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Lecture18CardiovascularDisease StrokeandHeartAttack 3 20 08LouiseOrganlorgan rice edu FromLastTime Burdenofcardiovasculardisease CVD CardiovascularsystemMeasuringcardiovascularhealthValvediseasesAtherosclerosis CADandtreatmentsStrokeHeartattackHeartfailureandtreatments MuddiestPoint ClearestPoint ClearestBloodpressureMeasurementSignificanceMuddiestMorecirculatorysystemandheartanatomyGuidantCDHeartvalvesandvalvediseasesGuidantCD http japi org august2007 U 575 pdf Outline TreatmentofHeartDisease Burdenofcardiovasculardisease CVD CardiovascularsystemMeasuringcardiovascularhealthValvediseasesAtherosclerosis CADandtreatmentsStrokeHeartattackHeartfailureandtreatments Atherosclerosis StrokeandHeartAttack Arteries MuscularbloodvesselsthatcarrybloodawayfromtheheartVeinscarrybloodtotheheartCoronaryarteriesfeedtheheartitself http www clevelandclinic org heartcenter pub guide disease cad cad arteries htm http www infovisual info 03 060 en html ArteryAnatomy AtheroscleroticPlaque http www nhlbi nih gov health dci Diseases Hbc HBC WhatIs html http medlib med utah edu WebPath jpeg5 CV119 jpg http www brown edu Courses Digital Path Heart atherosclerosis htm Atherosclerosis Histology Atherosclerosis TwoProblems Occlusion Stenosis NarrowedarterydiameterLessbloodflowThrombusFormationofclotsinsidebloodvesselsCancompletelyblockbloodflow Atherosclerosis Thrombus Thethinlayeror cap coveringaplaquecanruptureorburstTheinsideoftheplaqueisthenexposedtobloodThissendschemicalsignalstoahostofbloodcellsPlateletsaggregatetoformaclotThrombuscanblockbloodflowNotenoughoxygendelivered ischemiaTissuescanbegintodie infarction ThrombusDevelopment http www nlm nih gov medlineplus ency imagepages 18020 htm Atherosclerosis Embolus ThrombuscanbedisplacedfromtheoriginandtraveltoanotherlocationVesselsshrinkindiameterawayfromtheheartCanthenlodgeinnormallyhealthyvesselsCancauseblockageindistantlocation embolusIfvesselsintheneckorheadareaffectedIschemiaorinfarctionofthebraintissueStroke Stroke CerebrovascularEvent AleadingcauseofdeathinolderAmericans 1causeofadultdisabilityCausedbythrombusorembolusinvesselsfeedingbrainInfarctionresultsinbraindamageEffectsandlongtermdamagedependsonareaofinfarctionTwo thirdsofsurvivorshaveadisabilityLimbweakness speechimpediment paralysis http www stroke org site PageNavigator HOME Stroke RiskFactors HighbloodpressureHighcholesterollevelsTobaccouseExcessivealcoholconsumptionDiabetesSedentarylifestylePoordiet nutrition Stroke Symptoms StrokehasaveryrapidonsetSuddenappearanceofthefollowingsymptomswarrantsmedicalattentionNumbnessorweaknessofface armorleg especiallyononesideofthebodyConfusion troublespeakingorunderstandingTroubleseeinginoneorbotheyesTroublewalking dizziness lossofbalanceorcoordinationSevereheadachewithnoknowncause Stroke ActF A S T FaceAskthepersontosmileDoesonesideofthefacedroop ArmsAskthepersontoraisebotharmsDoesonearmdriftdownward SpeechAskthepersontorepeatasimplesentenceArewordslurred Cantheyrepeatcorrectly TimeTimeisimportant Call911and orseekmedicalhelpimmediately HeartAttack Atherosclerosisvs CoronaryArteryDisease CAD AtherosclerosisThebuild upofplaquesthroughoutvesselsystemsCanhaveeffectsatdistantsitesCADPlaquesinthecoronaryarteriesSpecificallyaffectstheheartmuscle Clotstopsflowofblood