Patho- Atherosclerosis
ischemia
to hold back blood; decreased blood flow to tissue caused by constriction or occlusion of a blood vessel **Local and temporary deficiency of blood supply due to circulatory obstruction
dilate
to make or become larger or wider; to expand upon
what does endothelial cell injury eventually lead to?
blood clots (from plaque) that block arteries
what is a false aneurysm?
"pseudoaneurysm"- localized dissection or tear in inner wall of artery w/ formation of extravascular thematoma that causes vessel enlargement -bound only by outer layers of vessel wall or supporting tissue
EKG
(electrocardiogram) instrument used in measuring the electrical potential during a heartbeat * (a graphical recording of the cardiac cycle produced by an electrocardiograph)
explain lipid accumulation and smooth muscle cell proliferation:
-activated macrophages release toxic oxygen species that oxide LDL -oxidized LDL is then ingested by macrophages forming foam cells= primary component of atherosclerotic lesions -activated macrophages also release growth factors that contribute to the migration and proliferation of smooth muscle cells and elaboration of extracellular matrix
why and when does varient/vasospastic/prinzmetal angina Chronic Ischemic Heart Disease occur?
-can occur in the absence of visible disease -occurs at rest or with minimal exercise -often occurs during sleep -often has a regular pattern---making it predicatable (ex. always happens at 2 AM)
what are the main causes for CHD?
-caused by impaired coronary circulation -usually caused by atherosclerosis
saccular aneurysm-
-extends over part of circumference of the vessel and appear saclike
explain migration of inflammatory cells:
-more inflammatory responses respond, show up and adhere -migrate b/w the endothelial cells to localize in the intima and transform into macrophages and engulf lipoproteins (largely LDL)
what is a good HDL count?
40 or higher is good!
Define Atherosclerosis
-most common type of hardening of arteries -accumulation of fatty deposits, platelets, neutrophils, monocytes & macrophages throughout the endothelial cell layer and eventually into the smooth muscle layer Dyslipidemia: an abnormal amount of lipids in the blood Atherosclerosis: LDL that accumulates in the blood when LDL receptors are saturated, leading to an inflammatory response in the blood vessel. Macrophages accumulate in response but cannot process the LDL and rupture. Macrophage and LDL material build up which leads to the blockage and eventual hardening of the vessel. If the plaque ruptures thrombosis can occur.
explain endothelial cell injury:
-smoking, increase in LDL, immune mechanisms, and mechanical stress associated with hypertension can cause endothelial cell injury with adhesion of monocytes and platelets
CHD can effect one or ALL 3 major coronary vessels
...
CHD is divided into 2 major health problems which are?
1. Chronic ischemia heart disease 2. Acute coronary syndrome
how is stable angina diagonsed?
1. EKG 2. Echocardiography (ultrasound of your heart- see valves pumping) 3. exercise stress testing (treadmill with gradual resistance- monitor heart) 4. Imaging studies- dye injections 5. Coronary angiography
what are the steps in developing atherosclerosis?
1. Endothelial cell injury (bc of high BP, over weight, diabetes, etc.) 2. Damage to these cells changes their permeability 3. Lipids can now enter your injured cell 4. WBC come try to get rid of lipids as an inflammatory response 5. When WBC and lipids combine they form= "foam cells" 6. WBC and vascular endothelium cells release Growth factors that promote plaque formation 7. plaques/platelets grow and block arteries :( **MAJOR COMPLICATION of atherosclerosis is the formation of blood clots (these are bad bc they may impede blood flow which could cause stroke or heart attacks)
what can CHD lead to?
1. Heart attack 2. Cardiac dysrhythmias (abnormal heart rhythm) 3. heart failure 4. sudden death
what are the hypothesized causes for atherosclerosis?
1. Hyperlipidemia- high lipid levels 2. High Blood Pressure- arteries could be weakened bc loss of elasticity 3. Infection- which causes an inflammatory response 4. High Blood Iron- can damage endothelium cells (mainly found in men because women typically suffer from low iron) 5. High Homocysteine levels BUT we truly do not know the cause for atherosclerosis
what are some complications of atherosclerosis?
