pathophysiologi ca dr. faesol
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PATOFISIOLOGI KARDIOVASKULAR
DR.dr.Zaenal M. Sofro, AIFM, Sport & Circ. Med.
Bagian Ilmu Faal Fak.Kedokteran UGM
Na+
K+Na+
K+
-70 mV
RESTING
THRESHOLD
-0
Graduallyincreasing PNa
AUTOMATICITY
Adapted from Dzau V, Braunwald E. Am Heart J. 1991
CV Risk Factors•Diabetes•Hypertension•Hyperlipidemia•Smoking
Atherosclerosis
MyocardialInfarction
Remodeling
CongestiveHeart Failure
End-StageHeart Disease
Death
VentricularDilation
Loss of contractility
CAD
Cardivascular Disease is a Continuum
Willem Einthoven(1860-1927)
Cardiac Physiology Electrocardiography Diagnosis
Cardiac Physiology Electrocardiography Diagnosis
Essential functions of the heart are secured Essential functions of the heart are secured by integration of electrical and mechanicalby integration of electrical and mechanical
functions of the heartfunctions of the heart
Cardiac output (CO) = heart rate (HR) x stroke vol.(SV)Cardiac output (CO) = heart rate (HR) x stroke vol.(SV)
- - changes of the heart ratechanges of the heart rate- changes of stroke volume- changes of stroke volume
• Control of HR:Control of HR:- autonomic nervous system- autonomic nervous system
- - hormonal(humoral) controlhormonal(humoral) control • Control of SVControl of SV:: - preload- preload
- contractility- contractility- afterload- afterload
ST Elevation InfarctionHere’s a diagram depicting an evolving infarction:A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion results in ST depression (not shown) and peaked T-waves
C. Infarction from ongoing ischemia results in marked ST elevation
D/E. Ongoing infarction with appearance of pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Q- waves, but normal ST segment and T- waves
ST changes: axis + anatomy• Lateral:
– I, aVL– LCA, CFX
• Anterior:– V1, V2, V3, V4– LAD
Inferior:-II, III and aVF-RCA (or LCA)
Memorize this slide
Location of infarct combinations
aVR V1 V4I
II
III
LATERAL
INFERIOR
ANTPOST ANT
SEPTAL
ANT
LAT
aVL
aVF
V2
V3
V5
V6
Figure 15-8
Blood Pressure
- - venous returnvenous return- extracellular fluid volume- extracellular fluid volume- myocardial contractility- myocardial contractility
- - vasoactive substancesvasoactive substances- thickening of arteriolarthickening of arteriolar wallwall
VEINS
CAPACITYVESSELS
HEART
80 mmHg 120 mmHg
SYSTOLE
DIASTOLE
ARTERIES (LOW COMPLIANCE)
CAPILLARIES
Cardiac Cycle
Ventricular Filling
Isovolumetric Relaxation
Isovolumetric Contraction
Ventricular Ejection
Cardiac cycle – everything that occurs from the start of 1 heartbeat to the start of the next.
-includes contraction (systole) and relaxation (diastole) of all 4 chambers
Left atrium
Left ventricle
Aorta
Adaptive mechanisms of the heart to increased load
• Frank - Starling mechanism
• Ventricular hypertrophy – increased mass of contractile elements strength of contraction
• Increased sympathetic adrenergic activity – increased HR, increased contractility
• Incresed activity of R–A–A system
Causes leading to changes of number and size of cardiomyocytes
(Brown, 1997)(Brown, 1997)
Physiologic Requirements to Perform Exercise
ERGOMETRY TEST
External to Internal environment
..a hint of integration?
Wellness Continuum
The Heart-Brain Connection
Vagus mammalia dan social engagement systemGambar 5
Blood PressureBlood Pressure
Diastolic pressure is measured when ventricles are at rest
Systolic pressure is measured as the ventricles contract
Based on: Harvard Family Health Guide
• The level of blood pressure in the healthy people is the very stable value.
• The stability of blood pressure is supported by regulative systems.
• Hayton (1974) divided them into two groups – hemodynamic system and regulative system.
Arterial blood pressure normal range:Systolic – 100 - 125 (equilibration 100 - 139) mm HgDiastolic – 70 - 80 (equilibration 60 - 89) mm Hg
Pressure Drops Within the Circulation
Art
erie
s
ArteriesA
rter
iole
s
ArteriolesC
apill
arie
s
Capillaries
Ven
ules
VenulesV
eins
Veins
• Blood pressure is one of the most variable but best regulated functions of the body.
