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Symptom and Treatment of Heart Disease www.AssignmentPoint.com www.AssignmentPoint.com Introduction to Heart Disease Heart is one of the most important organs in our bodies. Essentially a pump, the heart is a muscle made up of four chambers separated by valves and divided into two halves. Each half contains one chamber called an atrium and one called a ventricle. The atria (plural for atrium) collect blood, and the ventricles contract to push blood out of the heart. www.AssignmentPoint.com Figure: Human heart. The right half of the heart pumps oxygen-poor blood (blood that has a low amount of oxygen) to the lungs where blood cells can obtain more oxygen. Then, the newly oxygenated blood travels from the lungs into the left atrium and the left ventricle. The left ventricle pumps the newly oxygen-rich blood to the organs and tissues of the body. This oxygen provides our body with energy and is essential to keep our body healthy. Heart disease is a term that applies to a large number of medical conditions relating to the heart. These medical conditions relate to the abnormal health conditions that directly affect the heart and all its components. Heart disease is a major health problem within some cultures. One theory for heart disease is the radical changes within our lifestyles. People are often less active and eat diets high in fats. Takeaway food is abundant today and often people will eat it due to the increased availability. Some takeaway outlets are now helping cater to a healthier www.AssignmentPoint.com lifestyle by offering a variety of healthy dishes such as salads. People are becoming more aware of the risk of heart disease and choosing to change their diets. Exercise is extremely important in order to avoid heart disease. Exercise helps to keep the heart in peak performance. By using a combination of exercise and a balanced diet, the risk of heart disease is greatly decreased. The term Cardiovascular Disease covers a large number of diseases that directly affect the heart and the blood vessel system. It especially affects the veins and arteries that lead to and from the heart. Research has suggested that women who suffer with cardiovascular disease usually suffer from forms that affect the blood vessels. While men usually suffer from forms that affect the heart muscle itself. Other known or associated causes of cardiovascular disease include diabetes mellitus, hypertension and hypercholesterolemia. Heart disease and strokes are other common cardiovascular diseases. Two independent risk factors that have a major impact for heart diseases, cardiovascular diseases, are high blood pressure and high blood cholesterol. www.AssignmentPoint.com Now day’s heart disease does not have to be a death sentence. There are healthy lifestyle choices that can be made and science has come a long way in the early detection of heart disease. Heart disease and strokes are other common cardiovascular diseases. Two independent risk factors that have a major impact for heart diseases, cardiovascular diseases, are high blood pressure and high blood cholesterol. Now day’s heart disease does not have to be a death sentence. There are healthy lifestyle choices that can be made and science has come a long way in the early detection of heart disease. www.AssignmentPoint.com A Brief History of Heart Disease: Heart disease is the leading killer of people throughout the world. However, health problems involving the heart are not at all new to the human species. Although the knowledge of the causes and effects of heart disease began to appear in actual medical practice in the 20th century, the history of heart disease dates back to as far back as ancient Egypt. Archaeological findings in ancient Egypt indicate that Egyptians at that time thought of the heart as the seat of human wisdom and personality. They imagined some kinds of channels originating from the heart and carrying its products (in which they included blood, semen, saliva, and other fluids as well as air and nutrients) to the rest of the body. The history of heart disease may include the following steps:Medieval history of heart disease. www.AssignmentPoint.com History of heart disease in industrials society. Diet and the history of heart disease. Medieval History of Heart Disease: Research on the status of the health of the English in medieval times indicates that people at that time suffered from few cholesterol-related diseases (including heart disease). People living in Briton in the middle Ages had an infrequent history of heart disease and deaths caused by it. The main reason underlying the healthier heart condition of medieval English people was the use of natural food that was not loaded with carbohydrates; was not lacking in proteins; and was not rich in harmful fatty compounds. History of Heart Disease in Industrial Societies: Studies in the history of heart disease show that the occurrence of deaths resulting from heart problems was rare in pre-industrial societies. After the Industrial revolution of the 19th century, the incidence of deaths www.AssignmentPoint.com from heart disease went on a rise and more people became prone to dying from heart attacks. Health professionals hold the more relaxed and sedentary lifestyle of the modern technological age responsible for this change. Before the advent of sophisticated machines, most people used to earn their living by some kind of manual work which consumed the extra fatty deposits of the body. In addition, manual labor was a vigorous physical activity that kept the blood circulation high through the body. Diet and the History of Heart Disease: Diet also has a significant role in the history of heart disease. While the diet of an average person in preindustrial world consisted of a higher proportion of natural foods like whole grains and unprocessed dairy products (milk, and curd etc.), the invention of machines also started the trend of making rich foods. French fries, burgers, and processed dairy foods gained popularity. Their consumption became more a matter of social taste than individual choice. Also contributing to www.AssignmentPoint.com their popularity was the economy of time in preparing them (hence the term fast food'). All these factors combined to make fast food the primary choice of the general public. The result was an increased incidence of heart disease. Discover Heart Disease: Heart disease was discovered by the ancient Egyptians. During 1873–74, Georg Moritz Ebers , a German intellectual and Egyptologist, discovered an ancient Egyptian medical work or papyrus that proves the ancient Egyptians were the first to discover heart disease. The papyrus is called the Ebers papyrus in his honor. The discovery of heart disease was described in this paper, which is why the discovery of heart disease is attributed to the ancient Egyptians. www.AssignmentPoint.com Georg Moritz Ebers What is Heart Disease? When people think of heart disease, a heart attack may be the first disorder they envision. Clinically called a myocardial infarction, a heart attack tends to be serving, dramatic, and intense. A myocardial infarction occurs when a section of heart tissue dies due to serve disruption of blood flow to the area. However, a myocardial infarction is only one type heart disease. Under the umbrella term “Heart disease” is a number of other conditions, including coronary heart disease (CHD), angina pectoris (chest pain), congestive www.AssignmentPoint.com heart failure (a condition in which the heart loses its ability to pump effectively), cardiomyopathy, congenital heart disease (heart disorders that are present at birth), arrhythmias (disorders of the heart’s rhythm), myocarditis. In each disorder, the health and functioning of the entire cardiovascular system-heart, arteries, and veins, and such vital organs as the brains, lungs and kidneys are at issue. Definition of Heart Disease: Any disorder that affects the heart, sometimes the term "heart disease" is used narrowly and incorrectly as a synonym for coronary artery disease. Heart disease is synonymous with cardiac disease but not with cardiovascular disease which is any disease of the heart or blood vessels. Among the many types of heart disease, see, for example: coronary heart disease (CHDatherosclerosis of the arteries supplying the heart), angina pectoris (chest pain), congestive heart failure (a condition in which the heart loses its ability to pump effectively), www.AssignmentPoint.com cardiomyopathy, congenital heart disease (heart disorders that are present at birth), arrhythmias (disorders of the heart’s rhythm), myocarditis. Types of Heart Disease: Heart disease is a broad term that includes all types of diseases affecting different components of the heart. Heart means 'cardio.' Therefore, all heart diseases belong to the category of cardiovascular diseases. Some types of heart diseases are: Coronary heart disease (CHD) Angina pectoris Congestive heart failure Cardiomyopathy Congenital heart disease Arrhythmias Myocarditis www.AssignmentPoint.com Coronary Heart Disease (CHD): Coronary heart disease (CHD) is a narrowing of the small blood vessels that supply blood and oxygen to the heart. CHD is also called coronary artery disease. Causes Coronary heart disease (CHD) is the leading cause of death in the United States for men and women. Coronary heart disease is caused by the buildup of plaque in the arteries to our heart. This may also be called hardening of the arteries. Fatty material and other substances form a plaque build-up on the walls of our coronary arteries. The coronary arteries bring blood and oxygen to our heart. This buildup causes the arteries to get narrow. As a result, blood flow to the heart can slow down or stop. www.AssignmentPoint.com Figur: Coronary heart disease. Symptoms Symptoms may be very noticeable, but sometimes can have the disease and not have any symptoms. This is especially true in the early stages of heart disease. Chest