Heart Disease Quiz for Nursing Students

Cardiac Pathophysiology Overview

• Cardiac pathophysiology is the study of the disease processes affecting the heart.
• Coronary heart disease (CHD) is the leading cause of death in the US for men and women of most racial/ethnic groups.
• In 2022, approximately 702,880 Americans died from heart disease.
• CHD costs the US $252.2 billion annually.

Leading Causes of Death Related to Cardiac Issues

• Coronary heart disease is the most common type of heart disease, killing more than 375,000 Americans in 2021
• Heart disease impacts most racial and ethnic groups, including African Americans, American Indians, Alaska Natives, Hispanics, and White men.
• For women of Asian American or Pacific Islander, American Indian, Alaska Natives, or Hispanic descent, heart disease is second only to cancer.

Percentage Breakdown of CVD Deaths (2021)

• Coronary heart disease accounts for 40.3% of CVD deaths
• Stroke accounts for 17.5% of CVD deaths
• Other causes, including high blood pressure and heart failure, account for the remaining portion.

Medicine Admission Note

• A 93-year-old male with an ejection fraction (EF) of 30-35%, severe hypertension (HTN), and a history of recent CHF exacerbation was admitted for dyspnea.
• Past medical history (PMH) includes coronary artery disease (CAD), systolic heart failure, atrial fibrillation (AF), immune thrombocytopenia (ITP), prostate cancer, gastrointestinal bleeding, and previous coronary artery bypass graft (CABG) surgery.
• The patient frequently forgets to take medications, including Lasix.

Study Objectives

• Explain coronary heart disease (CHD) and the formation of atherosclerotic plaques.
• Identify types of angina.
• Describe myocardial infarction (MI), including types and zones of infarction, diagnosis, and treatment.
• Differentiate cardiac pump dysfunction from cardiac failure, including right-sided and left-sided heart failure (systolic and diastolic).
• Explain the consequences of congestive heart failure (CHF) and ventricular remodeling.
• Define and describe different types of cardiomyopathies.
• Describe valvular heart disease (including types, causes, and consequences).

Pathophysiology

• Ischemic Heart Disease: Includes angina, acute myocardial infarction (MI), and other related conditions.
• Valve Disease: Associated with conditions such as stenosis, insufficiency, and prolapse.
• Sudden Cardiac Death: Can result from fatal cardiac arrhythmias, often related to CAD.
• Aneurysms: Localized dilations and weakening of blood vessels.
• Vascular conditions: Endocarditis and pericarditis (infections affecting the endocardium and pericardium, respectively).
• Tumors, which include both benign and malignant types.

Coronary Heart Disease (CHD)

• Build-up of plaque in the heart's arteries that causes heart attacks.
• Coronary artery disease (CAD) and Coronary heart disease (CHD) are often used interchangeably.
• Ischemic means lack of oxygen.
• Infarction is the death of tissue due to lack of blood supply.

Risk Factors for CAD

• Lifestyles: Smoking, high saturated fat, high cholesterol, high calories, and low physical activity.
• Biochemical or physiological characteristics: high blood lipids, high cholesterol, high triglycerides, high blood glucose, and high blood pressure.
• Personal characteristics: Age, gender and family history of CHD or previous history of CHD.

Cholesterol

• Essential component used by the body for cell membrane structure and enzymatic activity
• Transports fatty acids and lipids
• Comes from two sources: our bodies produce 75% and food (25% primarily animal products.)

LDL and HDL Cholesterol

• LDL ("bad" cholesterol): Higher number = higher risk, <100 is desirable
• HDL ("good" cholesterol): Higher number = lower risk, >60 is optimal

Triglycerides

• Part of the lipoprotein profile; high levels are a high risk factor
• Fats carried in the blood from food.
  • <150 is normal; 150–199 is borderline high; 200–499 is high; >500 is very high.

Total Cholesterol

• A measure of LDL, HDL, and other lipid components
• <200 is desirable; 200–239 is borderline high; ≥240 is high
• LDL:HDL ratio is a useful predictor of cholesterol-related blockages (< or = 3:1 ratio is ↓ risk; > or = 5:1 is ↑risk)

Myocardial Infarction (MI)

• Complete interruption of blood supply to a part of the myocardium.
• Causes include prolonged myocardial ischemia (typically due to plaque rupture/thrombosis), prolonged vasospasm, inadequate myocardial blood flow, or excessive metabolic demand.
• Less frequent causes include embolic occlusions, coronary artery dissection, aortitis, and vasculitis.
• Can be subendocardial (partial thickness–NSTEMI/Non-Q-wave MI) or transmural (full thickness–STEMI/Q-wave MI).

