PATHOPHYSIOLOGY OF THE

CARDIO-VASCULAR SYSTEM

PRESENTED BY: MRS. CAROLYN BASCOMBE-Mc CAVE

 STRUCTURE AND FUNCTION
OVERVIEW

• Heart
• Arteries
• Veins
• Lymphatics
 FUNCTIONS
• Serves as the body’s transport system
• Transports oxygen and nutrients to cells
• Removes metabolic waste products
• Carries electrolytes and hormones from one
part of the body to another to regulate body
function
 CIRCULATORY SYSTEM
• PULMONARY /CENTRAL
• SYSTEMIC/PERIPHERAL
The pulmonary circulation transports blood through
the lungs ,facilitating gas exchange
The systemic circulation transports blood throughout
all other tissues in the body
The pulmonary circulation consists of the right side of
the heart, pulmonary arteries, capillaries and veins
It functions under low pressure
 CIRCULATORY SYSTEM
The systemic circulation consists of the left side of the
heart, the aorta and its branches
It functions under high pressure and often against the
effects of gravity
Blood flow through the heart

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 CARDIOVASCULAR DISORDERS
• Congenital e.g. ASD, VSD
• Diseases of the heart muscle-cardiac hypertrophy, myopathy dilatation
• Disorders of the heart wall-Infections/inflammation e.g. endocarditis,
pericarditis,myocarditis
• Diseases of the conductive system e.g heart block, arrythmias
• Valve disorders e.g. stenosis, regurgitation
• Diseases of the arteries -Coronary artery disease e.g. ischaemia, ACS
( myocardial infarction, angina) hypertension
• Venous disorders- varicose veins
• Vascular disorders- artherosclerosis peripheral vascular disease, aortic
aneurysms/dissection
• Heart failure
 COMMON MANIFESTATIONS
• Cyanosis
• Dyspnea
• Palpitations
• Weakness/fatigue
• Dizziness
• Chest pain
 Atherosclerosis
• Atherosclerosis is a condition in which patchy deposits of fatty material
(atheromas or atherosclerotic plaques) develop in the walls of medium-sized
and large arteries, leading to reduced or blocked blood flow (see figure
under peripheral vascular disease section).
• Is the leading cause of illness and death.
• Can affect the medium-sized and large arteries of the brain, heart, kidneys,
other vital organs, and legs.
• It is the most important and most common type of circulatory disorder and
is the underlying cause for several diseases in which result when the wall of
an artery becomes thicker and less elastic.
• Despite significant medical advances, heart attacks due to coronary artery
disease (atherosclerosis that affects the arteries supplying blood to the heart
and strokes (due to atherosclerosis that affects the arteries to the brain are
responsible for more deaths than all other causes combined.
• The term atherosclerosis means hardening of the blood
vessels
• Atherosclerosis is the most common cause of narrowing and
occlusion of the coronaries and consequently ischemic heart
diseases. In atherosclerosis there is deposition of large
quantities of cholesterol beneath the endothelium of many
arteries throughout the body. Eventually these deposits are
invaded by fibrous tissue and calcified. Finally these
atherosclerotic plaques bulge into the blood vessels’ lumen
and either partially or completely block the blood flow in the
affected blood vessels due to thrombus formation .
• This process commonly affect the first few centimeters of the
major coronary arteries
• Atherosclerosis is caused by aging, smoking, hypertension,
genetic predisposition and sedentary life style.

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 RISK FACTORS
NON MODIFIABLE
 Increasing age
 Male gender
 Genetic predisposition
 Family history
 RISK FACTORS
MODIFIABLE
 Cigarette smoking
 Obesity
 Hypertension
 Diabetes mellitus
 Hyperlipidemia
 Sedentary lifestyle
 Atherosclerotic Plaque

http://www.nhlbi.nih.gov/health/dci/Diseases/Hbc/HBC_WhatIs.html
 Atherosclerosis: Two Problems
• Occlusion (Stenosis)
– Narrowed artery diameter
– Less blood flow
• Thrombus
– Formation of clots inside blood vessels
– Can completely block blood flow
 Atherosclerosis: Thrombus
• The thin layer or “cap” covering a plaque can
rupture or burst
– The inside of the plaque is then exposed to
blood
– This sends chemical signals to a host of blood
cells
• Platelets aggregate to form a clot
– Thrombus can block blood flow
– Not enough oxygen delivered -- ischemia
– Tissues can begin to die -- infarction
 Thrombus Development

