cardiovascular system disorders 3 · © endeavour college of natural health endeavour.edu.au 2...

Cardiovascular System Disorders 3

Lecture 21

Pathology and Clinical

Science 1 (BIOC211)

Department of BioscienceText Reference:

Porth’s Pathophysiology: Concepts of Altered Health States

Sheila C. Grossman & Carol Mattson Porth.

Ninth Edition.

Copyright © 2014 Lippincott, Williams & Wilkins Publishers, Inc.

© endeavour.edu.au

© Endeavour College of Natural Health endeavour.edu.au 2

Session Learning Outcomes

This session aims to:

o Discuss the causes , clinical features, diagnosis and

treatment of various types of vascular diseases.

o Define hypertension and elaborate on the aetiology,

complications, investigations and management of

hypertension.


VASCULAR DISEASE AND

HYPERTENSION

o Peripheral arterial disease

• Chronic lower limb arterial disease

• Chronic upper limb arterial disease

• Raynaud’s phenomenon and Raynaud’s

disease.

o Diseases of the aorta

• Aneurysm

o Hypertension


PERIPHERAL ARTERIAL

DISEASE

Introduction

• Almost all PAD is due to atherosclerosis

• Rick factors are smoking, diabetes,

hyperlipidaemia and hypertension

Epidemiology

• 20% of 55-75 years old people in UK have PAD

Clinical manifestations

Depends on site, presence of collateral supply, speed of

onset and mechanism


CHRONIC LOWER LIMB

ARTERIAL DISEASE

PAD in the leg, 8 times more often than in

the arm

Clinical presentations

• Intermittent claudication

• Critical limb ischaemia

Other causes of lower limb arterial disease

• Diabetic vascular disease

• Buerger’s disease


CHRONIC LOWER LIMB

ARTERIAL DISEASE

Diabetic vascular disease

• 5- 10% of patients with Peripheral arterial disease

have diabetes

• 30-40% in those with critical limb ischaemia

Problems of diabetic foot which account for high

amputation rate

• Arterial calcification, immunocompromised state,

sensory and motor neuropathy, autonomic

neuropathy and multisystem arterial disease

© Endeavour College of Natural Health endeavour.edu.au

http://www.bing.com/images/search?q=arterial+foot+ulcer+images&qpvt=arterial+foot+ulcer+images&FORM=IGRE#view=detail&id=B7FC4F32BF4B5E260A612D

A0BD15C69B40F18FA9&selectedIndex=9


http://vascularcare.sg/wp-content/uploads/2013/04/Leg-Ulcer2.jpg


CHRONIC ARTERIAL DISEASE

Buerger’s disease

(Thromboangitis obliterans)• Inflammatory obliterative arterial disease

• Can affect hands or feet

• Strong genetic element present

• Presents in young male smokers

• Also affects veins ( superficial thrombophlebitis )

• Remits if the patients stop smoking, amputation is most frequent outcome if patients continue to smoke


THROMBOANGITIS OBLITERANS

http://www.nlm.nih.gov/medlineplus/ency/imagepages/18089.htm



Clinical Features

• Pain

• Intermittent claudication in arch of the foot and digits

• Cold sensitivity

• Absent peripheral pulses

• Cyanotic extremities

• Malformed nails

• Ulceration

• gangrene



Diagnosis and Treatment

• Quit smoking

• Promote vasodilation

• Prevent injury

• Sympathectomy

Complications

• Gangrene

• Loss of digits / feet


CHRONIC UPPER LIMB

ARTERIAL DISEASE

o Subclavian artery is most common site

o Presents with

• Arm claudication (rare)

• Atheroembolism (blue finger syndrome)

• Subclavian steal


INVESTIGATION AND

MANAGEMENT Investigation

• Duplex ultrasound

• CT, MRI with contrast agents

• Angiography

Management

• Medical

– Cessation of smoking, regular exercise, antiplatelet agent, peripheral vasodilators, reduction of cholesterol, diagnosis and treatment of diabetes, hypertension

• Surgical intervention

– Angioplasty, stenting, endarterectomy, bypass


RAYNAUD’S PHENOMENON &

RAYNAUD’S DISEASE

Epidemiology

• Affects 3% - 5% of population

• More common in women

o Cold and sometimes emotional stimuli trigger

vasospasm in peripheral arteries

o There is characteristic sequence of digital pallor

(vasospasm), followed by cyanosis (presence of

deoxygenated blood) and then rubor (reactive

hyperaemia)


