CHAPTER TWO

Literature Review

2.1 OVERVIEW OF CARDIOVASCULAR DISEASES

2.1.1 DEFINITION

Cardiovascular diseases are a group of conditions that affect the heart and blood vessels.

CVDs are caused by various factors can be simpler such as viral, bacterial and fungal or more

complex such as injuries. Globalization, urbanization and population aging are major

underlying socio-economic forces for the rising burden of CVDs. Behavioral risk factors such

as tobacco use, alcohol consumption, consumption of foods high in salt, physical inactivity

and metabolic risk factors such as raised blood pressure, raised blood glucose, raised

cholesterol, overweight or obesity increases risks of CVDs. The key to the reduction of

complications of CVDs burden lies in the management interventions.

2.1.2 SIGNS AND SYMPTOMS

It is crucial to be able to understand when someone has these diseases. The general
cardiovascular diseases symptoms are:

 Pressure or pain in the chest

 Pain or discomfort in the left shoulder, arms, jaws, elbows or the back.
 Fatigue and nausea
 Cold sweats
 Shortness of breath
 Dizziness or light-headedness
 Palpitation
 Fainting
 Cyanosis
 Edema
While these are the most common symptoms, they are not the only ones. Symptoms of CVDs
can manifest in several ways throughout the body. The symptoms are different for men and
women. Men tend to experience chest pain while women are more likely to experience other
symptoms such as difficulty in breathing, nausea and fatigue. Sometimes, the symptoms of
CVDs are difficult to diagnose until an individual suffers from any of the diseases such as a
heart attack, stroke or angina.

2.1.3 RISK FACTORS

As CVDs are such a collection of diseases, unsurprisingly there are numerous risk
factors that contribute to cardiovascular diseases. Some of the major risk factors associated
with CVDs are discussed below:

 Age
Getting older increases the risk of a damaged heart and narrowed blood vessels
leading to CVDs.
 Sex
Men are generally at higher risk of developing CVDs. However, the risk for women
increases after menopause.
 Stress
Emotional stress may damage blood vessels and increase cardiac output thereby
leading to CVDs.
 Smoking
Smoking increases the risk of developing heart diseases by 2-4 times. Smoking is a
powerful independent risk factor for sudden cardiac death in patients with coronary
heart diseases, where smokers have about twice the risk of non-smokers. The
mechanisms by which smoking increases the risk of CVDs are relatively well
understood. The main risk is in the increased tendency towards thrombosis seen in
smokers, which can lead to myocardial infarction. Other mechanisms include
increased atherosclerosis, blood pressure, heart rate, cardiac output and coronary blood
flow. Smoking also increases the levels of carbon monoxide in the body, which binds
to haemoglobin, reducing the amount of oxygen reaching body tissues.
 Obesity or overweight
Obesity, particularly in those with excess fat around the waist, increases the chance of
developing CVDs even if no other risk factors are present. Excess weight increases
strain on the heart, raises blood vessels and blood cholesterol and triglyceride levels.
 All of these factors can increase the risk of atherosclerosis and thrombolytic embolism
and also increases the risk of developing type II diabetes, another risk factor for
CVDs.
 Diabetes
Diabetes is a disease that affects an individual’s ability to maintain an appropriate
blood glucose level. The disease has two forms that is: Type I and Type II diabetes.
Type I is also known as insulin dependent diabetes and is caused by the body not
producing any insulin. Type II is the more common form of the disease and occurs
when the body either does not produce enough insulin or cells do not process the
insulin properly. Both of these diseases can lead to an increased risk of CVDs through
increased cholesterol levels, hypertension and atherosclerosis. Insulin resistance is also
related to cardiovascular diseases.
 High blood pressure
High blood pressure (hypertension) is strongly linked to both cardiac diseases and
those of the vascular system. High bp affects the hart causing it to thicken and stiffen
as it has to work harder to pump blood; this can lead to heart attacks. The effect on the
vascular system is one of pressure on vasculature walls, leading to aneurysms and
stroke.
 High cholesterol
The basic method increases the risk of CVDs is by increasing the fatty deposits in
blood vessels leading to atherosclerosis. Recently, research has suggested that this is
more of an active process than previously thought, with cholesterol actually activates
endothelial cells to express adhesion molecules that speed the process of
atherosclerosis.
 Family history
A family history of heart disease makes a person more likely to get a CVD. This is
especially true if a close relative (parent, sibling) developed a heart disease at an early
age.
 Socio-economic risks
CVDs are associated with low socio-economic standing, for example, in developing
countries such as Ukraine and India, the levels of CVDs are up to 6 times higher than
in developed countries such as Canada, Britain, and Australia. Even smoking is
correlated with lower socio-economic status.
 Other risk factors
 Several other risk factors are important in the onset of CVDs. For example, physical
inactivity can contribute to accumulation to cholesterol and fatty tissues, alcohol
intake is also a risk factor and one that is complex since low levels of alcohol can
reduce the risk of heart diseases (through antioxidant polyphenols inhibiting the
oxidation of LDL cholesterol (low density lipoprotein cholesterol) but high levels of
alcohol intake actually increase the risk of CVDs (by increasing bp). Also, nutrition
with poor diet having a direct effect on fat concentrations in the body, increased sugar
levels in the blood (increasing the risk of high type II diabetes) and increased salts
levels in the blood (increasing blood pressure and risk of stroke), advanced age.

