In diseased condition of heart involves changes in-

Cardiac function
Neurohumoral status
Systemic vascular function
Blood volume
Integration of cardiac and vascular changes

Cardiac dysfunction precipitates changes in vascular function, blood volume, and neurohumoral
status. These changes serve as compensatory mechanisms to help maintain cardiac output
(primarily by the Frank-Starling mechanism) and arterial blood pressure (by systemic
vasoconstriction). However, these compensatory changes over months and years can worsen
cardiac function. Therefore, some of the most effective treatments for chronic heart failure
involve modulating non-cardiac factors such as arterial and venous pressures by
administering vasodilator and diuretic drugs.
Cardiac and Vascular Changes Accompanying Heart disease most commonly includes--Cardiac ChangeDecreased stroke volume & cardiac output

Impaired filling (diastolic dysfunction)

Increased end-diastolic pressure

Reduced ejection fraction (systolic

dysfunction)

Ventricular dilation or hypertrophy

Vascular ChangesIncreased systemic vascular resistance

Decreased venous compliance

Decresed aterial pressure

Increased venous pressure

Impaired arterial pressure

Increased blood volume

Impaired organ perfusion

Some pathological condition of heart will be discussed here.

1

Myocardial Infarction

[1-11]

Introduction:
Myocardial infarction refers to the process by which myocardial tissue is destroyed in regions of
the heart that are deprived of an adequate blood supply because of a reduced coronary blood flow
(a prolonged lack of myocardial oxygenation leading to necrosis of a portion of the heart
muscle).

Symptoms:
The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes,
and rarely instantaneous. A person having an acute MI usually has
Chest pain is the most common symptom of
acute MI and is often described as a sensation
of tightness, pressure, or squeezing. Sudden
chest pain that is felt behind the sternum
radiates most often to the left arm, but may
also radiate to the lower jaw, neck, right arm,
back, and upper abdomen.
May have shortness of breath,
Sweating,
Nausea,

Figure: Chest pain

Vomiting,
Abnormal heartbeats,
Anxiety
Women experience fewer of these symptoms than men, but usually have the most common
symptoms of MI in women include:
Dyspnea,
Weakness,
2

 Shortness of breath,
A feeling of indigestion,
Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring
symptoms . In women, chest pain may be less predictive of coronary ischemia than in
men. women may also experience back or jaw pain during an episode.
In many cases, in some estimates as high as 64%, the person does not have chest pain or
other symptoms. These are called "silent" myocardial infarctions.At least one-fourth of all
MIs are silent, without chest pain or other symptoms.

Risk factor:
Many of the risk factors for myocardial infraction are following:

Lifestyle

Tobacco smoking
air pollution,
Socioeconomic

Alcohol
Dietary saturated fat

Disease:

Diabetes mellitus (type 1 or 2),

Dyslipidemia/hypercholesterolemia

High blood pressure,

Obesity

Infections including:

Chlamydophila pneumoniae,
influenza,

Helicobacter pylori,
Porphyromonas gingivalis

Genetic:
Genome-wide association studies have found 27 genetic variants that are associated with an
increased risk of myocardial infarction. The 9p21 genomic locus (containing CDKN2A,2B) has
the strongest association with MI. The majority of these variants are in regions that have not
been previously implicated in coronary artery disease. The following genes have an association
with MI: PCSK9, SORT1, MIA3, WDR12, MRAS, PHACTR1, LPA, TCF21, MTHFDSL,

ZC3HC1, CDKN2A, 2B, ABO, PDGF0, APOA5, MNF1ASM283, COL4A1, HHIPC1,

SMAD3, ADAMTS7, RAS1, SMG6, SMG6, SNF8, LDLR, SLC5A3, MRPS6, KCNE2.

Others:

At any given age, men are more at risk than women, particularly before menopause, but
because in general women live longer than men, ischemic heart disease causes slightly
more total deaths in women.

Family history of ischaemic heart disease or MI, particularly if one has a first-degree
relative (father, brother, mother, sister) who suffered a 'premature' myocardial infarction
(defined as occurring at or younger than age 55 years (men) or 65 (women).

Oral contraceptive pillwomen who use combined oral contraceptive pills have a
modestly increased risk of myocardial infarction, especially in the presence of other risk
factors, such as smoking.

An increased incidence of a heart attack is associated with time of day especially in the
morning hours, more specifically around 9 am.

Old age increases risk of a heart attack.