pain or discomfort (angina) is the most common symptom. Feel this pain when the heart is not getting enough blood or oxygen. How bad the pain is varies from person to person. It may feel heavy or like someone is squeezing our heart. We may feel it under our breast bone (sternum), but also in your neck, arms, stomach, or upper back. The pain usually occurs with activity or emotion, and goes away with rest or a medicine called nitroglycerin. www.AssignmentPoint.com Other symptoms include shortness of breath and fatigue with activity (exertion). Women, elderly people, and people with diabetes are more likely to have symptoms other than chest pain, such as: Fatigue Shortness of breath General weakness Exams and Tests Our doctor or nurse will examine. Doctor will often order more than one test before making a diagnosis. Tests may include: Coronary angiography -- an invasive test that evaluates the heart arteries under x-ray Echocardiogram stress test Electrocardiogram (ECG) www.AssignmentPoint.com Electron-beam computed tomography (EBCT) to look for calcium in the lining of the arteries -- the more calcium, the higher your chance for CHD Exercise stress test Heart CT scan Nuclear stress test Treatment We may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow our doctor's directions closely to help prevent coronary artery disease from getting worse. Goals for treating these conditions in people who have coronary artery disease: Blood pressure less than or equal to 140/90 (even lower for patients with diabetes, kidney disease, or heart failure) HbA1c levels if you have diabetes at a level recommended by our doctor www.AssignmentPoint.com LDL cholesterol level less than or equal to 100 mg/dL (even lower for some patients) Treatment depends on your symptoms and how severe the disease is. Doctor may give one or more medicines to treat heart disease, blood pressure, diabetes, or high cholesterol. Follow doctor's directions closely to help prevent coronary artery disease from getting worse. Never stop taking your medicines without talking to doctor first. Stopping heart medicines suddenly can make angina worse or cause a heart attack. Angina Pectoris: Angina pectoris–commonly known as angina–is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries. The main cause of angina pectoris is Coronary Artery Disease, due to atherosclerosis of the arteries feeding the heart. The term derives from the Latin angina ("infection of the throat") from the Greek ankhone ("strangling"), and the Latin pectus ("chest"), and can therefore be translated as "a strangling feeling in the chest". www.AssignmentPoint.com There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a heart attack, and a heart attack can occur without pain). Worsening ("crescendo") angina attacks, sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms of unstable angina (usually grouped with similar conditions as the acute coronary syndrome). As these may herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack. Figure: Angina pectoris. www.AssignmentPoint.com Classification: Stable angina Unstable angina Micro vascular angina Stable angina: Also known as effort angina, this refers to the more common understanding of angina related to myocardial ischemia. Typical presentations of stable angina is that of chest discomfort and associated symptoms precipitated by some activity (running, walking, etc.) with minimal or non-existent symptoms at rest. Symptoms typically abate several minutes following cessation of precipitating activities and reoccur when activity resumes. In this way, stable angina may be thought of as being similar to claudicating symptoms. Unstable angina: www.AssignmentPoint.com Unstable angina (UA) (also "crescendo angina;" this is a form of acute coronary syndrome) is defined as angina pectoris that changes or worsens. It has at least one of these three features: It occurs at rest (or with minimal exertion), usually lasting >10 min; It is severe and of new onset (i.e., within the prior 4– 6 weeks); and/or It occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than before). UA may occur unpredictably at rest which may be a serious indicator of an impending heart attack. What differentiates stable angina from unstable angina (other than symptoms) is the pathophysiology of the atherosclerosis. The path physiology of unstable angina is the reduction of coronary flow due to transient platelet aggregation on apparently normal endothelium, coronary artery spasms or coronary thrombosis. The process starts with atherosclerosis, and when inflamed leads to an active plaque, which undergoes thrombosis and results in acute ischemia, which finally results in cell necrosis after www.AssignmentPoint.com calcium entry. Studies show that 64% of all unstable anginas occur between 10 PM and 8 AM when patients are at rest. Instable angina, the developing thermo is protected with a fibrous cap. This cap (atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and further decrease the lumen of the coronary vessel. This explains why an unstable angina appears to be independent of activity. Micro vascular angina: Micro vascular Angina or Angina Syndrome X is characterized by angina-like chest pain, but has different causes. The cause of Micro vascular Angina is unknown, but it appears to be the result of poor function in the tiny blood vessels of the heart, arms and legs. Since microvascular angina isn't characterized by arterial blockages, it's harder to recognize and diagnose, but its prognosis is excellent. Signs and symptoms: Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described www.AssignmentPoint.com as a pressure, heaviness, tightness, and squeezing, burning, or choking sensation. Apart from chest discomfort, angina pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain, and is due to the spinal level that receives visceral sensation from the heart simultaneously receiving cetaceous sensation from parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. In this case, the pulse rate and the blood pressure increase. Chest pain lasting only a few seconds is normally not angina (such as pericardial catch syndrome). Myocardial ischemia comes about when the myocardial (the heart muscles) receive insufficient blood and oxygen to function normally either because of increased oxygen demand by the myocardia or by decreased supply to the www.AssignmentPoint.com myocardial. This inadequate perfusion of blood and the resulting reduced delivery of oxygen and nutrients is directly correlated to blocked or narrowed blood vessels. Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous system) such as nausea, vomiting and pallor. Major risk factors for angina include cigarette smoking, diabetes, high cholesterol, high blood pressure, sedentary lifestyle and family history of premature heart disease. A variant form of angina (Prinzmetal's angina) occurs in patients with normal coronary arteries or insignificant atherosclerosis. It is thought to be caused by spasms of the artery. It occurs more in younger women. Major risk factors/Causes: Age (≥ 55 years for men, ≥ 65 for women) Cigarette smoking Diabetes mellitus (DM) Dyslipidemia www.AssignmentPoint.com Family history of premature cardiovascular disease (men <55 years, female <65 years old) Hypertension (HTN) Kidney disease (microalbuminuria or GFR<60 mL/min) Obesity (BMI ≥ 30 kg/m2) Physical inactivity Decrease psychosocial stress. Routine counseling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behavior, and thus is not recommended. Conditions that exacerbate or provoke angina Medications vasodilators excessive thyroid replacement www.AssignmentPoint.com vasoconstrictors polycythemia which thickens the blood causing it to slow its flow through the heart muscle One study found that smokers with coronary artery disease had a significantly increased level of sympathetic nerve activity when compared to those without. This is in addition to increases in blood pressure, heart rate and peripheral vascular resistance associated with nicotine which may lead to recurrent angina attacks. Additionally, CDC reports that the risk of CHD (Coronary heart disease), stroke, and PVD (Peripheral vascular disease) is reduced within 1–2 years of smoking cessation. In another study, it was found that after one year, the prevalence of angina in smoking men under 60 after an initial attack was 40% less in those who had quit smoking compared to those who continued. Studies have found that there are short term and long term benefits to smoking cessation. Other medical problems: profound anemia www.AssignmentPoint.com uncontrolled HTN hyperthyroidism hypoxemia Other cardiac problems: Tachyarrhythmia Brady arrhythmia Valvular heart disease Hypertrophic cardiomyopathy Myocardial ischemia can result from: A reduction of blood flow to the heart that can be caused by stenosis, spasm, or acute occlusion (by an embolus) of the heart's arteries. Resistance of the blood vessels. This can be caused by narrowing of the blood vessels; a decrease in radius, Blood flow is inversely proportional to the radius of the artery to the fourth power. Reduced oxygen-carrying capacity of the blood, due to several factors such as a decrease in oxygen tension www.AssignmentPoint.com and hemoglobin concentration. This decreases the ability to of hemoglobin to carry oxygen to myocardial tissue. Atherosclerosis is the most common cause of stenosis (narrowing of the blood vessels) of the heart's arteries and, hence, angina pectoris. Some people with chest pain have normal or minimal narrowing of heart arteries; in these patients, vasospasm is a more likely cause for the pain, sometimes in the context of Prinzmetal's angina and syndrome X. Myocardial ischemia also can be the result of factors affecting blood composition, such as reduced oxygencarrying capacity of blood, as seen with severe anemia (low number of red blood cells), or long-term smoking. Pathophysiology: Angina results when there is an imbalance between