student-2023 PHA 3113 patho I Disorders of the cardiac function_Coucha (1).pptx

Disorders of Cardiac Function PHA 3113 Pathophysiology II Summer 2023 Dr. Coucha. B.Pharm. Ph.D. Associate Professor Department of Pharmaceutical Sciences South University School of Pharmacy [email protected] Office: 348 (Savannah) (912) 201-8146 Porth’s Pathophysiology, Ninth edition, Cha...

Disorders of Cardiac Function PHA 3113 Pathophysiology II Summer 2023 Dr. Coucha. B.Pharm. Ph.D. Associate Professor Department of Pharmaceutical Sciences South University School of Pharmacy [email protected] Office: 348 (Savannah) (912) 201-8146 Porth’s Pathophysiology, Ninth edition, Chapter 32 Porth’s Pathophysiology, Tenth edition, Chapter 27 Pathophysiology of Disease: An Introduction to Clinical Medicine, 1 Learning Objectives LO1: Characterize the function of the pericardium. LO2: Understand the pathological changes in Pericarditis, pericardial effusion and cardiac tamponade. LO3: Describe the etiology, clinical manifestations and treatment of acute pericarditis. LO4: Describe the etiology, clinical manifestations and treatment of constrictive pericarditis. LO5: Describe the clinical manifestations and treatment of cardiac tamponade. LO6: Describe the etiology, predisposing factors and diagnosis of infective endocarditis. LO7: Describe the pathogenesis, clinical manifestations and diagnosis of rheumatic fever. LO8: State the normal function of the heart valves. LO9: Describe the effects of stenotic and regurgitant mitral and aortic 2 valvular heart disease on cardiovascular function. Disorders of The Cardiac Function Disorders of cardiac function They are classified according to the cardiac area affected. Peri/cardium: Around/ heart, Myo/cardium: Muscular tissue of/ heart. Endo/cardium: Endothelial membrane lining/ heart. https://opentextbc.ca/anatomyandphysiology/chapter/19-1-heart-anatomy/ 3 Disorders of the Pericardium http://cnx.org/content/ m45990/latest/? collection=col11496/ latest Pericardial disease may include inflammation of the pericardium or abnormal amounts of fluid in the space between the visceral and parietal pericardia https://en.wikipedia.org/wiki/ Pericardium#/media/ File:Blausen_0724_PericardialSac .png What will happen if there is too much inflammation of the pericardium? What will happen if there is an increase in the fluid volume of the 4 : Characterize the function of the pericardium. pericardial sac? Types of Pericardial Disorders I. Pericarditis – An inflammatory process of the pericardium II. Pericardial Effusion – The accumulation of fluid in the pericardial cavity III. Cardiac Tamponade – Slow or rapid compression of the heart due to accumulation of fluid, pus, or blood in the pericardial sac LO2: Understand the pathological changes in Pericarditis, pericardial effusion and cardiac 5 Pericarditis Acute pericarditis: It results from a pericardial inflammation of less than 2 weeks Chronic pericarditis: It results from a pericardial inflammation of more than 6 months Etiology: “PERICarDiTis” Postcardiac surgery nEeoplastic invasion of the pericardium Radiation Infection (viral and bacterial) Connective tissue diseases Drug toxicity N.B. Viral infections are the most common cause of Trauma pericarditis. LO3: Describe the etiology, clinical manifestations and treatment of acute 6 Acute Pericarditis Clinical Manifestations include a triad of • Chest pain – Abrupt in onset and sharp. https://www.heart.org/HEARTORG/Conditions/ More/Symptoms-and-Diagnosis-of– May radiate to the neck, back, abdomen, or side. Pericarditis_UCM_444932_Article.jsp – worsens with deep breathing, coughing, swallowing, and positional changes.  Sitting up and leaning forward tends to ease the pain. LO3: Describe the etiology, clinical manifestations and treatment of acute 7 Acute Pericarditis Diagnosis of acute pericarditis is based on clinical manifestations, ECG, chest radiography, and echocardiography. A pericardial friction rub, often described as high pitched or scratchy. Laboratory markers of systemic inflammation may also be present, including an elevated WBC count, and elevated erythrocyte sedimentation rate (ESR). The goals of treatment include: • NSAIDs, Colchicine, and corticosteroids • Reducing pain and inflammation. • Treating the underlying cause, if it is known. • Checking for complications. • Occasionally, continual inflammation of the pericardium leads to fibrosis and the development of constrictive pericarditis LO3: Describe the etiology, clinical manifestations and treatment of acute 8 Constrictive Pericarditis • Fibrous, calcified scar tissue develops between the visceral and parietal layers of the serous pericardium. (loss of elasticity of the pericardium) • The scar tissue contracts and interferes with – diastolic filling of the heart LO4: Describe the etiology, clinical manifestations and treatment of constrictive pericarditis. 