1. MI - heart attack bc of blood clot 2. CVA- stroke 3. Aneurysms - pain bc weakening of the vessels 4. TIA- transient ischemic attack
Arteries are made up of how many walls? What are they?
1. Tunica Intima (made of Endothelium cells) 2. Tunica Media (made of smooth muscle cells) 3. Tunica Adventitia/Externa (made of collagen and elastic fibers)
what medication can be taken at home to reduce pain in stable, predictable angina?
1. aspirin 2. nitroglycerine- put under tongue, should take away the pain in 3 doses. it lowers BP
unstable plaque in CHD can does what?
1. can rupture and form thrombus 2. unstable angina 3. called "unstable" bc the plaque is NOT encapsulated so its at a higher risk to rupture, leaking materials into blood stream which causes blocks
unstable angina causes:
1. dyspnea 2. diaphoresis (short of breath) 3. anxiety 4. tachycardia- fast heart rate 5. EKG changes
what are the 4 developmental steps of atherosclerosis?
1. endothelial cell injury 2. migration of inflammatory cells 3. smooth muscle cell proliferation and lipid deposition 4. gradual development of the atheromatous plaque with a lipid core
what are 3 lesions that develop into atherosclerosis?
1. fatty streak 2. fibrous atheromatous plaque 3. complicated lesion
what are the two types of atherosclerotic lesions?
1. fixed (stable plaque) 2. unstable (vulnerable plaque)
what are some risk factors for developing atherosclerosis?
1. increasing age 2. males 3. family history 4. smoking 5. obesity 6. diabetes *we can manage diabetes, smoking and weight! BUT we truly do not know the cause for atherosclerosis
what will a patient show if experiencing atherosclerosis?
1. intermittent claudication- pain in legs 2. skin color changes- bc of blood flow changes 3. cold sensitivity- not enough blood flow 4. diminished pulses- not enough blood flow 5. angina- in the coronary arteries- which causes pain in chest, arm or neck
stable plaque in CHD does what?
1. obstruct blood flow 2. chronic ischemic disease 3. called "stable" because of the plaque being encapsulated in a fibrous covering protecting it
what are the 3 types of Chronic Ischemic Heart Disease bc of CHD?
1. stable angina 2. variant or "prinzmetal" angina 3. silent myocardial ischemia
acute coronary syndromes is divided into 2 different health problems:
1. unstable angina (USA) 2. Myocardial infarction (MI)- heart attack
how does coronary circulation work?
2 main coronary arteries (left and right) -left coronary artery is the main one- including the LAD and circumflex branches
what percentage of people with CHD experience stable angina?
50%
what percent of people with CHD have coronary atherosclerosis?
90%
nitroglycerine
A drug that helps to dilate the coronary vessels that supply the heart muscle with blood...medicine used for heart pain
hypolipidemia
Abnormally low cholesteral/fat levels in the blood
Homocysteine
Amino acid created during the metabolism of protein; elevated levels are believed to impair memory and contribute to above-normal cholesterol levels- which could attribute to development of atherosclerosis
anastomosis
An end-to-end union or joining of blood vessels, lymphatic vessels or nerves
Coronary angiography
An iodine compound angiogram that can determine the degree of obstruction of the arteries that supply blood to the heart.
what medication is used to keep platelets from aggregating?
Aspirin A1 mg used for heart disease
how could high blood pressure cause atherosclerosis?
Because body arteries could be weakened because loss of elasticity
what are some nontraditional risk factors for atherosclerosis?
C-reactive protein (CPR) serum homocysteine lipoprotein
exertional angina
Chronic unstable angina, occurs at a predictable level of physical activity or emotional stress; ceases with rest or nitroglycerine
CHD stands for?
Coronary Heart Disease
what part of the body does Atherosclerosis mainly effect?
Coronary arteries, aorta, cerebral arteries (it can effect many other places throughout the body as well)
silent myocardial ischemia disgnosis uses what machine?