Pathophysiology
Acute myocardial infarction refers to
two

subtypes

of

acute

coronary

syndrome, namely non-ST-elevated and

ST-elevated MIs, which are most
frequently
manifestation

(but
of

not

always)

coronary

artery

disease. The most common triggering event is the disruption of an atherosclerotic plaque
in an epicardial coronary artery, which leads to a clotting cascade, sometimes resulting in
total occlusion of the artery.
Atherosclerosis is the gradual buildup of cholesterol and fibrous tissue in plaques in the
wall of arteries (in this case, the coronary arteries), typically over decades. Blood stream
column irregularities visible on angiography reflect artery lumen narrowing as a result of
decades of advancing atherosclerosis. Plaques can become unstable, rupture, and
4

additionally promote the formation of a blood clot that occludes the artery; this
can occur in minutes. When a severe enough plaque rupture occurs in the coronary
vasculature, it leads to MI (necrosis of downstream myocardium).
Calcium deposition is another part of atherosclerotic plaque formation. Several studies
have shown that coronary calcium can provide predictive information beyond that of
classical risk factors.
If impaired blood flow to the heart lasts long enough, it triggers a process called the
ischemic cascade; the heart cells in the territory of the occluded coronary artery die
(chiefly through necrosis) and do not grow back.
This myocardial scarring also puts the patient at risk for potentially life-threatening
arrhythmias, and may result in the formation of a ventricular aneurysm that can rupture
with catastrophic consequences.
Injured heart tissue conducts electrical impulses more slowly than normal heart tissue.
The difference in conduction velocity between injured and uninjured tissue can trigger reentry or a feedback loop that is believed to be the cause of many lethal arrhythmias.
Hyperhomocysteinemia (high blood levels of the amino acid homocysteine) in
homocysteinuria is associated with premature atherosclerosis, whether elevated
homocysteine in the normal range is causal is controversial.

Classification:
Myocardial infarctions are generally classified into1. ST elevation MI (STEMI) and 2. NonST elevation MI (NSTEMI)

Figure : Types of MI
A STEMI is the combination of symptoms related to poor oxygenation of the heart with
elevation of the ST segments on the electrocardiogram followed by an increase in proteins in the
blood related to heart muscles death.
The phrase "heart attack" is often used non-specifically to refer
to a myocardial infarction and to sudden cardiac death. An MI is
different from, but can cause cardiac arrest, which is the stopping
of the heartbeat. It is also distinct from heart failure, in which the
pumping action of the heart is impaired. However, an MI may

lead to heart failure.

Figure : Location of infarction

6

Location of the infarction:

MIs can be located in the anterior, septal, lateral,

posterior, or inferior walls of the left ventricle.

Complications:
Complications may occur immediately following the heart attack (in the acute phase), or may
need time to develop.
Acute complications may include heart; aneurysm or rupture of the myocardium; mitral
regurgitation dysfunction of the papillary muscle; Dressler's syndrome; and arrhythmias,
such as ventricular fibrillation, ventricular tachycardia, atrial fibrillation, and heart block.
Longer-term complications include heart failure, atrial fibrillation, and the increased risk
of a second MI.

Diagnostic evaluation:

Electrocardiogram (ECG)

Coronary angiography

Blood test (Cardiac enzymes)

Exercise stress test.

Echocardiogram

Cardiac computerized tomography

Nuclear scan

(CT) or magnetic resonance imaging

Chest radiographs

(MRI).

Congenital heart disease

[1,2,12]

Congenital heart disease is a problem with

the heart's structure and function that is
present at birth.

Causes:
Congenital heart disease (CHD) can describe
a number of different problems affecting the heart. It is the most common type of birth defect.
Congenital heart disease causes more deaths in the first year of life than any other birth defects.
Congenital heart disease has been attributed to:
1.
2.
3.
4.
5.
6.

Genetic conditions such as Down's syndrome

Infections during pregnancy, such as rubella
Taking certain medications, drugs or drinking alcohol during pregnancy
Poor health of the mother such as inadequate nutrition
Being an older mother
Genes there is a greater risk of a child having congenital heart disease is if a parent
or a sibling has also had the condition.

Classification:
Congenital heart disease is often divided into two types:
1. Cyanotic (blue skin color caused by a lack of oxygen) and
2. Non-cyanotic. The following lists cover the most common congenital heart diseases:

Cyanotic:

Ebstein's anomaly

Hypoplastic left heart

Pulmonary atresia

Tetralogy of Fallot

Total

anomalous

pulmonary

venous return

Transposition of the great vessels

Tricuspid atresia

Truncus arteriosus

Non-cyanotic:

Atrial septal defect (ASD)

Aortic stenosis

Atrioventricular canal (endocardial cushion

defect)
9

Coarctation of the aorta

Patent ductus arteriosus (PDA)

Pulmonic stenosis

Ventricular septal defect (VSD)

These problems may occur alone or together. Most children with congenital heart disease do not
have other types of birth defects. However, heart defects can be part of genetic and chromosome
syndromes. Some of these syndromes may be passed down through families.
Examples include:

DiGeorge syndrome

Noonan syndrome

Down syndrome

Trisomy 13

Marfan syndrome

Turner syndrome

Often, no cause for the heart disease can be found. Congenital heart diseases continue to be
investigated and researched. Drugs such as retinoic acid for acne, chemicals, alcohol, and
infections (such as rubella) during pregnancy can contribute to some congenital heart problems.
Poorly controlled blood sugar in women who have diabetes during pregnancy has also been
linked to a high rate of congenital heart defects.

Symptoms
In adults, if symptoms of congenital heart disease are present, they may include:

Shortness of breath.

Limited ability to exercise.