Response to MI

• Cells die, forming a necrotic tissue zone in 18–24 hours
• Inflammation responds to necrosis in 2–4 days.
• Visible necrosis is present in 2-4 days.
• Myocardial recovery starts between 4–10 days.
• Debris clearing and matrix deposition occur in 4–10 days.
• Scar tissue formation is seen in 10–14 days.

Zones of Infarction

• Zone of Infarct—dead tissue
• Zone of Injury—injured but not dead tissue
• Zone of Ischemia—tissue at risk of death due to lack of blood flow

MI Classification

• Subendocardial MI: Partial thickness of the heart wall
• Transmural MI: Full thickness of the heart wall

Newer Classification of MIs

• Type 1 MI: Due to acute coronary atherothrombotic myocardial injury
• Type 2 MI: Due to oxygen imbalance for reasons other than atherothrombotic injury.

Location of MI

• Locations are related to the artery occluded: Anterior wall MI (LAD), Lateral wall MI (LCX), Inferior wall MI (RCA).

Diagnosis of MI

• Includes physical symptoms (angina, DOE, fatigue, etc.) and
• EKG changes (peaked T-waves, ST elevation, Q-wave presence, and T-wave inversion)
• Rising levels of cardiac enzymes (Troponins, CK-MB, and myoglobin).

Women's MI Symptoms

• Women are more likely to report unusual symptoms initially.

Silent Myocardial Infarction

• Occurs without angina symptoms.
• More prevalent in patients with diabetes or alcoholism
• It must be diagnosed through EKG and cardiac enzyme changes.

Cardiac Enzymes: Troponin

• Troponin is the preferred cardiac marker for MI.
• The level of troponin rises 4-6 hours after an MI and remains elevated for several days.
• Elevated high-sensitivity cardiac troponin I (hs-cTnI) is a very important marker for MI.

Cardiac Enzymes: CK-MB and Myoglobin

• Elevated levels indicate myocardial cell necrosis
• The levels rise 4-8 hours after MI and return to normal in 2–3 days.
• Myoglobin is released rapidly with injury and is a good indicator when the patient gets emergency care quickly

Diagnosis of Acute MI: Additional Tests

• Chest X-ray (CXR)
• Transesophageal echocardiogram (TEE)
• Coronary angiography (angiogram)
• Cardiac catheterization

Medical Treatment of MIs

• Reduce myocardial oxygen demand with beta-blockers and calcium channel blockers.
• Increase oxygen supply with vasodilators (eg, nitroglycerin).
• Improve myocardial function with other drugs, such as digitalis glycosides.

Surgical Treatment of MIs

• Thrombolysis
• Intra-aortic balloon pump (IABP)
• Percutaneous coronary intervention (PCI), with or without stent placement.
• Coronary artery bypass graft (CABG)
• Left ventricular assist device (LVAD)
• Cardiac transplantation

NYPH Post MI Protocol

• Stay within 20–25 bpm of baseline heart rate for the first 6–8 weeks after MI.
• Light warm-up exercises in a sitting position.
• Walking program.

Cardiac Muscle Pump Dysfunction Versus Failure

• Dysfunction: Small reduction in cardiac output.
• Failure: Significant reduction in cardiac output.

Congestive Heart Failure (CHF): Overview

• CHF is a syndrome where the heart's pumping ability is insufficient to meet the body's metabolic demands.
• May result from various structural and functional cardiac disorders impacting the ventricles' filling and pumping abilities.
• CAD, hypertension (HTN), diabetes mellitus (DM), valvular and congenital heart disease, arrhythmias, ETOH or drug abuse, and age are some risk factors for CHF.

Characteristics of CHF

• Dyspnea, tachypnea, paroxysmal nocturnal dyspnea (PND).
• Orthopnea, fatigue.
• Peripheral edema, cyanosis.
• Weight gain, hepatomegaly, jugular venous distension (JVD)
• Adventitious breath sounds such as rales/crackles or S3 and S4 heart sounds.
• Sinus tachycardia.
• Low exercise tolerance.

CHF Classification

• Systolic versus diastolic heart failure.
• Left-sided versus right-side heart failure.
• Heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF).

Systolic and Diastolic Heart Function

• Systolic: Time for ventricular contraction

  • Determinants: Preload, afterload, contractility, and rate of contraction

• Diastolic: Time for ventricular filling.

  • Determinants: LV end-diastolic pressure and the extent of muscle fiber stretch at the end of diastole.

