Chapter 23 Alterations of Cardiovascular Function Mosby items

Diseases of the Veins Varicose veins Ø Ø A vein in which blood has pooled Distended, tortuous, and palpable veins Caused by trauma or gradual venous distention Risk factors: • Age • Female gender • Family history • Obesity • Pregnancy • Peep vein thrombosis • Prior leg injury Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 2

Diseases of the Veins (cont’d) Chronic venous insufficiency Inadequate venous return over a long period due to varicose veins or valvular incompetence Ø Venous stasis ulcers Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 3

Diseases of the Veins (cont’d) Deep venous thrombosis Obstruction of venous flow leading to increased venous pressure Ø Factors: • Triad of Virchow Ø Venous stasis Venous endothelial damage Hypercoagulable states • Other (cancer, orthopedic surgery/trauma, heart failure, immobility) Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 4

Diseases of the Veins (cont’d) Superior vena cava syndrome Progressive occlusion of the superior vena cava that leads to venous distention of upper extremities and head Ø Oncologic emergency Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 5

Diseases of the Arteries and Veins Hypertension Ø Isolated systolic hypertension—becoming prevalent in all age groups • Elevations of systolic pressure are caused by increases in cardiac output, total peripheral vascular resistance, or both Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 6

Diseases of the Arteries and Veins (cont’d) Primary hypertension Essential or idiopathic hypertension Genetic and environmental factors Affects 92% to 95% of individuals with hypertension Ø Risk factors: • High sodium intake • Natriuretic peptide abnormalities • Obesity • Insulin resistance Ø Ø Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 7

Primary Hypertension Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Diseases of the Arteries and Veins Secondary hypertension Caused by a systemic disease process that raises peripheral vascular resistance or cardiac output Ø Renal artery stenosis, renal parenchymal disease, pheochromocytosis, drugs Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 9

Diseases of the Arteries and Veins (cont’d) Complicated hypertension Chronic hypertensive damage to the walls of systemic blood vessels Ø Smooth muscle cells undergo hypertrophy and hyperplasia with fibrosis of the tunica intima and media Ø Affects heart, kidneys, retina Ø Can result in transient ischemic attack/stroke, cerebral thrombosis, aneurysm, dementia Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 10

Diseases of the Arteries and Veins (cont’d) Malignant hypertension Ø Ø Ø Rapidly progressive hypertension Diastolic pressure is usually >140 mm Hg Life-threatening organ damage Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 11

Diseases of the Arteries and Veins (cont’d) Orthostatic (postural) hypotension Decrease in both systolic and diastolic blood pressure upon standing Ø Lack of normal blood pressure compensation in response to gravitational changes on the circulation Ø Acute orthostatic hypotension Ø Chronic orthostatic hypotension Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 12

Diseases of the Arteries and Veins (cont’d) Aneurysm Local dilation or outpouching of a vessel wall or cardiac chamber Ø True aneurysms • Fusiform aneurysms • Circumferential aneurysms Ø False aneurysms • Saccular aneurysms Ø Aorta most susceptible, especially abdominal • Causes include atherosclerosis, hypertension • Can lead to aortic dissection or rupture Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 13

Aneurysm Mosby items and derived items © 2012 Mosby, Inc. , an imprint of

Aneurysm (cont’d) Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Diseases of the Arteries and Veins Thrombus formation Blood clot that remains attached to the vessel wall Ø Risk factors include intimal injury/inflammation, obstruction of flow, pooling (stasis) Ø Thromboembolus Ø Thrombophlebitis Ø Arterial thrombi Ø Venous thrombi Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 17

Diseases of the Arteries and Veins (cont’d) Embolism Ø Bolus of matter that is circulating in the bloodstream • Dislodged thrombus • Air bubble • Amniotic fluid • Aggregate of fat • Bacteria • Cancer cells • Foreign substance Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 18

Diseases of the Arteries and Veins (cont’d) Peripheral artery disease Ø Atherosclerotic disease of the arteries that perfuses the limbs Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 19

Peripheral Artery Disease Thromboangiitis obliterans (Buerger disease) Occurs mainly in young men who smoke Inflammatory disease of peripheral arteries resulting in the formation of nonatherosclerotic lesions • Digital, tibial, plantar, ulnar, and palmar arteries Ø Obliterates the small and medium-sized arteries Ø Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 20

Peripheral Artery Disease (cont’d) Thromboangiitis obliterans (Buerger disease) (cont’d) Causes pain, tenderness, and hair loss in the affected area Ø Symptoms are caused by slow, sluggish blood flow Ø Can often lead to gangrenous lesions Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 21

Peripheral Artery Disease (cont’d) Raynaud phenomenon and Raynaud disease Episodic vasospasm in arteries and arterioles of the fingers, less commonly the toes Ø Raynaud disease is a primary vasospastic disorder of unknown origin Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 22

