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Heartattackandfailure
Physiology2016
Bloodsupplytotheheart:Thecoronarycirculation
Coronarycirculationisthecirculationofbloodin
thebloodvesselsoftheheartmuscle
(myocardium).Thevesselsthatdeliveroxygen
richbloodtothemyocardiumareknownas
coronaryarteries.Thevesselsthatremovethe
deoxygenatedbloodfromtheheartmuscleare
knownascardiacveins.
https://www.youtube.com/watch?v=tBQa8IBzP6I
Castofcoronaryarteries
(right=yellow,left=red)
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CoronaryHeartDisease
Themajorunderlyingcauseisatherosclerosis.
Atherosclerosis isaslow,progressivediseasewhichbeginsin
childhoodandtakesdecadestoadvance
Plaque (thebuildupoflipid/cholesterol)inthearterywall
formsasaresponseto injury totheendotheliumintheartery
wall.
CoronaryHeartDisease
(Plaque,Atherosclerosis)
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RiskFactorsOfCoronaryArtery
Diseases
Major Minor
Diabetes Obesity
HighBloodPressure Inactivity
AbnormalCholesterol Diet
FamilyHistory Gout
Smoking HormonalDisorders
STRESS
PresentationOfCAD
Nosymptoms
Angina
Heartattack
Suddendeath
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WhatisHeartattack?
MyocardialInfarction/Heartattack
Symptoms:
Uncomfortablepressure
Fullness
Squeezingpain
Painspreadingtotheshoulders
Neckandarms
Chestdiscomfortandlightheadedness
Anxiety/nervousness
sweating
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DiagnosisofCoronaryHeartDisease
Electrocardiogram(EKG)
Stresstest
Nuclearscanning
Coronaryangiography
ECG
normal
infarcted
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Complications
Relatedtosizeandlocationofinfarct
Dysrhythmias
Pumpfailure
Cardiogenicshock
Pericarditis
TreatmentforCHD
Lifestylechanges
Medication
Surgery
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LifestyleChanges
Changeofhabits
Lowfatdiet
Lowerweight
Increaseexercise
Stopsmoking
MedicationstoTreatCHD
Betablockers
Nitroglycerineandothernitrates
Calciumchannelblockers
Aspirin
Cholesterolloweringdrugs
lovastatin,colestipol,cholestyramine,etc
Digitalis
ACEinhibitors
Diuretics
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SurgerytoTreatCHD
Balloonangioplasty
Atherectomy
Laserangioplasty
Stentinsertion
Coronaryarterybypassoperation(CABG)
Angioplasty&Stent(PTCA)
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CoronaryArteryBypassSurgery
Themostfrequentlyperformed
majorsurgery.
SurgeryreroutesorBypasses
bloodaroundcloggedarteries.
CongestiveHeartFailure
Impairedcardiacpumpingsuchthatheartisunabletopump
adequateamountofbloodtomeetmetabolicneeds
Notadiseasebutasyndrome
Associatedwithlongstandinghypertensionandcoronary
arterydisease.
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PathophysiologyofCongestiveHeart
Failure
Pumpfailsdecreasedstrokevolume/CO.
CompensatorymechanismskickintoincreaseCO
SNSs mula onreleaseofepinephrine/norepinephrine
IncreaseHR
Increasecontractility
Peripheralvasoconstriction(increasesafterload)
Myocardialhypertrophy:wallsofheartthickentoprovidemoremuscle
massstrongercontractions
Hormonalresponse:drenalperfusioninterpretedbyjuxtaglomerular
apparatusashypovolemia.Thus:
Kidneysreleaserenin,whichstimulatesconversionofantiotensin I
angiotensinII,whichcauses:
AldosteronereleaseNareten onandwaterreten on(viaADH
secretion)
Peripheralvasoconstriction
PathophysiologyofCongestiveHeart
Failure
CompensatorymechanismsmayrestoreCOtonear
normal.
But,ifexcessivethecompensatorymechanismscanworsen
heartfailurebecause...
Vasoconstric on:stheresistanceagainstwhichheart
hastopump(i.e.,sa erload),andmaythereforeCO
Naandwaterreten on:suidvolume,whichs
preload.Iftoomuchstretch(d/ttoomuchuid)
strengthofcontrac onandsCO
Excessivetachycardiaddiastoliclling med
ventricularllingdSVandCO
afterload: the pressure in the wall of the left ventricle during ejection
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RiskFactors
Coronarydisease
Age
Hypertension
Obesity
Cigarettesmoking
Diabetesmellitus
Highcholesterol
FunctionalClassification
(NewYorkHeartAssociation)
ClassI:Nosymptomswithordinaryactivity
ClassII:Slightlimitationofphysicalactivityresultsin
fatigue,shortnessofbreath,chestpainorirregular
heartbeat
ClassIII:Markedlimitationofphysicalactivity.
Comfortableatrest,butlessthanordinaryphysical
activityresultsinfatigue,irregularheartbeat,painor
shortnessofbreath
ClassIV:Unabletocarryoutanyphysicalactivitywithout
discomfort.AllsymptomsinclassIIIevenatrest
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TypesofCongestiveHeartFailure
Leftsidedfailure
Mostcommonform
Bloodbacksupthroughtheleftatriumintothepulmonaryveins
Pulmonarycongestionandedema
Eventuallyleadstobiventricularfailure
Rightsidedfailure
Resultsfromdiseasedrightventricle
Bloodbacksupintorightatriumandvenouscirculation
Venouscongestion(Peripheraledema,Hepatomegaly,
Splenomegaly,Jugularvenousdistension)
CausesLVF left ventricular failure
Cor pulmonale:failureoftherightsideoftheheartbroughtonby
longtermhighbloodpressureinthepulmonaryarteriesandright
ventricleoftheheart
CongestiveHeartFailure
DiagnosticStudies
Primarygoalistodetermineunderlyingcause
Physicalexam
Chestxray
ECG
Hemodynamicassessment
Echocardiogram(Usesultrasoundtovisualize
myocardialstructuresandmovement,calculate
EF)
Cardiaccatheterization
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AcuteCongestiveHeartFailure
Management
PrimarygoalistoimproveLVfunctionby:
Decreasingintravascularvolume
Decreasingvenousreturn
Decreasingafterload
Improvinggasexchangeandoxygenation
Improvingcardiacfunction
Reducinganxiety
DecreasingintravascularvolumeimprovesLVfunctionbyreducingvenous
return.Loopdiuretic:drugofchoice
DecreasingafterloadDecreasespulmonarycongestion.Drugofchoice:
Angiotensinconvertingenzyme(ACE)inhibitors.
ImprovingcardiacfunctionbyusingPositiveinotropes increase the strength of heart contraction
Improvinggasexchangeandoxygenationbyadministeringoxygen,sometimes
intubateandventilate
ReducinganxietyusingMorphine
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