What are the three disorders of the pericarditis?
- 1. Acute pericarditis
- 2. Pericardial effusion
- 3. Constrictive pericarditis
Define acute pericarditis
inflammation of the pericardium characterized by chest pain, a pericardial friction rub and EKG abnormalities.
List 4 causes of acute pericarditis
- idiopathic (probably viral)
- connective tissue disorders
- radiation therapy
What are the clinical manifestations associated with acute pericarditis?
- chest pain
- friction rub
- EKG abnormalities
- low grade fever
What is the treatment and prognosis of acute pericarditis?
-Prognosis = favorable (usually self-limiting)
-Treatment = anti-inflammatory drugs, bedrest, NSAID, treat the cause
Define pericardial effusion.
accumulation of fluid in the pericardial cavity.
What are the causes of pericardial effusion?
- can occur in all types of pericarditis;
- indicates an underlying disorder
Increased capillary permeability and the development of exudate =
Define cardiac tamponade...
- accumulation of blood or fluid in the pericardial sac (pericardial effusion) that causes compression of the heart interfering with right atrial filling leading to decreased ventricular filling, stroke volume and cardiac output.
What is the classic manifestation of cardiac tamponade?
- paradoxical pulse - take bp manually- drop greater than 10mmHg
- Reflects impairment of diastolic filling of the left ventricle plus a reduction of bv in all four chambers.
Clinical manifestations of cardiac tamponade:
- paradoxical pulse
- muffled heart sound
- widened mediastinum
- distended neck vein
- ruddy appearance of head and neck
- EKG - electrical alterations
- feeling of impending doom
What is the treatment of a pericardial effusion or cardiac tamponade?
- Pericardiocentsis: therapeutic and diagnostic
- Anti-inflammatory medication
Define constrictive pericarditis.
- scar tissue develops between the visceral and parietal layers of the pericardium
- "heart is incased in a rigid shell"
What causes pericardial effusion?
- radiation exposure
- post CABG
What are the clinical manifestations associated with constrictive pericarditis?
- do NOT include paradoxical pulse.
- exercise intolerance/ fatigue
- weight loss
- hepatic congestion
- distended neck vein
- pericardial knock on heart sounds
- EKG- a fiv and t wave inversion
What is the treatment of constrictive pericarditis?
1. pharmalogical and dietary: digoxin, diuretics, Na restriction
If not successful then surgical excision- pericardectomy
Coronary Artery Disease-a condition and especially one caused by atherosclerosis that reduces the blood flow through the coronary arteries to the heart muscle and typically results in chest pain or heart damage.
What remains the leading cause of morbidity and mortality in the United States?
CAD and its clinical sequel, myocardial infarction
What is the leading contributing factor of CAD?
- (heredity, age, sex, race, Obesity, smoking, sedentary, HTN, COPD, DM)
What is the major risk factor leading to death from CAD?
When does ischemia occur?
when demand exceeds supply or when the supply is no longer able to keep up with metabolic demands
Define myocardial ischemia
- myocardial = pertaining to the muscles of the heart
- ischemia = to suppress or withhold blood flow
What is the most common cause of myocardial ischemia?
What are the factors that affect the supply of blood to the myocardium?
- Intramyocardial Tension
- Coronary Artery Resistance
- Decreased BV
What are the factors that affect the demand of blood flow to the myocardium?
- Myocardial wall tension
- Contractile state of myocardium
- Volume overload
- LV Hypertrophy
- Increase in PVR and Afterload
What are the factors that would increase coronary artery blood flow?
- Increase CO
- Increase aortic pressure
- Decrease coronary artery resistance
- Decrease the intramyocardial tension
What are the factors that decrease the myocardial oxygen demand?
- Decrease the HR
- Decrease the contractility of the myocardium
- Control HTN
- Afterload reduction
Define classic angina
- stable angina
- - chest pain with physical exertion or stress and diminishes with rest
Define unstable angina
chest pain that occurs unpredictably, with rest
- "cluster" periods of frequent chest pain followed by none
- due to spasms in arteries
What is the difference between a transmural infarction and a subendo infarction?
- transmural infarction = STEMI
- subendo infarction = NSTEMI
Myocardial Infarction = death of tissue associated iwth impaired blood flow sufficient to produce lethal cell death
What diseases are part of ACS?
- Unstable Angina
- NSTEMI- non ST elevated MI
- STEMI- ST elevated MI
Pathophysiology of MI
- 1. Ischemia
- 2. Injury
- 3. Infarction and Necrosis- NOT reversible
What are the precipitating events in MI
- at rest or moderate activity
- Combo of severe exertion, fatigue, or unusual emotional stress
- Common happenings are emotional stress and life events - death, divorce, marriage, loss of job, etc
What are the clinical manifestations associated with MI?
- 1. pain and autonomic responses (Chest pain-new, change in pattern, not relieved by rest or NTG)
- 2. weakness and (N& V, diaphoresis, tachycardia, hypotension, skin color, cold, clammy, dyspnea, deminished pulses, S4 or S3)
- 3. arrhythmias and EKG changes
- 4. signs of inflammation and elevated serum levels
What are key cardiac markers?