• Systolic Heart Failure: A decrease in contractility that leads to pump failure.

• Diastolic Heart Failure: Impaired ability for the ventricle to fill during diastole.

Physiologic Consequences of CHF

• Cardiovascular: Decreased myocardial performance and increased venous return.
• Neurochemical: Increased sympathetic stimulation, leading to a change in cardiac contractility
• Pulmonary: Edema due to increased filling pressures.
• Renal: Decreased CO and blood flow, leading to sodium and fluid retention.
• Musculoskeletal: Muscle wasting and possible skeletal muscle myopathies.
• Hematologic: Possible anemia and hemostatic abnormalities
• Hepatic: Possible cardiac cirrhosis
• Pancreatic: Possible impaired insulin release
• Nutritional: May result in anorexia leading to malnutrition

Compensatory Mechanisms for CHF

• Sympathetic nervous system (SNS): Increase heart rate and contractility while vasoconstriction to control BP
• Renin-angiotensin-aldosterone system (RAAS): Increases sodium and water retention to increase blood volume
• Natriuretic peptide counter-regulatory system: Responds to high filling pressures, increasing sodium loss and inhibiting RAAS.

Clinical Manifestations of CHF

• Symptoms: Left-sided (LVF) include progressive dyspnea (exertion-rest), dyspnea and orthopnea, PND; right-sided (RVF) include dependent edema, hepatomegaly, ascites, fatigue, anorexia and nausea

Diagnosis of CHF

• Echocardiograms (EF, below 40%)
• Blood tests (elevated BNP)
• Chest X-rays (CXR)
• EKG
• Hematology/Lab Values (blood values, electrolytes, renal function, and liver function)
• Cardiac catheterization
• Endomyocardial biopsy

Radiologic Findings in CHF

• Cardiac silhouette enlargement
• Edema (interstitial, perivascular, alveolar).
• Pleural effusion
• Atelectasis

NYHA Classification of CHF

• Functional classification based on how much the patient is physically limited
• Objective assessment of the degree of cardiovascular disease

Treatment of CHF

• Treatment is directed at the underlying cause.
• Goals include improving the heart's pumping ability, reducing workload, and controlling water and sodium retention.
• Non-drug management includes cardiac rehabilitation education, dietary and fluid restrictions, and weight monitoring.
• Medical management focuses on diuretics, vasodilators, digitalis (digoxin), beta-blockers, ACE inhibitors, and inotropes.
• Surgical management could include cardiac resynchronization therapy, angioplasty, bypass or transplantation

Compensated vs Decompensated CHF

• Compensated: Patients with mild to moderate symptoms are generally on medication.
• Decompensated: Patients have further deterioration of baseline symptoms as a result of the failure.

Cardiomyopathy (CM)

• Diverse group of diseases affecting the heart muscle.
• Primary causes of diseases to the heart muscle.
• Secondary causes due to other underlying diseases.
• Three major categories: dilated, hypertrophic, restrictive cardiomyopathy

Dilated Cardiomyopathy (DCM)

• Characterized by: increased cardiac mass, and dilation of all four chambers, with little or no wall thickening.
• Systolic dysfunction
• Symptoms include dyspnea, fatigue, and other signs of heart failure—presenting with ventricular dysrhythmias and possibly sudden death.
• Most common cause is idiopathic

Hypertrophic Cardiomyopathy (HCM)

• Characterized by considerable increase in cardiac mass (hypertrophy).
• No cavity dilation.
• Normal or increased systolic function.
• May have left ventricular outflow obstruction (ex: Hypertrophic obstructive cardiomyopathy—IHSS).
• Often not diagnosed until routine physical exams, with the patient having possible sudden collapse, death, dyspnea, fatigue, or angina.

Restrictive Cardiomyopathy (RCM)

• Rare condition characterized by restriction of ventricular filling.
• Rigid ventricular walls, with normal/slightly enlarged ventricles
• Dysfunction is often related to other diseases to the heart.
• May present with heart failure symptoms.

Valvular Heart Disease—Overview

• Heart valves ensure one-way blood flow.
• Valves can become stenotic (narrowed), insufficient (leaky), or prolapsed.
• Common causes include mechanical stress, rheumatic fever, ischemic heart disease, inflammatory diseases, and congenital conditions.
• The long-term dysfunction affects heart structure and function, leading to hypertrophy and dilation.

