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 1st degree
delay of signal but no missed ventricular beats

2nd degree
delay long enough to cause missed ventricular beats

3rd 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 jaw shoulder arms upper abdomen

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

May radiate to

May have dyspnea & sweating

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 & 1st 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 1st 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