- isoenzymes (CK-MB)
- myoglobin levels
diseases that affect the myocardium resulting in enlargement and ventricular dysfunction.
- "Congestive cardiomyopathy"
- = dilation of all four chambers of the heart
What is the most common type of cardiomyopathy?
What causes dilated/congestive cardiomyopathies?
- commonly idiopathic
- toxins- chemo
- MI - extensive or reoccuring
- familial -20-30%
- immunologic abnormalities
What are the clinical manifestations associated with dilated cardiomyopathy?
- dyspnea, fatigue are Most common! arrhythmias, palpitations
- 1. pulmonary congestion (not pulmonary edema)
- 2. chest pain
- 3. HTN
- 4. CHF
- 5. abnormal hs
- 6. emboli
Treatment for dilated cardiomyopathy
- Na restriction
- Digoxin, Diuretics, Anticoagulants
- Afterload/Preload reducers
- Steroids or immunosuppressants
- Resynchronization with pacemaker
- Cardiac Transplant ONLY CURE!
What is the prognosis for dilated cardiomyopathy?
- 75% of the time death is caused by left heart failure!
- Sudden cardiac death is common
- Majority of deaths occur in 5 years.
Define hypertrophic cardiomyopathy.
asymmetric dilation or thickening of the septum.
Hypertrophic cardiomyopathy is also known as..
- asymmetric septal hypertrophy
- muscular sub aortic stenosis
- IHSS - idiopathic hypertrophic sub aortic stenosis
hypertrophic cardiomyopathy is commonly the result of ______, ______ and _______.
- Valvular heart disease
Which type of cardiomyopathy has disproportional thickening of the interventricular septum but externally the heart is normal size?
What are the clinical manifestations of hypertrophic cardiomyopathy?
- Some people will remain asymptomatic
- (Variable) Dyspnea, Fatigue, Arrythmias, palpitations, chest pain
- - Left heart failure
- - syncope (faint)
- - MI if septum outgrows blood supply
How do you diagnose hypertrophic cardiomyopathies?
- Echo and cardiac cath
- EKG- LV hypertrophy and arrhythmias
What is the treatment for hypertrophic cardiomyopathies?
- 1. Beta blockers
- 2. Ca channel blockers
- 3. Surgical resection of septum
- 4. ICD- implantable cardioverter-defibrillator
What is the prognosis for hypertrophic cardiomyopathy.
long-term survival is expected.
Define restrictive cardiomyopathy
abnormal diastolic filling and excessive rigid ventricular walls.
What are the causes of restrictive cardiomyopathy?
- INFILTRATIVE DISEASES:
- -glycogen storage disease
Which type of cardiomyopathy has a common clinical manifestation of CHF?
What are the causes of restrictive cardiomyopathy?
- CHF- particularly R. sided HF
What are the treatments for restrictive cardiomyopathy?
- None. Treat underlying cause.
- Death occurs because of CHF and arrhythmias
Define rheumatic fever.
diffuse, inflammatory disease caused by group A beta-hemolytic streptococcus
Which valves are most frequently affected by rheumatic fever?
- Mitral and aortic.
- fibrous scar tissue deform chorade tendinae
Rheumatic heart disease
end result of untreated rheumatic fever causes scarring and deformity of cardiac structures.
Define bacterial endocarditis.
- aka: "infective"
- inflammation of the endocardium usually the cardiac valves.
What are the two forms of bacterial endocarditis and who do they typically affect?
- 1. Acute: affect people with normal hearts
- 2. Subacute (SBE): affect people with damaged hearts
What are the risk factors of developing bacterial endocarditis?
- 1. Valvular heart disease
- 2. Congenital heart disease
- 3. IV drug abusers
- 4. long-term indwelling CV catheters
- 5. Recent CV surgery
- 6. previous bacterial endocarditis
Define valvular dysfunction:
disorder of the cardiac valve, characterized by stenosis and obstructed blood flow OR degeneration and regurgitation.
Acquired or congenital.
What are the two types of mechanical disruptions in vavular dysfunction and what is the hemodynamic derangements?
- 1. Narrowing of the valve opening= stenosis
- 2. Failure of valve to close properly = regurgitation
1. what to blood
2. causes what where?
3. first evidence
4. leads to
- 1. decrease in flow
- 2. cause increased workload in preceding chamber
- 3. first evidence occurs with exercise
- 4. pressure increases leading to myocardial hypertrophy
2. causes what where?
3. leads to
- 1. an incompetent valve that doesnt close and allows blood to linger
- 2. causes increases workload of both preceding chamber and chamber after. (atrium and ventricle)
- 3. leads to cardiomegaly, chamber dilation, and hypertrophy
What are the treatments of valvular dysfunction?
- 1. cardiac glycosides- digoxin
- 2. Diuretics
- 3. Na restriction
- 4. Antibiotics until valve repair or replacement necessary.
Most common valves affected in valvular dysfunction=
mitral and aortic
What is MVP?
- Mitral Valve Prolapse
- - mitral valve billow upward during systole because cusps are enlarged. regurgitation occurs if blood goes back into atrium
Who is MVP most common in ?