the heart's oxygen demand and supply. This imbalance can result from an increase in demand (e.g. during exercise) without a proportional increase in supply (e.g. due to obstruction or atherosclerosis of the coronary arteries). www.AssignmentPoint.com Diagnosis: Suspect angina in people presenting with tight, dull, or heavy chest discomfort which is: Retrosternal or left-sided, radiating to the left arm, neck, jaw, or back. Associated with exertion or emotional stress and relieved within several minutes by rest. Precipitated by cold weather or a meal. Some people present with atypical symptoms, including breathlessness, nausea, or epigastric discomfort or burping. These atypical symptoms are particularly likely in older people, women, and those with diabetes. Angina pain is not usually sharp or stabbing or influenced by respiration. Anti-acids and simple analgesia do not usually relieve the pain. If chest discomfort (of whatever site) is precipitated by exertion, relieved by rest, and relieved by glyceryl trinitrate, the likelihood of angina is increased. In angina patients who are momentarily not feeling any one chest pain, an electrocardiogram (ECG) is typically www.AssignmentPoint.com normal, unless there have been other cardiac problems in the past. During periods of pain, depression or elevation of the ST segment may be observed. To elicit these changes, an exercise ECG test ("treadmill test") may be performed, during which the patient exercises to their maximum ability before fatigue, breathlessness or, importantly, pain intervenes; if characteristic ECG changes are documented (typically more than 1 mm of flat or downsloping ST depression), the test is considered diagnostic for angina. Even constant monitoring of the blood pressure and the pulse rate can lead us to some conclusion regarding the angina. The exercise test is also useful in looking for other markers of myocardial ischaemia: blood pressure response (or lack thereof, particularly a drop in systolic pressure), dysrhythmia and chronotropic response. Other alternatives to a standard exercise test include a thallium scintigram or sestamibi scintigram (in patients who cannot exercise enough for the purposes of the treadmill tests, e.g:- due to asthma or arthritis or in whom the ECG is too abnormal at rest) or Stress Echocardiography. www.AssignmentPoint.com In patients in whom such noninvasive testing is diagnostic, a coronary angiogram is typically performed to identify the nature of the coronary lesion, and whether this would be a candidate for angioplasty, coronary artery bypass graft (CABG), treatment only with medication, or other treatments. There has been research which concludes that a frequency is attained when there is increase in the blood pressure and the pulse rate. This frequency varies normally but the range is 45–50 kHz for the cardiac arrest or for the heart failure. In patients who are in hospital with unstable angina (or the newer term of "high risk acute coronary syndromes"), those with resting ischaemic ECG changes or those with raised cardiac enzymes such as troponin may undergo coronary angiography directly. Treatment: The most specific medicine to treat angina is nitroglycerin. It is a potent vasodilator that makes more oxygen available to the heart muscle. Beta-blockers and calcium channel blockers act to decrease the heart's www.AssignmentPoint.com workload, and thus its requirement for oxygen. Nitroglycerin should not be given if certain inhibitors such as Sildenafil (Viagra), Tadalafil (Cialis), or Vardenafil (Levitra) have been taken within the previous 12 hours as the combination of the two could cause a serious drop in blood pressure. Treatments are balloon angioplasty, in which the balloon is inserted at the end of a catheter and inflated to widen the arterial lumen. Stents to maintain the arterial widening are often used at the same time. Coronary bypass surgery involves bypassing constricted arteries with venous grafts. This is much more invasive than angioplasty. The main goals of treatment in angina pectoris are relief of symptoms, slowing progression of the disease, and reduction of future events, especially heart attacks and death. Beta blockers (e.g:- carvedilol, propranolol, atenolol) have a large body of evidence in morbidity and mortality benefits (fewer symptoms, less disability and longer life) and short-acting nitroglycerin medications have been used since 1879 for symptomatic relief of angina. Calcium channel blockers (such as nifedipine (Adult) and amlodipine), isosorbide mononitrate and www.AssignmentPoint.com nicorandil are vasodilators commonly used in chronic stable angina. A new therapeutic class, called if inhibitor, has recently been made available: ivabradine provides pure heart rate reduction leading to major anti-ischemic and antinational efficacy. ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit and, lastly, statins are the most frequently used lipid/cholesterol modifiers which probably also stabilize existing athermanous plaque. Low-dose aspirin decreases the risk of heart attack in patients with chronic stable angina, and was previously part of standard treatment; however, it has since been discovered that the increase in haemorrhagic stroke and gastrointestinal bleeding offsets this gain so they are no longer advised unless the risk of myocardial infarction is very high. Exercise is also a very good long term treatment for the angina (but only particular regimens - gentle and sustained exercise rather than intense short bursts),probably working by complex mechanisms such as improving blood pressure and promoting coronary artery collateralization. www.AssignmentPoint.com Identifying and treating risk factors for further coronary heart disease is a priority in patients with angina. This means testing for elevated cholesterol and other fats in the blood, diabetes and hypertension (high blood pressure), and encouraging smoking cessation and weight optimization. The calcium channel blocker nifedipine prolongs cardiovascular event- and procedure-free survival in patients with coronary artery disease. New overt heart failures were reduced by 29% compared to placebo; however, the mortality rate difference between the two groups was statistically insignificant. The fatty acid oxidation inhibitor mildronate is a clinically-used anti-ischemic drug for the treatment of angina and myocardial infarction. Mildronate shifts the myocardial energy metabolism from fatty acid oxidation to the more oxygen sparing glucose oxidation under ischemic conditions, by inhibiting enzymes in the carnitine biosynthesis pathway including gammabutyrobetaine deoxygenate. Mildronate also inhibits carnitine acetyltransferase and therefore acts as a myocardial energy metabolism regulator. www.AssignmentPoint.com Congestive heart failure: Congestive heart failure facts Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. The symptoms of congestive heart failure vary, but can include fatigue, diminished exercise capacity, shortness of breath, and swelling. The diagnosis of congestive heart failure is based on knowledge of the individual's medical history, a careful physical examination, and selected laboratory tests. The treatment of congestive heart failure can include lifestyle modifications, addressing potentially reversible factors, medications, heart transplant, and mechanical therapies. The course of congestive heart failure in any given patient is extremely variable. www.AssignmentPoint.com Congestive heart failure: Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by: Diseases that weaken the heart muscle, Diseases that cause stiffening of the heart muscles, or Diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood. Figure: Congestive heart failure. www.AssignmentPoint.com The heart has two atria (right atrium and left atrium) that make up the upper chambers of the heart, and two ventricles (left ventricle and right ventricle) that make up the lower chambers of the heart. The ventricles are muscular chambers that pump blood when the muscles contract. The contraction of the ventricle muscles is called systole. Many diseases can impair the pumping action of the ventricles. For example, the muscles of the ventricles can be weakened by heart attacks, infections (myocarditis) or toxins (alcohol, some chemotherapy agents). The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole. Diseases such as hemochromatosis (iron overload) or amyloidosis can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is longstanding high blood pressure resulting www.AssignmentPoint.com in a thickened (hypertrophied) heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body's tissues (for example, with hyperthyroidism or anemia) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure). In some individuals one or more of these factors can be present to cause congestive heart failure. The remainder of this article will focus primarily on congestive heart failure that is due to heart muscle weakness, systolic dysfunction. Congestive heart failure can affect many organs of the body. For example: The weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt (sodium) and water. This diminished kidney function can cause the body to retain more fluid. www.AssignmentPoint.com The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased. Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. The intestines may become less efficient in absorbing nutrients and medicines. Fluid also may accumulate in the extremities, resulting in edema (swelling) of the ankles and feet. Eventually, untreated, worsening congestive heart failure will affect virtually every organ in the body. Symptoms of congestive heart failure: The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness. An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible www.AssignmentPoint.com underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish. Patients may not even sense this decrease and they may subconsciously reduce their activities to accommodate this limitation. As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravitydependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common) In addition, fluid may accumulate in the lungs, thereby causing shortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air. www.AssignmentPoint.com Some may be unable to sleep unless sitting upright. The extra fluid in the body may cause increased urination, particularly at night. Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and decreased appetite. Diagnosis: The diagnosis of congestive heart failure is most often a clinical one that is based on knowledge of the patient's pertinent medical history, a careful physical examination, and selected laboratory tests. A thorough patient history may disclose the presence of one or more of the symptoms of congestive heart failure described above. In addition, a history of significant coronary artery disease, prior heart attack, hypertension, diabetes, or significant alcohol use can be clues. The physical examination is focused on detecting the presence of extra fluid in the body (breath sounds, leg swelling, or neck veins) as well as carefully www.AssignmentPoint.com characterizing the condition of the heart (pulse, heart size, heart sounds, and murmurs). Useful diagnostic tests include the electrocardiogram (ECG) and chest X-ray to detect previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. Perhaps the single most useful diagnostic test is the echocardiogram, in which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness. In addition, the test can suggest possible causes for the heart muscle weakness (for example, prior heart attack, and severe valve abnormalities). Virtually all patients in whom the diagnosis of congestive heart failure is suspected should ideally undergo echocardiography early in their assessment. Nuclear medicine studies assess the overall pumping capability of the heart and examine the possibility of inadequate blood flow to the heart muscle. Heart catheterization allows the arteries to the heart to be visualized with angiography (using dye inside of the blood vessels that can be seen using X-ray methods). www.AssignmentPoint.com During catheterization the pressures in and around the heart can be measured and the heart's performance assessed. In rare cases, a biopsy of the heart tissue may be recommended to diagnose specific diseases. This biopsy can often be accomplished through the use of a special catheter device that is inserted into a vein and maneuvered into the right side of the heart. Another helpful diagnostic test is a blood test called a BNP or B-type natriuretic peptid level. This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure. The choice of tests depends on each patient's case and is based on the suspected diagnoses. Treatment of congestive heart failure: Lifestyle modification Addressing potentially reversible factors www.AssignmentPoint.com Lifestyle modifications After congestive heart failure is diagnosed, treatment should be started immediately. Perhaps the most important and yet most neglected aspect of treatment involves lifestyle modifications. Sodium causes an increase in fluid accumulation in the body's tissues. Because the body is often congested with excess fluid, patients become very sensitive to the levels of intake of sodium and water. Restricting salt and fluid intake is often recommended because of the tendency of fluid to accumulate in the lungs and surrounding tissues. An American "no added salt" diet can still contain 4 to 6 grams (4000 to 6000 milligrams) of sodium per day. In individuals with congestive heart failure, an intake of no more than 2 grams (2000 milligrams) of sodium per day is generally advised. Reading food labels and paying close attention to total sodium intake is very important. Severe restriction of alcohol consumption also is advised. Likewise, the total amount of fluid consumed must be regulated. Although many people with congestive heart failure take diuretics to aid in the elimination of excess fluid, the action of these medications can be overwhelmed www.AssignmentPoint.com by an excess intake of water and other fluids. The maxim that "drinking eight glasses of water a day is healthy" certainly does not apply to patients with congestive heart failure. In fact, patients with more advanced cases of congestive heart failure are often advised to limit their total daily fluid intake from all sources to 2 quarts. The above guidelines for sodium and fluid intake may vary depending on the severity of congestive heart failure in any given individual and should be discussed with their physician. An important tool for monitoring an appropriate fluid balance is the frequent measurement of body weight. An early sign of fluid accumulation is an increase in body weight. This may occur even before shortness of breath or swelling in the legs and other body tissues (edema) is detected. A weight gain of two to three pounds over two to three days should prompt a call to the physician, who may order an increase in the dose of diuretics or other methods designed to stop the early stages of fluid accumulation before it becomes more severe. Aerobic exercise, once discouraged for congestive heart failure patients, has been shown to be beneficial in www.AssignmentPoint.com maintaining overall functional capacity, quality of life, and perhaps even improving survival. Each person's body has its own unique ability to compensate for the failing heart. Given the same degree of heart muscle weakness, individuals may display widely varying degrees of limitation of function. Regular exercise, when tailored to the person's tolerance level, appears to provide significant benefits and should be used only when the individual is compensated and stable. Addressing potentially reversible factors: Depending on the underlying cause of congestive heart failure, potentially reversible factors should be explored. For example: In certain persons whose congestive heart failure is caused by inadequate blood flow to the heart muscle, restoration of the blood flow through coronary artery surgery or catheter procedures (angioplasty, intracoronary stenting) may be considered. www.AssignmentPoint.com Congestive heart failure that is due to severe disease of the valves may be alleviated by valve surgery in appropriate patients. When congestive heart failure is caused by chronic, uncontrolled high blood pressure (hypertension), aggressive blood pressure control will often improve the condition. Heart muscle weakness that is due to longstanding, severe alcohol abuse can improve significantly with abstinence from drinking. Congestive heart failure that is caused by other disease states may be similarly partially or completely reversible by appropriate measures. Cardiomyopathy: Cardiomyopathy (literally "heart muscle disease") is the measurable deterioration of the function of the myocardium (the heart muscle) for any reason, usually leading to heart failure; common symptoms are dyspnea (breathlessness) and peripheral edema (swelling of the legs). People with cardiomyopathy are often at risk of www.AssignmentPoint.com dangerous forms of irregular heart beat and sudden cardiac death.The most common form of cardiomyopathy is dilated cardiomyopathy. Figur: Dilated cardiomyopathy. Classification: Although in theory the term "cardiomyopathy" could apply to almost any disease affecting the heart, in practice it is usually reserved for "severe myocardial disease leading to heart failure".Cardiomyopathies can be categorized as extrinsic or intrinsic. www.AssignmentPoint.com An extrinsic cardiomyopathy is a cardiomyopathy where the primary pathology is outside the myocardium itself. Most cardiomyopathies are extrinsic; by far the most common cause of an extrinsic cardiomyopathy is ischemia. Ischemia can be understood as poor oxygen supply of the heart muscle (the demand for oxygen is higher than the current supply). The World Health Organization calls these specific cardiomyopathies: An intrinsic cardiomyopathy is defined as weakness in the muscle of the heart not due to an identifiable external cause. This definition was used to categorize previously idiopathic cardiomyopathies although specific external causes have since been identified for many. For example, alcoholism has been identified as a cause for some forms of dilated cardiomyopathy. To make a diagnosis of an intrinsic cardiomyopathy, significant coronary artery disease should be ruled out first (amongst other causes). The term intrinsic cardiomyopathy does not describe the specific etiology of weakened heart muscle. The intrinsic cardiomyopathies consist of a variety of disease states, each with their own causes. Many intrinsic cardiomyopathies now have identifiable external causes www.AssignmentPoint.com including drug and alcohol toxicity, certain infections (including Hepatitis C), and various genetic and idiopathic (i.e., unknown) causes. It is also possible to classify cardiomyopathies functionally, as involving dilation, hypertrophy, or restriction. Types: Primary/intrinsic cardiomyopathies • Genetic Hypertrophic cardiomyopathy (HCM or HOCM) Arrhythmogenic right ventricular cardiomyopathy (ARVC) Isolated ventricular non-compaction Mitochondrial myopathy • Mixed Dilated cardiomyopathy (DCM) Restrictive cardiomyopathy (RCM) • Acquired www.AssignmentPoint.com Takotsubo cardiomyopathy Loeffler endocarditis Secondary/extrinsic cardiomyopathies • Metabolic/storage amyloidosis hemochromatosis • Inflammatory Chagas disease • Endocrine diabetic cardiomyopathy hyperthyroidism acromegaly • Toxicity chemotherapy Alcoholic cardiomyopathy • Neuromuscular muscular dystrophy www.AssignmentPoint.com • Nutritional diseases Obesity-associated cardiomyopathy • Other "Ischemic cardiomyopathy" is a weakness in the muscle of the heart due to inadequate oxygen delivery to the myocardium with coronary artery disease being the most common cause. Not supported by current cardiomyopathies