• The purpose of the control of blood pressure is to keep blood flow constant to vital organs such as the heart, brain, and kidneys.
• The continuous elevation of blood pressure that occurs with hypertension is a contributor to premature death and disability due to its effect on the heart, blood vessels, and kidneys.
Regulation of arterial pressure (АP)by hemodynamic system
Formula: АP = CO · PRCO – cardiac output
PR – peripheral vascular resistance (depended to arterioles tone)
CO leads to PR and АP normalizes finally
PR leads to CO and АP normalizes finally
AP normal range:Systolic – 100 - 125 (equilibration 100 - 139) mm HgDiastolic – 70 - 80 (equilibration 60 - 89) mm Hg
Mechanisms of Blood Pressure Regulation
• Short-term regulation
• neural mechanisms• hormonal mechanisms
• Long-term regulation
Gravity: role of baroreceptor reflex in orthostatic adjustment
Baroreceprotsin aorta & carotid bodies
Cardiovascular ctr in medulla oblongata
Vaso-constricti
on
Heart rate
Sym
p. +
Para
sym
p. -
pressure
NEURAL MECHANISMS
43
The Polyvagal TheoryBy Stephen Porges The Vagus Nerve in three parts, all working simultaneously:
Ventral Vagal System: Is part of the Parasympathetic Nervous System (Social Engagement/frontal cortex)
Sympathetic Nervous System:(Fight/Flight, Freeze - Limbic Brain)
Dorsal Vagal System: Is part of the Parasympathetic Nervous System(Freeze/Immobility/Brainstem)
Location and innervation of the aortic arch and carotid sinus baroreceptors and the carotid
body chemoreceptors.
Regulative systems
1. Barroreceptors of aorta arch and sinus caroticus
Barroreceptors of the vessels
Medulla oblongata (vessel’s active center)
Afferent impulses
Heart (CO increase at decreased АP)
Arterioles (spasm) Еfferent і impulses
Pusat vagus bermielin dan yang tidak bermielin di medulla oblongata. Sumber: Porges (2011)Gambar 17
Regulative systems
Role of the vasopressin in arterial hypertension pathogenesis
AP elevation (value above 139/89 mm Hg), which is resulted from rising of peripheral vessels resistance
(one of the most common cardiovascular disorders)
Arterial hypertension (АH)
Classification
Arterial hypotension
Arterial hypertension
AcuteChronic
Secondary
AP above 139/89 mm Hg
Primary
AP less than 100/60 mm Hg
Classification
Primary AH (essential, hypertonic disease)
Secondary AH (that is happened in 10 - 20 % cases).
It’s a symptom of some disease course
Reason is unknown.AH is polyetiological disease.
AH arises on the ground of genetically peculiarities of metabolism.
That is possible to have genetically defect of the systems, which control relaxation of the smooth
muscle cells of the arterioles.