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 Atherosclerosis: Embolus
• Thrombus can be displaced from the origin
and travel to another location
– Vessels shrink in diameter away from the heart
• Can then lodge in normally healthy vessels
– Can cause blockage in distant location -- embolus
• If vessels in the neck or head are affected
– Ischemia or infarction of the brain tissue
– Stroke
 Coronary Artery Disease
• Coronary artery disease (CAD) is a condition in which the blood supply to the
heart muscle is partially or completely blocked.
• CAD is almost always due to the build-up of cholesterol and other fatty
materials (called atheromas or atherosclerotic plaques) in the wall of a
coronary artery.
• Occasionally CAD results from a spasm of an artery, and rarely, the cause is a
birth defect, or an infection leading to inflammation of the arteries (arteritis),
or physical damage (from an injury or radiation therapy).
• CAD is the most common cause of myocardial ischemia. The major
complications of coronary artery disease are chest pain due to myocardial
ischemia (angina) and heart attack (myocardial infarction).
• CAD is the most common type of cardiovascular disease, occurring in about 5
to 9% of people aged 20 and older. The death rate increases with age and
overall is higher for men than for women. After age 55, the death rate for
men declines, and the rate for women continues to climb. After age 70 to 75,
the death rate for women exceeds that for men who are the same age.
 Ischemic heart disease
• A leading cause of death
• The outcome of ischemic heart disease vary from complete
recovery, all the way to death.
• Death may occur suddenly due to acute coronary occlusion or
fibrillation of the heart.
• It can also occur slowly over weeks or years due to weakening
of the cardiac muscle and heart failure.
• Recovery depends on rapid diagnosis and treatment as well as
preexisting cardiac physiology (the role of collateral
circulation).

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 Pathophysiology of ischemic heart diseases

• Ischemia means decrease blood flow to the cardiac

muscle which results in either arrhythmia and/or
weakening of cardiac muscle depending on the
location and the size of the ischemic area.
• Infarction means tissue death due to complete
loss/block of blood supply.
• The clinical presentation of both conditions is very
similar and commonly known as Angina pectoris.

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 Causes of Ischemic heart disease

• Partial or complete occlusion of one or more of coronary

blood vessels can result from an array of causes the most
common however are the following:
1. Atherosclerosis
2. Hypertension
3. Embolism
4. Obesity
5. Diabetes
6. Severe spasm of the coronary arteries due to irritation by
an atherosclerotic plaque

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 Atherosclerosis vs. Coronary Artery Disease
(CAD)
• Atherosclerosis
– The build-up of plaques throughout
vessel systems
– Can have effects at distant sites
• CAD
– Plaques in the coronary arteries
– Specifically affects the heart muscle Atherosclerosis

CAD
Coronary Atherosclerotic Plaque
Clot stops flow of blood

Plaque build up
on vessel walls

Where the blockage

occurs in the artery

Part of the heart affected

 Early Warning Signs: Angina
• Many people with CAD have no symptoms
• Most prevalent symptom is angina
– Chest pain
• Two types of angina: stable and unstable
– Stable is brought on by stress or exercise
– Unstable may be sudden or more variable
• Angina is typically the result of ischemia
– Heart needs more oxygen
 Angina pectoris
• Is the clinical picture of most of coronary heart diseases.
• Symptoms: sudden severe chest pain following increased load on the
heart due to exercise, heavy meals, stress etc. the pain typically stops
patient from any other activity this is an emergency !!!! The pain is
usually referred to the left side of the neck, jaw, left shoulder, arm, and
hand. Some times it present as epigastric pain.
• Diagnosis: clinical picture, ECG, and echo-cardiography
• Treatment: vasodilators e.g. nitroglycerine (GTN). Also beta blockers
may be used as a treatment for these cases . Surgical treatment (cardiac
angioplasty) also may be indicated for more complicated cases this
includes a wide range of procedures e.g. cardiac catheterization, stunts
and by-pass surgery.