Symptoms of heart failure or valve disease.

In infants and children may include:

Cyanosis (a bluish tint to the skin, fingernails,lips).

Fast breathing and poor feeding.

Poor weight gain.

10

Recurrent lung infections.

Inability to exercise.

Examination and Tests

Most congenital heart defects are found during a pregnancy ultrasound. When a defect is found,
a pediatric heart doctor, surgeon, and other specialists can be there when the baby is delivered.
Having medical care ready at the delivery can mean the difference between life and death for
some babies.
Which tests are done on the baby depend on the defect, and the symptoms.

Cerebrovascular Disease

[1,2,14-17]

Introduction:
Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels
supplying the brain.

Figure Cerebrovascular system

11

Types
Cerebrovascular disease can be divided into embolism, aneurysms, stroke and low flow states
depending on its cause.

Embolism: In medicine, an embolism is the lodging of an embolus, which may be a

blood clot, a fat globule or a gas bubble, in the bloodstream. This can cause a blockage in
a blood vessel. Such a blockage (vascular occlusion) may affect a part of the body
distanced from the actual site of the embolism. This is in contrast to a thrombus, which
causes a blockage at the site of origin. Strokes can also result from embolism or due to a
ruptured blood vessel. Embolism blocks small arteries within the brain, causing
dysfunction to occur.

Aneurysms:A brain (cerebral) aneurysm is a bulging, weak area in the wall of

an artery that supplies blood to the brain. In most cases, a brain aneurysm causes no
symptoms and goes unnoticed. In rare cases, the brain aneurysm ruptures, releasing blood
into the skull and causing a stroke.

12

Figure: Angiography of an aneurysm in a cerebral artery

Low flow: The arteries are blood vessels that supply blood, oxygen and nutrients to the

body from the heart. Narrow, hardened arteries make it more difficult for blood to flow
through and reach the tissue in question.
Stroke: Carotid artery affects retina, cerebral hemisphere, or both. Spontaneous rupture
of a blood vessel in the brain causes a hemorrhagic stroke.

Hemorrhagic stroke A blood vessel in the brain may become weak and burst damaging a part
of the brain. The hemorrhagic stroke is not as common as the ischemic stroke.
Ischemic stroke This is caused by the blood supply to the brain being blocked. This may be
caused by a blood clot forming in an artery of the brain that is already narrow. This is known as
thrombus or a thrombotic stroke. Another cause is a blood clot that forms elsewhere in the body,
breaks off, and travels to the brain. This is an embolism or embolic stroke.

13

TIA (transient ischemic attack) This is also known as a mini-stroke and occurs when
blood flow to a part of the brain is blocked for a short period of time and then the blood flow
resumes such that the symptoms only last briefly. This should be considered as a warning for a
possible stroke and should not be ignored. The symptoms will be similar to a stroke but only last
for a few minutes.

Figure: Cerebrovascular stroke

Mechanism
Hypertension

damages

the

blood

vessel

lining,

endothelium,

exposing

the

underlying collagen where platelets aggregate to initiate a repairing process which is not always
complete and perfect.
Sustained hypertension permanently changes the architecture of the blood vessels making them
narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure.

14

Hypertension

Change in
architecture of
blood vessels

Intracranial
Hemorrhage

A fall in blood pressure during sleep can then lead to a marked reduction in blood flow in the
narrowed blood vessels causing ischemic stroke in the morning.
Conversely, a sudden rise in blood pressure due to excitation during the daytime can cause
tearing of the blood vessels resulting in intracranial hemorrhage.

Causes and Factors

Hypertension is the most important cause; Cerebrovascular disease can be divided into
embolism, aneurysms, and low flow states depending on its cause.
Major modifiable risk factors include

Hypertension ,
Smoking,

Obesity, and
Diabetes.

Unhealthy diet
Blood cholesterol/lipids
Overweight and obesity

Modifiable risk factors:

Hypertension (high blood pressure)

Tobacco use
Raised blood glucose (diabetes)
Physical inactivity

Non-modifiable risk factors

In addition to the modifiable risk factors, there are some risk factors that cannot be changed.
However, people in these high-risk categories should receive regular check-ups.

Age

CVD becomes increasingly common with advancing age. As a person gets older, the heart
undergoes subtle physiologic changes, even in the absence of disease.

15

The heart muscle of the aged heart may relax less completely between beats, and as a
result, the pumping chambers become stiffer and may work less efficiently. When a condition
like CVD affects the heart, these age-related changes may compound the problem or its
treatment.

Gender

A man is at greater risk of heart disease than a pre-menopausal woman. Once past the
menopause, a womans risk is similar to a mans. Risk of stroke, however, is similar for men
and women.

Family history

A familys history of CVD indicates a persons risk. If a first-degree blood relative has had
coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a
female relative), the risk increases.