EKG nuclear imaging
why is it important to know the walls of the artery?
It is important because diseases mainly effect the tunica Intima (endothelium cells) and Tunica media (smooth muscle cells)
left anterior descending
LAD ARTERY This supplies 55% blood to the anterior wall of the left ventricle, the anterior ventricular septum & the apex of the left ventricle.
what does LDL do?
LDL Lipoproteins carry cholesterol & fats in the blood to body tissues. it carries most of the cholesterol to the cells, and elevated blood levels of LDL.
what is a good LDL number?
LDL: lower then 100 is great! above 160 is terrible Cholesterol: Less than 200 mg/dl (over 240 is BAD)
lipoprotein
Large conglomerations of proteins, fats, and cholesterol that transport lipids in the bloodstream. Contains a lipid core surrounded by phospholipids and apoproteins. Are classified by their density. (fat carrying proteins that encase lipids and transport them throughout the blood)
What does LDL stand for? is it good or bad?
Low density lipids. BAD- means you have HIGH cholesterol/fat
abdominal aortic aneurysms:
MOST FREQUENT from of aneurysms -develop after 50 -associated with severe atherosclerosis - occurs more in men -usually hypertensive ppl -smoking and genetic play a role -located below renal artery -MOST AB ANEURYSMS= asymptomatic -pulsating mass >4 cm- palpable seen during routine exam -main MAYBE present
thoracic aneurysm
Major Cause: ATHEROSCLEROSIS, HTN, causes compression of structures within mediastinum and thorax, presents with horse voice, dyspnea, dysphagia, chronically can result in aortic valve insufficiency -asymptomatic -substernal back neck pain occur maybe dypsnea, stridor, brassy cough, caused by pressure on trachea -hoarseness -hard time swallowing -may compress vena cava causing distension of neck veins and edema of face and neck
how many connections are there bw coronary arteries?
NONE
VLDL
Very Low Density Lipoprotein -- carries triglycerides. Made when the liver can't make enough HDL and LDL. Can also mean a compromised liver. ---want this number to be LOW
thrombus
a stationary clot. When it has grown enough to close off a blood vessel, this dangerous event is a thrombosis
dysrhythmia
abnormal heart rhythm
what is a true aneurysm?
abnormal localized dilation of a blood vessel (most common in aorta) bound by a complete vessel wall- blood remains with in vascular compartment
how are aneurysms classified?
according to their cause, location and anatomic features
what happens if there is a problem in major coronary circulation?
anastomosis of smaller vessels
unstable angina treatment:
antithrombotics ("clot busters", PTCA- put balloon in artery to open it up, maybe put stint in)
unstable angina symptoms occur when?
at rest and normally last about 20 minutes (sitting in classroom and feel pain)
what is the most common cause of CHD?
atherosclerosis
explain plaque structure :
atherosclerotic plaque is made of : aggregation of smooth muscle cells (SMCs), macrophages and other leukocytes, extracellular matrix (like collagen and elastic fibers) - cap is made of SMC and ECM -inside cap= central core of lipid-laden foam cells and fatty debris ***rupture, ulceration or erosion of an unstable or vulnerable fibrous cap may lead to hemorrhage into plaque or thrombotic occlusion od vessel lumen.
what are fibrous antheromatous plaque?
basic lesion of clinical atherosclerosis -accumulation of intracellular and extracellular lipids, proliferation of vascular smooth muscle cells and formation of scar tissue and calcification
why is vasoconstriction bad?
bc it impedes blood flow- risk for blood clots
how could infection cause atherosclerosis?
because infections might cause an inflammatory response
how can high blood iron cause atherosclerosis?
because iron can damage endothelium cells (this is mainly found in men) (women typically suffer from low iron)
CVA
cerebrovascular accident (stroke) **a sudden loss of consciousness resulting when the rupture or occlusion of a blood vessel leads to oxygen lack in the brain
unstable angina
chest pain at REST or with increasing frequency resulting from plaque rupture in a coronary artery * This type of angina occurs at rest, or with minimal exertion & is not relieved with nitroglycerin. Client is more susceptible to myocardial infarction & sudden death.
