Unit 8: Cardiovascular, Circulatory, and Hematologic Systems
Disorder/Condition/Disease
Coronary Atherosclerosis
Angina Pectoris
Myocardial Infarction
Mitral Valve Prolapse
Chapters 26, 28, 29, 31, 32, & 33
Pathophysiology
Abnormal accumulation of lipid deposits and
fibrous tissue within arterial walls and lumen.
Blockages and narrowing of the coronary vessels
reduce blood flow to the myocardium
A syndrome characterized by episodes of pain or
pressure in the anterior chest caused by
insufficient coronary blood flow. Physical
exertion or emotional stress increases
myocardial oxygen demand, and the coronary
vessels are unable to supply sufficient blood flow
to meet the oxygen demand. Typical angina
subsides with rest or NTG
An area of the myocardium is permanently
destroyed. Usually caused by reduced blood flow
in a coronary artery due to rupture of an
atherosclerotic plaque and subsequent occlusion
of the artery by a thrombus. In unstable angina,
the plaque ruptures but the artery is not
completely occluded. “Acute coronary
syndrome” includes unstable angina and
myocardial infarction. The longer the MI
continues, the more damage that is done
The cause of mitral valve prolapsed is usually an
inherited connective tissue disorder resulting in
enlargement of one or both of the mitral valve
leaflets. A portion of one or both of the mitral
valve leaflets balloons back into the atrium
during systole. Rarely, the ballooning stretches
the leaflet to the point that the valve does not
remain closed during systole
Clinical Manifestations
Symptoms and complications are related
to the location and degree of vessel
obstruction. Angina; MI; Heart failure;
sudden cardiac death. Atypical symptoms
are more common in women and in
persons who are older or who have a
history of heart failure or diabetes. Nausea
& weakness may be present. Dyspnea is a
presenting symptom in elderly patients.
Tightness, choking, or heavy sensation.
Frequently retrosternal and may radiate to
neck, jaw, shoulders, back, or arms (usually
left). Anxiety frequently accompanies pain.
Dyspnea/SOB; dizziness; nausea/vomiting
Chest pain that occurs suddenly and
continues despite rest and medication is
the presenting symptom in most patients;
central and peripheral cyanosis. SOB;
indigestion; nausea; anxiety; cool, pale,
moist skin
Most patients have no symptoms. Fatigue,
SOB, lightheadedness, dizziness, syncope,
palpitations, chest pain, and anxiety
Assessment and Diagnostic
Studies
Laboratory tests
ECG, cardiac catheterization, hx
related coronary artery angiography,
clinical manifestations of ischemia,
C-reactive protein
ECG; biomarkers; See Table 28-3 (p.
876)
Physical exam of the heart reveals
an extra sound, referred to as a
mitral click. A systolic click is an early
sign that a valve leaflet is ballooning
into the left atrium. In addition to
the mitral click, a murmur of mitral
regurgitation may be heard if
progressive valve leaflet is stretching
and regurgitation have occurred.
Doppler echocardiography may be
used to diagnose and monitor the
progression of mitral valve prolapse
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Chapters 26, 28, 29, 31, 32, & 33
Often the margins of the mitral valve cannot
close during systole. Involves blood flowing back
from the left ventricle into the left atrium during
systole. With each beat of the left ventricle,
some of the blood is forced back into the left
atrium. Because this blood is added to the blood
flowing in from the lungs, the left atrium must
stretch. It eventually hypertrophies and dilates.
The backward flow of blood from the ventricle
diminishes the volume of blood flowing into the
atrium from the lungs. As a result, the lungs
become congested, eventually adding extra
strain on the right ventricle. Mitral regurgitation
ultimately involves the lungs and the right
ventricle.