Associated Complications and Pathophysiology

In a healthy, anatomical structure of the body, the carotid arteries form the main blood supply to
the brain. Following a stroke, voluntary control of the muscles may be lost, depending on the
type of stroke the victim is encountering.
In females with defective collagen, the weak branching points of arteries give rise to
protrusions with a very thin covering of endothelium that can tear to bleed easily with
minimal rise of blood pressure. This can also occur with defective capillaries caused by
tissue cholesterol deposition especially in hypertensive subjects with or without
dyslipidemia. If bleeding occurs in this process, the resulting effect is a hemorrhagic
stroke in the form of subarachnoid hemorrhage, intracerebral hemorrhage or both.

16

Figure: Two types of stroke

Ischemia is the loss of blood flow to the focal region of the brain. The beginning process
of this is quite rapid. The duration of a stroke is usually two to fifteen minutes. One side
of the face, hand, or arm may swell up. During this time, the person may lose conscious
control and faint. Brain deficits may improve over a maximum of 72 hours. Deficits do
not resolve in all cases. The neurological recovery period includes stable, to improving,
brain function. Stable is the period by which neither nutrient supply is regained, nor is it
lost. Improving, depending on a hospital code, generally means that the arteries gain
control and blood flow functions consistently within the brain. The carotid arteries
connect to the vertebral arteries. These branch off into the cerebellar and posterior
meningenial arteries, which supply the back of the brain.
During the stage of paralysis, the spinal tracts do not have much to do with the enduring
condition of cerebrovascular disease, either, in time may shorten the life of a victim who
is suffering because the nutrient supply is weakened in transmission during
cerebrovascular disease. Descending and ascending tracts will generally be cut off during

17

cerebrovascular disease, which conduct impulses down from the cord of the
brain. This is known as anesthesia in a minor case.
In a healthy body, the cerebrospinal fluid (also known as CSF) may also weaken the choroid
plexus, into a network of brain capillaries. Certain types of hydrocephalus ("water" or CSF on
the brain) may be treated by using a shunt (medical) or a cerebral shunt, which involves inserting
a hollow tube through a blocked channel so the CSF can be used to be drained to another portion
of the body. The dermatomes are a skin surface area which is regulated by the spinal cord.
During a stroke, these may be damaged.
Vascular dementia usually involves arterioles and capillaries rather than the larger
cerebral arteries. Blockages and ruptures occur all over the brain, but most severely in the
white matter. Microscopic examination may reveal various things in the brain such as
coagulated blood, lipid deposits, and other debris caused by ruptured vessels.

Figure: Vascular dementia

Sign and Symptoms:

The results of cerebrovascular disease can include a stroke, or occasionally a hemorrhagic stroke.
Ischemia or other blood vessel dysfunctions can affect the person during a cerebrovascular
incident.

18

There are several symptoms that a person may experience during stroke; these symptoms
include:
* Vision impairment, particularly blindness
or vision field problems in one eye
* Depression, mood and behavioral
disturbances

* Coma or lower level of consciousness

* Partial loss of vision or hearing
* Unusual movements

* Impaired speech and verbal

comprehension

* General Weakness

* Paralysis affecting only one side of the

body

* Seizures

* Loss of balance

* Falling
* Drooling or difficulty eating or
swallowing
The symptoms a person may experience in association with hemorrhagic disease depends on the
extent of the bleeding involved. Symptoms the person may experience include:
* Difficulty speaking or understanding
* Severe onset of headache
* Loss of memory

* Pain in the neck

* Motor difficulties
* Vomiting

Diagnosis:
Stroke: A stroke normally produces sudden symptoms. Depending on the artery affected, these
can include numbness or paralysis on one side, speech difficulties, difficulty swallowing and
problems with vision, balance and coordination.
The pneumonic to use to diagnose a stroke is FAST.
F is for face, you should ask the patient to smile, and look to see if both the left and right half of
the face move normally and symmetrically.
A is for arms, ask them to move their arms, do they move normally, or is one arm weaker than
the other.
S is for speech, is their speech slurred, or do the words come out but not make sense.
T is for telephone (for help) if any of the above is abnormal.

19

It is crucial to quickly diagnose a stroke, as the use of clot-busting drugs can be used to
improve outcome, but these drugs can only be safely used in the first 3 hours from the onset of
symptoms, hence the need for rapid diagnosis
A doctor commonly diagnoses a stroke through a physical examination of the person affected as
well as a description of the symptoms they are experiencing.
A doctor attempts to find the location in the person's brain that has experienced damage
through testing involving a CT or MRI scans, which may also help to rule out brain
hemorrhage or tumors.
A doctor considers the person's age, as well as any vascular, cardiac, or brain conditions
the person may have.
The doctor will attempt to determine whether the stroke was either hemorrhagic or
ischemic.
Ischemic strokes are often followed by additional strokes unless the problem is treated.
A doctor may order an EEG if the person has experienced seizure activity, or an
echocardiogram if they have a pre-existing heart condition.
A doctor will attempt to rule out things such as encephalitis, meningitis, bleeding inside
the person's skull, neurodegenerative disorders, brain abscess, or migraines as causes of
the stroke symptoms the person is experiencing.
There are a number of tests that a doctor can use to assist in reaching a diagnosis of
cerebrovascular disease. The majority of the tests involved are designed to detect carotid
artery disease (CAD) before the person experiences a stroke. CAD, unlike hemorrhagic
cerebrovascular disease, often progresses for many years while presenting no symptoms
at all, accounting for approximately ninety-five percent of all cases of cerebrovascular
disease.

