Diseases of the Heart

Major Determinants of Disease

Most heart disease is the result of atherosclerotic obstruction of the
coronary arteries
Congestive heart failure is mechanical failure of the heart to eject
blood delivered to it
Metabolic or autoimmune disease may cause heart muscle or valve
damage
High blood pressure accelerates atherosclerosis & most other
cardiac disease
Cardiac valves are one-way gates for blood flow & are susceptible to
obstruction & regurgitation
Cardiac valves are susceptible to infection
Abnormal embryonic development of the heart produces significant
cardiac anatomic malformations
Abnormal heartbeat patterns (arrhythmias) can cause cardiac
dysfunction or death & can complicate any heart condition
Arrhythmias
Mechanically inefficient
CO decreases
Potentially fatal
Caused by
myocardial ischemia
MI
electrolyte imbalance
stress
caffeine
drugs, especially stimulants
congenital defects in the electrical network
Normal rhythm is ~ 70 beats/min
bradycardia is < 60 beats/min
tachycardia is > 100 beats/min
Premature atrial contractions
extra atrial beats
common in healthy people
not harmful
due to
stress
lack of sleep
caffeine
some drugs
Atrial flutter
rapid, regular atrial rhythm
~ 300 beats/min
Atrial fibrillation
rapid, irregular atrial rhythm
AV node filters out alot
decreased CO
Each year heart disease accounts for
about 1/3 of deaths in the US, most of
which are associated with coronary
artery atherosclerosis. If
cerebrovascular disease, vascular
complications of diabetes, & other
vascular diseases are included, the
figure is over 40%. After age 40 the
lifetime risk for developing
symptomatic coronary artery disease is
50% in men & 40% in women.
Heart Block
Atrial signal is delayed & cannot cross into the
ventricle
Common cause is anatomic abnormalities
Can also be caused by digitalis
1
st
degree
delay of signal but no missed ventricular beats
2
nd
degree
delay long enough to cause missed ventricular beats
3
rd
degree
total block of atrial signal
decreased CO
Premature ventricular contractions
occur in healthy people
chest palpitations & anxiety
Ventricular tachycardia
spontaneous, regular beating at > 120
beats/min
decreased CO
Ventricular fibrillation
extremely rapid & irregular
negligible CO
Congestive Heart Failure
CHF
Heart unable to eject volume of blood delivered
to it
Endpoint for
coronary atherosclerosis
HTN
valve disease
cardiomyopathy
congenital cardiac malformation
Affects about 1% of Americans
die within 5 years
Most common cause is cardiac muscle
damage usually due to CAD
Less commonly due to valve defects
Heart tries to compensate for either of
these by increasing HR & force of
contraction & through cardiac muscle
hypertrophy
In L ventricular failure, low CO causes
systemic hypoperfusion & pulmonary
venous congestion
In R ventricular failure, low CO causes
systemic venous congestion
The most common cause of R heart failure
is L heart failure
The low CO of L heart failure reduces
renal blood flow which stimulates the
renin-angiotensin-aldosterone system
R & L ventricles
can fail
independently but
usually fail
together
2 components to
uncompensated
failure
forward failure
low ventricular
output
backward failure
venous congestion
L Heart Failure
L ventricle dilates
Forward component
decreased blood flow
to organs
Backward component
blood backs up into L
atrium & lungs
pulmonary edema
dyspnea
R Heart Failure
R ventricle dilates
Forward component
decreased blood flow to lungs
Backward component
systemic venous congestion
congestion of liver, spleen
edema in feet & legs
ascites
Usually not by itself but found in combination
with pulmonary HTN
known as cor pulmonale
Etiology
L heart failure
damaged cardiac
muscle
HTN
valve disease
cardiomyopathy
R heart failure
L heart failure
pulmonary HTN
lung disease
valve disease
congenital heart
disease involving L to
R shunt
Coronary Artery Disease
CAD
Almost all from atherosclerotic narrowing
or complete obstruction
Depending on the degree & character of
the obstruction
angina pectoris
MI
sudden cardiac death
chronic ischemic heart disease with CHF
Epidemiology
Begins in the crib
Risk factors
age
high LDL
low HDL
HTN
smoking
fatty diet
sedentary lifestyle
diabetes
familial history
Average patient
overweight
diet high in saturated fat
big belly
little exercise
high cholesterol
has diabetes or HTN
Causes of Coronary Ischemia
Partial obstruction
usually stable plaques