Obstruction of blood flowing from the left atrium
into the left ventricle. Normally, the mitral valve
opening is as wide as the diameter of three
fingers. In cases of marked stenosis, the opening
narrows to the width of a pencil. The left atrium
has great difficulty moving blood into the
ventricle because of the increased resistance of
the narrowing orifice. The left atrium dilates and
hypertrophies because of the increased blood
volume it holds. Because there is no valve to
protect the pulmonary veins from the backward
flow of the blood from the atrium, the
pulmonary circulation becomes congested. As a
result, the right ventricle must contract against
an abnormally high pulmonary arterial pressure
and is subjected to excessive strain. Eventually,
the right ventricle fails. The enlarged left atrium
may create pressure on the left bronchial tree,
resulting in a dry cough or wheezing
Blood from the aorta returns to the left ventricle
during diastole, in addition to the blood normally
delivered by the left atrium. The left ventricle
dilates in an attempt to accommodate the
increased volume blood. It also hypertrophies in
an attempt to increase muscle strength to expel
more blood with above-normal force, thus
Chronic mitral regurgitation is often
symptomatic, but acute mitral
regurgitation (resulting from MI) usually
manifests as severe congestive heart
failure. Dyspnea, fatigue, and weakness
are the most common symptoms.
Palpitations, SOB on exertion, and cough
from pulmonary congestion also occur
Dyspnea on exertion as a result of
pulmonary venous hypertension.
Symptoms usually develop after the valve
opening is reduced by one-third t one-half
its usual size. Patients are likely to show
progressive fatigue as a result of low
cardiac output. They may expectorate
blood; cough; wheeze; and experience
palpitations, orthopnea, paroxysmal
nocturnal dyspnea (PND) and repeated
respiratory infections
Aortic insufficiency develops without
symptoms in most patients. Some patients
are aware of a forceful heartbeat,
especially in the head or neck. Marked
arterial pulsations that are visible or
palpable at the carotid or temporal
arteries may be present as a result of
A systolic murmur is heard as a high-
pitched, blowing sound at the apex.
The pulse may be regular and of
good volume, or it may be irregular
as a result of extrasystolic beats or
atrial fibrillation. Doppler
echocardiography is used to
diagnose and monitor the
progression of mitral regurgitation.
TEE provides the best images of the
mitral valve
The pulse is weak and often irregular
because of atrial fibrillation (caused
by strain on the atrium). A low-
pitched, rumbling, diastolic murmur
is heard at the apex. As a result of
the increased blood volume and
pressure, the atrium dilates,
hypertrophies, and becomes
electrically unstable, and patients
experience atrial dysrhythmias.
Doppler ECG and cardiac
catheterization with angiography
may be used to help determine the
severity of the mitral stenosis
A diastolic murmur is heard as a
high-pitched, blowing sound at the
third or fourth intercostals space at
the left sternal border. The pulse
pressure is considerably widened in
patients with aortic regurgitation.
One characteristic sign of the
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems
AortIc Stenosis
Rheumatic Endocarditis
Chapters 26, 28, 29, 31, 32, & 33
increasing systolic blood pressures. The arteries
attempt to compensate for the higher pressures
by reflex vasodilation; the peripheral arterioles
relax, reducing peripheral resistance and
diastolic blood pressure
Progressive narrowing of the valve orifice occurs,
usually over several years to several decades.
The left ventricle overcomes the obstruction to
circulation by contracting more slowly but with
greater energy than normal, forcibly squeezing
the blood through the smaller orifice. The
obstruction to the left ventricle outflow increases
pressure on the left ventricle. The ventricular
wall thickens, or hypertrophies. When these
compensatory mechanisms of the heart begin to
fail, clinical signs and symptoms develop
Injury is caused by an inflammatory or sensitivity
reaction to streptococci. Leukocytes accumulate
in the affected tissues and form nodules, which
eventually are replaced by scar tissue. The
myocardium is involved in the inflammatory
process. Rheumatic myocarditis develops, which
temporarily weakens the contractile power of
the heart. The pericardium is affected, and
rheumatic pericarditis occurs during the acute
illness. Myocardial and pericardial involvement
usually resolves without serious complications.