20

Arrhythmia

[1,2,18-23]

Definition:
Arrhythmia (also known as cardiac dysrhythmia or
irregular heartbeat) is any of a group of conditions
in which the electrical activity of the heart is
irregular or is faster or slower than normal. The
heartbeat may be too fast (over 100 beats per
minute) or too slow (less than 60 beats per
minute), and may be regular or irregular. A heart
beat that is too fast is called tachycardia and a
heartbeat that is too slow is called bradycardia. Although many arrhythmias are not lifethreatening, some can cause cardiac arrest.
Arrhythmias can occur in the upper chambers of the heart (atria), or in the lower chambers of the

21

heart (ventricles). Arrhythmias may occur at any age. Some are barely perceptible,
whereas others can be more dramatic and can even lead to sudden cardiac death.
The term sinus arrhythmia refers to a normal phenomenon of mild acceleration and slowing of
the heart rate that occurs with breathing in and out. It is usually quite pronounced in children and
steadily decreases with age. This can also be present during meditation breathing exercises that
involve deep inhaling and breath holding patterns. Proarrhythmia is a new or more frequent
occurrence of pre-existing arrhythmias, paradoxically precipitated by antiarrhythmic therapy,
which means it is a side effect associated with the administration of some existing antiarrhythmic
drugs, as well as drugs for other indications. In other words, it is a tendency of antiarrhythmic
drugs to facilitate emergence of new arrhythmias.

Classification
Arrhythmias are classified according to two factors:
1. Where they originate - the atria or ventricles.
2. The heart rate - fast (tachycardia - over 100 beats per minute), slow (bradycardia - less
than 60 beats per minute).
High or slow heart beats do not necessarily mean there is heart disease. Our heart rate increases
during exercise - this is normal. Some extremely fit athletes have a resting heart rate of less than
60 beats per minute.
Tachycardia in the atria:

Atrial fibrillation - this means irregular beating of the atrial chambers - usually fast. Atrial
fibrillation is a common type of arrhythmia and mainly affects elderly patients. A person's
risk of developing atrial fibrillation increases significantly after the age of 60; especially if
he/she had hypertension or some other heart problem. Instead of producing a single, strong
contraction, the chamber fibrillates (quivers). In some cases the heartbeat of a person with
atrial fibrillation can go up to 350 beats per minute, and even 500 or 600. Over the medium
or long-term atrial fibrillation can cause stroke, as well as some other serious conditions.

22

Atrial flutter - the difference between atrial flutter and fibrillation is that flutter is
well organized while fibrillation is not. Atrial flutter can come and go, as can atrial
fibrillation. Atrial flutter can be serious. A patient with atrial flutter will typically experience
250 to 350 beats per minute.

Supraventricular tachycardia (SVT) - a regular, abnormally rapid heartbeat caused by

rapid firing of electrical impulses from a focus above the atrioventricular node (in the heart).
It is called SVT because the rapid heartbeat originates above the ventricles of the heart. The
patient experiences a burst of accelerated heartbeats that can last from a few seconds to some
hours. These bursts often occur when the electrical impulse from a heartbeat starts to circle
through the extra pathway. Typically, a patient with SVT will have a heart rate of between
160 and 200 beats per minute.

Wolff-Parkinson-White (WPW) syndrome - there is an extra electrical connection inside

the heart that acts as a short circuit, resulting in an abnormally fast heart beat (sometimes
irregular). This syndrome can be life-threatening, although it is unusual.

Tachycardia in the ventricles:

Ventricular tachycardia - abnormal electrical impulses that start in the ventricles cause
abnormally fast heart beating. Typically, the heart will have a scar from a previous heart
attack, which forces the electrical signal to travel around it. Usually, the ventricle will
contract more than 200 times a minute. Ventricular tachycardia (VT) affects people with
heart-related problems, such as scars or ventricle muscle damage caused by artery disease or
a heart attack. There are two types of VT:
o

Unsustained VT - this lasts for up to about 30 seconds and is usually harmless.

However, there is a risk of longer-lasting VT eventually.

Sustained VT - this is longer-lasting and is a medical emergency.

Ventricular fibrillation - irregular heart rhythm consisting of very rapid, uncoordinated

fluttering contractions of the ventricles (lower chambers of the heart). The ventricles do not
pump blood properly (they quiver uselessly instead). Blood pressure drops dramatically,
depriving vital organs, including the brain, of their essential blood supply. The majority of
patients lose consciousness fairly quickly and require emergency medical assistance,
23

including CPR (cardiopulmonary resuscitation). Patients who receive CPR until their
heart can be shocked back into a normal rhythm with a defibrillator have much better
survival rates. If the patient does not receive CTP or defibrillation he/she will die within
minutes. Ventricular fibrillation is usually associated with some kind of heart disease.
Ventricular fibrillation is often triggered by a heart attack.