2.1.4 TYPES OF CARDIOVASCULAR DISEASES

A) Congenital heart disease

This is a condition characterized by defects in the structure of the heart that is present
at birth. Heart defects symptoms could include:
 Pale gray or blue skin color.
 Swelling in the legs, abdomen or areas around the eyes.
 In an infant, there is shortness of breath during feedings, which results in poor weight
gain.
B) Rheumatic heart disease
Rheumatic heart disease is a condition in which the heart valves are damaged by
rheumatic fever caused by streptococcal infection. Rheumatic fever is an inflammatory
disease that affect many of the body’s connective tissues especially those of the heart,
joints, brain and skin. Rheumatic heart disease can last a life, symptoms include:
 Chest pain
 Fainting
 Shortness of breath
 Fatigue
 Irregular heartbeats
Also, symptoms of rheumatic fever include:
 Fever
 Pain
 Swelling of the joints
 Nausea and vomiting
 Stomach cramps
 C) Coronary heart disease
Coronary heart disease (CHD) also called coronary artery disease (CAD) and
atherosclerotic heart disease (AHD), which is the result of the accumulation of
atheromatous plaques (usually cholesterol plaques) within the walls of the arteries that
supply the myocardium. In other words, the major blood vessels that supply the heart
(coronary arteries) struggle to send enough blood, oxygen and nutrients to the heart
muscles. Some common symptoms may include:
 Chest pain
 Complete blockage of blood flow
 Shortness of breath
 Inadequate supply of oxygen-rich blood
D) Cardiomyopathy
It is a disease that affects the heart muscle. In early stages of cardiomyopathy, the
patient may not have any symptoms but as the condition worsens, symptoms may
arise, some of which include:
 Shortness of breath with exertion or at rest
 Swelling in the legs, ankles and feet
 Bloating of the abdomen due to fluid buildup
 Fatigue
 Irregular heartbeats that feel rapid, pounding or fluttering
 Dizziness, lightheadedness and fainting.

