Cardiovascular

• Heart - muscular pumping organ of the body.
• The heart is located on the left chest.
• The heart resembles a closed fist.
• The heart weighs approximately 300-400g.
• Heart is covered by a double layered membrane called the pericardium or pericardial membrane.
• Layers of the pericardium

  • Parietal
  • Visceral
• Layers of the heart:

  • Epicardium
  • Myocardium
  • Endocardium
• Chambers of the heart:

  • Upper chamber
  • Atria
  • Lower chamber
  • Ventricles
• Valves:

  Atrioventricular valves

  • Tricuspid valve
  • mitral valve

  Semi-lunar valves

  • Sinoatrial valve
  • atrioventricular vavle

  Bundle of his

  • Pulmonic
  • Aortic
• Coronary arteries:

  • Right main coronary artery
  • left main coronary artery
• Cardiac Conduction System

  1. Sino-atrial node
  2. Atrio-ventricular node
  3. Bundle of his
  4. Purkinje fibers
• Cardiac Conduction System

  1. Sino-atrial node

  • Located at the junction of crista terminalis and right atrium.
  • Acts as a natural pacemaker of the heart.
  • Initiates an electrical pulse of 60 - 100 bpm.
• Cardiac Conduction System

  1. Atrio-ventricular node

  • Located at the interatrial septum.
  • Delay of electrical impulse for about 120ms to allow ventricular filling.
• Cardiac Conduction System

  1. Bundle of his

  • Right main bundle of his
  • Left main bundle of his
  • Located at the atrium and ventricles of the heart.
• Cardiac Conduction System

  1. Purkinje Fibers

  • Located at the walls of the ventricles
• Purkinje fibers

  • P wave
  • QRS wave
  • T wave
• Most common pacemaker is metal pacemaker that lasts upto 2-5 years.
• Abnormal ECG tracing

  • Positive U wave
  • Peak T wave
  • ST segment depression
  • ST segment elevation
  • T wave inversion
  • Widening of QRS coplexes
• Representative Cardiovascular Disorders

  • Hypertension
  • Congested heart failure
• Hypertension - It is a major cause of cerebrovascular

  accident, cardiac disease, and renal

  failure
• Hypertension

  Diagnosis:

  1. Elevated BP readings on at least two consecutive

  occasions after initial screening

  b. U/A

  ❑ may show CHON, casts, RBC, or WBC

  ❑ Presence of catecholamines

  ❑ Glucose

  c. Lab Test

  ❑ ↑ BUN

  ❑ ↑ Serum creatinine levels

  ❑ Hypokalemia

  d. CBC*

  ❑ Polycythemia

  ❑ Anemia

  e. Excretory urography

  ❑ Renal atrophy**

  ❑ One kidney smaller than

  the other suggests

  unilateral renal disease

  f. Electrocardiography

  ❑ May show left ventricular

  hypertrophy or ischemia

  g. Chest X-ray

  ❑ Cardiomegaly

  h. Echocardiography

  ❑ Left ventricular

  hypertrophy
• Hypertension is an important

  risk factor for the future development of

  cardiovascular disease.

  2 major types:

  1. Essential Hypertension

  b. Secondary Hypertension

  c. Malignant Hypertension

  d. Hypertensive crisis
• Causes pf hypertension

  ❑Primary Hypertension (90%-95%)

  1. Essential hypertension

  • SNS activity, Sodium Intake

  ❑Secondary Hypertension (5-10%)

  1. Renal diseases
  2. Endocrine diseases

  • Steroid Excess, GH excess, Catecholamine excess

  1. Vascular diseases

  • Renal artery stenosis

  Drugs
• ➢ Factors Influencing Blood Pressure

  1. BLOOD PRESSURE = CO x Systemic Vascular

  Resistance

  2. Heart Rate

  3. SNS/PNS

  4. Vasoconstriction/Vasodilation

  5. Fluid retention

  ◼Renin angiotensin

  ◼Aldosterone

  ◼ADH
• Risk factors pf hypertension

  • Age (>55 for men; >65

  for women)

