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Transcript
Congestive Heart Failure and CAD Heart Rate • Is the number of beats per minute Stroke Volume • Is the volume of blood pumped per beat, let’s say about 70ml Cardiac Output • CO = SV x HR • = is the volume of blood pumped over one minute. About 5 liters per minute Preload • - volume of blood in ventricle before contraction, end diastolic volume Afterload • Volume of blood in ventricle after contraction, end systolic volume Stroke Volume • Volume of blood pumped during a single beat, preload minus afterload Ejection Fraction • Percentage of blood pumped during a single beat, stroke volume divided by preload Stroke Volume and Ejection Fraction • An elephant has a much larger stroke volume than a mouse, but similar ejection fractions A healthy heart is like a spring • The Frank-Starling law of contractility is the same as the Hooke’s law of springs • More stretch, more force • The Frank-Starling law states that the more the heart fills, the stronger the force of contraction Frank-Starling Curve • Just like a spring if the heart is overstretched, it loses it’s capacity to return force Starlings Curve • Healthy hearts are like a spring, more filling results in more contractile force Starlings Curve • Just like springs, if the heart is overstretched, it loses it’s capacity to return force Dilated Cardiomyopathy picture Congestive Heart Failure • Is a common debilitating condition defined by the heart’s mechanical ability to pump blood Normal Cardiac Output • CO = SV x HR Dilated Cardiomyopathy • - thin, weak floppy heart muscle • - low EF, low CO, high preload, high afterload Ventricular Hypertrophy picture • Thick, weak stiff heart muscle • Low EF, low CO Starlings Curve • Just like springs, if the heart is too stiff, it loses it’s capacity to return force Congestive Heart Failure CHF • Results in a decrease of blood circulation, which decreases oxygen supply to the organs, and fluid accumulation in the tissues. This is called edema CHF and edema • Congestive heart failure results in edema – Pulmonary edema – Systemic edema - legs - total body (anasarca) Pitting edema picture • Edema can be mild and localized, like a pitting of the feet Congestive Heart Failure • CHF can cause the lungs to fill with fluid causing shortness of breath, difficulty breathing, fluid retention and swollen legs, and decreased blood flow to organs NYHA Classification of CHF • Class 1 Asymptomatic • No limitation of physical ability. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). NYHA classification of CHF • Class 2 Mild • Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea NYHA Classification of CHF • Class 3 moderate • Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnea. NYHA Classification of CHF • Class 4 severe • Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. Drugs to treat CHF • • • • • ACE inhibitors - also prevents scarring of the cardiac muscle Calcium channel blockers Β-Blockers Diuretics CHF • • • • Rx: Dobutamine - adrenergic agonist Rx: Natrecor - NONadrenergic vasodilator • Rx: Digoxin • - action on Na/K Pumps • - increased cardiotoxic effects with hypokalemia (remember diuretics?) • Mostly used in atrial fibrillation • Digitalis purpurea • Foxglove Rx: Digitalis Digoxin • Cardiac glycosides work by inhibiting the Na+/K+ pump. This eventually causes an increase in calcium flowing into the cardiac muscle cell, improving cardiac output and reducing distention of the heart. Rx: Digoxin • GI upset • “Yellow Vision” • Can produce arrhythmia Angina • Chest pain CAD • Coronary artery disease • The coronary arteries supplying the heart can become narrowed over time CAD • The narrowed arteries limit the amount of blood supplied to the myocardium especially during strenuous activities Angina Pectoris • Stable – predictable chest pain, directly related to amount of exertion, does not occur at rest • Unstable – unpredictable chest pain, occurs at rest • Vasospastic (Prinzmetal) – condition of spasm of the coronary arteries, not associated with atherosclerosis Prevention • Until now we have tried to prevent atherosclerosis by: • - better diet • - more exercise • - stop smoking • - control HTN • - lowering LDL and triglycerides Drugs to treat Angina • Nitrates • - dilates vascular vessels • - relaxes smooth muscle Nitroglycerin • Class: nitrate • Increases coronary blood flow by dilating coronary arteries and improving blood flow to ischemic regions • Produces vasodilation, dropping blood pressure Nitroglycerin • Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload) Dilated Cardiomyopathy • • • • Low EF Low CO High preload High afterload Sublingual Nitro • SL Nitro – Avoids first pass effect – Better bioavailability – DO NOT SWALLOW SL NITRO Drugs to treat angina • Antithrombotic agents Rx: Digitalis Digoxin • Cardiac glycosides work by inhibiting the Na+/K+ pump. This eventually causes an increase in calcium flowing into the cardiac muscle cell, improving cardiac output and reducing distention of the heart. Rx: Digoxin • GI upset • “yellow vision” • Can produce arrhythmia Angina • Chest pain CAD Coronary Artery Disease • The coronary arteries supplying the heart can become narrowed over time CAD • The narrowed arteries limit the amount of blood supplied to the myocardium, especially during strenuous activity Angina Pectoris • Stable – predictable chest pain, directly related to amount of exertion, does not occur at rest • Unstable – unpredictable chest pain, occur at rest • Vasospastic (Prinzmetal) – condition of spasm of the coronary arteries, not associated with atherosclerosis Prevention • Until now we have tried to prevent atherosclerosis by: - Bettter diet - More exercise - Stop smoking - Control HTN - Lowering LDL and triglycerides Anticoagulation • • • • • • Warfarin (Coumadin) Heparin Aspirin Clopidogrel (Plavix) tPA Streptokinase Hemostasis • Development of a thrombus is lifesaving when a large vessel is ruptured or is severed • However, when a thrombus develops in the unruptured cardiovascular system it can be life threatening Thrombus • Diminish or obstruct vascular flow causing ischemic injury to tissues and organs • May become dislodged or fragment to create emboli Emboli • An intravascular solid, liquid, or gaseous mass that is through the blood to a different location in the body • - heart • - lung • - brain Hemostasis • • • • • • • • Dependent on 3 components - endothelium - lining of the vascular wall Platelets - essential for thrombus formation Coagulation proteins - created by the clotting cascase - end result is fibrin Anticoagulants • • • • • • A-fib Angina & Coronary Artery Disease Myocardial Infarction Stroke Pulmonary embolism Deep vein thrombosis (DVT) Anticoagulants • Aspirin and heparin for emergency intervention • Thrombolytics for emergency intervention Clotting Factors and Related Coagulation Tests • Heparin therapy – intrinsic system – aPTT • Coumadin therapy – extrinsic system – PT Cascade Picture Coagulation Cascade Picture • Coagulation Cascade – thrombin Anticoagulant Strategies 1. Interfere with platelet aggregation or clot formation 2. Interfere with clotting proteins or their formation 3. Dissolve thrombus Rx: Coumadin Warfarin • Today’s coumadin dose affects blood clotting two to seven days later Rx: Coumadin Warfarin • Yes, the rumors are true… • Warfarin was initially developed as a rat poison, causing internal bleeding • As long as the patient’s PT/INR is carefully monitored, there are no ill effects • Know teratogen, Cat X – contraindicated in pregnancy Rx: Coumadin Warfarin • Oral medication • Not used much IV due to delay between dose and effect, no better bioavailability Rx: Heparin • • • • • Antithrombin activator Effect is immediate Lab every 6 hours - PTT (Partial Thromboplastin Time) IV only Rx: Heparin • Although heparin is an anticoagulant • It can cause a rare disorder called HIT • - Immune mediated hypercoagulation Rx: Heparin • Protamine is the reversal agent for heparin • Protamine binds to heparin and terminate it’s action Low Molecular Weight Heparins • Rx: enoxaparin; Lovenox • Does not require close lab monitoring • Subcutaneously Antiplatelet • Rx: salicylates (Aspirin) • Rx: clopidogrel (Plavix) Thrombolytics “clot busters” • Rx: streptokinase • Rx: tPA tissue plasminogen activator • Rx: reteplase (Retevase)