classification schemes. Signs and symptoms: Symptoms and signs may mimic those of almost any form of heart disease. Chest pain is common. Mild myocarditis or cardiomyopathy is frequently asymptomatic; severe cases are associated with heart failure, arrhythmias, and systemic embolization. Manifestations of the underlying disease (e.g., Chagas' disease) may be prominent. Most patients with biopsy-proven myocarditis report a recent viral prodrome preceding cardiovascular symptoms. EKG abnormalities are often present, although the changes are frequently nonspecific. A pattern www.AssignmentPoint.com characteristic of left ventricular hypertrophy may be present. Flat or inverted T waves are most common, often with low-voltage QRS complexes. Intraventricular conduction defects and bundle branch block, especially left bundle branch block, are also common. An echocardiogram is useful to detect wall motion abnormalities or a pericardial effusion. Chest radiographs can be normal or can show evidence of congestive heart failure with pulmonary edema or cardiomegaly. Treatment: Treatment depends on the type of cardiomyopathy and condition of disease, but may include medication (conservative treatment) or iatrogenic/implanted pacemakers for slow heart rates, defibrillators for those prone to fatal heart rhythms, ventricular assist devices (LVADs) for severe heart failure, or ablation for recurring dysrhythmias that cannot be eliminated by medication or cardioversion. The goal of treatment is often symptom relief, and some patients may eventually require a heart transplant. Treatment of cardiomyopathy (and other heart diseases) using alternative methods such as stem cell www.AssignmentPoint.com therapy is commercially available but is not supported by convincing evidence. Congenital heart disease: A congenital heart defect (CHD) is a defect in the structure of the heart and great vessels which is present at birth. Many types of heart defects exist, most of which either obstruct blood flow in the heart or vessels near it, or cause blood to flow through the heart in an abnormal pattern. Other defects, such as long QT syndrome, affect the heart's rhythm. Heart defects are among the most common birth defects and are the leading cause of birth defect-related deaths. Approximately 9 people in 1000 are born with a congenital heart defect. Many defects don't need treatment, but some complex congenital heart defects require medication or surgery. www.AssignmentPoint.com Figur: Congenital heart disease. Signs and symptoms: Signs and symptoms are related to the type and severity of the heart defect. Symptoms frequently present early in life, but it's possible for some CHDs to go undetected throughout life.[3] Some children have no signs while others may exhibit shortness of breath, cyanosis, syncope,[4] heart murmur, under-developing of limbs and muscles, poor feeding or growth, or respiratory infections. Congenital heart defects because abnormal heart structure resulting in production of certain sounds called heart murmur. These can sometimes be detected by auscultation; however, not all heart murmurs are caused by congenital heart defects. www.AssignmentPoint.com Associated symptoms: Congenital heart defects are associated with an increased incidence of some other symptoms, together being called the VACTERL association: V - Vertebral anomalies A - Anal atresia C - Cardiovascular anomalies T - Tracheoesophageal fistula E - Esophageal atresia R - Renal (Kidney) and/or radial anomalies L - Limb defects Ventricular septal defect (VSD), atrial septal defects, and tetralogy of Fallot are the most common congenital heart defects seen in the VACTERL association. Less common defects in the association are truncus arteriosus, and transposition of the great arteries. www.AssignmentPoint.com Embryology: There is a complex sequence of events that result in a well formed heart at birth and disruption of any portion may result in a defect.The orderly timing of cell growth, cell migration, and programmed cell death ("apoptosis") has been studied extensively and the genes that control the process are being elucidated. Around day 15 of development, the cells that will become the heart exist in two horseshoe shaped bands of the middle tissue layer (mesoderm),and some cells migrate from portion of the outer layer (ectoderm), the neural crest which is the source of a variety of cells found throughout the body. On day 19 of development, a pair of vascular elements, the "endocardial tubes", form. The tubes fuse when cells between then undergo programmed death and cells from the first heart field migrate to the tube, and form a ring of heart cells (myocytes) around it by day 21. On day 22, the heart begins to beat and by day 24, blood is circulating. At day 22, the circulatory system is bilaterally symmetrical with paired vessels on each side and the heart consisting of a simple tube located in the midline of the body layout. The portion that will become the atria www.AssignmentPoint.com and will be located closest to the head are the most distant from the head. From days 23 through 28, the heart tube folds and twists, with the future ventricles moving left of center (the ultimate location of the heart) and the atria moving towards the head. On day 28, areas of tissue in the heart tube begin to expand inwards; after about two weeks, these expansions, the membranous "septum primum" and the muscular "endocardial cushions", fuse to form the four heart chambers of the heart. A failure to fuse properly will result in a defect that may allow blood to leak between chambers. After this happens, cells which have migrated from the neural crest begin to divide the bulbus cordis, the main outflow tract is divided in two by the growth a spiraling septum, becoming the great vessels—the ascending segment of the aorta and the pulmonary trunk. If the separation is incomplete, the result is a "persistent truncus arteriosis". The vessels may be reversed ("transposition of the great vessels"). The two halves of the split tract must migrate into the correct positions over the appropriate ventricles. A failure may result in some blood flowing into the wrong vessel (e.g. overriding www.AssignmentPoint.com aorta). The four chambered heart and the great vessels have features required for fetal growth. The lungs are unexpanded and cannot accommodate the full circulatory volume. Two structures exist to shunt blood flow away from the lungs. Cells in part of the septum primum die creating a hole while muscle cells, the "septum secundum", grow along the right atrial side the septum primum, except for one region, leaving a gap through which blood can pass from the right artium to the left atrium, the foramen ovale. A small vessel, the ductus arteriosus allows blood from the pulmonary artery to pass to the aorta. Changes at birth: The ductus arteriosus stays open because of circulating factors including prostaglandins. The foramen ovale stays open because of the flow of blood from the right atrium to the left atrium. As the lungs expand, blood flows easily through the lungs and the membranous portion of the foramen ovale (the septum primum) flops over the muscular portion (the septum secundum). If the closure is incomplete, the result is a patent foramen ovale. The two flaps may fuse, but many adults have a foramen ovale that www.AssignmentPoint.com stays closed only because of the pressure difference between the atria. Theories: Rokitansky (1875) explained congenital heart defects as breaks in heart development at various ontogenesis stages. Spitzer (1923) treats them as returns to one of the phylogenesis stages.Krimsky (1963), synthesizing two previous points of view, considered congenital heart diseases as a stop of development at the certain stage of ontogenesis, corresponding to this or that stage of the phylogenesis. Hence these theories can explain feminine and neutral types of defects only. Causes: The cause of congenital heart disease may be either genetic or environmental, but is usually a combination of both. Genetics: Most of the known causes of congenital heart disease are sporadic genetic changes, either focal mutations or deletion or addition of segments of DNA. Large www.AssignmentPoint.com chromosomal abnormalities such as trisomies 21, 13, and 18 cause about 5-8% of cases of CHD, with trisomy 21 being the most common genetic cause.[5] Small chromosomal abnormalities also frequently lead to congenital heart disease, and examples include microdeletion of the long arm of chromosome 22 (22q11, DiGeorge syndrome), the long arm of chromosome 1 (1q21), the short arm of chromosome 8 (8p23) and many other, less recurrent regions of the genome, as shown by high resolution genome-wide screening (Array comparative genomic hybridization). The genes regulating the complex developmental sequence have only been partly elucidated. Some genes are associated with specific defects. A number of genes have been associated with cardiac manifestations. Mutations of a heart muscle protein, α-myosin heavy chain (MYH6) are associated with atrial septal defects. Several proteins that interact with MYH6 are also associated with cardiac defects. The transcription factor GATA4 forms a complex with the TBX5 which interacts with MYH6. Another factor, the homeobox (developmental) gene, NKX2-5 also interacts with www.AssignmentPoint.com MYH6. Mutations of all these proteins are associated with both atrial and ventricular septal defects; In addition, NKX2-5 is associated with defects in the electrical conduction of the heart and TBX5 is related to the HoltOram syndrome which includes electrical conduction defects and abnormalities of the upper limb. Another Tbox gene, TBX1, is involved in velo-cardio-facial syndrome DiGeorge syndrome, the most common deletion which has extensive symptoms including defects of the cardiac outflow tract including tetralogy of Fallot. Examples of gene products and associated features MYH6 GATA4 NKX2-5 TBX5 TBX1 Locus 14q11.2-q13 