Cardiovascular Disease Overview

Cardiovascular Disease

• Hypertension (HTN) is a condition where blood pressure (BP) is consistently above 140/90 mmHg.
• Essential hypertension affects 90-95% of hypertensive patients; it has no identifiable cause.
• Secondary hypertension has a specific identified cause for elevated BP.
• Hypertensive crises involve markedly elevated BP (>180/120 mmHg).

Clinical Presentation and Complications

• Uncomplicated primary hypertension is usually asymptomatic.
• Common complications include stroke and myocardial infarction.
• Diagnosis is made after averaging two or more BP measurements taken on separate occasions.

Treatment and Desired Outcome

• Goal blood pressure values are less than 140/90 mmHg for uncomplicated hypertension and less than 130/80 mmHg for patients with chronic kidney disease, coronary artery disease, or stroke (myocardial infarction [MI] or angina).
• People with diabetes and hypertension should be treated to a systolic blood pressure (SBP) goal of <140 mmHg. Lower systolic targets (<130 mmHg) may be appropriate for younger patients. Patients with diabetes should be treated to a diastolic blood pressure (DBP) <80 mmHg.
• Nonpharmacological therapy includes weight reduction (BMI < 25 kg/m²), a low-fat and low-sodium diet, regular exercise (at least 30 minutes per day), and smoking cessation.

Pharmacologic Therapy

• Initial drug selection depends on BP elevation and comorbid conditions.
• Acceptable first-line options include thiazide-type diuretics, ACE inhibitors, ARBs, and calcium channel blockers (CCBs).
• Beta-blockers are generally not recommended as first-line agents unless there's a compelling indication.
• ACE inhibitors or ARBs are the recommended treatment for patients with diabetes and hypertension.

Thiazides and Other Diuretics

• Thiazides are the preferred type of diuretic for treating hypertension.
• Loop diuretics are effective only in cases of significantly impaired renal function and are a suitable choice if heart failure is present.
• Methyldopa is suitable for use in pregnancy.

Heart Failure

• Heart failure (HF) is a condition where the heart cannot pump sufficient blood to meet the body's metabolic needs.
• Systolic failure involves decreased ejection of blood during systole; diastolic failure involves reduced ventricular filling during diastole.
• Common causes include coronary artery disease and hypertension.

Clinical Manifestations of Heart Failure

• Left-sided failure causes pulmonary congestion and edema (shortness of breath, exertional dyspnea, orthopnea, nocturnal dyspnea).
• Right-sided failure causes systemic congestion and edema (especially in the legs).

Investigations for Heart Failure

• Echocardiogram is used to assess left ventricle (LV) size and ejection fraction (EF).
• Chest X-ray helps detect cardiac enlargement and pulmonary edema.
• ECG assesses other cardiac problems, such as arrhythmias.

Nonpharmacological Interventions for Heart Failure

• Dietary modifications involve sodium restriction and sometimes fluid restriction.
• Aerobic exercise is encouraged when patients are stable, while heavy weight training is not.
• Modifying classic risk factors (tobacco and alcohol consumption) is important to minimize the potential for further damage.

Pharmacologic Treatment of Heart Failure

• ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists, and the combination of angiotensin-receptor/neprilysin inhibitors (ARNIs) are effective for specific symptoms and disease progression.
• Neprilysin inhibitors increase the availability of natriuretic peptides improving heart function.
• Loop diuretics (furosemide, bumetanide, torsemide) are commonly used for fluid retention.
• Nitrates and hydralazine can be used for persistent symptoms despite other treatments.

Digoxin in Heart Failure

• Digoxin provides symptomatic benefits but does NOT improve survival.
• It is often added for patients who remain symptomatic despite optimal HF regimen (ACE inhibitor or ARB, beta-blocker, and diuretic).
• Consideration of Digoxin is for patients with atrial fibrillation.
• Recent research suggests limited benefit from digoxin for mild to moderate diastolic HF for symptom and heart rate control.