9 Constrictive Pericarditis Clinical Manifestations • Ascites is a prominent early finding. • Pedal edema, dyspnea on exertion, and fatigue. • The Kussmaul sign • Exercise intolerance, muscle wasting, and weight loss develop in end-stage constrictive pericarditis. The Kussmaul sign is an inspiratory distention of the jugular veins caused by the inability of the right atrium, encased in its rigid pericardium, to accommodate the increase in venous return that occurs with inspiration. LO4: Describe the etiology, clinical manifestations and treatment of constrictive pericarditis. 10 Pericardial Effusion and Cardiac Tamponade Pericardial effusion • The accumulation of fluid in the pericardial cavity, usually as a result of an inflammatory or infectious process. • It can lead to a condition called cardiac tamponade, in which there is compression of the heart due to the accumulation of fluid, pus, or blood in the pericardial sac. LO5: Describe the etiology, clinical manifestations and treatment of cardiac tamponade. https://en.wikipedia.org/wiki/ Cardiac_tamponade#/media/ 11 File:Blausen_0164_CardiacTamponade_02 Pericardial Effusion and Cardiac Tamponade Cardiac tamponade results in • ____ intracardiac pressure • Progressive limitation of ________ • Reductions in _____and ______. • The severity of the condition depends on the amount of fluid present and the rate at which it accumulates. LO5: Describe the etiology, clinical manifestations and treatment of cardiac tamponade. 12 Cardiac Tamponade Signs “Beck's triad” • Low blood pressure • Jugular-venous distension • Muffled heart sounds (Why? ) LO5: Describe the etiology, clinical manifestations 13 http://www.baronerocks.com/index.php/mnemonics/mnemonics-cardiology/470-cardiacand treatment of cardiac tamponade. Pericardial Effusion and Cardiac Tamponade Treatment Our main goal is to ________ • In small pericardial effusions or mild cardiac tamponade – Medications may minimize fluid accumulation. • Pericardiocentesis (Initial management in hospital) LO5: Describe the etiology, clinical manifestations and treatment of cardiac tamponade. 14 15 Cardiac Tamponade Pulsus paradoxus is an Other signs of tamponade include exaggerated drop in blood • Pulsus Paradoxus pressure when you breathe in – a drop of > 10 mmHg in arterial blood pressure with inspiration https://www.youtube.com/watch?v=7AXIYQK5BBM 16 Case A 65-year-old woman is hospitalized with a large anterior myocardial infarction. After 4 days in the hospital, she is doing well and plans are being made for discharge to a rehabilitation facility to help her regain her strength and recover her cardiac function. While going to the bathroom she passed out suddenly on examination her blood pressure is 60/40mmHg her heart rate is 120 and she has a distant heart sounds. An emergent echocardiogram shows rupture of the anterior wall and pericardial tamponade. • What are the three classic signs of pericardial tamponade? • What is the pathophysiology of pericardial tamponade? 17 Endocardium is the innermost layer of tissue that lines the chambers of the heart. http:// upload.wikimedia.org/ wikipedia/commons/b/ b9/2011_Heart_Valves.jp g Endocardium is in continuum with other cardiac structures e.g. valves so both may be affected at the same time. http://www.easynotecards.com/notecard_set/19651#&ui- 18 Infective Endocarditis (IE) • It is an inflammation or infection of the inner surface of the heart (the endocardium). It is characterized by colonization or invasion of the heart valves and the mural endocardium by a microbial agent, leading to the formation of bulky, friable vegetations and destruction of underlying cardiac tissues. LEADING cause Staphylococcus Aureus (S. Aureus), then streptococci andDescribe enterococci. LO6: the etiology, predisposing factors and diagnosis of infective endocarditis. Medical Illustration Copyright © 2019 Nucleus Medical Media, All rights reserved. 19 Infective Endocarditis (IE) Common causes are 1. Heart valves disease 2. Prosthetic heart valves 3. Implantable devices such as pacemakers and defibrillators. 4. Congenital heart disease Exaggerating factors: • Immnuosuppression (by drugs) • Immunocompromized (by diseases e.g. HIV/cancer/ DM) • Alcohol http://www.neheart.com/our-services/ electrophysiology-and-arrhythmia-services/ • IV drug abuse arrhythmia-and-device-clinic/ LO6: Describe the etiology, predisposing factors and diagnosis of infective 20 Infective Endocarditis (IE) Endocardial damage Aggregation of platelets and fibrin to create a sterile vegetation The portal of entry into the bloodstream may be through a dental or surgical procedure that causes transient bacteremia, injection of a contaminated substance directly into the blood by intravenous drug users. LO6: Describe the etiology, predisposing factors and diagnosis of infective endocarditis. Transient bacteremia Microbial proliferation on and invasion of the endothelial surface Local destructive effects Metastatic infection to visceral 21 organs Infective Endocarditis (IE) Clinical Manifestations • Fever • Systemic signs of inflammation – such as spleen enlargement, anorexia, malaise, and lethargy. – Aching joints and muscles • Small petechial hemorrhages – most often found on the conjunctiva, palate, and extremeties) LO6: Describe the etiology, predisposing factors and diagnosis of infective endocarditis. 