CARDIOVASCULAR DISEASE

(Overview)

Toni Mustahsani Aprami, dr., Sp.PD, Sp.JP

Department of Cardiology and Vascular MedicineCardiovascular Subdivision, Department of Internal Medicine

Hasan Sadikin Hospital/Medical School, Padjadjaran University

Understanding the Cardiovascular System

• The Heart: A Mighty Machine

–Four chambers• Two upper chambers are

called atria• Two lower chambers are

called ventricles–Valves regulate the flow

of blood.

Conduction System of the Heart

5

The Heartbeat Is Controlled

• Each heartbeat is referred to as a cardiac cycle.

• Takes a total of 0.85 seconds / cycle on the

average when at rest. . . . .

• That’s ~70 X/minute, range 60-80 beats/ minute.– Systole - Contraction of heart muscle.

– Diastole - Relaxation of heart muscle.

Blood Flow within the Heart

Blood Vessels

11

Capillary Bed Anatomy

12

Capillary Exchange

Functions of the Cardiovascular System

1. Contractions of the heart generates blood pressure, which moves blood through blood vessels.

2. Blood vessels transport blood, which moves from the heart into arteries, capillaries, and veins, before returning to the heart.

3. Exchanges at the capillaries (smallest vessels) refreshes blood and then tissue fluid (interstitial fluid).

4. The heart and blood vessels regulate blood flow, according to the needs of the body.

CARDIOVASCULAR DISEASECongenital Heart Disease (ASD, VSD, PDA, TOF)

Rheumatic Heart Disease (MS/MR, AS/AR)

Hypertensive Heart Disease

Coronary Artery Disease

Cardiomyopathies

Pericarditis

Peripheral Artery Disease

Aneurysm and Disectie Aortae

Deep Vein Thrombosis

Cardiac Tumor

Coronary Artery Disease

90% Atherosclerosis Process

Atherosclerosis can, and does, occur in almost any artery in the body. But in the heart it’s effects can be crucial. “The body depends on a strong pumping heart to circulate life-giving blood, and this includes to the heart muscle itself. If the coronary arteries become blocked, the cardiac muscle begins to fail, and so the blood circulation decreases, which includes the circulation to the heart muscle itself.” (Thibodeau, 494)

Atherosclerosis is a disease of large (elastic) and medium sized (muscular) arteries characterized pathologically by smooth muscle proliferation, lipidaccumulation, cell necrosis, fibrosis, and calcification.

Most commonly involved : AortaCoronaryCarotidIliacMesentric

Uncontrollable

•Sex•Hereditary•Race•Age

Controllable•High blood pressure•High blood cholesterol•Smoking•Physical activity•Obesity•Diabetes•Stress and anger

Predict Risk

Diagnostic/Screening test : EST, CRP, Echocardiography , CACS

Atherogenesis

Normal Artery

Endothelium

Internal elastic lamina

External elastic lamina

Media

Intima

Adventitia

Response to Injury

Endothelial Dysfunction

Initiation of Fatty Streak

Fatty Streak

Fibro-fatty Atheroma

                                                                                                     

                                               

FIBROUS CAP

NECROTIC CENTER

MEDIA

(smooth muscle cells, macrophages, foam cells, lymphocytes, collagen, elastin, proteoglycans, revascularization)

(cells debris, cholesterol crystals,foam cells, calcium)

Endothelial Dysfunction

•Foam•Cells

• Fatty•Streak

•Intermediate• Lesion •Atheroma

•Fibrous• Plaque

• Complicated•Lesion/Rupture

•Endothelial injury•nitric oxide•endothelin-1•vasodilation

•Lipid accumulation•adhesion molecules (ICAM, VCAM)•monocyte adhesion•macrophage LDL uptake

•Inflammation•continued macrophage/lipid accumulation•leukocyte accumulation•cytokines (IL-6,TNFa, IFNg)

•MMP's•CRP (hepatic)

