of cardiovascular disease Flashcards
Learning objectives
Revise thrombosis
• Seeing Disease section 6 to revise thrombosis https://sway.office.com/kyen3WcSyrK6jWrb
Define cardiac failure
• Appreciate the differences between the following pairs of terms:
– acute and chronic cardiac failure;
– systolic and diastolic cardiac failure; – right and left ventricular failure
• Describe the causes of left and right ventricular failure
– Describe the clinical effects of left and right ventricular failure
• Distinguish between pulmonary and systemic hypertension
• Be aware of B-natriuretic peptide BNP
• Describe the causes of systemic hypertension
– Describe the end-organ effects of systemic hypertension
• Describe the causes of pulmonary hypertension
– Describe the end-organ effects of pulmonary hypertension
Define cardiac failure
• Failure of the heart to pump sufficient
blood, and deliver sufficient oxygen, to satisfy
metabolic demands
• Results in under-perfusion which may cause fluid retention and increased blood volume
Discuss acute and chronic cardiac failure
• Acute heart failure
– rapid onset of symptoms, often with definable cause e.g. myocardial infarction
• Chronic heart failure
– slow onset of symptoms, associated with, for
example, ischaemic or valvular heart disease
• Acute-on-chronic heart failure
– chronic failure becomes decompensated by an acute event
Discuss systolic cardiac failure
Systolic failure • Failure of the pump to move blood in systole • Reduced ejection fraction • Reduced ventricular contraction Causes • Myocardial ischaemia • Myocardial infarction • Myocardial scarring • Myocarditis • Drugs eg alcohol, anti-cancer cytotoxics, cocaine • Muscular disorders eg DMD Effects • Reduced cardiac output • Feedback to atria and right side of heart • Pulmonary oedema then • Peripheal oedema Treatment • Support - what else?
Discuss diasystolic cardiac failure
Diastolic failure •Failure of ventricular wall to relax •Restrictive, stiff ventricle •Reduced ventricular filling leads to reduced blood for systole •Elevated end diastolic pressure Causes •Scarring plus most causes of systolic •Infiltrative disease eg amyloid Effects •None •Pulmonary and peripheral oedema •Response to exercise •Tachycardia and pulmonary acute oedema Treatment •Reduce AV conduction – what else?
Describe the causes of left and right ventricular failure
• Coronary heart disease
• Hypertension
• Cardiomyopathies-Familial/genetic or non-familial/non-genetic (including acquired, e.g. Myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassified
• Drugs-beta-Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents
• Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic)
• Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma
• Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia
• Infiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue
disease
• Others Chagas’ disease, HIV infection, peripartum cardiomyopathy, end- stage renal failure
Discuss left ventricular failure
- Particularly resulting from hypertensive and ischaemic heart failure
- Causes pulmonary oedema, with associated
- symptoms
- Leads to pulmonary hypertension and, eventually, right ventricular failure
- Combined left and right ventricular failure often called ‘congestive’ cardiac failure
Right ventricular
Common causes • Secondary to left ventricular failure • Related to intrinsic lung disease • ‘Cor pulmonale’ due to pulmonary hypertension • Primary pulmonary hypertension
scuss key features of the clinical examination inpatients with failure
• Appearance -alertness, nutritional status, weight
• Pulse rate -rhythm, and character
• Blood pressure -systolic, diastolic, pulse
pressure
• Fluid overload -jugular venous pressure
• Peripheral oedema -(ankles and sacrum),
hepatomegaly, ascites
• Respiratory rate, crackles, effusion (transudate)
• Apex displacement, gallop rhythm, third heart sound, flow murmurs suggesting valvular dysfunction
Discuss clinical features of heart failure
• “Forward” failure
– Reduced perfusion of tissues
– Tends to be more associated with advanced failure
• “Backward” failure
– Due to increased venous pressures
– Dominated by fluid retention and tissue congestion
Discuss B-natriuretic protein
- BNP is one of of the natriuretic peptide hormone family, produced by ventricular muscle. It is a stress response protein that increases in heart failure.
- ANP produced in atrial muscle
- CNP from large blood vessels
- DNP present in blood probably originates from heart
- Vessel dilatation
- Natriuresis
- Modulation angiotensin and aldosterone
- Reduction in blood pressure
Systemic hypertension
• Common
• Classification
– Primary vs secondary (based on cause)
– Essential vs accelerated (based on clinical presentation)
– (be aware of the previous use of the term “essential” hypertension)
• Definition
– Persistent raised blood pressure above 140/90 mmHg (Framingham, Multiple Risk Factor Intervention Trial –both suggest systolic pressure more important in determining cardiovascular risk)
Why is understanding hypertension
• Hypertension is a major risk factor for: – Cardiovascular disease
– Ischaemic heart disease
– Accelerated atherosclerosis
– Alzheimer type dementia?
• Important preventable cause of premature disease and death in developed and developing countries.
Discuss the epidemiology of hypertension
- Hypertension is often symptomless, so screening is vital -before damage is done.
- About 30% of people aged 45-54 years have blood pressure (BP) that is at least 140/90 mm Hg.
- About 70% of people aged 75 years or older have BP that is at least 140/90 mm Hg
Discuss normal ranges of bp
• Optimal 120/80 mm Hg
– Normal <130/<85 mm Hg
– High normal 130-139/85-89 mm Hg (labelled ‘pre- hypertension’ in the USA)
• Hypertension
– Mild hypertension Grade 1 140-159/90-99 mm Hg
– Moderate hypertension Grade 2 160-179/100-109 mm Hg – Severe hypertension Grade 3 180/110 mm Hg
• Isolated systolic hypertension – Grade 1 140-159/<90 mm Hg – Grade 2 160/<90 mm Hg