8p23.1-p22 5q34 12q24.1 Syndrome Holt-Oram www.AssignmentPoint.com 22q11.2 DiGeorge Atrial septal defects ✔ ✔ ✔ ✔ Ventricular septal defects ✔ ✔ ✔ Electrical conduction abnormalities ✔ ✔ Outflow tract abnormalities ✔ Non-cardiac manifestations Upper abnormalities Small or absent thymus limb Small or absent parathyroids Facial abnormalities The notch signaling pathway, a regulatory mechanism for cell growth and differentiation, plays broad roles in several aspects of cardiac development. Notch elements are involved in determination of the right and left sides of the body plan, so the directional folding of the heart tube can be impacted. Notch signaling is involved early in the formation of the endocardial cushions and continues to be active as the develop into the septa and valves. It is also involved in the development of the ventricular wall and www.AssignmentPoint.com the connection of the outflow tract to the great vessels. Mutations in the gene for one of the notch ligands, Jagged1, are identified in the majority of examined cases of arteriohepatic dysplasia (Alagille syndrome), characterized by defects of the great vessels (pulmonary artery stenosis), heart (tetralogy of Fallot in 13% of cases), liver, eyes, face, and bones. Though less than 1% of all cases, where no defects are found in the Jagged1 gene, defects are found in Notch2 gene. In 10% of cases, no mutation is found in either gene. For another member of the gene family, mutations in the Notch1 gene are associated with bicuspid aortic valve, a valve with two leaflets instead of three. Notch1 is also associated with calcification of the aortic valve, the third most common cause of heart disease in adults. Mutation of a cell regulatory mechanism, the Ras/MAPK pathway are responsible for a variety of syndromes, including Noonan syndrome, LEOPARD syndrome, Costello syndrome and cardiofaciocutaneous syndrome in which there is cardiac involvement.[16] While the conditions listed are known genetic causes, there are likely many other genes which are more subtle. It is www.AssignmentPoint.com known that the risk for congenital heart defects is higher when there is a close relative with one. Environmental: Known antenatal environmental factors include maternal infections (Rubella), drugs (alcohol, hydantoin, lithium and thalidomide) and maternal illness (diabetes mellitus, phenylketonuria, and systemic lupus erythematosus). Maternal obesity: As noted in several studies following similar body mass index (BMI) ranges, prepregnant and gestating women, who were obese (BMI ≥ 30), carried a statistically significant risk of birthing children with congenital heart defects (CHD) compared to normal-weight women (BMI= 19-24.9).Although there are minor conflicting reports, there was significant support for the risk of fetal CHD development in overweight mothers (BMI= 2529.9). Additionally, as maternal obesity increased, the risk of heart defects did too indicating a trend between BMI and CHD odds. Altogether, these results present reasonable concern for women to achieve a normalwww.AssignmentPoint.com weight BMI prior to pregnancy to help decrease risk for fetal heart defects. A distinct physiological mechanism has not been identified to explain the link between maternal obesity and CHD, but both prepregnancy folate deficiency and diabetes have been implicated in some studies. Identification of the mechanism could aid health officials to develop reduction strategies and curb CHD’s prevalence in this preventable situation. Classification: A number of differing classification systems exist for congenital heart defects. In 2000 the International Congenital Heart Surgery Nomenclature was developed to provide a generic classification system. Hypoplasia: Hypoplasia can affect the heart, typically resulting in the underdevelopment of the right ventricle or the left ventricle. This results in only one side of the heart capable www.AssignmentPoint.com of pumping blood to the body and lungs effectively. Hypoplasia of the heart is rare but is the most serious form of CHD. It is called hypoplastic left heart syndrome when it affects the left side of the heart and hypoplastic right heart syndrome when it affects the right side of the heart. In both conditions, the presence of a patent ductus arteriosus (and, when hypoplasia affects the right side of the heart, a patent foramen ovale) is vital to the infant's ability to survive until emergency heart surgery can be performed, since without these pathways blood cannot circulate to the body (or lungs, depending on which side of the heart is defective). Hypoplasia of the heart is generally a cyanotic heart defect. Obstruction defects: Obstruction defects occur when heart valves, arteries, or veins are abnormally narrow or blocked. Common defects include pulmonic stenosis, aortic stenosis, and coarctation of the aorta, with other types such as bicuspid aortic valve stenosis and subaortic stenosis being comparatively rare. www.AssignmentPoint.com Any narrowing or blockage can cause heart enlargement or hypertension. Septal defects: The septum is a wall of tissue which separates the left heart from the right heart. Defects in the interatrial septum or the interventricular septum allow blood to flow from the left side of the heart to the right, reducing the heart's efficiency. Ventricular septal defects are collectively the most common type of CHD, although approximately 30% of adults have a type of atrial septal defect called probe patent foramen ovale. Cyanotic defects: Cyanotic heart defects are called such because they result in cyanosis, a bluish-grey discoloration of the skin due to a lack of oxygen in the body. Such defects include persistent truncus arteriosus, total anomalous pulmonary venous connection, tetralogy of Fallot, transposition of the great vessels, and tricuspid atresia. www.AssignmentPoint.com Defects: Aortic stenosis Atrial septal defect (ASD) Atrioventricular septal defect (AVSD) Bicuspid aortic valve Dextrocardia Double inlet left ventricle (DILV) Double outlet right ventricle (DORV) Ebstein's anomaly Hypoplastic left heart syndrome (HLHS) Hypoplastic right heart syndrome (HRHS) Double inlet left ventricle Mitral stenosis Pulmonary atresia Pulmonary stenosis Transposition of the great vessels www.AssignmentPoint.com o dextro-Transposition of the great arteries (d-TGA) o levo-Transposition of the great arteries (l-TGA) Tricuspid atresia Persistent truncus arteriosus Ventricular septal defect (VSD) Some conditions affect the great vessels or other vessels in close proximity to the heart, but not the heart itself, but are often classified as congenital heart defects. Coarctation of the aorta (CoA) Interrupted aortic arch (IAA) Patent ductus arteriosus (PDA) Scimitar syndrome (SS) o Partial anomalous pulmonary venous connection (PAPVC) o Total anomalous pulmonary venous connection (TAPVC) Some constellations of multiple defects are commonly found together. www.AssignmentPoint.com Tetralogy of Fallot (ToF) Pentalogy of Cantrell Shone's syndrome/ Shone's complex / Shone's anomaly Diagnosis: Many congenital heart defects can be diagnosed prenatally by fetal echocardiography. This is a test which can be done during the second trimester of pregnancy, when the woman is about 18 – 24 weeks pregnant. It can be an abdominal ultrasound or transvaginal ultrasound. If a baby is born with cyanotic heart disease, the diagnosis is usually made shortly after birth due to the blue color of their skin (called cyanosis). If a baby is born with a septal defect or an obstruction defect, often their symptoms are only noticeable after several months or sometimes even after many years. Treatment www.AssignmentPoint.com Sometimes CHD improves without treatment. Other defects are so small that they do not require any treatment. Most of the time CHD is serious and requires surgery and/or medications. Medications include diuretics, which aid the body in eliminating water, salts, and digoxin for strengthening the contraction of the heart. This slows the heartbeat and removes some fluid from tissues. Some defects require surgical procedures to restore circulation back to normal and in some cases, multiple surgeries are needed. Interventional cardiology now offers patients minimally invasive alternatives to surgery for some patients. The Melody Transcatheter Pulmonary Valve (TPV), approved in Europe in 2006 and in the U.S. in 2010 under a Humanitarian Device Exemption (HDE), is designed to treat congenital heart disease patients with a dysfunctional conduit in their right ventricular outflow tract (RVOT). The RVOT is the connection between the heart and lungs; once blood reaches the lungs, it is enriched with oxygen before being pumped to the rest of the body. Transcatheter pulmonary valve technology provides a www.AssignmentPoint.com less-invasive means to extend the life of a failed RVOT conduit and is designed to allow physicians to deliver a replacement pulmonary valve via a catheter through the patient’s blood vessels. Most patients require lifelong specialized cardiac care, first with a pediatric cardiologist and later with and adult congenital cardiologist. There are more than 1.8 million adults living with congenital heart defects. Arrhythmias: An arrhythmia is a disorder of the heart rate (pulse) or heart rhythm, such as beating too fast (tachycardia), too slow (bradycardia), or irregularly. Causes Normally, your heart works as a pump that brings blood to the lungs and the rest of the body. To help this happen, your heart has an electrical system that makes sure it contracts (squeezes) in an orderly way. www.AssignmentPoint.com The electrical impulse that signals your heart to contract begins in the sinoatrial node (also called the sinus node or SA node). This is your heart's natural pacemaker. The signal leaves the SA node and travels through the heart along a set electrical pathway. Different nerve messages signal your heart to beat slower or faster. Arrhythmias are caused by problems with