Peripheral Artery Disease (cont’d) Raynaud phenomenon and Raynaud disease (cont’d) Raynaud phenomenon is secondary to other systemic diseases or conditions: • Collagen vascular disease • Smoking • Pulmonary hypertension • Myxedema • Cold environment Ø Manifestations include pallor, cyanosis, cold, pain Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 23

Diseases of the Arteries and Veins Arteriosclerosis Ø Chronic disease of the arterial system • Abnormal thickening and hardening of the vessel walls • Smooth muscle cells and collagen fibers migrate to the tunica intima Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 24

Arteriosclerosis Mosby items and derived items © 2012 Mosby, Inc. , an imprint of

Diseases of the Arteries and Veins Atherosclerosis Form of arteriosclerosis Thickening and hardening caused by accumulation of lipid-laden macrophages in the arterial wall Ø Plaque development Ø Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 26

Diseases of the Arteries and Veins (cont’d) Atherosclerosis (cont’d) Progression • Inflammation of endothelium • Cellular proliferation • Macrophage migration and adherence • LDL oxidation (foam cell formation) • Fatty streak • Fibrous plaque • Complicated plaque Ø Risk factors include hyperlipidemia/dyslipidemia, diabetes, smoking, hypertension Ø Result in—inadequate perfusion, ischemia, necrosis Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 27

Atherosclerosis Mosby items and derived items © 2012 Mosby, Inc. , an imprint of

Atherosclerosis (cont’d) Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Peripheral Arterial Disease Atherosclerotic disease of arteries that perfuse limbs Intermittent claudication Mosby items

Coronary Artery Disease Any vascular disorder that narrows or occludes the coronary arteries leading to myocardial ischemia Atherosclerosis is the most common cause Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 31

Coronary Artery Disease (cont’d) Risk factors: Ø Major: • Increased age • Family history • Male gender or female gender post menopause Ø Modifiable: • Dyslipidemia • Hypertension • Cigarette smoking • Diabetes mellitus • Obesity/sedentary lifestyle • Atherogenic diet Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 32

Coronary Artery Disease (cont’d) Nontraditional risk factors: Ø Markers of inflammation and thrombosis • High density C-reactive protein, erythrocyte sedimentation rate, von Willebrand factor concentration, interleukin-6, interleukin-18, tumor necrosis factor, fibrinogen, and CD 40 ligand Ø Ø Ø Hyperhomocysteinemia Adipokines Infection Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 33

Coronary Artery Disease (cont’d) Myocardial ischemia Local, temporary deprivation of the coronary blood supply Ø Stable angina Ø Prinzmetal angina Ø Silent ischemia Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 34

Myocardial Ischemia Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Coronary Artery Disease Acute coronary syndromes: Transient ischemia Unstable angina Sustained ischemia Myocardial infarction • STEMI or non-STEMI Ø Myocardial inflammation and necrosis Ø Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 36

Myocardial Infarction Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Coronary Artery Disease Myocardial infarction Sudden and extended obstruction of the myocardial blood supply Ø Subendocardial infarction Ø Transmural infarction Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 38

Myocardial Infarction Cellular injury Cellular death Structural and functional changes: Ø Ø Ø Myocardial stunning Hibernating myocardium Myocardial remodeling Repair Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 39

Myocardial Infarction (cont’d) Manifestations: Ø Ø Sudden severe chest pain; may radiate Nausea, vomiting Diaphoresis Dyspnea Complications: Ø Sudden cardiac arrest due to ischemia, left ventricular dysfunction, and electrical instability Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 40

Myocardial Infarction (cont’d) Mosby items and derived items © 2012 Mosby, Inc. , an

Disorders of the Heart Wall Disorders of the pericardium: Acute pericarditis Pericardial effusion • Tamponade Ø Constrictive pericarditis Ø Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 44

Pericarditis Mosby items and derived items © 2012 Mosby, Inc. , an imprint of

Disorders of the Myocardium Cardiomyopathies: Dilated cardiomyopathy (congestive cardiomyopathy) Ø Hypertrophic cardiomyopathy • Asymmetrical septal hypertrophy • Hypertensive (valvular hypertrophic) cardiomyopathy Ø Restrictive cardiomyopathy Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 46

Cardiomyopathy Mosby items and derived items © 2012 Mosby, Inc. , an imprint of

Disorders of the Endocardium Valvular dysfunctions: Valvular stenosis • Aortic stenosis • Mitral stenosis Ø Valvular regurgitation • Aortic regurgitation • Mitral regurgitation • Tricuspid regurgitation Ø Mitral valve prolapse syndrome (MVPS) Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 48