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 CAD and Heart Attacks
• Myocardial infarction (MI or AMI)
– Myocardium: heart muscle
– Infarction: tissue death due to lack of blood
(oxygen)
• Pathophysiology
– Functional changes associated
with or resulting from MI
• Diagnosis
• Treatment
Guidant Heart Attack
 Warning Signs of Heart Attack
• Many heart attacks start slowly; symptoms may come and go
• Chest discomfort
– Most heart attacks involve discomfort in the center of the chest that
lasts for more than a few minutes, or goes away and comes back. The
discomfort can feel like uncomfortable pressure, squeezing, fullness,
or pain
• Discomfort in other areas of the upper body
– Can include pain or discomfort in one or both arms, the back, neck,
jaw, or stomach
• Shortness of breath
– Often comes along with chest discomfort. But it also can occur before
chest discomfort
• Other symptoms
– May include breaking out in a cold sweat, nausea, or light-headedness

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Heart Attack: Diagnosis of Atherosclerosis

• Blood tests
• Electrocardiograms (ECG)
• Ultrasound (echocardiogram)
• Stress tests
• Coronary angiography
• Computer tomography (CT)
Treatment of Coronary Occlusions
• Thrombolytic drugs
 Streptokinase, heparin
• Angioplasty
• Stents
– Often in combination with angioplasty
• Coronary artery bypass graft (CABG)
 Treatment of Atherosclerosis
• Percutaneous Transluminal Angioplasty (PCTA)
– Balloon Angioplasty
 Treatment of Atherosclerosis
• Coronary artery bypass graph (CABG)
• A graft vessel from another area of the body is
used to circumvent the occlusion and return
blood flow
• To do this we
we have to stop
the heart from
beating
http://www.nlm.nih.gov/medlinep
lus/tutorials/coronaryarterybypass
graft/htm/index.htm
 Hypertension
• This means the increase of mean arterial
blood pressure above 110 mm Hg (normally it
is about 90 mm Hg). This occurs when the
diastolic blood pressure is greater than 90 mm
Hg and systolic is above 140 mm Hg.
• It is clinically classified as mild, moderate or
severe depending on the level of blood
pressure.

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 Types of hypertension

• Essential (Idiopathic -primary) hypertension:

in which there is no known reason for
hypertension.
• Secondary hypertension: in which
hypertension occurs secondary to a
preexisting condition or disease.
• Malignant/Uncontrolled hypertension

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 Essential hypertension
• About 90-95% of people with hypertension are said
to have essential hypertension. This means simply
that their hypertension is of unknown origin.
• Essential hypertension is hereditary and polygenic.
• This is a research area hypothesis includes:
1. Overactive renin-angiotensin system.
2. Overactive sympathetic nervous system.
3. Inability of the kidney to secrete salt.

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 Secondary hypertension
• Patho-physiology:
1. Volume loading hypertension: due to excess
accumulation of extracellular fluid in the
body. This results from:
a) Excessive salt intake.
b) Renal tissue damage.
c) Primary aldosteronism.

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2. Hypertension due to excessive secretion of
renin or angiotensin II. Causes include:
a) Renin-secreting tumor
b) Renal ischemia due to renal artery stenosis.
• Angiotensin leads to hypertension due to its
vasoconstrictive effects as well as salt and
water retention.

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3. Hypertension due to a combination of
volume loading and vasoconstriction.
a) Coarctation of the aorta
b) Toxemia of pregnancy
c) Neurogenic hypertension due to over
stimulation of sympathetic nervous system

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 Diagnosis of hypertension
• Measurement of blood
pressure at 3 different
settings (not at the same
time) using a
sphygmomanometer.
• Readings above normal
range of blood pressure.
• Classified as mild, moderate
or severe depending on the
reading and age of the
patient.

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 Treatment of hypertension
• Treatment of the underlying cause in case of
secondary hypertension.
• Essential hypertension is managed according to the
severity with one or a combination of the
following:
1. Life style modification: weight reduction, exercise,
quit smoking, low salt diet. This indicated in pre
hypertension (borderline hypertension) and
concomitantly when medical treatment is indicated
2. Medication in hypertension

