Cardiovascular notes

Arteriosclerosis (Atherosclerosis)

• It is a progressive inflammatory disorder resulting in the thickening and loss of elasticity in the arteries due to plaque buildup.
• Common in older adults, diabetics, hypertensive patients, individuals with high cholesterol, post-menopausal women, and men and linked to genetics, lifestyle, and smoking.
• Risk factors include high LDL cholesterol, hypercholesterolemia, hyperlipidemia, smoking, alcohol use, poor diet, hypertension, diabetes, obesity, sedentary lifestyle, family history, increased platelet activation, and social deprivation

Symptoms and Hallmarks of Arteriosclerosis:

• Initially asymptomatic
• Symptoms begin to show when there is >70% narrowing of the vessel occurs, which impedes blood flow and impairs tissue perfusion.
• Early symptoms include transient ischemic attacks (TIAs), exertional angina, and intermittent vascular claudication; Stable angina.
• Hallmarks of advanced disease include pain at rest, unstable angina, myocardial infarction, stroke, and sudden death.
• Common causes of advanced atherosclerosis include complete occlusion of the vessel, ulceration of the plaque, and plaque rupture, causing embolus formation.
• Thrombosis can also occur, leading to vessel blockage

Advanced Atherosclerosis Symptoms

• Pain at rest (due to severe ischemia)
• Unstable angina (chest pain occurring unpredictably)
• Ischemic stroke (CVA) (neurological deficits due to blocked cerebral arteries)
• Myocardial infarction (MI) (heart attack due to coronary artery blockage)
• Sudden cardiac death (in severe cases)

Examinations and Treatments for Arteriosclerosis

• Examination and exploration includes ECG (may show ischemic changes), echocardiography (to assess heart function and blood flow), angiography (to visualize arterial blockages), and a lipid panel (to check cholesterol levels).
• Lipid panel can show hypercholesterolemia, premature cardiovascular issues, HTN, metabolic syndrome, and chronic inflammatory disease; inflammation and non-invasive markers.
• Treatment includes lifestyle modifications: Healthy diet, exercise, smoking and alcohol cessation, and patient awareness.
• Medications: Statins (lower cholesterol), antihypertensives, antiplatelets (aspirin), beta-blockers *(atenolol, propranolol). Angiotensin II receptor blockers.
• Procedures: Angioplasty with stenting, bypass surgery (if severe blockages present), surgical removal of plaque.

Angina Pectoris

• Angina Pectoris is chest pain or discomfort caused by temporary myocardial ischemia(reduced blood flow to the heart muscle) without causing permanent damage
• The primary cause is coronary artery disease (CAD) due to atherosclerosis, where plaque buildup narrows the coronary arteries and reduces blood supply to the heart. and other causes include coronary artery spasm, microvascular dysfunction, severe hypertension, anemia, aortic stenosis, and hypertrophic cardiomyopathy.

Angina Occurrences

• Angina mostly effects patients with coronary artery disease (CAD), older adults, smokers, diabetics, hypertensive individuals, and those with high cholesterol or a sedentary lifestyle

Angina Risk factors

• The highest risk factor is atherosclerosis (most common underlying cause), hypertension, diabetes, high LDL cholesterol, smoking, obesity, family history of heart disease, and physical inactivity

Stable Angina

• Pattern is predictable and occurs during exertion/stress
• Can be relieved by rest or nitroglycerin
• Triggered by the 4 E's: Exercise, Emotion (stress), Eating (large meals), and Exposure to cold

Unstable Angina

• Occurs unpredictably, even at rest
• More severe and prolonged than stable angina
• Can't be relieved by rest or usual medications
• Requires urgent medical attention (risk of heart attack)

Symptoms and Hallmarks Of Angina

• Chest pain (described as pressure, tightness, or squeezing)
• Central diffuse constrictive chest pain.
• Vague troublesome ache.
• Pain radiation to jaw, left arm, shoulder, or back. Occasionally refers to the right arm.
• Dyspnea (shortness of breath)
• Diaphoresis (excessive sweating)
• Nausea or dizziness (less common but possible)
• Symptoms may alleviate within 5 mins upon resting or nitrates intake.
• Physical exam: Usually unremarkable, but must rule out myocardial infarction (MI).
• Patient reports that pain increases with activity or extreme emotion and decreases with rest.
• Blood pressure: Hyper / hypotension; Pulse rate: Tachy / bradycardia