the heart's electrical conduction system. Abnormal (extra) signals may occur Electrical signals may be blocked or slowed Electrical signals travel in new or different pathways through the heart Some common causes of abnormal heartbeats are: Abnormal levels of potassium or other substances Heart attack, or a damaged heart muscle from a past heart attack Heart disease that is present at birth (congenital) www.AssignmentPoint.com Heart failure or an enlarged heart Overactive thyroid gland Arrhythmias may also be caused by some substances or drugs, including: Alcohol, caffeine, amphetamines or stimulants such as Beta-blockers Cigarette smoking (nicotine) Drugs that mimic the activity of your nervous system Medicines used for depression or psychosis Sometimes anti-arrhythmic medications -- prescribed to treat one type of arrhythmia -- will cause another type of arrhythmia. Some of the more common abnormal heart rhythms are: Atrial fibrillation or flutter Atrioventricular nodal reentry tachycardia (AVNRT) Heart block or atrioventricular block Multifocal atrial tachycardia www.AssignmentPoint.com Paroxysmal supraventricular tachycardia Sick sinus syndrome Ventricular fibrillation or ventricular tachycardia Wolff-Parkinson-White syndrome Symptoms: When we have an arrhythmia, our heartbeat may be: Too slow (bradycardia) Too quick (tachycardia) Irregular, uneven, or skipping beats An arrhythmia may be present all of the time or it may come and go. We may or may not feel symptoms when the arrhythmia is present. Or, we may only notice symptoms when we are more active. Symptoms can be very mild, or they may be severe or even life-threatening. Common symptoms that may occur when the arrhythmia is present include: www.AssignmentPoint.com Chest pain Fainting Light-headedness, dizziness Paleness Shortness of breath Sweating Exams and Tests: The doctor will listen to your heart with a stethoscope and feel your pulse. Our blood pressure may be low or normal. Heart monitoring devices are often used to identify the rhythm problem, such as a: Holter monitor (used for 24 hours) Event monitor or loop recorder (worn for 2 weeks or longer) Other tests may be done to look at heart function: Coronary angiography www.AssignmentPoint.com ECG (electrocardiogram) Echocardiogram A special test, called an electrophysiology study (EPS), is done to take a closer look at the heart's electrical system. Treatment: When an arrhythmia is serious, you may need urgent treatment to restore a normal rhythm. This may include: Electrical cardioversion) "shock" therapy (defibrillation or Implanting a short-term heart pacemaker Medications given through a vein (intravenous) or by mouth Sometimes, getting better treatment for your angina or heart failure will decrease the chance of having an arrhythmia. Medications called anti-arrhythmic drugs may be used: To prevent an arrhythmia from happening again www.AssignmentPoint.com To keep heart rate from becoming too fast or too slow Some of these medicines can have side effects. Take them as prescribed by your health care provider. Do not stop taking the medicine or change the dose without first talking health care provider. Other treatments to prevent or treat abnormal heart rhythms include: Cardiac ablation used to destroy areas in heart that may be causing heart rhythm problems An implantable cardiac defibrillator is placed in people who are at high risk of sudden cardiac death Pacemaker, a device that senses when heart is beating irregularly, too slowly, or too fast. It sends a signal to heart that makes heart beat at the correct pace. Myocarditis: Myocarditis or inflammatory cardiomyopathy inflammation of heart muscle (myocardium). www.AssignmentPoint.com is Myocarditis is most often due to infection by common viruses, such as parvovirus B19, less commonly nonviral pathogens such as Borrelia burgdorferi (Lyme disease) or Trypanosoma cruzi, or as a hypersensitivity response to drugs. The definition of myocarditis varies, but the central feature is an infection of the heart, with an inflammatory infiltrate, and damage to the heart muscle, without the blockage of coronary arteries that define a heart attack (myocardial infarction) or other common noninfectious causes.Myocarditis may or may not include death (necrosis) of heart tissue. It may include dilated cardiomyopathy. www.AssignmentPoint.com Figur: Myocarditis Myocarditis is often an autoimmune reaction. Streptococcal M protein and coxsackievirus B have regions (epitopes) that are immunologically similar to cardiac myosin. During and after the viral infection, the immune system may attack cardiac myosin. Because a definitive diagnosis requires a heart biopsy, which doctors are reluctant to do because they are invasive, statistics on the incidence of myocarditis vary widely. www.AssignmentPoint.com The consequences of myocarditis thus also vary widely. It can cause a mild disease without any symptoms that resolves itself, or it may cause chest pain, heart failure, or sudden death. An acute myocardial infarction-like syndrome with normal coronary arteries has a good prognosis. Heart failure, even with dilated left ventricle, may have a good prognosis. Ventricular arrhythmias and high-degree heart block have a poor prognosis. Loss of right ventricular function is a strong predictor of death. Signs and symptoms: The signs and symptoms associated with myocarditis are varied, and relate either to the actual inflammation of the myocardium, or the weakness of the heart muscle that is secondary to the inflammation. Signs and symptoms of myocarditis include:Chest pain (often described as "stabbing" in character) Congestive heart failure (leading breathlessness and hepatic congestion) Palpitations (due to arrhythmias) www.AssignmentPoint.com to edema, Sudden death (in young adults, myocarditis causes up to 20% of all cases of sudden death) Fever (especially when infectious, e.g. in rheumatic fever) Symptoms in infants and toddlers tend to be more nonspecific, with generalized malaise, poor appetite, abdominal pain, and/or chronic cough. Later stages of the illness will present with respiratory symptoms with increased work of breathing, and is often mistaken for asthma. Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent with a recent viral infection, including fever, rash, diarrhea, joint pains, and easy fatigueability. Myocarditis is often associated with pericarditis, and many patients present with signs and symptoms that suggest concurrent myocarditis and pericarditis. Causes: A large number of causes of myocarditis have been identified, but often a cause cannot be found. In Europe www.AssignmentPoint.com and North America, viruses are common culprits. Worldwide, however, the most common cause is Chagas' disease, an illness endemic to Central and South America that is due to infection by the protozoan Trypanosoma cruzi. Infections: Viral (parvovirus B19, coxsackie virus, HIV, enterovirus, rubella virus, polio virus, cytomegalovirus, human herpesvirus 6 and possibly hepatitis C) Protozoan (Trypanosoma cruzi causing Chagas disease and Toxoplasma gondii) Bacterial (Brucella, Corynebacterium diphtheriae, gonococcus, Haemophilus influenzae, Actinomyces, Tropheryma whipplei, Vibrio cholerae, Borrelia burgdorferi, leptospirosis, and Rickettsia) Fungal (Aspergillus) Parasitic (ascaris, Echinococcus granulosus, Paragonimus westermani, schistosoma, Taenia solium, Trichinella spiralis, visceral larva migrans, and Wuchereria bancrofti) www.AssignmentPoint.com Bacterial myocarditis is rare in patients without immunodeficiency. Toxins: Drugs (ethanol, anthracyclines and some other forms of chemotherapy, and antipsychotics, e.g. clozapine, also some designer drugs such as mephedrone)[5] Immunologic: Allergic (acetazolamide, amitriptyline) Rejection after a heart transplant Autoantigens (scleroderma, systemic lupus erythematosis, sarcoidosis, systemic vasculitis such as Churg-Strauss syndrome, and Wegener's granulomatosis) Toxins (arsenic, toxic shock syndrome toxin, carbon monoxide, or snake venom) Heavy metals (copper or iron) Physical agents: Electric shock, hyperpyrexia, and radiation www.AssignmentPoint.com Diagnosis: Endomyocardial biopsy specimen with extensive eosinophilic infiltrate involving the endocardium and myocardium (hematoxylin and eosin stain) Myocarditis refers to an underlying process that causes inflammation and injury of the heart. It does not refer to inflammation of the heart as a consequence of some other insult. Many secondary causes, such as a heart attack, can lead to inflammation of the myocardium and therefore the diagnosis of myocarditis cannot be made by evidence of inflammation of the myocardium alone. Myocardial inflammation can be suspected on the basis of electrocardiographic (ECG) results, elevated C-reactive protein (CRP) and/or Erythrocyte sedimentation rate (ESR) and increased IgM (serology) against viruses known to affect the myocardium. Markers of myocardial damage (troponin or creatine kinase cardiac isoenzymes) are elevated. The ECG findings most commonly seen in myocarditis are diffuse T wave inversions; saddle-shaped ST-segment www.AssignmentPoint.com elevations may be present (these are also seen in pericarditis). The gold standard is still biopsy of the myocardium, generally done in the setting of angiography. A small tissue sample of the endocardium and myocardium is taken, and investigated by a pathologist by light microscopy and—if necessary—immunochemistry and special staining methods. Histopathological features are myocardial interstitium with abundant edema and inflammatory infiltrate, rich in lymphocytes and macrophages. Focal destruction of myocytes explains the myocardial pump failure. Cardiac magnetic resonance imaging (cMRI or CMR) has been shown to be very useful in diagnosing myocarditis by visualizing markers for inflammation of the myocardium. Recently, consensus criteria for the diagnosis of myocarditis by CMR have been published. Treatment: As most viral infections