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 Medication in hypertension
1. ACE inhibitors e.g. captopril, enalapril. These drugs inhibit the
enzyme responsible for activation of angiotensin resulting in
vasodilation
2. Angiotensin II (A2) receptor antagonist e.g. Losartan. Indicated
when the above mentioned class is not well tolerated.(causes
blood vessels to relax and dilate making it easier for blood to
flow through the vessels)
3. Calcium channel blockers are used for their vasodilator effect.eg
nifedipine
4. Diuretics are used to reduce the volume load but cautiously
because of their electrolyte depleting and cardio toxic effects.
5. Beta blockers eg inderal/propranolol
p.s. these medication can be used in combination or singly
depending on the condition. They should be used under strict
medical supervision.
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 Why hypertension is lethal?
• Hypertension is a silent killer and even moderate elevation of
blood pressure leads to shortened life expectancy.
• This occurs mainly in 3 ways:
1. Excess work load on the heart which leads to congestive
heart failure, coronary heart disease or both which can cause
death from a heart attack.
2. High blood pressure leads to rupture of major blood vessels
in the brain followed by death of major portions of the brain
this is a cerebral infarcts clinically known as stroke depending
on which part of the brain affected this could lead to
paralysis, blindness or other serious effects.
3. High blood pressure causes multiple hemorrhages in the
kidneys producing destruction of kidney tissue, eventually
renal failure and death.
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 Heart Failure
• Heart failure is a disorder in which the heart pumps blood inadequately,
leading to reduced blood flow, back-up (congestion) of blood in the veins and
lungs, and other changes that may further weaken the heart.
• Heart failure has two main forms: the more common, systolic dysfunction
and less common diastolic dysfunction.
• In systolic dysfunction, the heart contracts less forcefully and cannot pump
out as much of the blood that is returned to it as it normally does. As a
result, more blood remains in the lower chambers of the heart (ventricles).
Blood then accumulates in the veins.
• In diastolic dysfunction, the heart is stiff and does not relax normally after
contracting. Even though it may be able to pump a normal amount of blood
out of the ventricles, the stiff heart does not allow as much blood to enter its
chambers from the veins. As in systolic dysfunction, the blood returning to
the heart then accumulates in the veins. Often, both forms of heart failure
occur together.
 Mechanisms and Examples that Cause Left Sided Heart Failure

Impaired Contractility Increased Afterload

(Pressure Overload)
1. Aortic Stenosis
1. Myocardial infarction
2. Uncontrolled hypertension
2. Transient myocardial ischaemia
3. Chronic volume overload
a. Mitral regurgitation
b aortic regurgitation Systolic
4. Dilated cardiomyopathy
Dysfunction

Left-sided
Heart Failure

Diastolic
Impaired Ventricular Dysfunction Increased Afterload
Relaxation (Pressure Overload)
1. Left ventricular hypertophy 1. Mitral Stenosis

2. Hypertrophic cardiomyopathy 2. Pericardial constriction or

3. Restrictive cardiomyopathy tamponade

4, Transient myocardial ischaemia

 Heart Valve Disorders
• Heart valves regulate the flow of blood through the atria and the ventricles
• Each ventricle has a one-way inlet valve and a one-way outlet valve and each
valve consists of flaps (cusps or leaflets
• In the right ventricle, the inlet valve is the tricuspid valve, which opens from
the right atrium, and the outlet valve is the pulmonary (pulmonic) valve,
which opens into the pulmonary arteries.
• In the left ventricle, the inlet valve is the mitral valve, which opens from the
left atrium, and the outlet valve is the aortic valve, which opens into the
aorta.
• The heart valves can malfunction either by leaking (causing regurgitation) or
by not opening adequately and thus partially blocking the flow of blood
through the valve (causing stenosis). Either problem can greatly interfere
with the heart's ability to pump blood. Sometimes a valve has both
problems.
 Diastole Systole