•oxidized LDL•homocysteine•smoking•aging•hyperglycemia•hypertension

35-45 yrs 45-55 yrs 55-65 yrs >65 yrs

The Evolution of Atherosclerosis

Common Consequences of Atherosclerosis in Vessels

Altered Vessel Function

• Vessel change– Plaque narrows

lumen– Wall weakened

– Thrombosis

– Breaking loose of plaque

– Loss of elasticity

• Consequence– Ischemia, turbulence– Aneurysms, vessel

rupture– Narrowing, ischemia,

embolization– Athero-embolization

– Increase systolic blood pressure

Burden and causes of cardiovascular diseases:with an emphasis on Asia

Chronic diseases and

injuries

Infectious, maternal, perinatal and

nutritional conditions

0

20

40

60

1990 2020 1990 2020

Changing patterns of deathWorldwide: 1990-2020

Global Burden of Disease Project, 1996

Millions of deaths

Leading causes of deathWorldwide: 1990-2020

Rank Cause % Rank Cause %1 Coronary Artery disease 12.4 1 Coronary Rtery disease 16.32 Cerebrovascular disease 8.7 2 Cerebrovascular disease 11.23 Lower respiratory infections 8.5 3 COPD 6.94 Diarrhoeal diseases 5.8 4 Lower respiratory infections 3.75 Perinatal conditions 4.4 5 Respiratory tract cancers 3.56 COPD 3.9 6 Road traffic accidents 3.47 Tuberculosis 2.1 7 Tuberculosis 3.48 Measles 2.1 8 Stomach cancer 2.39 Road traffic accidents 1.9 9 HIV 1.810 Respiratory tract cancers 1.9 10 Self inflicted injuries 1.8

1990 2020

Global Burden of Disease Study, 1996

Reported in 1990 14 million deaths worldwide 5 million in developed countries 9 million in developing countries

Predicted for 2020 25 million deaths worldwide 6 million in developed countries19 million in developing countries

Deaths from cardiovascular disease

Worldwide: 1990-2020

Global Burden of Disease Study, 1996

World population change

0

2

4

6

8

10

1700 1800 1900 2000 2100

Wor

ld p

opul

atio

n (b

illio

ns)

United Nations 1999

Regional population change

Population (billions)2000 2050 Change

Developing world 4.9 7.9 3.0Developed world 1.0 1.0 0.0Total 5.9 8.9 3.0

United Nations 1999

0

500

1000

1500

2000

2500

3000

3500

Trends in per capita cigarette consumption: 1971-1991

1971 1981 1991

Per c

apita

cig

aret

te c

onsu

mpt

ion

High income countries

Low & middle income countries

China

The World Health Report, 1999: Making a Difference

Tobacco-related death and disability

19902020

Deaths (millions) 3.0 8.4 India 0.1 1.5 China 0.8 2.2

DALYS (%) 2.6 9.0

Global Burden of Disease Project, Lancet 1997

Trends in overweight/obesity (BMI 25+ kg/m2)

0

50

100

150

200

250

300

350

Developed Developing World

Mill

ions

19952025 Projected

King et al. Diabetes Care 1998; 21:1414-31

0

50

100

150

200

250

300

350

Asia-Pacific

Global distribution of diabetes

Prevalence of smokingin the Asia

Pacific

APCSC, 2006

Indonesia

Prevalence of hypertension140/90mmHg +

Indonesia 27 11

Prevalence of obesity and overweight

Prevalence of, and predictions for, diabetes

Summary I

· Global epidemic of CVD; the leading cause of death and disability

· About 11 million new cardiovascular deaths each year by 2020

· By 2020, 80% of cardiovascular deaths will occur in low and middle income countries

· About half of these deaths will occur in the Asia-Pacific region

Summary II

· Classic CVD risk factors act similarly in different populations

· These risk factors are already common in many low/middle-income countries, and are often increasing (e.g. Asia)

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