Exams For Angina

• An ECG may show ST-depression or T-wave inversion during an episode
• Echocardiography: Assesses heart function and blood flow
• Stress test: Identifies exercise-induced ischemia
• Coronary angiography: Determines the extent of arterial blockage.
• Auscultation of the heart: 3rd / 4th gallop rhythm
• Apical impulse palpation: lateralization *(cardiomegaly), double bounce (cardiomyopathy), Absent (ventricular tachycardia due to decrease SV).
• Percussion: Cardiomegaly
• Blood test: NAD
• Conservative management / Lifestyle modifications: Smoking cessation, weight loss, exercise, stress management

Treatments For Angina

• Medications: Nitroglycerin (for immediate relief), Beta-blockers (reduce heart workload), Calcium channel blockers (improve blood flow), Aspirin/Antiplatelets (prevent clot formation), and Statins (reduce cholesterol/ – SIMVASTATIN, ATORVASTATIN)
• Interventions for severe cases: Angioplasty with stent placement and Coronary artery bypass grafting (CABG)

Unstable Angina (UA) vs. Myocardial Infarction (MI)

• UA is acute coronary syndrome due to partial artery blockage but without myocardial cell death; MI is acute coronary syndrome caused by complete or prolonged blockage, leading to myocardial cell death (necrosis).
• UA is caused by rupture, of an atherosclerotic plaque leading to incomplete occlusion of a coronary artery by a thrombus; MI is caused by rupture of an atherosclerotic plaque leading to complete occlusion of a coronary artery by a thrombus.
• Patients with coronary artery disease (CAD), smokers, diabetics, hypertensives, and high cholesterol are more likely to be diagnosed with UA whereas MI is more likely in older adults and males.
• Risk factors for UA and MI include hypertension, diabetes, smoking, high cholesterol, obesity, sedentary lifestyle, stress, and family history and MI risk factors include prior UA or MI history.

Comparing Symptoms Of UA vs MI

• UA: Chest pain at rest or with minimal exertion. Pain lasts longer (>10-20 min). Not relieved by rest or nitroglycerin. No myocardial cell death.
• Can progress to MI.
• MI: Severe, crushing chest pain. Radiates to left arm, jaw, or back. Not relieved by rest or nitroglycerin. Accompanied by nausea, sweating, dyspnea, dizziness. Causes myocardial necrosis.
• ECG findings for UA may be normal or show ST-depression/T-wave inversion and no ST-elevation; for MI, ST-segment elevation (STEMI) or ST-depression (NSTEMI). New Q waves may appear.
• With UA, cardiac biomarkers are negative with no myocardial necrosis and with MI it is positive which indicates myocardial damage
• Urgent medical attention is needed with both diseases, with UA treatment includes antiplatelets (aspirin, clopidogrel), anticoagulants (heparin), beta-blockers and nitrates and possible coronary intervention (PCI or CABG)
• MI emergency, requires the same treatment as UA but includes thrombolytics, angioplasty (PCI), or CABG and oxygen, pain relief (morphine), nitrates, aspirin and anticoagulants

Key differences between UA and MI

• Unstable Angina: No myocardial necrosis, negative biomarkers, no ST-elevation.
• Myocardial Infarction: Myocardial necrosis occurs, positive biomarkers, may have ST-elevation (STEMI) or not (NSTEMI).
• Both require urgent treatment, but MI is more severe and life-threatening.

Myocardial Infarction (MI)