Valvular Dysfunction Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Acute Rheumatic Fever and Rheumatic Heart Disease Rheumatic fever Systemic, inflammatory disease caused by a delayed immune response to pharyngeal infection by the group A beta-hemolytic streptococci Ø Febrile illness • Inflammation of the joints, skin, nervous system, and Ø heart Ø If left untreated, rheumatic fever causes rheumatic heart disease Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 50

Acute Rheumatic Fever and Rheumatic Heart Disease (cont’d) Rheumatic fever (cont’d) Ø Common manifestations: • Fever • Lymphadenopathy • Arthralgia • Nausea/vomiting • Tachycardia • Abdominal pain • Epistaxis Ø Major clinical manifestations: • Carditis • Polyarthritis • Chorea • Erythema marginatum Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 51

Infective Endocarditis Inflammation of the endocardium Agents: Ø Ø Ø Bacteria Viruses Fungi Rickettsiae Parasites Pathogenesis Ø Ø Ø Damaged (prepared) endocardium Blood-borne microorganism adherence Proliferation of the microorganism (vegetations) Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 52

Infective Endocarditis (cont’d) Manifestations: Ø Classic finding: s • Fever • New or changed cardiac murmur • Petechial lesions of the skin, conjunctiva, and oral mucosa Ø Characteristic physical findings: • Osler nodes (painful erythematous nodules on the pads of the fingers and toes) • Janeway lesions (nonpainful hemorrhagic lesions on the palms and soles) Ø Other: weight loss, back pain, night sweats, and heart failure Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 53

Infective Endocarditis (cont’d) Mosby items and derived items © 2012 Mosby, Inc. , an

Bacterial Endocarditis Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Cardiac Complications of AIDS Myocarditis Endocarditis Pericarditis Cardiomyopathy Pericardial effusion Pulmonary hypertension Antiviral drug-related cardiotoxicity Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 56

Dysrhythmias (Arrhythmias) Disturbance of the heart rhythm Range from occasional “missed” or rapid beats to severe disturbances that affect the pumping ability of the heart Can be caused by an abnormal rate of impulse generation or abnormal impulse conduction Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 57

Dysrhythmias Examples: Ø Ø Ø Ø Tachycardia Flutter Fibrillation Bradycardia Premature ventricular contractions (PVCs) Premature atrial contractions (PACs) Asystole Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 58

Heart Failure General term used to describe several types of cardiac dysfunction that result in inadequate perfusion of tissues with bloodborne nutrients Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 59

Heart Failure (cont’d) Left heart failure (Congestive heart failure) Ø Systolic heart failure • Inability of the heart to generate adequate cardiac output to perfuse tissues • Ventricular remodeling • Causes include myocardial infarction, myocarditis, cardiomyopathy Ø Diastolic heart failure • Pulmonary congestion despite normal stroke volume and cardiac output • Causes include myocardial hypertrophy and ischemia, diabetes, valvular and pericardial disease Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 60

Heart Failure (cont’d) Manifestations of left heart failure: Result of pulmonary vascular congestion and inadequate perfusion of the systemic circulation Ø Include dyspnea, orthopnea, cough of frothy sputum, fatigue, decreased urine output, and edema Ø Physical examination often reveals pulmonary edema (cyanosis, inspiratory crackles, pleural effusions), hypotension or hypertension, an S 3 gallop, and evidence of underlying CAD or hypertension Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 61

Heart Failure (cont’d) Right heart failure Most commonly caused by a diffuse hypoxic pulmonary disease Ø Can result from an increase in left ventricular filling pressure that is reflected back into the pulmonary circulation Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 62

Heart Failure (cont’d) High-output failure Inability of the heart to supply the body with blood-borne nutrients, despite adequate blood volume and normal or elevated myocardial contractility Ø Causes include anemia, hyperthyroidism, septicemia Ø Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 63

Right Heart Failure Mosby items and derived items © 2012 Mosby, Inc. , an

High-Output Failure Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Shock Cardiovascular system fails to perfuse the tissues adequately Leads to impaired cellular metabolism Ø Ø Impaired oxygen use Impaired glucose use Manifestations vary based on stage but often include hypotension, tachycardia, increased respiratory rate Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 66

Shock (cont’d) Mosby items and derived items © 2012 Mosby, Inc. , an imprint

Types of Shock Cardiogenic Hypovolemic Neurogenic Anaphylactic Septic Mosby items and derived items ©

Types of Shock (cont’d) Mosby items and derived items © 2012 Mosby, Inc. ,

Multiple Organ Dysfunction Syndrome Progressive dysfunction of two or more organ systems resulting from an uncontrolled inflammatory response to severe illness or injury Causes: Manifestations: Most common: sepsis, septic shock Ø Other: any severe injury (trauma, burns, major surgery) Ø Ø Ø Respiratory Hepatic Renal GI Myocardial failure Mosby items and derived items © 2012 Mosby, Inc. , an imprint of Elsevier Inc. 74