However, rheumatic endocarditis results in
permanent and often crippling adverse effects
increased force and volume of blood
ejected from the hypertrophied left
ventricle. Exertional dyspnea and fatigue
follow. Progressive signs and symptoms of
left ventricular failure include breathing
difficulties (orthopnea, PND)
Many patients are asymptomatic. When
symptoms develop, patients usually have
exertional dyspnea, caused by increased
pulmonary venous pressure due to left
ventricular failure. Orthopnea, PND, and
pulmonary edema may also occur. Other
symptoms and dizziness and syncope
because of reduced blood flow to the
brain. Angina pectoris is a frequent
symptom resulting from increased oxygen
demands of the hypertrophied left
ventricle, the decreased time in diastole
for myocardial perfusion, and the
decreased blood flow into the coronary
arteries. Blood pressure may be low but is
usually normal. Pulse pressure may be low
(30 mm Hg or less) because of diminished
blood flow
Fever, headache, weight loss, fatigue,
malaise, diaphoresis, and pallor. Patients
who have had a group A beta-hemolytic
streptococcal infection are diagnosed with
rheumatic fever if they develop at least
two of the following: carditis, polyarthritis,
subcutaneous nodules, erythema, or
chorea
disease is the water-hammer
(Corrigan’s) pulse, in which the pulse
strikes the palpating finger with a
quick, sharp stroke and then
suddenly collapses. The diagnosis
may be confirmed by Doppler
echocardiography (preferably
transesophageal), radionuclide
imaging, ECG, MRI, and cardiac
catheterization
On physical exam, a loud, rough
systolic murmur may be heard over
the aortic area. The sound to listen
for is a systolic crescendo-
decrescendo murmur, which may
radiate into the carotid arteries and
to the apex of the left ventricle. The
murmur is low-pitched, rough,
rasping, and vibrating. An S4 sound
may be heard. If the examiner rests
a hand over the base of the heart
(second intercostal space next to the
sternum and above the suprasternal
notch up along the carotid arteries),
a vibration may be felt. Doppler
echocardiography is used to
diagnose and monitor the
progression of aortic stenosis.
A sore throat, or a history of one
within 5 weeks, is a first symptom of
possible rheumatic fever. Throat
cultures are necessary to diagnose.
ECG
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems Chapters 26, 28, 29, 31, 32, & 33
Myocarditis Inflammatory process involving the myocardium,
can cause heart dilation, thrombi on the heart
wall, infiltration of circulating blood cells around
the coronary vessels and between the muscle
fibers, and degeneration of the muscle fibers
themselves. May develop cardiomyopathy and
heart failure
Pericarditis Inflammation of the pericardium, the
membraneous sac enveloping the heart. May be
caused from infection, cancer, or trauma.
Restricts the heart’s ability to fill with blood
Arteriosclerosis Most common disease of the arteries; the term
means “hardening of the arteries” It is a diffuse
whereby the muscle fibers and the endothelial
lining of the walls of small arteries and arterioles
become thickened. Coronary arteries are
susceptible because of many twists and turns
Atherosclerosis Involves a different process, affecting the intima
of the large and medium-sized arteries. These
changes consist of the accumulation of lipids,
calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery.
The accumulations are referred to atheromas or
plaques. The most common direct results of
atherosclerosis in arteries include narrowing of
the lumen, obstruction by a thrombosis,
aneurysm, ulceration, and rupture. Places patient
Patient may be asymptomatic, and the Clinical assessment may disclose
infection resolves on its own. Fatigue and cardiac enlargement, faint heart
dyspnea, tachycardia, palpitations, and sounds, a gallop rhythm, or a systolic
occasional discomfort in the chest and murmur. Endocardial biopsy, ECG,
upper abdomen. The most common WBC AND ESR may be elevated
symptoms are flu-like. Patients may have
sudden cardiac death or quickly develop
severe congestive heart failure
Patients may be asymptomatic. The most Diagnosis made based on H&P, signs
characteristic symptom of pericarditis is and symptoms. Echocardiogram,
chest pain, although pain also may be Pericardiocentesis. TEE; CT; MRI; 12-
located beneath the clavicle, in the neck, lead ECG
or in the left trapezius (scapula) region.