• Blockage of a coronary artery leading to heart muscle death.
• Patients with atherosclerosis, smokers, diabetics, hypertensive patients, and high cholesterol all prone to myocardial infractions.
• High cholesterol, smoking, hypertension, obesity, diabetes, sedentary lifestyle, stress, and family history are all risk factors.
• Severe chest pain (not relieved by rest), commonly chief complaint diaphoresis(sweating), nausea, left arm pain, jaw pain, dyspnea are the symptoms
• Atypical presentation for women: indigestion, nausea, vomiting, neck, jaw, dizziness, palpations, rales on lung auscultation, pulmonary oedema.
• Examination / Exploration: ECG (ST-elevation or depression), cardiac biomarkers (troponin, CK-MB), echocardiography.
• Pulse: tacky/bradycardia, arrhythmias.
• Blood pressure: hypo/hypertension. Palpation: apical impulse, diffuse lateralized.
• Temperature: fever
• Auscultation: 4th heart sound, soft 1st heart sound or 3rd heart sound gallop rhythm crepitus in lungs.
• Blood tests include inflammatory biomarkers, cardiac biomarkers
• Raised jugular pulse; Urgent referral
• Treatment: Emergency care with aspirin, nitrates, thrombolytics, percutaneous coronary intervention (PCI), or bypass surgery.

Heart Failure

• Heart Failure(HF) is a clinical syndrome where the heart is unable to pump blood effectively, leading to inadequate tissue perfusion and fluid overload.
• HF can either be chronic(progressive) or acute(sudden onset).

Chronic Heart Failure

• Caused by Coronary artery disease (CAD), Hypertension (long-term strain on the heart), and Dilated cardiomyopathy

Acute Heart Failure

• Caused by Acute myocardial infarction (MI), Hypertensive crisis, Severe arrhythmias, Pulmonary embolism, and Infections (sepsis, myocarditis)
• Those more likely to be diagnosed with Acute and Chronic Heart Failure are Older adults, Patients with hypertension, CAD, diabetes, and obesity, those with a history of heart valve disease or cardiomyopathy
• Those with excessive alcohol use or chemotherapy-induced toxicity are also prone.

Symptoms Of Heart Failure

• Hypertension (increases cardiac workload), Coronary artery disease (CAD) (causes ischemic damage), Diabetes (leads to vascular damage), Obesity (increases metabolic demand), Smoking & excessive alcohol consumption, and Sedentary lifestyle; A patient may say they "can't catch my breath"

Chronic Congestive Heart Failure (CHF) vs. Acute Heart Failure (AHF)

• CHF is a gradual decline in cardiac function over time, leading to progressive symptoms while AHF is a sudden worsening of cardiac function due to an acute trigger
• CHF symptoms includes Fatigue & dyspnea on exertion - Peripheral edema, Orthopnea, and Paroxysmal nocturnal dyspnea and AHF symptoms includes Severe dyspnea & respiratory distress, Pulmonary edema and Hypoxia & cyanosis
• Examination includes elevated JVP, elevated S3, Pitting edema, and Crackles while other heart failure displays S4, Hypotension, and cold clammy skin
• Diagnostic results may show signs of old ischemia ,atrial fibrillation and pulmonary edema
• Elevated BNP, Diuretics, and ARB blockers all can improve signs of Heart Failure
• AHF treatment plan includes ventilation therapy, IV diuretics, vasodilators, Inotropes, and immediate intervention

AHF and CHF Characteristics

• Left-sided HF symptoms include Pulmonary congestion, dyspnea, orthopnea, crackles on auscultation, cough, confusion, fatigue, and decreased gas exchange.
• Right-sided HF symptoms include Fluid collects in feet and lower limbs/ pitting oedema and Peripheral edema
• A patient may state "I can't catch my breath".
• Progressive
• Weight loss due to anorexia and low absorption to GIT congestion. Poor tissue perfusion due to low CO and Skeletal muscle atrophy due to immobility are also signs of HF
• Elevated jugular venous pressure (JVP)
• S3 gallop (CHF) or S4 gallop (AHF)
• BNP / NT-proBNP levels elevated levels indicate heart Failure
• An ECG can test for irregularities

Treatment for Chronic HF

• 1st line - Diuretics (furosemide) to reduce fluid
• 2nd line ace inhibitors - ARBs to reduce afterload
• 3rd line Vasodilators like nitrates, reduce preload and Aterial dilators
• Lifestyle changes as diet and weight management
• Surgical intervention
• CHF occurs slowly while Acute HF may happen suddenly, both have to be treated with attention

Arrhythmias

• Arrhythmias are disturbances to the electrical rhythm of the heart. Normal is 60-100 BPM.
• Tachycardia: More than 100 BPM
• Bradycardia: Less than 60 BPM

Aetiology of Tachycardia:

• Increased automaticity, rate of cardia action potential generation; Re-entry retrograde depolarization of tissue causing premature depolarization, ectopic beat.
• Causes: palpitations dizziness, dyspnoea, chest discomfort.

