1. Cardiovascular System Biomedicine Review Felix Hernandez, M.D.

2. Normal Heart

3. Chambers of the Heart

4. The Peripheral Vascular System

5. Blood Pressure Blood pressure is regulated by cardiac output and peripheral vascular resistance Systolic Blood Pressure the blood pressure measured during the period of ventricular contraction In a blood pressure reading, it is the higher of the two measurements. Diastolic Blood Pressure the minimum level of blood pressure measured between contractions of the heart. Can vary with age, gender, weight and emotional state.

6. Hypertension Primary Hypertension elevated blood pressure without a known causative factor this is the most common type causes: genetic predisposition and obesity stress, increased alcohol intake diabetes, sodium and water retention Secondary Hypertension elevated blood pressure with an identifiable cause Causes: renal artery stenosis, congenital heart defects, cushing’s syndrome, sleep apnea, pregnancy, stimulants

7. Risk Factors

8. Hypertension Signs and Symptoms no initial symptoms usually occur chronic fatigue headache dizziness dyspnea chest pain and palpitations

9. Treatment ABC A: ACE Inhibitor Enalapril (Vasotec), Lisinopril (Zestril) block the conversion of angiotensin I to angiotensin II which would normaly act as a vasoconstrictor this blocking causes vasodilation which will cause a decrease in resistance and a decrease in BP B: Beta Blocker Action: blocks the beta adrenergic receptors of the sympathetic nervous system which results in vasodilation and a decrease in the release of renin Contraindications: Pregnancy and Lactation Cautions: asthma, diabetes Side Effects: Hypotension, bradycardia, wheezing, dyspnea C: Calcium Chanel Blocker Amlodipine (Norvasc), Diltiazem (Cardizem), Nifedipine (Procardia) block calcium influx into the beta receptors which causes a decrease in the force of contraction and reduces the heart rate

10. Specific Side Effects of Beta Blockers Propranolol (Inderal) bradycardia, CHF, impotence Atenolol (Tenormin) dizziness, fatigue, cold extremities, depression, impotence Timolol (Blocarden) fatigue, bradycardia, extremity pain, impotence Metoprolol (Lopressor) fatigue, dizziness, depression, confusion, short term memory loss, headache, impotence

11. Treatment Diuretics Loop Diuretics Furosemide (Lasix) inhibit the reabsorption of sodium and chloride in the ascending loop of Henle Thiazide Diuretics Hydrochlorothiazide inhibit sodium and chloride reabsorption in the the distal tubules Used to treat hypertension and edema Contraindications: hypersensitivity to sulfonamides, anuria, oliguria, fluid and electrolyte depletion Side Effects: tiredness, weakness, dizziness, orthostatic hypotension, tinnitus

12. Treatment Potassium Sparring Diuretic Spironolactone (Aldactone) MOA: Antagonist of Aldosterone Side Effects: Hyperkalemia, glucose intolerance in DM patients

13. Unstable Angina an anginal attack occurring at rest or increasing in frequency caused by blockage of the coronary arteries has a high risk of subsequent myocardial infarction Labs: is evaluated with EKG. First you do a resting EKG, if that comes back normal then you perform an exercise stress test.

14. Treatment Nitroglycerin Uses: Relief of anginal pain and to suppress tachycardia MOA: relaxes vasculature (both arteries and veins but mostly veins) causing a decreased in preload and afterload Contraindications: hypersensitivity, severe anemia, head trauma or cerebral hemorrhage Side Effects: orthostatic hypotension, dry mouth, blurred vision, tachycardia, headache

15. Myocardial Infarction Is the leading cause of death caused by an obstruction of a coronary artery S/S: chest pain that lasts for more than 30 minutes and radiates to the left arm. The pain is not relieved by nitroglycerin Labs: Increased Troponin and CK-MB EKG Changes: T-wave inversion, ST elevation, Q-wave formation Treatment: Oxygen, aspirin, morphine, beta- blocker, ARB

16. Ventricular Fibrillation Dangerous electrical dysfunction Commonly associated with MI, CHF and shock EKG: rapid, chaotic, and distorted S/S: cheat pain, SOB, sudden death Tx: Direct Current Cardioversion

17. Ventricular Flutter Heart rate of 150-350 BPM Associated with hypoxia or ischemic insults S/S: hypotension and sudden death EKG: loss of normal QRS morphology Tx: defibrillation

18. Atrial Fibrillation Uncoordinated rapid contractions of the atria S/S: dizziness, papitations, irregularly irregular pulse associated with the development of thrombi that can embolize Tx: Warfarin (Coumadin), anti- arrhythmics

19. Renal Artery Stenosis Caused by fibromuscular dysplasia in young women and atherosclerosis in older men S/S: HTN, audible abdominal bruit, high renin levels Tx: ACE, angioplasty

20. Hypothermia A decrease in body temperature S/S: decreased peripheral perfusion, decreased respiratory rate, decreased bowel sounds, decreased DTR Can also cause arrhythmia, bradycardia and hypotension

