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2/15/2016

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?

Coronary artery becomes


blocked - usually by a
clot.
Blood flow is closed off
and the myocardium
becomes infarcyed. A
heart attack begins.
If blockage continues,
parts of the heart muscle
start to die.
Heart may stop beating.

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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