angina
chest pain relieved with nitroglycerin, pain in the heart region caused by lack of oxygen
how are aneurysms controlled or treated?
cholesterol and BP controlled smoking stopped surgical repair * common
collateral circulation
circulation by secondary channels after obstruction of the principal channel supplying the heart-- GOOD THING TO NATURALLY HAPPEN- BODY'S DEFENSE
occlusion
closure or blockage (as of a blood vessel)
emboli
clots that travel to and suddenly block a blood vessel
what are some causes of aneurysms?
coagulation defects trauma infections atheroscerlosis
silent myocardial ischemia is seen in ____ patients with neuropathy or sensory denervation
diabetics --may have sores on their feet and not even feel them and older people
fusiform aneurysm-
envolves the entire circumference of vessel- gradual and progressive dilation of vessel
who can develop atherosclerosis?
even healthy, exercising people because it can be genetically inherited
unstable angina can cause new onsets if?
exertional angina- less then a month duration- may have had pain in chest only when they were stressed, now when they exercise too)
dissecting aneurysm-
false aneurysm resulting from a tear in the intimal layer of vessel that allows blood to enter the blood vessel wall, dissecting its layers to create blood filled cavity
what are primary components of atherosclerotic lesions?
foam cells
what type of cells form when WBC and lipids combine?
foam cells
circumflex branches
follows the coronary sulcus wrapping around the left side of heart and mainly supplies the Left ventricle *passes posteriorly btw the groove of the left atrium and ventricle -branches that supply left lateral wall of left ventricle
silent myocardial ischemia usually occurs in people who ____?
have already had a heart attack
asymptomatic
having no symptoms of illness or disease
silent myocardial ischemia may be noticed if the person has an extra ____
heart sound, xanthelasmas or aruc senilis (ex. look at pictures!)
HDL stands for? is it good or bad?
high density lipoprotein... GOOD! **H for HAPPY!!** want a higer number of HDL bc that means you have higher protein count then cholesterol
how can high levels of homocysteine cause atherosclerosis?
high levels of amino acids can attribute to more cholesterol in blood which could cause heart problems
the more the protein the ____ the density
higher
variant angina causes dysrthmias that can occur during episodes of pain but can only see changes on EKG if
if EKG is done during episode of pain
chronic ischemic disease
imbalance between blood supply & demand for oxygen; stable angina
chronic ischemic heart disease is what?
inadequate blood flow in the heart, patients will experience chest pain
persons with dysrhythmias during pain have __________
increased risk of sudden death
how is stable angina precipitated?
increased work demands of the heart: 1. exercise 2. changes in temperature (seen more in the winter) ** thats why it is predictable! medication can be taken at home!
what are some constitutional factors that lead to atherosclerosis?
increasing age male gender family history alterations in lipoproteins women after menopause by 70-80 equal chance for men and women
ischemia
insufficient blood flow to an area
silent myocardial ischemia is hard to disgnosis because
it can occur without ANY chest pain
what does HDL do?
it removes lipids from plac, carries cholesterol from the tissues to the liver for eventual excretion. It is beleived that low serum levels of HDL can contribute to atherosclerosis
when are symptoms typically seen in atherosclerosis?
late in the process, because of temporary fix naturally occurring in the body
LAD
left anterior descending (coronary artery) it passes btw grooves of ventricles gives off diagonal and perforating branches *diagonal branch goes to left ventricle *perforating branch goes to anterior interventricular septum and anterior papillary muscle of left ventricle
the more the lipid the _____ the density.
lower
*elevated cholesterol levels lead to the attachment of monocytes to the endothelium that do what?
monocytes transform into macrophages that eat lipids- these activated macrophages release free radicals that oxidize LDL (which is toxic to endothelium) which damages endothelial cells
where is stable angina pain felt? what is it provoked by? and how can it be relieved?