Long QT syndrome - a heart rhythm disorder that may sometimes cause rapid,
uncoordinated heartbeats. The name of the syndrome comes from the QT segment in the
tracing on the electrocardiogram, which lasts slightly longer in the syndrome than normal.
The rapid heartbeats can result in fainting, which may be life-threatening. In severe cases the
heart rhythm may become so chaotic that it causes sudden death. Some people inherit a faulty
gene which increases their risk of developing Long QT syndrome. A significant number of
medications may also cause Long QT syndrome.

Bradycardia (heart beats abnormally slowly) A slow heartbeat (under 60 beats per minute) does
not necessarily mean there is a problem. A physically fit person with a healthy, strong heart may
have a low resting heart rate, lower than 60 beats per second, and be in the best of health.
24

Bradycardia is a problem if the heart is faulty and does not pump enough blood;
examples include:

Sick sinus - a problem with the sinus node of the heart. The sinus node is the heart's natural
pacemaker. If it does not function properly the patient's resting heart rate may be abnormally
low (bradycardia). If the sinus node functions properly, sick sinus may be caused by scarring
near the sinus node which undermines the movement of electrical impulses.

Conduction block - a block of the electrical pathways of the heart. This can occur in or close
to the atrioventricular node, located on the pathway between the atria and the ventricles. The
block may be along the other pathways to each ventricle. The electrical impulses between the
upper and lower halves of the heart may be slowed or blocked; this depends on the type of
block and where it is. If the signal is totally blocked, some cells in the atrioventricular node
or ventricles can make a steady but slower heartbeat. The patient may experience skipped
heartbeats or bradycardia - sometimes there are no symptoms at all.

Premature heartbeats - this occurs in the ventricles and comes before the ventricles have had
time to fill with blood after a regular heartbeat. A premature heartbeat occurs between two
normal heartbeats. However, the patient will feel he/she has skipped a heartbeat. In most cases
the occasional premature beat is nothing to worry about. However, it can trigger a longer-lasting
arrhythmia - this is especially the case if the patient has heart disease.

Symptoms of arrhythmias

An arrhythmia can be silent and not cause

any symptoms. A doctor can detect an
irregular heartbeat during a physical exam
by taking your pulse or through an
electrocardiogram (ECG).
When symptoms of an arrhythmia occur,
they may include:

25

Palpitations.

Shortness of breath.

Pounding in chest.

Chest discomfort.

Dizziness or feeling light-headed.

Weakness or fatigue (feeling very

Fainting.

tired).

Risk factors for arrhythmia

Old age - the heart inevitably weakens as we get old and loses some of its flexibility this affects the conduction of electrical impulses.

Inherited gene defects - people who are born with a heart abnormality have a higher risk
of developing arrhythmia.

Heart problems - people with heart problems, narrowed arteries, those who have had a
heart attack, heart valves that do not function properly, previous heart surgery, and
cardiomyopathy, are more likely to develop arrhythmia.

Hypothyroidism or hyperthyroidism - people with a thyroid gland problem are more

likely to develop arrhythmia.

Medications - some prescription medications, as well as OTC drugs, such as cough and
cold drugs containing pseudoephedrine may help in the development of arrhythmia.

Hypertension - people with high blood pressure are much more likely to develop
coronary artery disease and other heart problems which result in the improper conduction
of electrical impulses.

Obesity - obesity is linked to a huge number of health problems, including diabetes type
2, cancer, cardiovascular disease, heart disease, and arrhythmia.

Uncontrolled diabetes - a patient with uncontrolled diabetes is significantly more likely

to develop arrhythmia compared to a patient who has his diabetes under control (receives
proper treatment).

Obstructive sleep apnea - patients with obstructive sleep apnea may experience
bradycardia or atrial fibrillation more commonly than other people.

Electrolyte imbalances - electrolytes are essential for the proper conduction of

electricity between cells and through cells. If electrolyte levels are wrong - either too low
or too high - the electrical impulses in the heart may be affected, resulting in arrhythmia.

26

Heavy and regular alcohol consumption - people who regularly consume large
quantities of alcohol are much more likely to develop atrial fibrillation.

Too much caffeine - caffeine, and some other stimulants, may accelerate the heart rate
and eventually cause arrhythmias.

Illegal drugs - amphetamines and cocaine can cause arrhythmias, especially ventricular
fibrillation.

Differential diagnosis
The doctor, a GP (general practitioner) or cardiologist (a specialist in heart and cardiovascular
diseases and conditions) will try to find out what triggers the patient's arrhythmia. This will
involve a detailed interview which includes the patient's medical history, family history, diet,
lifestyle, etc. The following tests may be ordered:
Blood and urine tests - these will check the patient's blood count and liver, thyroid, and kidney
function. The doctor may also want to check the blood for specific chemical markers of heart
failure, such as BNP (brain natriuretic peptide) - this hormone is secreted at high levels by the
heart if it is injured or overburdened, but is first identified in the brain. Serum electrolytes may
also be tested to evaluate sodium and potassium levels.
An ECG (electrocardiogram) - this device records the electrical activity and rhythms of the
patient's heart. Electrodes are attached to the patient's skin and impulses are recorded as waves
and displayed on a screen (or printed on paper). The test may also reveal any damage to the heart
from a heart attack.
A Holter monitor - the patient wears a portable device which records all his/her heartbeats. It is
worn under the clothing and records information about the electrical activity of the heart while
the patient goes about his/her normal activities for one or two days. It has a button which can be
pressed if symptoms are felt - then the doctor can see what heart rhythms were present at that
moment.