The pain or discomfort usually remains
fairly constant, but it may worsen with
deep inspiration and when lying down or
turning. It may be relieved with a forward-
leaning or sitting position. A creaky or
scratchy , leathery friction rub heard most
clearly at the left lower sterna border is
the most characteristic sign. Other signs
include mild fever, increased WBC count,
anemia, and an elevated ESR or C-reactive
protein level. Non-productive cough;
dyspnea
Angina pectoris with exertion if coronary Laboratory tests
arteries are involved
Depends on the organ or tissue affected Laboratory tests
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems Chapters 26, 28, 29, 31, 32, & 33
at greatest risk for hypertension
Peripheral Arterial Disease (PAD) Obstructive lesions are predominantly confined
to segments of the arterial system. The legs are
most often affected
Buerger’s Disease Recurring inflammatory process of the small and
intermediate vessels of (usually) the lower
extremities; probably an autoimmune disorder.
Most often occurs in men ages 20-35. Tobacco is
a risk or aggravating factor; Nicotine is a
vasoconstrictor
Arterial Embolism/Thrombosis Acute vascular occlusion; possibly caused by
embolus or acute thrombosis
Raynaud’s Disease Intermittent arteriolar vasoconstriction, usually
of the fingertips or toes. Episodes are brought on
by a trigger such as cold or stress. Occurs most
frequently in women
Venous Thrombosis/Thrombophlebitis Blood clot
Deep Vein Thrombosis (DVT) Obstruction of deep veins by a thrombi. Bed rest,
age, obesity, and oral contraceptives place the
patient at risk for DVT
Phlebitis Inflammation of a vein, which can be categorized
as chemical, mechanical, or bacterial; however,
two or more of these types of irritations often
occur simultaneously
Arteritis Inflammation of a artery
Thromboembolism Blood clots embolize to other vessels or organs.
The hallmark symptom is intermittent
claudication. This pain is described as
aching, cramping, or inducing fatigue or
weakness that occurs with the same
degree of exercise or activity and is
relieved with rest
Progressive occlusion of vessels results in
pain, ischemic changes, ulcerations, and
gangrene
Severe pain, poor circulation, gradual loss
of sensory and motor function
Sudden vasoconstriction results in color
changes, numbness, tingling, and burning
pain
May be swollen, tense, painful, and cool to
touch
Edema and swelling of the extremity
because of outflow of venous blood is
inhibited. The extremity may feel warm to
touch or cool to touch and superficial veins
may appear more prominent. Tenderness
is produced by inflammation of the vein
wall and can be detected by gently
palpating the affected extremity
Reddened, warm area around the insertion
site or along the path of the vein, and
swelling
Reddened, warm area around the insertion
site or along the path of the vein, and
swelling
Dyspnea, chest pain, hemoptysis,
Physical assessment; the extremity is
cool and pale when elevated or
ruddy and cyanotic when placed in a
dependent position. Skin and nail
changes, ulcerations, gangrene, and
muscle atrophy may be evident.
Examine peripheral pulses. Skin may
be atrophic and dry with sparse hair
growth. Edema is common. Doppler,
ultrasound, and imaging studies
Segmental limb pressures are taken
to demonstrate the distal location of
the lesions or occlusions. Constrast
angiography. Ultrasound
Ultrasound
Assessment, transthoracic
echocardiography, TEE CXR, ECG
Assessment, ultrasound
Physical assessment. Homan’s sign is
not specific for a DVT because it can
be elicited with any painful condition
of the calf
Assessment
Assessment
Chest x-ray; ventilation-perfusion
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems Chapters 26, 28, 29, 31, 32, & 33
Pulmonary embolism is the most common
Hypertention A systolic pressure greater than 140 mm Hg and
a diastolic pressure greater than 90 mm Hg,
based on the average of two or more accurate
blood pressure measurements taken during two
or more contacts with a health care provider.
Greatest risk factor is atherosclerosis
Aneurysm Localized sac or dilation formed at a weak point
in the wall of the artery
Anemia A condition, in which the hemoglobin
concentration is lower than normal, reflects the
presence of fewer than normal erythrocytes
within the circulation. As a result the amount of
oxygen delivered to body tissues is also
diminished
Iron Deficiency Anemia Typically results when intake of dietary iron is
(Hypoproliferative) inadequate for hemoglobin synthesis. The body
can store about one fourth to one third of its
iron, and it is not until those stores are depleted
that iron deficiency anemia actually begins to
develop. Iron deficiency anemia is the most
common type of anemia
Aplastic Anemia (Hypoproliferative) Can be congenital or acquired, but most causes
are idiopathic. Caused by a decrease in or
damage to marrow stem cells, damage to the
microenvironment within the marrow, and
replacement of the marrow with fat
Megoblastic Anemia In the anemias caused by deficiencies of vitamin
(Hypoproliferative) B12 or folic acid, identical bone marrow and
tachycardia, and symptoms of deep vein lung scan, CT scan, D-dimer
thrombosis
Elevated BP. Angina, SOB, altered speech, H&P; Cholesterol levels, blood
altered vision, nosebleeds, headaches, chemistry, ECG
dizziness, balance problems, and nocturia.
