Lecture 18Cardiovascular Disease:Stroke and Heart Attack3.20.08Louise [email protected] Last Time• Burden of cardiovascular disease (CVD)• Cardiovascular system• Measuring cardiovascular health• Valve diseases• Atherosclerosis/CAD and treatments–Stroke– Heart attack• Heart failure and treatmentsMuddiest Point/Clearest Point• Clearest– Blood pressure• Measurement• Significance• Muddiest– More circulatory system and heart anatomy• Guidant CD– Heart valves and valve diseases• Guidant CDhttp://japi.org/august2007/U-575.pdfOutline: Treatment of Heart Disease• Burden of cardiovascular disease (CVD)• Cardiovascular system• Measuring cardiovascular health• Valve diseases• Atherosclerosis/CAD and treatments–Stroke– Heart attack• Heart failure and treatmentsAtherosclerosis:Stroke and Heart AttackArteries• Muscular blood vessels that carry blood away from the heart– Veins carry blood to the heart• Coronary arteries feed the heart itselfhttp://www.clevelandclinic.org/heartcenter/pub/guide/disease/cad/cad_arteries.htmhttp://www.infovisual.info/03/060_en.htmlArtery AnatomyAtherosclerotic Plaquehttp://www.nhlbi.nih.gov/health/dci/Diseases/Hbc/HBC_WhatIs.htmlhttp://medlib.med.utah.edu/WebPath/jpeg5/CV119.jpghttp://www.brown.edu/Courses/Digital_Path/Heart/atherosclerosis.htmAtherosclerosis: HistologyAtherosclerosis: Two Problems• Occlusion (Stenosis)–Narrowed artery diameter–Less blood flow• Thrombus–Formation of clots inside blood vessels–Can completely block blood flowAtherosclerosis: Thrombus• The thin layer or “cap” covering a plaque can rupture or burst– The inside of the plaque is then exposed to blood– This sends chemical signals to a host of blood cells• Platelets aggregate to form a clot– Thrombus can block blood flow– Not enough oxygen delivered -- ischemia– Tissues can begin to die -- infarctionhttp://www.medimagery.com/pathology.jpegThrombus Developmenthttp://www.nlm.nih.gov/medlineplus/ency/imagepages/18020.htmAtherosclerosis: Embolus• Thrombus can be displaced from the origin and travel to another location– Vessels shrink in diameter away from the heart• Can then lodge in normally healthy vessels– Can cause blockage in distant location --embolus• If vessels in the neck or head are affected– Ischemia or infarction of the brain tissue–StrokeStroke (Cerebrovascular Event)• A leading cause of death in older Americans• # 1 cause of adult disability• Caused by thrombus or embolus in vessels feeding brain• Infarction results in brain damage• Effects and long term damage depends on area of infarction• Two-thirds of survivors have a disability–Limb weakness, speech impediment, http://www.stroke.org/site/PageNavigator/HOMEStroke: Risk Factors• High blood pressure• High cholesterol levels• Tobacco use• Excessive alcohol consumption• Diabetes• Sedentary lifestyle• Poor diet/nutritionStroke: Symptoms• Stroke has a very rapid onset• Sudden appearance of the following symptoms warrants medical attention– Numbness or weakness of face, arm or leg -especially on one side of the body– Confusion, trouble speaking or understanding– Trouble seeing in one or both eyes– Trouble walking, dizziness, loss of balance or coordination– Severe headache with no known causeStroke: “Act F.A.S.T”•Face– Ask the person to smile• Does one side of the face droop?•Arms– Ask the person to raise both arms• Does one arm drift downward?•Speech– Ask the person to repeat a simple sentence• Are word slurred? Can they repeat correctly?•Time– Time is important!• Call 911 and/or seek medical help immediatelyHeart AttackAtherosclerosis vs. Coronary Artery Disease (CAD)• Atherosclerosis – The build-up of plaques throughout vessel systems– Can have effects at distant sites•CAD – Plaques in the coronary arteries– Specifically affects the heart muscleAtherosclerosisCADClot stops flow of bloodPlaque build upon vessel wallsWhere the blockage occurs in the arteryPart of the heart affectedCoronary Atherosclerotic PlaqueEarly Warning Signs: Angina• Plenty of people with CAD have no symptoms• Most prevalent symptom is angina– Chest pain• Two types of angina: stable and unstable– Stable is brought on by stress or exercise– Unstable may be sudden or more variable• Angina is typically the result of ischemia– Heart needs more oxygenProgression of Heart DiseaseHigh Blood PressureHigh Cholesterol LevelsAtherosclerosisIschemiaHeart AttackHeart FailureCAD and Heart Attacks• Myocardial infarction (MI or AMI)– Myocardium: heart muscle– Infarction: tissue death due to lack of blood (oxygen)• Pathophysiology– Functional changes associatedwith or resulting from MI• Diagnosis• TreatmentGuidant Heart AttackMI Pathophysiology: Case Study• Three months following his first visit to your office, Mr. Solomon presents to the ER in the early morning, with chest pain of one hour duration. • Mr. Solomon describes the pain as being severe and "like someone was sitting on his chest." The pain, located "in the lower part of my breast bone," awakened him from his sleep. Although he tried to relieve the pain by changing positions in bed, sitting up and drinking water, it remained unchanged. • He did not sleep well because "I had an upset stomach an acid-burning feeling." He attributed these symptoms to over eating and drinking at a Christmas party. • He has no pain or discomfort in his arms but says he has an "achiness" in his left jaw which he attributes to "bad teeth."• Physical examination reveals the patient to be anxious, pale, diaphoretic and in obvious discomfort. He is unshaven and accompanied by his wife. He tries to relieve his pain by belching. He coughs occasionally. Mr. Solomon says "the flu has been going around the office, and I’ve had a little cough and fever all week.”Warning Signs of Heart Attack• Many heart attacks start slowly; symptoms may come and go• Chest discomfort– Most heart attacks involve discomfort in the center of the chestthat lasts for more than a few minutes, or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain• Discomfort in other areas of the upper body– Can include pain or discomfort in one or both arms, the back, neck, jaw, or stomach• Shortness of breath – Often comes along with chest discomfort. But it also can occur before
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