RAYNAUD’S PHENOMENON &

RAYNAUD’S DISEASE

http://www.nlm.nih.gov/medlineplus/ency/imagepages/17127.htm


RAYNAUD’S DISEASE

o Primary Raynaud’s phenomenon

o 5-10% of young women in temperate climate

o Often familial and appears between 15- 30

years

o Does not progress to ulceration or infarction

Management

• Avoidance of cold


RAYNAUD’S SYNDROME

o Also known as secondary Raynaud's

phenomenon

o Tends to occur in older people in association

with connective tissue disease, vibration induced

injury and thoracic outlet syndrome

o Finger ulceration and necrosis common

Management

• Protection of fingers from cold and trauma

• Antibiotics for infection


Patchy Necrosis

http://www.bing.com/images/search?q=Raynaud%27s+syndrome+x-ray+images&FORM=HDRSC2#view=detail&id=92D51A4453F42C3BD9E89FCDC1899A1F5DFE1F7E&selectedIndex=13


http://www.arthritis.org.nz/wp-content/uploads/2011/08/scleroderma-300x157.jpg


http://www.bing.com/images/search?q=Raynaud%27s+syndrome+finger+necrosis&qs=n&form=QBIR&pq=raynaud%27s+syndrome+finger+necrosis&sc=0-0&sp=-1&sk


DISEASE OF THE AORTAAortic aneurysm

An abnormal dilation of the aortic wall

Aetiology and Types

Non-specific aneurysms

– Common site – infra-renal abdominal aorta

– Risk factors – smoking, hypertension

Marfan’s syndrome

– Inherited connective tissue disorder

– Site – ascending aorta

Aortitis

– Due to syphilis leads to saccular aneurysm of ascending aorta

Thoracic aneurysm

Abdominal aneurysm


DISEASE OF THE

AORTA

From Porth’s Pathophysiology: Concepts of Altered Health States. (9th ed., p. 757),

By Sheila C. Grossman & Carol Mattson Porth.

Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins


Atherosclerosis and aneurysm

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http://www.bing.com/images/search?q=aortic+aneurysm++images&qs=n&fo

rm=QBIR&pq=aortic+aneurysm+images&sc=0-0&sp=-

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2&selectedIndex=549

http://www.bing.com/images/search?q=aortic+aneurysm++images&qs=n&form=QBIR&pq=aortic+aneur

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Aortic

Stent

Graft

http://www.eurorad.org/mediafiles/eurorad/0000011662/000006_text.jpg


HYPERTENSION

Classification:

o Primary (essential) (>95% = unknown cause, ?

multifactorial)

o Secondary (specific & potentially treatable cause)

Epidemiology:

o One of the commonest chronic conditions of

developed world

o Present in 20-30% of adults

o More common in some ethnic groups


HYPERTENSIONDefinition (British hypertension society)

systolic (mmHg) diastolic

Optimal <120 <80

Normal <130 <85

High normal 130-139 85-89

Hypertension

Grade I (mild) 140-159 90-99

Grade II

(moderate)

160-179 100-109

Grade III (severe) >180 >110


BLOOD PRESSURE RANGE

From Porth’s Pathophysiology: Concepts of Altered Health States. (9th ed., p. 774), by




HYPERTENSIONPathophysiology:

o Primary HTN = unclear (raised cardiac output/HR/catecholamines = altered baroreceptor sensitivity)

o Chronic HTN = increased peripheral resistance

o Atheroma development, left ventricular hypertrophy, activation of Renin-Angiotensin/aldosterone system

Causes:

o Primary = multifactorial (genetic, fetal, environmental, humoral)

o Secondary (Renal, Endocrine, cardiovascular system, Drugs, Pregnancy)


MECHANISMS

OF BLOOD

PRESSURE

REGULATION





HYPERTENSION

Investigations

o Urinalysis for blood, protein and glucose

o Blood U&E and creatinine, glucose

o Serum total and HDL cholesterol

o 12-lead ECG

o For selected patients – chest X ray,

ambulatory BP, echocardiogram, renal

ultrasound and angiography


HYPERTENSION

Clinical Features

o Generally asymptomatic

o CF associated with quite high BP (headache, epistaxis, nocturia)

o CF associated with target organ damage

o Accurate measurement vital (White coat effects)