27

Event recorder (event monitor) - This machine is similar to a Holter monitor, but it
does not record all the heartbeats. There are two types: 1. One uses a phone to transmit signals
from the recorder while the patient is experiencing symptoms. 2. The other is worn all the time
for a long time; sometimes as long as a month (it must be taken off when showering or having a
bath). This device is good for diagnosing rhythm disturbances that happen at random moments.
An echocardiogram - this is an ultrasound scan that checks the pumping action of the patient's
heart. This test also helps distinguish systolic heart failure from diastolic heart failure (the heart
is stiff and does not fill properly). Sound waves are used to create a video image of the patient's
heart, which helps the doctor see how well the heart is pumping. The doctor measures the
percentage of blood pumped out of the patient's left ventricle (the main pumping chamber) with
each heartbeat - this measurement is call the ejection fraction.
An ejection fraction is a crucial measurement which determines how well the heart is pumping.
A healthy heart pumps out approximately 60% of the blood that fills the ventricle with each beat
- a healthy heart has an ejection factor of 60%.
Chest X-ray - The images help the doctor check the state of the patient's heart and lungs. A
chest X-ray may also help a doctor determine whether the patient has any congenital heart
defects. Other conditions that may explain the signs and symptoms might also be detected.
Tilt-table test - If the patient experiences fainting spells, dizziness or lightheadedness, and
neither the ECG nor the Holter revealed any arrhythmias, a tilt-table test may be performed. This
monitors the patient's blood pressure, heart rhythm and heart rate while he/she is moved from a
lying down to an upright position. A healthy patient's reflexes cause the heart rate and blood
pressure to change when moved to an upright position - this is to make sure the brain gets an
adequate supply of blood. If the reflexes are inadequate, they could explain the fainting spells,
etc.
Electrophysiologic testing (or EP studies) - This is an invasive, relatively painless, nonsurgical test and can help determine the type of arrhythmia, its origin, and potential response to
treatment.

28

The test is carried out in an EP lab by an electrophysiologist, and makes it possible to

reproduce troubling arrhythmias in a controlled setting. During an EP study:
o

The patient is given a local anesthetic.

After an initial puncture an introducer sheath is inserted into a blood vessel.

A catheter is inserted through the introducer sheath and is threaded up the blood
vessel, through the body and into the right chambers of the heart.

The electrophysiologist can see the catheter moving up the body on a monitor.

When it is inside the heart the catheter stimulates the heart and records where
abnormal impulses start, their speed, and which normal conduction pathways they
bypass.

Treatments can be given to find out whether they stop the arrhythmia.

The catheter and introducer sheaths are then removed, and the insertion site is
closed up either by applying pressure to the site or with stitches.

29

Congestive Heart Failure

[1,2,23-30]

Definition:Congestive heart failure (CHF) is a chronic condition that affects the chambers of our heart. We
have four heart chambers: two atria in the upper half of the heart and two ventricles in the lower
half. The ventricles send blood to organs and tissues and the atria receive blood as it circulates
back from the rest of the body. CHF develops when our ventricles cannot pump blood in
sufficient volume.

Figure: Congestive heart failure

The most common types of CHF:

Left-sided CHF damages the left ventricle (the chamber that pumps blood to the body),
and is the most common type of CHF. It can cause fluid to build up in the lungs, which
makes breathing difficult.
Right-sided CHF may accompany left-sided CHF, but does not always. Right-sided
CHF is when the right ventricle has difficulty pumping blood to the lungs. Blood builds
up in your blood vessels, which causes fluid retention in your lower extremities,
abdomen, and other vital organs.

30

Causes and Risks

CHF may result from other health conditions that directly affect the cardiovascular system.
Thats why it is important to get annual checkups to lower the risk for heart health problems,
including:

High Blood Pressure

When blood pressure is higher than normal (greater than 120/80 mm Hg), it may lead to CHF.

Coronary Artery Disease

This disease damages hearts coronary arteries (the small arteries that supply blood to the heart)
by restricting blood flow. Cholesterol and other types of fatty substances block the arteries and
cause them to narrow.

Valve Conditions

Our heart valves regulate blood flow through our heart by opening and closing to let blood in and
out of the chambers. Valves that do not open and close correctly may force the ventricles to work
harder to pump blood.

Cardiomyopathy

It is the damage to the heart muscle from causes other than artery or blood flow problems, such
as from infections or alcohol or drug abuse.

