Cardivascular The fur cncepts related t xygenatin and perfusin are: 1. Hypxemia: Decreased xygen cncentratin f arterial bld 2. Hypxia: Oxygen deficiency in bdy tissues 3. Ischemia: Tissue nt getting enugh xygen 4. Necrsis: The tissue dies Overview CV disease is the leading cause f death in the US. One death ccurs every 33 secnds, and 25% f the ppulatin has CV disease. It s bad. Technlgy Varius diagnstic prcedures are used t detect disease and varius prcedures/surgery are used t treat disease: Ultrasund (ECHO) is used t evaluate the structure and functin f the heart. It s nt really d-able in pts with COPD (due t a lt f air between heart and chest cavity) and pts wh are bese. EKG uses mnitring electrdes t create a graphic representatin f the electrical impulses that the heart generates during the cardiac cycle. Interfering factrs are electrlyte imbalances and certain drugs such as digitalis, quinidine and barbiturates. Angigraphy is cardiac catherizatin, and it is used t visualize the heart chambers, arteries and great vessels. It is used mst ften t evaluate pts with chest pain. Pts with a psitive stress test als underg this test t lcate the regin f crnary cclusin. It is als used t determine the effects f valvular heart disease. Right heart catheterizatin is used t calculate cardiac utput and measure right heart pressures (als used t identify pulmnary embli). Radiistpe studies (culdn t find anything abut this nline that was understandable) Clt preventin drugs and lysis drugs Angiplasty invlves placing a balln is placed at the stentic area t widen a narrwed r bstructed bld vessel. Endarterectmy is a surgical prcedure t remve plaque material r blckage in the lining f an artery. Stent placement hlds an artery pen CABG and Peripheral Bypass are surgical prcedures. CABG is crnary artery bypass, in which arteries r veins frm elsewhere in the bdy are grafted t the crnary arteries t bypass arthersclertic narrwings and imprve the bld supply t the heart. Peripheral arterial bypass refers t treating blckages in the legs. Amputatin is ften fr a vascular reasn (if nt fr diabetes r trauma). Arterial Disrders These are disrders that affect arteries nt veins! Try t keep that straight! Examples are: Arthersclersis (CAD and Peripheral): thickening and hardening f arterial walls. Hypertensin: BP ver 140/90 Aneurysm: lcalized abnrmal dilatin f a bld vessel (usually artery)
Raynaud s: A primary vasspsastic disease f small arteries, presents as an exaggerated respnse f vasmtr cntrls t cld r emtin. Buerger s: a chrnic, recurring, inflammatry, vascular cclusive disease, chiefly f the peripheral arteries and veins f the extremeties. Venus Disrders (ex) Thrmbphlebitis: inflammatin f a vein in cnjunctin with the frmatin f a thrmbus. Embli: masses f undisslved matter present in a bld r lymphatic vessel and brught there by the bld r lymph. Venus Stasis Ulcers: ulcers in the lwer leg (usually inner part f leg just abve ankle). Cmmn in pts wh have a histry f leg swelling, varicse veins r bld clts. Lymphedema: an abnrmal accumulatin f tissue fluid in the interstitial spaces. CV Disease Thugh CV disease is the leading cause f death in the U.S. the really sad thing is that there are many risk factrs assciated with this disease that are mdifiable: Hypertensin Obesity Smking Hyperlipidemia Stress Lack f Exercise Diabetes Na Intake Alchl Hypertensin affects abut 25% f the US ppulatin (50 millin flks), and represents any BP abve 140/90. Hwever, it is imprtant t nte that ANYTHING abve 120/80 is cnsidered risky b/ c there is a direct relatinship t CV s it s nt like if yu re 138/84 that yu re a-k. HTN damages the intima f the vessel wall. This attracts macrphages which cme in and cause an increase in inflammatin. This creates mre wrk fr the heart t pump against (afterlad), and can lead t CHF and cardivascular events such as heart attack and strke. Nte that elderly peple can have an increase in systlic pressure nly this is b/c arthersclersis causes a lss f elasticity in the large arteries and diastlic pressure des nt increase as well. Pathphysilgy f HTN: Kidnesys relase renin int the bldstream, which travels t the liver where it cnverts anitensingen t ang I. Ang I ges t the lungs where it is cnverted t ang II. Ang II then ges t the kidneys which cause aldsterne t be released. Aldsterne causes sdium and water retentin. This retained sdium and water increase bld vlume. Arterilar cnstrictin increases peripheral vascular resistance (remember that ang II is a ptent vascnstrictr). Increased bld vlume and vascular resistance cause hypertensin. Studies shw that the incidence f MI increases prprtinately with increases in systlic pressure ver 120. Studies als shw that diabetics are less at risk f CV events when diastlic pressure is <80.