22 Infective Endocarditis (IE) Clinical Manifestations • Osler nodes – small, painful nodules on the palmar surfaces of the fingers and toes) • Janeway lesions – hemorrhagic non painful macules on palms and soles Splinter hemorrhages – linear brownish red lesions in LO6: Describe the etiology, predisposing factors the nail beds endocarditis. and diagnosis of infective • 23 Infective Endocarditis (IE) Clinical Manifestations • Roth spot (retinal hemorrhage) • Murmur (fibrosis and calcification of the valve) • Valve incompetence and volume overload • Congestive heart failure https://depts.washington.edu/physdx/heart/demo.htm LO6: Describe the etiology, predisposing factors and diagnosis of infective endocarditis. 24 Infective Endocarditis (IE) Diagnosis: • The diagnosis of IE cannot be made through any single test but rather includes the use of clinical, laboratory, and echocardiographic features – The blood culture Results – Echocardiographic data (imaging to show vegetations and damage) Duke criteria: for the diagnosis of infective endocarditis • 2 major or • 1 major and 3 minor criteria or • 5 minor criteria LO6: Describe the etiology, predisposing factors and diagnosis of infective endocarditis. 25 Infective Endocarditis (IE) • Major criteria • Positive blood culture for IE • Evidence of endocardial involvement • • • Minor criteria Predisposing heart condition or intravenous drug use Fever >38 Vascular phenomena: major arterial emboli, conjunctival hemorrhages, and Janeway lesions Immunologic phenomena: • Osler nodes • Roth spots • Microbiologic evidence such as blood culture that does not meet major criteria LO6: Describe the etiology, predisposing factors and diagnosis of infective 26 • A. B. C. D. Who of the following patients is having a definite diagnosis of infective endocarditis? Blood culture positive for endocarditis and fever A patient with conjunctival hemorrhages, Osler’s nodes, and Fever Blood culture positive for endocarditis and new valvular regurgitation Roth’s spot, Osler’s nodes, Fever, and major arterial emboli. 27 Infective Endocarditis (IE) Treatment: • Identifying and eliminating the causative microorganism • Minimizing the residual cardiac effects • Treating the pathologic effect of emboli Prevention: Prophylaxis is recommended only for people with previous IE, congenital heart disease, and prosthetic cardiac valve. https://www.perio.org/consumer/ heart_disease LO6: Describe the etiology, predisposing factors and diagnosis of infective 28 29 Rheumatic Heart Disease(RHD)/ Rheumatic fever (RF) • Inflammatory disease that typically develops two to four weeks after a streptococcal throat infection • Immune-mediated response to group A streptococcal (GAS) throat infection. • The most serious aspect of RF is the development of chronic valvular disorders that produce permanent cardiac dysfunction and sometimes cause fatal heart failure years later. LO7: Describe the pathogenesis, clinical manifestations and diagnosis of rheumatic fever. 30 RHD/ RF Pathogenesis Molecular mimicry • Antibodies directed against the M protein of certain strains of streptococci cross-react with glycoprotein antigens in the heart, joints, and other tissues to produce an autoimmune response. M protein: defines the virulence of the bacterium (GAS) LO7: Describe the pathogenesis, clinical manifestations and diagnosis of 31 RHD/RF/ Clinical Manifestations • Most people with RF have a history of sore throat, headache, fever (101°F to 104°F), abdominal pain, nausea, vomiting, swollen glands (usually at the angle of the jaw), and other signs and symptoms of streptococcal infection. • Other clinical manifestations associated with an acute episode of RF are related to the acute inflammatory process and the structures involved in the disease process. LO7: Describe the pathogenesis, clinical manifestations and diagnosis of 32 RHD/RF Jones criteria for the diagnosis of RF A- The presence of two major signs : 1. J-Joints “Polyarthritis” 2. (Pan-card-itis) “all layers-heart-inflammation” – mitral and aortic valves are most commonly affected 3. N-subcutaneous Nodules – Hard, painless, and freely movable. – Over the extensor muscles of the wrist, elbow, ankle, and knee joints. LO7: Describe the pathogenesis, clinical