Symptoms seen related to organ damage
are seen late and are serious: retinal and
other eye changes, renal damage,
myocardial infarction, cardiac hypertrophy,
stroke
Thoracic aortic aneurysm-patient may be If large veins are compressed by an
asymptomatic. Usually, pain is the most aneurysm, the superficial veins of
prominent symptom. The pain is usually the chest, neck , and arms become
constant and boring and may only occur dilated and edematous areas on the
when the patient is supine chest wall; cyanosis; CXR; TEE CT
Abdominal aortic aneurysm-some patients scan
complain they feel their heart beat when
lying down
Depends upon the type, rapidity with CBC, Hemoglobin, hematocrit,
which the anemia developed, duration of reticulocyte count, RBC, iron studies,
the anemia, metabolic requirements of the serum B12 and folate levels
patient, other concurrent disorders,
disabilities, or special complications.
Fatigue, weakness, malaise, pallor or
jaundice, cardiac and respiratory
symptoms, tongue changes, nail changes,
angular cheilosis, pica
Fatigue, pallor, dyspnea. Smooth, sore CBC, hemoglobin, hematocrit, iron
tongue, brittle and rigid nails, angular studies, bone marrow aspiration
cheilosis, pica
Fatigue, pallor, dyspnea. Purpura may CBC, bone marrow aspiration
develop
Weakness, fatigue, pale, mild diarrhea, Serum levels of Folic acid and B12
confusion, paraesthesias, red, smooth,
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems
Sickle Cell Anemia (Hemolytic)
Polycythemia
Thrombocytopenia
Idiopathic Thrombocytopenic Purpura
Chapters 26, 28, 29, 31, 32, & 33
peripheral blood changes occur because both sore tongue
vitamins are essential for normal DNA synthesis.
In both Folic Acid Deficiency and Vitamin B12
Deficiency, the erythrocytes that are produced
are abnormally large and are called
megaloblastic red cells. Pernicious anemia is a
common type
Results from inheritance of the sickle Fatigue, weakness, malaise, pallor or Hemoglobin Electrophoresis
hemoglobin gene. The RBC becomes deformed, jaundice, cardiac and respiratory
rigid, and sickle-shaped. The sickle hemoglobin symptoms, nail changes, angular cheilosis,
acquires a crystal-like formation when exposed pica
to low oxygen tension. The long, rigid RBC’s can
adhere to the endothelium of small vessels;
when they adhere to each other, blood flow to a
region or an organ may be reduced. If ischemia
or infarction results, the patient may have pain,
swelling, and fever. The sickling process takes
time; if the RBC is again exposed to adequate
oxygen before the membrane becomes too rigid,
it can revert to a normal shape. Cold can
aggravate the sickling process, because
vasoconstriction slows the blood flow. Oxygen
delivery can also be impaired by an increased
blood viscosity, with or without occlusion due to
adhesion of sickled cells. The sickle hemoglobin is
a gene inherited in people of African descent and
to a lesser extent in people from the Middle East,
Mediterranean Sea and India
Increase in viscosity and volume of erythrocytes Headache, dizziness, dyspnea, tinnitus, Patients may have increased HCT,
fatigue, ruddy completion, splenomegaly, increased WBC, increased
parasthesias, angina erythrocyte mass
Low platelet level that can result from various Bleeding and petechiae, usually do not Platelet count; examination of bone
factors: decreased production of platelets within occur with platelet counts greater than marrow
the bone marrow, increased destruction of 50,000/mm3, although excessive bleeding
platelets, or increased consumption of platelets can follow surgery or other trauma. When
platelet levels drop to less than
20,000/mm3 petechiae can appear, along
with nasal and gingival bleeding, excessive
menstrual bleeding, and excessive
bleeding after surgery
Low platelet count Patients often have no symptoms, and the Platelet count; examination of bone
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems Chapters 26, 28, 29, 31, 32, & 33

(ITP) low platelet count (often less than marrow

20,000/mm3; less than 5,000mm3 is not
uncommon). Easy bruising, heavy menses,
petechiae on extremities and trunk.