E) Heart diseases caused by heart infections

These are heart conditions which are mainly caused by infections. These infections
can either be caused by a bacterial, fungal, viral or other infections. There are three
types of heart infections:
 Pericarditis: It is the inflammation of the pericardium, the thin, two-layered, fibrous,
fluid-filled sac that covers the outer surface of the heart. Pericarditis usually clears up
after some few months but sometimes when there is an extra fluid in the space
between the pericardial layers, it is called pericardial effusion.
Symptoms of pericarditis include:
 Chest pain which worsens when coughing, swallowing, lie flat or take a deep
breath
  Pain in the back, neck or left shoulder
 Palpitations
 Anxiety or fatigue
 Fever
 Swelling of legs, feet and ankles (in severe cases)
 Myocarditis: It is the inflammation of the myocardium, the thick middle layer of the
heart muscle. It can also be due to an injury and can develop suddenly (acute) and can
also be long-lasting (chronic), most people will recover without any lasting effects.
Sometimes, myocarditis can affect the heart’s electrical system, leading to an irregular
heartbeat called arrhythmia.
Symptoms of myocarditis include:
 Chest pain or discomfort or feeling of tightness in the chest
 Shortness of breath either at rest or when active or in a certain position like
lying down
 Unusual tiredness
 Palpitations
 An irregular heartbeat
 Feeling light-headed of fainting
 Flu-like symptoms like high temperature, headaches, body aches, joint pain or
sore throat
 Rarely swelling of hands, feet, ankles or legs
 Endocarditis: It the inflammation of the endocardium, which is the thinner lining of
the heart chambers and heart valves. It is usually caused by a bacterial, fungal or other
germs infection. Things that increases an individual risk of developing endocarditis
are artificial heart valves, damaged heart valves or other heart defects.
Symptoms of endocarditis are:
 Aching joints and muscles
 Chest pain when breathing
 Fatigue
 Flu-like symptoms such as fever and chills
 Night sweats
 Shortness of breath
 Swelling in the feet, legs or belly
 A new or changed whooshing sound in the heart (murmur)
 F) Cerebrovascular disease
It is a disease that affects the blood flow and blood vessels supplying the brain.
Symptoms include:
 A sudden or severe headache.
 Paralysis of one side of the body or hemiplegia.
 Confusion.
 Weakness on one side, also known as hemiparesis.
 Difficulty communicating including slurred speech.
 Losing vision on one side.
 Loss of balance.
 Unconsciousness.

2.1.4 DIAGNOSTIC TESTS FOR CARDIOVASCULAR DISEASES

To diagnose CVDs, the health care provider does a physical exam and ask questions
about medical history as well as important informations on symptoms. Also, tests are
done to help confirm or rule out cardiovascular diseases. These tests include:
 Blood tests: To check the level of oxygen in blood, check for any damage to major
organs such as kidneys, heart and liver. Also, electrolytes levels are checked.
 Electrocardiogram (ECG or EKG): A quick test which measures the electrical
activity of the heart, it can show how fast or slow the heart is beating.
 Echocardiogram: It uses sound waves to create pictures of the beating heart. It can
show movement of blood through the heart and heart valves.
 Chest X-ray: To look for fluid in the lungs and get pictures of the heart and blood
vessels.
 Blood pressure cuff: To check for low blood pressure.
 Cardiac catheterization and Angiogram: It aims at finding blockages in the arteries
that supply blood to the heart, check the amount of blood the heart is pumping with
each beat (cardiac output).
 Cardiac computerized tomography (CT): A scan of the heart can show calcium
deposits and blockages in the heart arteries. Calcium deposits can narrow the arteries.
 Ultrasound imaging through the esophagus if the results of the echocardiogram are not
clear.
  Holter monitoring: It is a type of portable electrocardiogram (ECG) which records
the electrical activity of the heart continuously over 24hours or longer when away
from the doctor’s office.
 Cardiac magnetic resonance imaging (MRI): It is a non-invasive test that uses a
magnetic field and radiofrequency wave to create detailed pictures of the heart and
blood vessels.
 Cardiac biopsy: It is a minimally invasive procedure whereby a small amount of
heart tissue for evaluation under a microscope to look for cell changes that indicate
heart damage or another heart problem.

2.1.6 PREVENTION OF CARDIOVASCULAR DISEASES

Certain types of cardiovascular diseases such as congenital heart diseases cannot be

prevented. However, some CVDs can be prevented by just making some few lifestyle
changes but only if strict measures are followed.

For primary prevention of cardiovascular diseases, that is prevention in those who do not
have the disease:

 Quit smoking and lower the consumption of alcohol.