cannot be treated with directed therapy, symptomatic treatment is the only form of therapy for those forms of myocarditis. In the acute www.AssignmentPoint.com phase, supportive therapy, including bed rest, is indicated. For symptomatic patients, digoxin and diuretics provide clinical improvement. For patients with moderate to severe dysfunction, cardiac function can be supported by use of inotropes such as Milrinone in the acute phase, followed by oral therapy with ACE inhibitors (Captopril, Lisinopril) when tolerated. People who do not respond to conventional therapy are candidates for bridge therapy with left ventricular assist devices. Heart transplantation is reserved for patients who fail to improve with conventional therapy. In several small case series and randomized control trials, systemic corticosteroids have shown to have beneficial effects in patients with proven myocarditis. However, data on the usefulness of corticosteroids should be interpreted with caution, since 58% of adults recover spontaneously, while most studies on children and infants lack control groups. Epidemiology: The exact incidence of myocarditis is unknown. However, in series of routine autopsies, 1–9% of all patients had www.AssignmentPoint.com evidence of myocardial inflammation. In young adults, up to 20% of all cases of sudden death are due to myocarditis. Among patients with HIV, myocarditis is the most common cardiac pathological finding at autopsy, with a prevalence of 50% or more. Heart Disease Risk Factors: Some conditions as well as some lifestyle factors can put people at a higher risk for developing heart disease. All persons can take steps to lower their risk of heart disease and heart attack by addressing these risk factors. Control of risk factors is especially need by people who already have heart disease. Conditions Behavior Heredity Heart Disease Conditions: www.AssignmentPoint.com Blood cholesterol levels High blood pressure Diabetes mellitus Blood Cholesterol Levels: Cholesterol is a waxy substance produced by the liver or consumed in certain foods. It is needed by the body, and the liver makes enough for the body's needs. When there is too much cholesterol in the body—because of diet and the rate at which the cholesterol is processed—it is deposited in arteries, including those of the heart. This can lead to narrowing of the arteries, heart disease, and other complications. Some cholesterol is often termed "good," and some often termed "bad." A higher level of high–density lipoprotein cholesterol, or HDL, is considered "good," and gives some protection against heart disease. Higher levels of low–density lipoprotein, or LDL, are considered "bad" and can lead to heart disease. A lipoprotein profile can be done to measure several different forms of cholesterol, as well as triglycerides (another kind of fat) in the blood. www.AssignmentPoint.com High Blood Pressure: High blood pressure is another major risk factor for heart disease. It is a condition where the pressure of the blood in the arteries is too high. There are often no symptoms to signal high blood pressure. Lowering blood pressure by changes in lifestyle or by medication can lower the risk of heart disease and heart attack. Diabetes Mellitus: Diabetes also increases a person's risk for heart disease. With diabetes, the body either doesn't make enough insulin, can't use its own insulin as well as it should, or both. This causes sugars to build up in the blood. About three–quarters of people with diabetes die of some form of heart or blood vessel disease. For people with diabetes, it is important to work with a healthcare provider to help in managing it and controlling other risk factors. Heart Disease Behavior: Tobacco use Diet www.AssignmentPoint.com Physical inactivity Obesity Alcohol Tobacco Use Tobacco use increases the risk of heart disease and heart attack. Cigarette smoking promotes atherosclerosis and increases the levels of blood clotting factors, such as fibrinogen. Also, nicotine raises blood pressure, and carbon monoxide reduces the amount of oxygen that blood can carry. Exposure to other people's smoke can increase the risk of heart disease even for nonsmokers. Diet Several aspects of peoples' dietary patterns have been linked to heart disease and related conditions. These include diets high in saturated fats and cholesterol, which raise blood cholesterol levels and promote atherosclerosis. High salt or sodium in the diet causes raised blood pressure levels. Physical Inactivity www.AssignmentPoint.com Physical inactivity is related to the development of heart disease. It also can impact other risk factors, including obesity, high blood pressure, high triglycerides, a low level of HDL (good) cholesterol, and diabetes. Regular physical activity can improve risk factor levels. Obesity Obesity is excess body fat. It is linked to higher LDL (bad) cholesterol and triglyceride levels and to lower HDL (good) cholesterol, high blood pressure, and diabetes. Alcohol Excessive alcohol use leads to an increase in blood pressure, and increases the risk for heart disease. It also increases blood levels of triglycerides which contribute to atherosclerosis. Heart Disease Heredity: Heart disease can run in the family. Genetic factors likely play some role in high blood pressure, heart disease, and other vascular conditions. However, it is also likely that www.AssignmentPoint.com people with a family history of heart disease share common environments and risk factors that increase their risk. The risk for heart disease can increase even more when heredity is combined with unhealthy lifestyle choices, such as smoking cigarettes and eating a poor diet. Prevention of Heart Disease: We can help prevent heart disease by making healthy choices and managing any medical conditions you may have. Live a Healthy Lifestyle Guidelines and Recommendations Live a Healthy Lifestyle Eat a healthy diet. Choosing healthful meal and snack options can help avoid heart disease and its complications. Be sure to eat plenty of fresh fruits and vegetables. www.AssignmentPoint.com Eating foods low in saturated fat and cholesterol and high in fiber can help prevent high blood cholesterol. Limiting salt or sodium in diet can also lower blood pressure. For more information on healthy diet and nutrition, see CDC's Nutrition and Physical Activity Program Web site. Maintain a healthy weight. Being overweight or obese can increase your risk for heart disease. To determine whether your weight is in a healthy range, doctors often calculate a number called the body mass index (BMI). Doctors sometimes also use waist and hip measurements to measure a person's excess body fat. If you know your weight and height, you can calculate your BMI at CDC's Assessing Your Weight Web site. Exercise regularly. Physical activity can help you maintain a healthy weight and lower cholesterol and blood pressure. The Surgeon General recommends that adults should engage in moderate-intensity exercise for at least 30 minutes on most days of the week. For more information, see CDC's Nutrition and Physical Activity Program Web site. www.AssignmentPoint.com Don't smoke. Cigarette smoking greatly increases your risk for heart disease. So, if you don't smoke, don't start. If you do smoke, quitting will lower your risk for heart disease. Your doctor can suggest ways to help you quit. For more information about tobacco use and quitting, see CDC's Smoking & Tobacco Use Web site. Limit alcohol use. Avoid drinking too much alcohol, which causes high blood pressure. For more information, visit CDC's Alcohol and Public Health Web site. Prevent or Treat Medical Conditions If we have high cholesterol, high blood pressure, or diabetes, there are steps we can take to lower risk for heart disease. Have cholesterol checked. Our health care provider should test cholesterol levels at least once every five years. Talk with doctor about this simple blood test. www.AssignmentPoint.com Monitor blood pressure. High blood pressure has no symptoms, so be sure to have it checked on a regular basis. Manage diabetes. If we have diabetes, closely monitor blood sugar levels. Talk with health care provider about treatment options. Take medicine. If taking medication to treat high cholesterol, high blood pressure, or diabetes, follow doctor's instructions carefully. Always ask questions if we don't understand something. Talk with health care provider. Doctor can work together to prevent or treat the medical conditions that lead to heart disease. Discuss treatment plan regularly and bring a list of questions to appointments. www.AssignmentPoint.com Guidelines and Recommendations: Recommendations of Aspirin for Prevention of Cardiovascular Disease. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. This report provides evidence-based guidelines about preventing and managing high blood pressure. From the National Heart, Blood, and Lung Institute. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Provides evidence-based guidelines about screening for and treating high cholesterol. From the National Heart, Blood, and Lung Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Provides evidence-based guidelines about screening for and treating overweight and obesity. From the National Heart, Lung, and Blood Institute. www.AssignmentPoint.com Physical Activity and Health: A Report of the Surgeon General the first Surgeon General’s Report specifically addressing physical activity and health. 2008 Physical Activity Guidelines for Americans. These science-based guidelines provide strategies for Americans to improve their health through physical activity. Surgeon General's Reports Related to Tobacco Use Links to reports concerning smoking and health, including reports on involuntary exposure to tobacco smoke and on tobacco use among ethnic minority groups. Dietary Guidelines for Americans. Provides authoritative advice about good dietary habits that can promote health and reduce risk of disease. www.AssignmentPoint.com