Hemoptysis
Hemophilla A-genetic defect that Inherited bleeding disorder; inherited as x-linked Severe bleeding-often occurs into joints. Assess for bleeding; CBC
results in deficient or defective factor traits; almost all affected are males; females can Spontaneous hematuria and GI bleeding
VIII. be carriers but are almost always asymptomatic can occur. Injuries can result in
Hemophilla B (Christmas Disease)- hemorrhage
stems from genetic defect that causes
deficient or defective factor IX
Neutropenia
Dysrhythmias (p. 828-840)
Heart Failure
Cardiomyopathy
Unit 8: Cardiovascular, Circulatory, and Hematologic Systems
Diagnostic Evaluation
Cardiac Biomarker Analysis
Lipid Profile
Cholesterol Levels
Triglycerides
Chest x-ray
Fluoroscopy
Electrocardiography (ECG)
Telemetry
Cardiac Stress Test
Echocardiogram (ECHO)
Transespageal echocardiogram (TEE)
Myocardial Perfusion Imaging
Cardiac catheterization
C-reactive protein
D-dimer
Chapters 26, 28, 29, 31, 32, & 33
p. 876. Analyzed in an acute MI. They are the first enzymes to increase. Creatine Kinase (CK) and its coenzyme MB is the most specific
enzyme for heart muscle injury. Myoglobin and troponin are proteins only found in the cardiac muscle. Elevated levels indicate cardiac
muscle injury. May stay elevated x 3 weeks
Assesses cholesterol, triglycerides, and lipoproteins
Lipids and fibrous tissue on the inner lumen of the arteries
Chemical form in which fat exists in food and in the body
Obtained to determine the size, contour, and position of the heart. Correct placement of cardiac catheters, such as pacemakers and
pulmonary artery catheters, is also confirmed by chest x-ray
Allows visualization of the heart on an x-ray screen. It shows cardiac and vascular pulsations and unusual cardiac contours.
Fluoroscopy is useful for positioning IV pacing electrodes and for guiding catheters insertion during cardiac catheterization
Graphic recording of the electrical activity of the heart. The standard 12-lead ECG is used to diagnose dysrhythmias, conduction
abnormalities, enlarged heart chambers, and myocardial ischemia or infarction and to monitor high or low calcium and potassium
levels and the effects of some medication
The transmission of radiowaves from a battery-operated transmitter worn by the patient to a central bank of monitors; wireless
system allowing the patient to ambulate while being monitored
Exercise (patient walks on treadmill or pedals a bike or arm crank; exercise intensity increases), pharmacologic (vasodilating agents,
Pesantine or Adenocard, are administered IV), and mental & emotional (uses a mental or arithmetic test or simulated public speech to
determine whether an ischemic myocardial response occurs) stress tests are noninvasive ways to evaluate the response of the
cardiovascular system to stress. BP, physical appearance, skin temperature, perceived exertion, chest pain, dyspnea, dizziness,
nausea/vomiting, fatigue, and ECG changes are monitored
Noninvasive ultrasound test that is used to examine the size, shape, and motion of cardiac structures. The ultrasound is generated by a
hand-held transducer applied to the front of the chest. The transducer picks up the echoes, converts them to electrical impulses and
transmits them. Test takes 30 – 45 minutes
Echo transducer in placed in the esophagus; the esophagus sits behind the heart. Provides a clear image of the heart
Used to assess myocardial perfusion
Insertion of catheter through arm or leg; advanced to the heart; frequently used to assess CAD and assess coronary artery patency
A marker for inflammation of vascular endothelium
Measures fibrin breakdown; helps diagnose a thrombosis