Treating HTN: Lifestyle mdificatins are fantastic, but they wn t fix everyne s HTN. Mst peple need t be n mre than ne drug (fr example, a diuretic wuld lwer BP, as wuld a beta-blcker and an Aceinhibitr r vasdilatr lts f ways t drp BP!) If smene is ging t implement lifestyle changes, they can drp their BP 5-20 mmhg fr every 10kg they lse this is great IF they can stick t it! Pre-hypertensin: Stage I: Stage II: the plan is lifestyle mdificatin (diet, stp smking, be mre active, cut back n Na). thiazide diuretic +/- beta blcker (als fr pre-hypertensin diabetic the treatment is mre aggressive) thiazide diuretic + ACEi/ARB/BB/CCB Obesity Obesity is assciated with increased risk f CV disease. This is especially true fr central besity. Obesity is als assciated with ther risk factrs Type 2 DM, HTN, Inactivity and Hyperlipidemia. Nte that besity is an INDEPENDENT risk factr, but it is ften cmbined with thers. The dangers are very real ne study fllwed 1 millin Americans fr 14 years and fund the risk f CV death t be 2x higher in bese individuals. Get ff the cuch!!! Sme scary statistics: 60% f adults are verweight r bese the % f yung peple wh are verweight has mre than dubled in the past 30 years between 10-15% f Americans age 6-17 are verweight The annual cst fr the US is $100 billin. Get ff the cuch!!! Smking Envirnmental smke has 24% f adults in the US cntinue t smke, but this is dwn frm 42% in 1965. abut 34% f the impact n We re ding better, but we re nt there yet! Smking is the strngest prmter arthersclertic prgressin fr arthersclersis a truly hrrible disease. Hw des this happen: Well, that ccurs with active smking increases PVR, increases LDL ( lethal chlesterl) and decreases smking. HDL ( healthy chlesterl). The arterial endthelium is damaged, and platelets (which have increased aggregatin due t smking), are thught t adhere t subendthelial cnnective tissue expsed by endthelial denutatin, initiating the smth muscle prliferatin that leads t arthersclertic plaque frmatin. What s mre, as many as 30% f CHD deaths in the US each year are attributed t smking and the risk is strngly dse-related. It als nearly dubles the risk f ischemic strke because the carbn mnxide mre readily binds t hemglbin than des xygen and tissues suffer frm lack f xygen. Smkers wh have had an MI: If yu quit smking, there is a 50% reductin in the risk f reinfarctin, sudden cardiac death and ttal mrtality This grup is highly receptive t teaching, s teach! When MI pts are given infrmatin abut quitting, there is a 50% lng-term cessatin rate this is awesme! Mdest telephne-based cunseling can increase this percentage t 70% and is cheap!
Quitting: ~1.3 millin quit each year After 1 year ff cigarettes, the excess risk f heart disease is reduced by half. After 15 years f abstinence, the risk is similar t that f peple wh never smked. In 5-15 years, the risk f strke returns t the level f thse wh ve never smked. Only 50% f smkers seen in primary care were spken t abut smking. It is better t have a quit day than t taper. Hypnsis is nt supprted by sufficient evidence There is a vaccine in clinical trials Cunseling wrks! Drugs wrk! Nictine patch r gum, buprpin, varenicline Chart all smking cessatin teaching! Smking is the cause f mre than 10% f CV deaths Smking csts the US $90 billin year Lipids LDL = lethal. Each 1% drp in LDL cnfers t a 2% reductin in CV events. Yay fr atmeal! HDL = healthy Treatment fr hyperlipidemia depends n lipid prfile/levels, ther CV risks and the cst f therapy. Generally, pts shuld change their diet (lw-fat, lw chlesterl), adpt lifestyle changes, and take drugs (statins, resins, fibrates, niacin). Stress Perceived high stress DOUBLES the risk f CV mrbidity. S RELAX! Lack f Exercise Sadly, 60% f Americans are sedentary! Physical inactivity is anther ne f thse independent risk factrs fr CVD. Imprving activity reduces weight, imprves lipid prfiles and reduces BP yay fr exercise! A 1996 statement frm the NIH recmmends that adults accumulate at least 30 mins f mderate activity n mst days (and yes, walking t class cunts s park far far away!), and mre vigrus activity 3-4x a week fr 30-60 minutes. Yur heart and lungs will thank yu! Diabetes The mre I learn abut diabetes the mre I am cnvinced it is a truly hrrible disease. Interestingly, the gal is nt t keep pts at the right level fr their bld glucse this is because there were t many incidents f hypglycemia. Instead, the gal is t keep pts within a healthy range and all I knw abut that is that <200 is the gal fr wund healing s maybe that s it? One f the prblems diabetics have is with arterial perfusin, which leads t necrtic tissues in the periphery. And yes, there is a definite parallel between besity and diabetes. Once mre flks, get ff the cuch! Na intake In besity, each 2g increase in sdium intake is assciated with a 61% increase in CV mrtality.
Alchl Intake And nw fr sme gd news! Mderate alchl cnsumptin (identified as 1 glass f wine fr wmen and 2 glasses fr men) increases HDL, may decrease cagulatin and lwer BP! Yippeee! Hwever, mderatin is the key. Large alchl intake increases BP, risk f strke, cardimypathy and nn-cardiac disrders. S, d the benefits utweigh the risks? In the US, 100k excess deaths can be attributed t alchl-related deaths each year. On the ther hand, if current alchl cnsumers abstained frm drinking, apprximately 80,000 f them wuld die frm CV disease. Binge drinking is a real prblem, especially amng cllege aged males. Hmcysteine, Flic Acid and CVD Hmcysteine is an amin acid, and high levels f this are assciated with CAD, CVA and PVD in epidemilgical studies. Hwever, flic acid and ther B vitamins break dwn this amin acid in the bdy. Nte that there have been n cntrlled studies supprting whether taking these vitamins decreases the risk s the AHA des nt currently recmmend. Hwever, it is imprtant t get lts f fruit and green leafy veggies.