Etiology (primary AH)
Contributing factors
Family history of hypertension
Age-related increases in blood pressure
Race
Diabetes mellitus
Risk Factors
Contributing factorsLifestyle Factors
Physical inactivity
High sodium intake
Stress
Excessive calorie intake and obesity
Excessive alcohol consumption
Oral contraceptive drugs
Emotional excitement (SNS activation)
Increase of circulative blood volume (CBV)
Cardiac output (CО) increase
Kidney functions violation
Peripheral vessels resistance increase
PathogenesisAP = СO х PR
Increase of circulative blood volume (CBV)
Pathogenesis
Reasons
NaCl (intake more 5 g/day)
Decrease Na excretion by kidney (kidney diseases)
1. CBV increase
Na retention in blood
Blood osmotic pressure increase
Hypervolemia
Cardiac output increase
AP elevation
Na accumulation in vessels smooth muscle wall and increase of its
osmotic pressure
Vessels wall edema
Vessels narrowing
Peripheral vessels resistance increase
Vessels smooth muscle sensitivity to
vasoconstrictive influences increase
(noradrenalin, adrenalin, endothelin, angiotensin)
Formula: АP = CO · PR
Pathogenesis
Vessels spasm
2. Cardiac output increase (CO)
Reasons
Circulative blood volume increase (CBV)
Physical (overload) stress
Emotional stress
Hyperthyroidism
Pathogenesis
2. Cardiac output increase
SAS activation
Adrenalin excretion
Increase of cardiac contractility force
Increase of cardiac output
Increase of heart beats
AP elevation
Pathogenesis
Formula: АP = CO · PR
3. SAS activation
Interaction adrenalin and alpha-adrenoreceptors
Arterioles smooth muscles spasm
Suprarenal glands activation
Venues smooth muscles spasm
Increase of circulative blood in big blood
circle adrenoreceptors of
heart
АdrenalinNoradrenalin
Increase of CBV
CO increaseArterioles
narrowing
alpha-adrenoreceptors of vessels
CO increase
AP increase
SAS activation
Arterioles narrowing
PR increase
Pathogenesis
Formula: АP = CO · PR
4. Kidney functions violation
Long time spasm of kidney arteries
AP increase
AP decrease in renal capillaries
Activation of JGA
Renin excretion
Angiotensin 2 synthesis
Angiotensin 2 effects
• Smooth muscles contraction in the vessels
• Stimulation of the vasoactive center in brain
• Noradrenalin excretion increase• Adrenalin excretion increase from
suprarenal glands• Aldosteron excretion increase from
suprarenal glands (Na retention due to kidney)
Pathogenesis
Depressive function of kidney – synthesis of the substances for AP reduce
PG Е 2
Phospholipid Renin Inhibitor
Angiotensinase
Phosphatydilcholin alkali ethers
! ! !Exhaustion of kidney
depressive function leads to arterial
hypertension stabilization
dilates renal arteries, reduces renin synthesis and reduces Na
reabsorbing in kidney
Increase of vesseles resistance
• It is the defining mechanism. Irrespective of first reason, in the patients with hypertonic disease almost always increases peripheral resistance.
• It is considered, that the essence hypertonic disease just is in increase of peripheral vessels tonus. Hyperkinetic phase, which is connected to increase of cardiac output, happens only at early stages of disease and not in all patients.
The hereditary predisposition
1. Renal (resulted from kidney pathology)
Etiologysecondary АH
Acute renal failure
Kidney damage at collagenosis
Kidney amiloidosis
Diabetic nephropathy Nephropathy of the pregnant
Hereditary defect of renal vessels Renal vessels atherosclerosis,
embolism or thrombosis
Kidney tumor
Acute urinary tract obstruction
Glomerulonephritis Pyelonephritis
Polycystic kidney disease
4. Endocrinopathy (develops in the result of endocrine glands pathology)
Etiologysecondary АH
Cushing's disease (Adrenocorticotropin over
production by the pituitary gland anterior part)
Acromegaly (Somatotropin over production by
the pituitary gland anterior part)
Hyperaldosteronism (aldosteron over excretion by suprarenal
glands)
Menopause(age-depended decrease of female
gonads activity – estrogens excretion decrease)
Possible mechanism – deficit of NO synthesis by endotheliocytesPheochromocytoma
5. Neurogene (is accompanying to nerves system pathology)
Etiologysecondary АH
Brain hemorrhage
Encephalitis
Brain tumor
Brain trauma
Brain ischemia
7. Drug-induced
6. Cardiac
Etiologysecondary АH
Heart failureHeart defect
Drugs, which cause vessels spasm (influent on kidney), hormonal contraceptives
1st period functional violations (heart hypertrophy)
2d periodPathological changes in arteries and arterioles (dystrophy):- Arterioles sclerosis- Arteriole’s wall infiltration by plasma (leads to dystrophy)- Arterioles necrosis (hypertonic crisis arises in clinic)- Vein’s wall thickening
Arterial hypertension after-effects
3d period Secondary changes in organs and systems
Kidney (nephrosclerosis and chronic
kidney insufficiency)
CNS – brain hypoxia – neurons destruction– apoplexy (because vessels destruction and rupture
leads to brain hemorrhages and brain destruction)
HeartDecompensate heart failure
Organs of vision- retinopathy (retina’s vessels injury)- hemorrhages and separation (exfoliation) of
retina, that leads to blindness
Endocrine systemGlands atrophy and sclerosis
Arterial hypertension after-effects
JAZAA KUMULLAH KHAIRAN KATSIRAN
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