Aetiology of Bradycardia:

• Decrease automaticity, decreased rate of cardiac action potential generation
• Blocked / slow conduction rate
• Causes: Fatigue syncope

Atrial Fibrillation (Arrhythmia)

• Irregular and rapid atrial contraction leading to inefficient blood flow.
• Typically seen in Elderly and hypertensive patients as well as those with structural heart disease.
• Caused by abnormal firing and multiple interacting re-entry circuits looping around the atria resulting in irregular heartbeat
• 3 classifications of heart Disease: Paoxymal, Persistent and Permanent

Atrial Fibrillation Symptoms

• Risk Factors include hypertension, coronary artery disease, hyperthyroidism, alcohol, sleep apnea
• Asymptomatic in early disease stages symptoms may include heart palpitations and fatigue
• Palpitations, dizziness, fatigue, irregular pulse, increased stroke risk, oedema, pre-syncope, fatigue, weakness, dyspnoea, poor effort tolerance. Examination / Exploration: ECG (irregularly irregular rhythm), echocardiography, Holter monitoring

Treatment for arrythmia

• Rate and rhythm control treatment includes beta blockers and antiarrhythmics in severe cases a pace maker and catheter

Heart Valve Disease

• Condition where one or more heart valves fail to open properly (stenosis) or fail to close properly (regurgitation/insufficiency), leading to impaired blood flow and increased cardiac workload.
• Common to see valve related health problems such as: congenital defects,rheumatic fever, endocarditis

Stenosis Vs Regurgitation

• Stenosis is the narrowing of blood flow and heart has to work harder to combat high blood pressure
• Regurgitation is backflow valve not closing properly
• All both conditions can lead to heart failure and cardiac output

Hallmarks of Heart Disease

• Valvue narrowing causing increase in high pressure
• increase workload leading to heart failure and stroke
• Patient may have heart dyspnea and fatigue

Treatment

• If severe valve have to be replaced or repaired a patient can be treated with medicines if not in critical condition

Rhematic Fever

• Autoimmune inflammatory disease following "Group A Strep" infection that causes antibodies to combat the spread.

Who is at risk

• Ages 5 through 15 and more common in "3rd World Countries"

Treatment for Rhuematic Fever

• Anti-inflammatory like aspirin and medication like corticosteroids

Endocardatis

• Opportunistic infection in the chambers by bacterial build-up, it is characterized by fever and heart murmurs
• Patients can be treated with Antibiotics and possible surgery

Pericarditis

• Viral illness that causes chest pain where patients are treated with steroids

Rayanauds syndrome

• Is is vascular disorder that triggers vessels to vasospasm caused by cold conditions.
• More women tend to have the condition
• Symptoms include blue disolcolration and numbness especially during cold conditions,

Treatment and Key Takeaways

• Avoidness of the cold can reduce the side effects, color dysregulation and if benign nothing has to be done unless another condition arises
• Athereal sclerosis can trigger PVD or PAD if blocked in limbs it results in reduced bloodflow and or Ischemia

PAD vs PVD

• PAD is a bloodclow in the leg and can is caused with patients who smoke and or have heart problems a change a lifestyle is needed.
• PVD leads to long term swelling and skin discoloration and medication to improve blood circulation in certain areeas

What is Abdominal Anerysm

• The diliation of the vessels can cause life threatening bleed and is linked to smoking this disease is asymtomatic until a rupture
• Blood pressure needs to be controlled

What is Arotic Dissection

• It occures that the inside vessel tears and then blood flow get between the tear
• Treated with beta blocker and or surgery

Anigna vs Myocardial Infraction

• Chest pain vs muscle daage caused by blockage The main difference is damage myocardial is has death

Reurgative vs vs Stenotic

• valve opening vs valve closing both can lead tp pulmonary congestion

Pericarditis Vs endocardatis

• viral illness and bacteria
• Pericarditas is treated with steroids where endocardatis must be treated with antibiotics.

What is chronic heart Failure

The disorder is progressive in certain ventricular activity that could eventually lead to death.