  • Alcohol
  • Cigarette smoking
  • Diabetes mellitus
  • Elevated serum lipids
  • Excess dietary sodium
  • Gender
  • Family History
  • Obesity
  • Ethnicity
  • Sedentary lifestyle
  • Socioeconomic status
  • Stress
• 1. Non-pharmacologic approaches

  • Weight reduction if overweight
  • DASH eating plan
  • Sodium <2,4g/day
  • Regular aerobic physical activity
  • Moderate alcohol
  • Smoking cessation
• 2. Treatment Goals

  • Rule out uncommon secondary causes of

  hypertension

  • Determine the presence and extent of

  target organ damage

  • Determine the presence of other CV risk

  factors

  • To lower BP with minimal side effects
• 3. Pharmacologic

  • Primary Agents: Diuretics, BBs,

  ACEIs, ARBs, CCBs

  • Alternatives: a-blockers, a2

  agonists, adrenergic inhibitors,

  vasodilators
• 4. Diuretics

  • Thiazides (hydrochlorothiazide,

  chlorthalidone, indapamide, metolazone,

  microzide

  S/E: hypokalemia, hypomagnesemia,

  hypercalcemia, hyeruricemia,

  hyperglycemia, hyperlipidemia
• labelling

  A) carbonic anhydrase inhibitor

  B) acidosis

  C) proximal

  D) thiazide

  E) hyperurecemia

  F) loop diuretics

  G) ototoxicity

  H) loop of henle

  I) distal tubule

  J) potassium sparing

  K) glomerulus

  L) hypovolemia

  
• labelling

  A) meniere's disease

  B) nephrolithiasis

  C) hypercalcemia

  D) CHF

  E) lithium toxicity

  
• 1. ACE inhibitors

  • Captopril, Ramipril, Enalapril, Imidapril
  • Blocks the conversion of angiotensin I to

  angiotensin II

  • Blocks the degradation of bradykinin –

  angioedema

  • Given once daily EXCEPT captopril (2-3 x a

  day)

  • S/E: Dry cough, contraindicated in pregnancy
• 1. Angiotensin II receptor blockers

  • Losartan, Valsartan. Candesartan,

  Irbesartan, Valsartan

  • Blocks angiotensin type 1 (AT1)

  receptor

  • Lack of cough side effect
• 1. B blockers

  • Negative inotropic, chronotropic inhibits

  release from kidneys

  • Atenolol, betaxolol, bisoprolol, metoprolol –

  cardioselelective at low doses

  • Acebutolol, carteolol, penbutolol, pindolol –

  intrinsic sympathomimetic activity

  • S/E: bronchospasm
• 1. Calcium Channel Blockers

  • Blocks voltage sensitive calcium channels in

  cardiac and smooth muscle

  • Cardiac

  ◼Nonhydropyridine – verapamil and diltiazem

  • Smooth muscle

  ◼Dihydropyridine – nifedipine, felodipine and

  amlodipine
• 1. Alpha 1 receptor blockers

  • Prazosin, terazosin, doxasozin
  • Reserved for patients with BPH
  • S/E: First dose phenomenon-orthostatic

  hypotension
• 1. Centrally acting alpha 2 agonist

  • Methyldopa, clonidine, guanabenz,

  guanfacine

  • Presynaptic a2 agonist
  • SE:
  • Methyldopa: false (+) Coomb’s test for

  hemolytic anemia, sodium and water

  rentention

  • Clonidine: Rebound hypertension
• 1. Reserpine

  • Depletes NE and blocks transport of NE

  into its storage vesicles

  • SE: sodium and fluid retention
• 1. Direct arteriolar vasodilators

  • Hydralazine, minoxidil
  • Increases HR and renin release – should be

  given with a diuretic and a beta blocker

  • Hydralizine for eclampsia; methyldopa for

  chronic HTN in pregnant patients

  • SE:

  ◼Hydraline; SLE

  ◼Minoxidil: Hypertrichosis
• 1. Postganglionic sympathetic

  inhibitors

  • Guanethidine, guanadrel
  • Deplete and inhibit release of NE
  • S/E: Orthostatic hypotension