Valve Disease—Stenosis

• Narrowing of the valve, preventing complete opening.
• Causes include diseases, scars, and abnormal deposits
• Symptoms include DOE and fatigue

Valve Disease—Insufficiency/Regurgitation

• Leaky backflow of blood.
• Common on the left side of the heart, due to abnormal or malfunctioning valve leaflets.
• Leads to volume overload of the heart with possible chamber dilation or hypertrophy.

Aortic Stenosis (AS)

• Narrowed aortic valve opening
• Symptoms including DOE, fatigue, and syncope.

Mitral Stenosis (MS)

• Narrowed mitral valve opening
• Symptoms include DOE, fatigue, and shortness of breath

Aortic Insufficiency (AI)

• Leaky aortic valve
• Symptoms include DOE, fatigue, bounding pulses, and dizziness

Mitral Regurgitation (MR)

• Leaky mitral valve, causing blood to flow backward.
• Symptoms include fatigue, palpitations, dyspnea, and possibly non-angina chest pain.

Mitral Valve Prolapse

• Often causes regurgitation.
• Most commonly seen in mitral valve
• Symptoms (often asymptomatic) include fatigue, palpitations, and dyspnea; non-anginal chest pain
• May have an audible "click" sound.

Treating Valve Disease

• Medical treatment: Medications help reduce workload and regulate heart rhythm
• Surgical treatment: Repair or replacement of valves; choices include commissurotomy, balloon valvotomy, valvuloplasty, or valve replacement; mechanical or biological valves with specific anticoagulation needs.

Sudden Cardiac Death

• Sudden, unexpected death due to abrupt cessation in heart function.
• Typically results from fatal cardiac arrhythmias.
• Most common causes include scarring from previous MI, ischemic heart disease, cardiomyopathy, valvular heart disease, electrical abnormalities, blood vessel abnormalities, and certain medications.
• Categorized into pulseless ventricular tachycardia/fibrillation and asystole.

Aneurysms

• Localized dilation and weakening of a blood vessel wall.
• Can result in pulsating swelling, and potentially a murmur or rupture and hemorrhage.

Types of Aneurysms

• True Aneurysm: Aneurysm from a weakened vessel wall, with possible splitting of the media.     - Classified by shape—saccular (spherical) and fusiform (“spindle-shaped”).
• False/Pseudo-aneurysm: Collection of blood leaking out of a vessel, but confined nearby.     - Classified by etiology (ex: mycotic, from fungi/bacteria, or dissecting, from hemorrhage).

Location of Aortic Aneurysm

• Infrarenal aortic aneurysms (below renal arteries) are the most common type (90%)
• Thoracic aortic aneurysms are less common, often due to atherosclerotic changes to the vessel wall

Aortic Dissections

• Intimal tears in the aortic wall
• Proximal or distal tears, with possible rupture into pericardial sac, or pleural space; leading to acute aortic regurgitation and left ventricular failure
• Aggressive measures to lower HTN with fast-acting medications.

Peripheral Artery Aneurysms

• Most occur in men.
• Can be asymptomatic or present with pulsatile masses in different areas such as the groin and thigh—popliteal artery aneurysms are most common
• Can also occur at sites of previous vascular surgery.

Treatment of Aneurysms

• Surgical excision and grafting (open repair or endovascular repair—EVAR) is the main treatment modality.

Endocarditis

• Inflammation of the endocardium, usually due to microbial infections (typically bacterial).
• Characterized by fever, murmur, and vegetation on the heart valves.
• Treated with antibiotics.

Pericarditis

• Inflammation of the pericardium (the sac surrounding the heart), frequently caused by viral infections.
• Can be triggered by heart surgery, MI, trauma, tumors, cancer, radiation, autoimmune diseases, or medications like immunosuppressives.
• Symptoms include chest pain, dyspnea, fever, and a pericardial rub on auscultation.
• Can progress to pericardial effusion (excess fluid), potentially leading to cardiac tamponade (a life-threatening emergency).
• Treated with analgesics (NSAID or aspirin), antibiotics if bacterial origin, and sometimes surgical intervention if a severe pericardial effusion or tamponade occurs.

Cardiac Tumors

• Benign (more common) and malignant tumors
• Benign myxoma is common
• Malignant sarcomas (ex: Hemangiosarcoma, Rhabdomyosarcoma.) are less common.
• Symptoms can include DOE, PND, fever, weight loss, dizziness, syncope, hemoptysis, Raynaud's, arrhythmias, and even sudden death.

Test your knowledge on heart disease, its prevalence, and its impact on patients. This quiz focuses on clinical considerations for older adults with cardiovascular conditions. Explore questions on diagnosis, treatment, and important assessments.