HYPERTENSION

Management

o Aim – to reduce the incidence of adverse cardiovascular

events (CAD, stroke, heart failure)

o Non-drug therapy

• Lifestyle measures for borderline HTN, to reduce the

dose & number of drugs e.g. correcting obesity,

reducing salt and alcohol intake, physical exercise,

quitting smoking

o Antihypertensive drugs

• Diuretics, beta blockers, ACE inhibitors, angiotensin

receptor blockers, calcium antagonists

o Adjuvant drug therapy

• Aspirin, statins


MANAGEMENT OF HYPERTENSION

LIFE-STYLE MODIFICATIONS

Modification Recommendation Approximate systolic BP

reduction (mmHg)

Weight

reduction

Maintain healthy body weight

(BMI – 18.5-24.9 kg/m2)

5-20 mmHg/ 10kgs weight

loss

Adopt DASH

eating plan

Fruit/ veg/ moderate fat intake 8-14 mmHg

Salt reduction Sodium intake 100

mmol/day

2-8 mmHg

Physical activity Regular aerobic (brisk walk),

30 minutes/ day

4-9 mmHg

Moderate

alcohol

consumption

No more than 2 standard

drinks/ day for males and 1 for

females

2-4 mmHg


HYPERTENSION

Target organ damage (complications)

o Blood vessel – atheroma, aneurysm

o CNS - stroke

o Retina - retinopathy

o Heart – LV hypertrophy, coronary artery disease

o Kidneys – proteinuria, renal failure

o Malignant or accelerated phase HTN – due to

microvascular damage with necrosis


MCA - CVA

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HYPERTENSIVE RETINOPATHY





ACUTE MYOCARDIAL INFARCTION





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Hypertensive Nephropathy

http://www.bing.com/images/search?q=hypertensive+nephropathy++images&qs=n&form=QBIR&pq=hypertensive+nephropathy+images&sc=0-0&sp=-

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Readings and ResourcesResources:

o Set Textbooks:

Colledge, N.R., Walker, B.R. & Ralston S.H. (2014). Davidson’s Principles and Practice of Medicine, (22nd ed.). Edinburgh.

Churchill Livingstone.

Grossman, S.C. & Porth, C.M. (2014). Porth’s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia,

U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins.

o Additional textbooks:

Davies, A. & Moores, C. (2010). The respiratory system: basic science and clinical conditions, (2nd ed.). Edinburgh. Churchill,

Livingstone, Elsevier.

Field, M., Pollock, C., Harris, D. (2010). Systems of the Body: The Renal System; Basic Science and Clinical Conditions. (2nd

ed.). United Kingdom: Churchill Livingstone.

Jamison, J.R. (2006) Differential Diagnosis for Primary Care: a handbook for health care practitioners. (2nd ed.). Edinburgh.

Churchill Livingstone.

Lee, G. & Bishop, P. (2013). Microbiology and Infection Control for Health Professionals, (5th ed.). Frenchs Forest, NSW.

Pearson Education.

McCance, K.L. & Huether, S.E. (2014). Pathophysiology: the biological basis for disease in adults and children, (7th ed.). St.

Louis, MO. Elsevier.

Murphy, K. (2011). Janeway’s immunobiology, (8th ed.). New York. Garland Science.

Noble, A., Johnson, R. & Bass, P. (2010). The cardiovascular system: basic science and clinical conditions, (2nd ed.).

Edinburgh. Churchill, Livingstone, Elsevier.

Pagana, K.D. & Pagana, T.J. (2013). Mosby’s diagnostic and laboratory test reference, (11th ed.). St. Louis, MO. Elsevier.

Smith, M.E. & Morton, D.G. (2010). The digestive system: basic science and clinical conditions, (2nd ed.). Edinburgh.

Churchill, Livingstone, Elsevier.

VanMeter, K.C. & Hubert, R. (2014). Gould’s pathophysiology for health professions, (5th ed.). St. Louis, MO. Elsevier.


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