In mitral stenosis, the mitral valve In mitral regurgitation, the mitral valve
opening is narrowed, and blood flow leaks when the left ventricle contracts
from the left atrium into the left (during systole), and some blood flows
ventricle during diastole is reduced. backward into the left atrium.
 ARTERIAL DISEASE OF THE EXTREMITIES
• Disorders of circulation in the extremities are
referred to as Peripheral Vascular Disorders
• They produce symptons of
 Pain
 ischaemia
 Impaired function
 Infarction
 Tissue necrosis
Major peripheral vascular disorders are
 Peripheral arterial disease
 Peripheral vascular disease
 Thromboangitis obliterans( Buerger’s Disease)
 Raynaud phenomenon
 Peripheral Arterial Disease
• Peripheral arterial disease results in reduced blood flow in the arteries of the
trunk, arms, and legs. Disorders affecting arteries that supply the brain are
considered separately as cerebrovascular disease.
• Peripheral arterial disease may be described as occlusive or functional.
• Occlusive peripheral arterial disease is due to structural changes that narrow
or block arteries and often results from atherosclerosis.
• Functional peripheral arterial disease is usually due to a sudden temporary
narrowing (spasm) or, rarely, to a widening (vasodilation) of arteries.
Raynaud's disease and Raynaud's phenomenon are conditions in which small
arteries (arterioles), usually in the fingers or toes, constrict more tightly in
response to exposure to cold.
• Functional peripheral arterial disease usually occurs when the normal
mechanisms that dilate and constrict these arteries are exaggerated. The
affected arteries constrict more tightly and more often.
ARTERIAL OCCLUSIVE DISEASE/PERIPHERAL VASCULAR DISEASE
• The presence of systemic atherosclerosis distal to the arch of
the aorta which causes obstruction/narrowing of lumen of the
aorta and its major branches
• More common in men 60-70
• Risk factors –same as for atherosclerosis
• Most common risk factors are cigarette smoking and diabetes
• Signs and symptoms depend on the site
• Primary symptom for femoral and popliteal artery is
intermittent claudication/ calf pain on walking(calf muscle has
the highest oxygen consumption of leg muscle group while
walking)
• Other symptoms include a vague aching feeling or numbness
rather than pain
 PERIPHERAL VASCULAR DISEASE cont’d
• Cool extremities
• Weak/absent popliteal and pedal pulses
When blood flow is reduced to the extent it can no
longer meet the minimal needs of the resting muscle
 Ischaemic pain at rest
 Ulceration
 Gangrene/tissue necrosis
 Pain is now more severe, worsens at night when the
limb is elevated and lessens on standing
 DIAGNOSTIC TESTS
• Inspection of limbs for ischaemia eg brittle toenails,
hair loss, pallor coolness
• Palpation of pedal pulses to detect obstruction
(femoral, popliteal, posterior tibial and dorsalis pedis)
• Doppler ultrasound
• MRI
• CT
• Angiography
 TREATMENT
AIMS
 To protect affected tissues
 To preserve functional capacity
TREATMENT
 Depends on cause, location and size of obstruction
 Includes
 Cessation of smoking
 Control of hypertension and diabetes
 thromboendarterectomy
 Embolectomy
 Bypass graft
 Atherectomy
 Balloon angioplasty
 Thrombolytic therapy
 Antiplatelet therapy
The fingertips of the hand on the
right have turned blue due to
Raynaud's disease (i.e. unknown
cause).

How Atherosclerosis Develops

This patient's toes have a whitish
discoloration due to Raynaud's
phenomenon caused by scleroderma.
 Venous Disorders
• The main problems that affect the veins include inflammation, clotting, and
defects that lead to distension and varicose veins. The veins in the legs are
particularly affected because when a person is standing, blood must flow
upward from the leg veins, against gravity, to reach the heart.
• Venous disorders results from poor blood flow can be classified as follows;
• An arteriovenous fistula is an abnormal channel between an artery and a
vein.
• Deep vein thrombosis is the formation of blood clots (thrombi) in the deep
veins. Thrombi can occur either in the deep leg veins, causing deep vein
thrombosis, or in the superficial leg veins, causing superficial
thrombophlebitis
• Superficial thrombophlebitis (superficial phlebitis) is inflammation and
clotting in a superficial vein.
• Varicose veins of the lower extremities are abnormally enlarged/dilated and
tortuous/twisted superficial veins in the legs.
One-Way Valves in the Veins Valves in Varicose Veins
 What is Congestive Heart Failure?
• Congestive heart failure leads to a reduction in Cardiac output
• Reflex sympathetic compensation can increase Cardiac Output
• Consequently elevated afterload reduces Cardiac Output
• A cascade of events can lead to left ventricular hypertrophy (see
diastolic dysfunction)
• Angiotesin II also increases Cardiac Output & sodium retention
• However the angiotensin induced increase in Cardiac Output
raises preload and Left Ventricular Diastolic Pressure which in
turn leads to pulmonary oedema and premature death
Factors that lead to Congestive Heart Failure

1. See bullet points 1- 5 for explanation