mostly in substernal area of chest -may radiate to left shoulder, arm, jaw, neck -provoked by exertion or emotional stress -relieved by rest or medication within minutes!
acute coronary syndrome is usually caused because:
of atherosclerotic plaque disruption with thrombus formation
silent myocardial ischemia is without _____
pain
angina
pain in the heart region caused by lack of oxygen
silent myocardial ischemia can occur if person has a defect in ______
pain threshold or pain transmission
what is "intermittent claudication"?
pain while walking bc not enough blood flows to the legs * Episodic muscular ischemia. While exercising, muscles require increased blood flow, but an occluded artery can't provide it, causing ischemia in the muscle. *BREIF only lasts a couple of minutes
aneurysm
people can walk around with aneurysms without even knowing it (pretty common and maybe removed) ***a cardiovascular disease characterized by a sac-like widening of an artery resulting from weakening of the artery wall ***The balooning out of an artery wall at a point where it has grown weak
stable angina is:
persistent pain in the chest -REOCCURRING episodes of chest pain or pressure sensation (can be in chest, neck or arms) -Restricting squeezing, suffocating sensation
main idea: what happens when there is plaque disruption?
platelets aggregate and vasoconstriction occurs- which can cause thrombus
what body cell plays a major role in linking unstable plaque to CHD?
platelets... thus the use of anti-platelet medications in prevention treatment
Hyperlipidemia
presence of excess lipids in the blood
unstable angina disgnosis:
presenting symptoms ekg
silent myocardial ischemia treatment involves?
reduced myocardial oxygen use and demand by resting, meditating, keep heart from working as hard
RCA
right coronary artery -passes through right atrioventricular groove -branch supply right ventricle, sinoatrial node -moves to back of the heart and supplies posterior portion of the heart
berry aneurysm =
small, spherical dilation of vessel at bifurcation
what happens if there is a gradual occlusion of larger coronary vessels?
smaller vessels increase in size to create collateral circulation
what is varient/vasospastic/prinzmetal angina Chronic Ischemic Heart Disease?
spasms of coronary artery where tests do not show anything!! :( symptoms lead to disgnosis
bypass surgery
surgical technique using a vein to "detour" blood around plaque or blood clot, veins are used because they are bigger to maximize bloodflow, usually veins from the leg *This involves taking part of an artery or vein from another part of the body (like the arm or leg) and using it to channel blood around a blocked area in an artery.
bifurcation
the act of splitting into two branches
vasoconstriction
the narrowing of blood vessels. When blood vessels become narrow, blood pressure increases.
lipoproteins are named after what?
their blood lipid density
what happens after an aneurysm has developed?
they grow larger as tension in vessel increases if untreated, may rupture bc increased tension -even an unruptured aneurysm can cause damage by exerting pressure on adjacent structures and interrupting blood flow
what is a fatty streak?
thin, flat, yellow intimal discolorations-become enlarged by becoming thicker and slightly elevated as they grow in length -made of macrophages and smooth muscle cells that mix with lipids to form foam cells -present in children -first year of life- happens regardless of race, gender, or setting -increase in # until 20 years old0 then remain static or regress
TIA
transient ischemic attack **temporary interference with the blood supply to the brain ("mini stroke")
what is the treatment for stable angina?
treatment aimed at preventing MI (heart attack) and symptom reduction by both "nonpharmacologic" - life style changes- exercise, diet, stress management, reduce cholesterol 4 legged animals worst, 2 legged better, no legs- great!! "pharmacologic methods"- medications
lipids are made of what?
triglycerides and cholesterol
how are aneurysms diagnosed?
ultrasounds, echocardiograph, CT scan, MRI
xanthelasma
white growth near eyelid -seen alot in older people -white area= fatty sac -find these ppl have heart disease sometimes - we DONT KNOW WHY THIS HAPPENS -red flag, tells you to examine further -usually have NO symptoms or chest pain
arcus senilis
white ring around eye that should not be there -lipid ring -cause by elevated cholesterol/lipids -need to run lipid panel