Plaquebuilduponvesselwalls Wheretheblockageoccursintheartery Partoftheheartaffected CoronaryAtheroscleroticPlaque EarlyWarningSigns Angina PlentyofpeoplewithCADhavenosymptomsMostprevalentsymptomisanginaChestpainTwotypesofangina stableandunstableStableisbroughtonbystressorexerciseUnstablemaybesuddenormorevariableAnginaistypicallytheresultofischemiaHeartneedsmoreoxygen ProgressionofHeartDisease HighBloodPressureHighCholesterolLevels Atherosclerosis Ischemia HeartAttack HeartFailure CADandHeartAttacks Myocardialinfarction MIorAMI Myocardium heartmuscleInfarction tissuedeathduetolackofblood oxygen PathophysiologyFunctionalchangesassociatedwithorresultingfromMIDiagnosisTreatment GuidantHeartAttack MIPathophysiology CaseStudy Threemonthsfollowinghisfirstvisittoyouroffice Mr SolomonpresentstotheERintheearlymorning withchestpainofonehourduration Mr Solomondescribesthepainasbeingsevereand likesomeonewassittingonhischest Thepain located inthelowerpartofmybreastbone awakenedhimfromhissleep Althoughhetriedtorelievethepainbychangingpositionsinbed sittingupanddrinkingwater itremainedunchanged Hedidnotsleepwellbecause Ihadanupsetstomachanacid burningfeeling HeattributedthesesymptomstoovereatinganddrinkingataChristmasparty Hehasnopainordiscomfortinhisarmsbutsayshehasan achiness inhisleftjawwhichheattributesto badteeth Physicalexaminationrevealsthepatienttobeanxious pale diaphoreticandinobviousdiscomfort Heisunshavenandaccompaniedbyhiswife Hetriestorelievehispainbybelching Hecoughsoccasionally Mr Solomonsays thefluhasbeengoingaroundtheoffice andI vehadalittlecoughandfeverallweek http www meddean luc edu lumen meded mech cases case2 Case f htm WarningSignsofHeartAttack Manyheartattacksstartslowly symptomsmaycomeandgoChestdiscomfortMostheartattacksinvolvediscomfortinthecenterofthechestthatlastsformorethanafewminutes orgoesawayandcomesback Thediscomfortcanfeellikeuncomfortablepressure squeezing fullness orpainDiscomfortinotherareasoftheupperbodyCanincludepainordiscomfortinoneorbotharms theback neck jaw orstomachShortnessofbreathOftencomesalongwithchestdiscomfort ButitalsocanoccurbeforechestdiscomfortOthersymptomsMayincludebreakingoutinacoldsweat nausea orlight headedness http www archive org details gov hhs nih 56 042n TakeHomePoints EveryoneisdifferentSymptomswillvaryYoudon thavetobe old tohaveaheartattackWomenandmenareequallysusceptibleThespeedwithwhichyoureceivetreatmentcanmakethedifferenceImportanceofprevention USBurdenofHeartAttack 1 1million year460 000ofthoseheartattacksarefatal 40 Halfofthosedeathsoccurwithin1hourofsymptomonset beforepersonreacheshospitalHighmortalityhighlightstheimportanceofpreventionAnddiagnosisifyouhaveanginaorothersymptoms HeartAttack DiagnosisofAtherosclerosis BloodtestsElectrocardiograms ECG Ultrasound echocardiogram StresstestsCoronaryangiographyComputertomography CT AtherosclerosisDiagnosis Angiography CatheterthreadeduptoheartContrastagentisinjectednearproblemareaBloodlookssameastissuestoX raysUsestandardX rayorCTtotakepicturesandimageocclusions http www nlm nih gov medlineplus ency imagepages 18129 htm Angiography Hardware Angiography Images AtherosclerosisandHeartAttacks TreatmentofAcuteOcclusion TreatmentofCoronaryOcclusions IntroducedinLecture4ThrombolyticdrugsAngioplastyStentsOftenincombinationwithangioplastyCoronaryarterybypassgraft