coronary vasospasm
Complete obstruction
usually an unstable
plaque
Angina Pectoris
Distinctive sensation caused by
myocardial ischemia
Described as
smothering
pressing
aching
heaviness
May radiate to
jaw
shoulder
arms
upper abdomen
May have dyspnea & sweating
Stable angina
rises & falls smoothly over a few
minutes
rest & medication helps
usually precipitated by exertion or
emotion
Unstable angina
caused by platelets aggregating
on a plaque
may herald an impending MI
new onset, intensification,
nocturnal, prolonged
need intervention
Unremitting angina
does not fluctuate
no relief
due to MI
Myocardial Infarction
MI
Area of necrosis caused by
ischemia
Most common cause of death
in industrialized nations
Most initiated by plaque
disruption & accompanying
thrombosis
Size of infarct determined by
vessel involved
Age of infarct determined by
gross & microscopic findings
coagulative necrosis early
development of granulation
tissue
mature scar
Nearly of all infarcts involve anterior descending
About 1/3 involve the R coronary artery
The rest involve the circumflex artery
Deepest muscle is last supplied & 1
st
to die
subendocardial infarct
In 3-6 hours, can enlarge to involve the full thickness of
the ventricular wall
transmural infarct
Anatomic complications
Infarct papillary muscles
Release of substances from necrotic muscle that attracts
platelets & WBCs to form mural thrombus
Chronic Myocardial Ischemia
Elderly
Usually have CHF
Ventricles dilated, thin-walled, & flabby
May lead to heart failure
Sudden Cardiac Death
Death within 1 hour of onset of symptoms
About of all cardiac deaths
Most common cause of instantaneous
death in industrialized society
Most due to electrical malfunction
asystole
ventricular fibrillation
Hypertensive Heart Disease
L ventricular hypertrophy
Stiff myocardium
susceptible to infarction
reduced compliance &
stroke volume
increases diffusion
distance
Predisposed to
atherosclerosis
End result is often CHF,
MI, or arrhythmias
Valvular Heart Disease
Causes
Inflammation & infection
Syphilitic aortitis
Myxomatous degeneration of the mitral
valve
Ruptured mitral valve chordae tendineae
Massive L ventricular dilation
Rheumatic Heart Disease
Calcific Aortic Stenosis
Age-related
degenerative changes
Fibrosis, calcification,
deformity
Have
systolic murmur
L ventricular
hypertrophy
angina
syncope
Mitral Valve Prolapse
Most common valve
disease
floppy valve
Cause unknown
Late systolic murmur
& mid-systolic click
Most patients
asymptomatic
Noninfective Thrombotic
Endocarditis
Vegetations of platelets &
fibrinous material
No microbes in lesions
but susceptible to
microbial colonization
Linked to
cachexia
DVT
hypercoagulable blood
malignancies
May embolize
Infective Endocarditis
Almost always caused by
bacterial infection
L-sided valves most commonly
affected
Vegetations containing
microbes
May embolize
Greatest hazard is erosion &
perforation of the valve
Usually affects previously
disease valves
Staphylococcus more
dangerous than Streptococcus
or Enterococcus
Myocarditis
Usually due to virus
coxsackie A or B
Most resolve without therapy but a few
cases proceed to CHF
Cardiomyopathies
Primary
Intrinsic disease of
cardiac muscle
Cause usually
unknown
Secondary
Associated with
ischemic heart disease
HTN
infections
valvular disease
congenital
abnormalities
Dilated Cardiomyopathy
Hypertrophy, dilation,
& low ejection fraction
Cause usually
unknown
Heart is flabby &
weak
All chambers dilated
Hypertrophic Cardiomyopathy
About the cases are genetic
Sudden death in children & young adults
during or immediately after exertion
Myocardium is stiff
Diastolic filling incomplete
Restrictive Cardiomyopathy
Stiff, noncompliant ventricle which fills
incompletely during diastole
Systole not forceful
Usual outcome is CHF
Congenital Heart Disease
One of most common congenital
abnormalities
8 in 1000 live births
Cause usually unknown
Defects develop in 1
st
10 weeks
Malrotation defects
Expansion defects
Septal defects
Malformations with Shunts
Most common
May cause pulmonary HTN & R heart
failure
Malformations with Obstruction to
Flow
Embryonic vessels fail to expand properly
Coarctation of the aorta
high BP in arms but low BP in legs
low blood flow to kidneys
50% of cases also have PDA
Pericardial Disease
Pericarditis
usually viral infection
atypical chest pain
friction rub
Pericardial effusion
may occur in noninflammatory conditions
hemopericardium