 Maintaining normal levels of blood pressure, cholesterol or high fat levels and blood
sugar.
 Engaging in regular physical activity.
 Reducing and managing stress levels.
 Managing body weight.
 Maintaining a healthy diet that is rich in fruits and vegetables while avoiding foods
that are high in salts and fat.
For secondary prevention of cardiovascular diseases, that is in those with established
diseases, treatment with the following medications is necessary to avoid complications:
 Aspirin
 Alpha-blockers such as Oxazocine (Carura), Prazosin hydrochloride (Minipress).
 Beta-blockers such as Atenolol (Tenormin), Metoprolol (Toprol XL).
 Angiotensin converting enzyme inhibitors (ACE inhibitors).
 Statins
 Combined Alpha and Beta-blockers such as Carvedilol, Labetalol hydrochloride.
Some surgical treatments may include:
 Coronary artery bypass grafting.
 Vascular catheterization.
 Valve replacement.
 Heart transplant from a donor.
  Artificial heart transplant.
2.2 MANAGEMENT OF CARDIOVASCULAR DISEASES
2.4 COMPLICATIONS OF CARDIOVASCULAR DISASES
A) Stroke
It is an acute neurological injury whereby the blood supply to a part of the brain is interrupted
either by arterial blockage or rupture (haemorrhage). The brain cells are therefore damaged or
die (become necrotic), impairing the function of that part of the skin. It is of two major types;
it can either be ischemic or hemorrhagic. Stroke can cause permanent neurological damage or
death if not promptly diagnosed and treated.
Common symptoms include:
 Numbness on one side of the body.
 Confusion.
 Trouble speaking.
 Loss of balance or coordination.
B) Heart failure
It is the inability of the heart to pump (contract and relax) as it should. It can be of two types:
 Left ventricular failure: This is the failure of the left ventricle to pump blood from
the left side of the heart to the aorta.
 Right side heart failure or congestive cardiac failure: This is a condition of stasis
of or as a result of the right ventricle to pump blood into the pulmonary artery.
Some symptoms may include:
 Dyspnea on exertion.
 Cough on exertion or when supine.
 Nocturia and oliguria.
 Anorexia and nausea.
 Pallor and cyanosis.
 Weight gain and fatigue.
 Difficulty lying flat on the back because of shortness of breath.
 Swelling of the feet (pedal edema) or entire body (anasarca).
C) Heart attack
It is a condition which arises when the blood flow and the oxygen supply to the heart are
blocked. Symptoms of heart attack include:
 Pain or discomfort in the center of the chest.
 Pain or discomfort in the arms, left shoulder, elbows jaw or back.
 Difficulty in breathing or shortness of breath.
 Nausea and vomiting
 Light-headedness or fainting.
 Sweating
D) Arrhythmia: It is a series of abnormal heartbeat or rhythm. Symptoms include:
  Heart palpitations.
 Dizziness or lightheadedness.
 Fainting episodes.
 Shortness of breath.
 Chest pain or discomfort.
 Weakness of fatigue.
E) Peripheral arterial disease
In peripheral arterial disease, the arteries that supply blood to the legs become
narrowed or completely blocked off. The narrowing of the artery usually occurs in the
upper part of the legs.
Some common symptoms may include:
 A burning or aching pain in the feet, toes while resting especially at night
while lying flat.
 Cold skin in the feet.
 Redness or other color changes of the skin.
 More frequent skin and soft tissue infection usually in the feet or leg.
 Toe and foot sore that do not heal.
F) Cardiac arrest
It occurs when the heart suddenly stops beating. It is usually caused by an electrical
disturbance in the heart. Here, in this case the heart actually stops beating and patient
would not have a sense on their pulse, therefore which indicates that there is no blood
flow to the brain and other organs causing a patient ton pass within seconds.
Symptoms include:
 Sudden collapse.
 No pulse.
 No breathing.
 Loss of consciousness.
 Fast-beating, fluttering or pounding hart called palpitations.
 Chest discomfort.
 Weakness.
 Unexplained wheezing.
 Dizziness.
G) Aortic dissection
It is a serious condition in which there is a tear in the inner layer of the major artery carrying
blood from the heart to the body (aorta).
Symptoms are:
 Sudden severe chest or upper back pain, often described as tearing or ripping
sensation that spreads to the neck or down the back.
 Sudden severe stomach pain.
 Loss of consciousness.
 Weak pulse in one arm or thigh compared with the other.
 Leg pain and difficulty walking.