manifestations and diagnosis of 33 RHD/RF Jones criteria for the diagnosis of RF A- The presence of two major signs : 4- Erythema marginatum – Maplike, macular areas most commonly seen on the trunk or inner aspects of the upper arm and thigh, but never on the face. 5- S-Sydenham chorea – The major central nervous system manifestation of RF. – Involuntary rapid and irregular movements of arms, legs, and the facial muscles. https://www.youtube.com/watch?v=VFBOTwmVA0A LO7: Describe the pathogenesis, clinical manifestations and diagnosis of 34 RHD/RF Jones criteria for the diagnosis of RF B- One major and two minor signs Arthralgia, Fever, Elevated ESR, High leukocyte count (normal, 5-10 X 103 µl) • Jones criteria accompanied by evidence of a preceding GAS infection (antistreptolysin O antibodies or positive throat culture) indicates a high probability of RF • Treatment is designed to control the acute inflammatory response and prevent cardiac complications and recurrence of the disease. LO7: Describe the pathogenesis, clinical manifestations and diagnosis of 35 36 Valvular Heart Disease • It is any disease process involving one or more of the four valves of the heart. • The aortic and mitral valves on the left and the pulmonary and tricuspid valves on the right. 8: State the normal function of the heart valves. 37 http://healthzen.org/heart-health/heart-valve-problem-care-heart- Valvular Heart Disease What is the function of the heart valves? Dysfunction of the heart valves can result from – Congenital defects – Trauma – Ischemic damage – Secondary to infection e.g. IE and RF. – Inflammation • The mitral and aortic valves are the mostly affected. O8: State the normal function of the heart valves. 38 Valvular Heart Disease Stenosis – Narrowing of the valve opening • it does not open properly – Increases the resistance to blood flow through the valve • Leading to turbulent BF – This increases the volume and work of the chamber emptying through the narrowed valve  ____in the case of mitral stenosis  ____in case of aortic stenosis. https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSele ct=stenos LO9: Describe the effects of stenotic and regurgitant valvular heart disease on 39 Mitral Valve Stenosis • • The resistance to flow through the valve increases, the ____becomes dilated and left atrial pressure ____. The increased left atrial pressure eventually is transmitted to the ____ venous system, causing ______. Mitral valve stenosis most commonly is the result of RF. http://physioknowledgebd.blogspot.com/2016/02/mitralstenosis_25.html LO9: Describe the effects of stenotic and regurgitant valvular heart disease on 40 Aortic Valve Stenosis • • is characterized by increased resistance to ejection of blood from the LV into the aorta. The left ventricular wall becomes thicker, or hypertrophies, but a normal chamber volume is maintained. LO9: Describe the effects of stenotic and regurgitant valvular heart disease on 41 Valvular Heart Disease An incompetent or regurgitant valve – Distortion of the valve so it does not close properly – Permits backward flow Flowing back into • ___ during diastole when the aortic valve is affected • ____during systole when the mitral valve is affected. https://watchlearnlive.heart.org/CVML_Mobile.php?moduleSel ect=prolap LO9: Describe the effects of stenotic and regurgitant valvular heart disease on 42 http://drugline.org/img/term/mitral-regurgitation-9679_1.jpg Mitral Valve Regurgitation • The left ventricular stroke volume being divided between the forward stroke volume that moves into the aorta and the regurgitant stroke volume that moves back into the left atrium during systole. – – – – the forward stroke volume is ___ ____ cardiac output rapid rise in left atrial pressure pulmonary edema and decrease in CO http://drugline.org/img/term/mitral-regurgitation-9679_1.jpg LO9: Describe the effects of stenotic and regurgitant valvular heart disease on cardiovascular function. RHD is associated with a rigid and thickened valve that does not open or close completely. 43 Aortic Valve Regurgitation • Causes the back flow of blood to the LV during ___. – severe elevation in LVED pressure – ____ edema. – A __ in CO LO9: Describe the effects of stenotic and regurgitant valvular heart disease on 44 Porth’s Pathophysiology P.824 45 Case A 50-year-old woman presents with complaints of dyspnea and orthopnea, palpitations, and fatigue. An echocardiogram demonstrates a thickened, immobile mitral valve with anterior and posterior leaflets moving together due to mitral valve stenosis, slow early diastolic filling of the ventricle; and left atrial enlargement. • Explain the pathologic significance of the slow early diastolic filling and distended left atrium • How would the systemic and the pulmonary be affected as this woman’s mitral valve disorder progresses? 46