21. Deep Vein Thrombosis Development of a blood clot in the deep veins of the lower extremity Associated with cancer, estrogen therapy, and prolonged immobility Virchow’s Triad: hypercoagulability, venostasis, endothelial injury S/S: Homan’s Sign --> pain on foot dorsiflexion Tx: Heparin (works faster so it is used initially) and Warfarin (Coumadin) Prothrombin Time (PT) is used to measure the effects of Warfarin

22. Cholesterol Total Cholesterol desired levels is <200 >240 is considered high risk HDL desired level is >60 considered protective against heart disease levels are increase by: vigorous exercise, insulin, estrogens levels are decreased by starvation, obesity, hypothyroidism, smoking, DM and liver disease LDL desired level <100 >190 gives you the highest increased risk of heart disease Levels are increased by atherosclerosis, CHD Levels are decreased by depression, anxiety

23. Cholesterol Lowering Drugs Cholestyramine MOA: forms insoluble complexes with bile salts allowing them to be excreted in feces. The body compensates by increasing the number of LDL receptors and oxidizing cholesterol to bile acids Indications: LDL>190 or 160 with 2 risk factors Lipid Profile Effects: decreases TC, and LDL Increases Triglycerides, VLDL and HDL

24. Cholesterol Lowering Drugs MOA: inhibit HMG-CoA reductase in the liver which is the enzyme that catalyzes the rate limiting step in cholesterol synthesis. Profile Changes: Decreases TC, LDL, VLDL and Triglycerides Increases HDL Side Effects: Myalgia Drugs: Simvastatin (Zocor) Atorvastatin (Lipitor) Rosuvastatin (Crestor)

25. Chronic Congestive Heart Disease

27. Digitalis MOA: inhibits the Na-K ATPase which alters the mechanical and electrical actions of the heart and causes an increase in myocardial contractility Uses: Heart Failure (improves CO) and atrial fibrillation Contraindications: hypersensitivity, ventricular tachycardia Side Effects: dizziness, muscle weakness, visual disturbances, hypokalemia, bradycardia, arrhythmia

28. Cardiomyopathy Dilated—viral infection, alcohol, cardiotoxic drugs Ventricles are dilated and the myocardium is flabby and thinned Hypertrophic—genetic Thickening of LV myocardium Mutation in the genes that code for myocardium constrictive proteins Restrictive—amyloidosis, endomyocardial fibrosis Heart cant expand to receive inflowing blood Heart transplant is the only treatment

29. Leukocytes Granulocytes Basophil: allergic and histamine reactions Eosinophil: parasitic infection, fungal infection Neutrophil: bacterial infection, inflammation, stress (Not Viral) Agranulocytes Lymphocyte: viral infection, chronic infection Monocyte: chronic infection

30. White Blood Cell Count Increased by: acute infection, neoplasm, leukemia Decreased by: bone marrow malfunction, immune deficiency, iron deficiency, AIDS, chemotherapy

31. Immunoglobulins IgG: most predominant, can cross the placenta and pass immunity to the fetus IgM: is the first to appear IgA: secretory antibody, is found in colostrum, secretions, saliva, tears IgE: least predominant, promotes histamine allergic reactions IgD: serves as a receptor on B-cells

32. Anemia General Causes: chemo, GI bleed, rheumatoid arthritis, Lupus, AIDS, Cancer S/S: decreased hemoglobin, decreased hematocrit, changes in fingernail beds, pale skin, fatigue Specific Types: Aplastic anemia: caused by damage to the bone marrow from toxic chemicals or radiation Hemolytic Anemia: destruction of red blood cells by toxic chemicals or antibodies Iron Deficiency Anemia: caused by a dietary lack of iron which leads to deficient hemoglobin synthesis Pernicious Anemia: caused by an inability to absorb B12 which leads to immature RBCs Sickle Cell Disease: caused by a defective gene leading to sickle shaped RBCs Thalassemia: caused by a defective gene which causes the formation of abnormal hemoglobin and a shortened lifespan of RBCs

33. Blood Labs Red Blood Cell Count (RBC) increased in: polycythemia, renal disease, pulmonary disease decreased in: anemia, Hodgkin’s leukemia, sickle cell disease Hemoglobin and Hematocrit Increased by: dehydration, shock, COPD, CHF, polycythemia Decreased by: anemia, leukemia, hyperthyroidism, cirrhosis, massive trauma Iron Increased by: acute hepatitis, nephrosis Decreased by: anemia, lupus, RA, hypothyroidism, 3rd trimester of pregnancy

34. Aspirin MOA: inhibits cyclooxygenase which is required for prostaglandin synthesis. Decreases inflammation and pyrogen-induced fever Decreases pain caused by injury or inflammation Prevents platelet aggregation Indications: symptomatic relief of minor main, inflammation, fever or RA. Reduction of stroke risk. Side Effects: GI upset and bleeding, allergic reaction. Increased risk of Reye’s Syndrome in children Occurs when giving aspirin after an infection. Can cause brain, liver and kidney damage with possible death Overdose is called salicylism and involves tinnitus, dizziness, HA, fever, mental status changes, hyperventilation, and respiratory alkalosis which can lead to a metabolic acidosis Contraindications: bleeding disorders and peptic ulcer disease

35. Quiz Next Week 25 questions 20 Cardiovascular 5 Musculoskeletal 2 bone diagrams 3 multiple choice on muscles (action, innervation, special notes)