CABG Whichonewouldyouchoose ThrombolyticDrugs Tissueplasminogenactivator tPA ProteasethatdissolvesbloodclotsApprovedforuseincertainheartattackorstrokepatientsClinicalStudies tPAandotherclot dissolvingagentscanreducetheamountofdamagetotheheartmuscleandsavelivesTobeeffective theymustbegivenwithinafewhoursaftersymptomsbeginFewMIpatientsqualifyAdministeredthroughanintravenous IV lineinthearmbyhospitalpersonnelPatientstreatedwithin90minafteronsetofchestpainare1 7aslikelytodiecomparedtopatientswhoreceivetherapylater ThrombolyticDrugs Risksofthrombolytics Intra cranialhemorrhageIncreasedriskinthose age70InsteadofischemicstrokethiscanleadtohemorrhagicstrokePatientsmayrequirefurtherinterventionCostsofthrombolytics tPA 2300Streptokinase 320 EffectivenessofThrombolytics ClinicalTrial In15countriesand1081hospitals41 021patientswithevolvingmyocardialinfarctionRandomlyassignedto4differentstrategies StreptokinaseandsubcutaneousheparinStreptokinaseandIVheparinAcceleratedtissueplasminogenactivator t PA andIVheparinComboofstreptokinaseplust PAwithIVheparinPrimaryendpointwas30 daymortalityResult Streptokinase subcutaneousheparin 7 2 stroke0 49 Streptokinase IVheparin 7 4 stroke0 54 Acceleratedt PA IVheparin 6 3 stroke0 72 ComboofbothwithIVheparin 7 0 stroke0 94 Cost EffectivenessofThrombolytics TreatmentofAtherosclerosis PercutaneousTransluminalAngioplasty PCTA BalloonAngioplasty PCTA Effectiveness CannotalwayssuccessfullyperformprocedureDiffusediseaseTotalocclusionCalcifieddiseaseHardeningofthearterialwallsRestenosisOccursin25 54 ofpatientsUsuallyoccurswithin6months TreatmentofAtherosclerosis Stents Awire typically cageisinsertedalongwithaballoonIncorporatesangioplastyInflatetheballoonPlacethestentRetractballoonStentremains Stents Stents Stents Arestentsmoreeffectivethanangioplasty ThecagedoesprovidesupportforthevesselRestenosisisstillamajorconcernEndothelialcellsproliferateandgrowoverandaroundthestent Drug ElutingStents SlowlyreleasesdrugsHindercellproliferationaroundandoverthestentSlowrestenosisMayincreasethrombosisFDAapprovedfornewlesionsinsmallvesselsMoreexpensive 3 4times VerypopularwithpublicNPRstoryfromOctober2003Long termeffectivenessRestenosisispronouncedinsmallvesselsTheverdictisstillout http www npr org features feature php wfId 1452217 TreatmentofAtherosclerosis Coronaryarterybypassgraph CABG AgraftvesselfromanotherareaofthebodyisusedtocircumventtheocclusionandreturnbloodflowTodothiswewehavetostoptheheartfrombeating http www nlm nih gov medlineplus tutorials coronaryarterybypassgraft htm index htm CABGProcedure Patientisprepped generalanesthesiaChestaccessisgained throughsternumGraftvesselisretrievedExposeheartthroughpericardiumDivertbloodthroughheartlungmachineStopheartInsertgraftReturncirculationtoheartCloseincision Heart Lung Bypass Machine ConnectedtopatientbyaseriesoftubesthatthesurgicalteamplacesConsistsofachamberthatreceivesthebloodfromthebodyBloodispumpedbymachinethroughanoxygenatorOxygenatorremovesCO2andaddsoxygenPumpthenpumpsthisnewlyoxygenatedbloodbacktothebody HeartLungMachine HeartLungMachine HeartLungMachine CABGEffectiveness 2001 516 000CABGproceduresperformedProceduretakes4 6hours 5 7dayhospitalstayGraftsremainopen functioningfor10 15yrsLittlerestenosisRisks Heartattack 5 Stroke 5 riskgreatestinthoseover70yearsold Death 1