Conditions that overwork the heart

Conditions including high blood pressure, valve disease, thyroid disease, kidney disease,
diabetes, or heart defects present at birth can all cause heart failure. In addition, heart failure can
occur when several diseases or conditions are present at once.

31

Symptoms
In the early stages of CHF, there are no noticeable changes in health. But, as the condition gets
worse, patient will experience gradual changes in the body. He/ She may feel more tired than
usual, or experience noticeable weight gain even when their dietary habits have not changed.
Symptoms may be noticed first:

Fatigue

Swelling in your ankles, feet, and legs

Weight gain

Increased need to urinate, especially at night

Symptoms that indicate the condition has worsened:

Irregular heartbeat

A cough that develops from congested lungs

Wheezing

Symptoms that indicate a severe heart condition that requires immediate medical
attention:

Chest pain that radiates through the upper body (this can also be a sign of a heart attack)

Rapid breathing

Skin that appears blue (from lack of oxygen in your lungs)

Fainting

Diagnosis
To confirm an initial diagnosis, cardiologist might order specific diagnostic tests to examine your
hearts valves, blood vessels, and chambers.
These tests may include:

Magnetic resonance imaging (MRI), which takes pictures of your heart

Stress tests to see how well your heart performs under different levels of stress

Blood tests to check for abnormal blood cells and infections

32

Cardiomyopathy [1,2,31-41]
Introduction:
Cardiomyopathy (literally "heart muscle disease") is
the measurable deterioration for any reason of the
ability of the myocardium (the heart muscle) to
contract, usually leading to heart failure. The most
common

form

of

cardiomyopathy

is

dilated

"cardiomyopathy"

could

cardiomyopathy.
Although

the

term

theoretically apply to almost any disease affecting the

heart, it is usually reserved for "severe myocardial
disease leading to heart failure.

Types of Cardiomyopathy:
Cardiomyopathy mainly two typesPrimary/intrinsic cardiomyopathies

Genetic
o

Hypertrophic cardiomyopathy (HCM or HOCM)

Arrhythmogenic right ventricular cardiomyopathy (ARVC)

Mixed
o

Dilated cardiomyopathy (DCM)

Restrictive cardiomyopathy (RCM)

Acquired
o

Peripartum cardiomyopathy

Takotsubo cardiomyopathy

33

Secondary/extrinsic cardiomyopathies

Metabolic/storage
o amyloidosis
o hemochromatosis
Inflammatory
o "viral myocarditis"
Endocrine
o diabetic cardiomyopathy
o hyperthyroidism
Toxicity
o chemotherapy
o Alcoholic cardiomyopathy
Neuromuscular
o muscular dystrophy
Nutritional diseases
o Obesity-associated cardiomyopathy

Causes:
Often, the cause of the cardiomyopathy is unknown. In some people, however, doctors are able
to identify some contributing factors. Possible causes of cardiomyopathy include:

Long-term high blood pressure

Heart valve problems

Heart tissue damage from a previous heart attack

Chronic rapid heart rate

Metabolic disorders, such as obesity, thyroid disease or diabetes

Nutritional deficiencies of essential vitamins or minerals, such as thiamin (vitamin B-1)

Pregnancy

Drinking too much alcohol over many years

Use of cocaine, amphetamines or anabolic steroids

Use of some chemotherapy drugs to treat cancer

Certain viral infections, which may injure the heart and trigger cardiomyopathy

Iron buildup in your heart muscle (hemochromatosis)

Genetic conditions

34

Signs and symptoms

Some people who have cardiomyopathy never have signs or symptoms. Others don't have signs
or symptoms in the early stages of the disease. As cardiomyopathy worsens and the heart
weakens, signs and symptoms of heart failure usually occur.
These signs and symptoms include:

Shortness of breath or trouble breathing, especially with physical exertion

Fatigue (tiredness)

Swelling in the ankles, feet, legs, abdomen and veins in the neck

Other signs and symptoms may include dizziness; light-headedness; fainting during physical
activity; arrhythmias (irregular heartbeats); chest pain, especially after physical exertion or heavy
meals; and heart murmurs.

Diagnosis of Cardiomyopathy
The condition usually can be diagnosed by characteristic physical findings, electrocardiogram,
echocardiogram, and, if doubt still exists, cardiac catheterization and radionuclide angiography.
A biopsy of the heart wall tissue may help distinguish between the different types of
cardiomyopathy.

35

Heart Valve Disease

[1,2,22, 27, 42]

Definition
Valvular heart disease is any disease process involving one or more of the four valves of the
heart (the aortic and mitral valves on the left and the pulmonary and tricuspid valves on the
right). Valve problems may be congenital (inborn) or acquired (due to another cause later in life).

Figure : Defective Heart

Types:
There are several types of heart valve disease:
I.

Valvular stenosis:

This occurs when a heart valve doesn't fully

open due to stiff or fused leaflets. The narrowed
opening may make the heart work very hard to

Figure: Heart valve and Valvular stenosis

36

pump blood through it. This can lead to heart failure and other symptoms. All four
valves can develop stenosis; the conditions are called tricuspid stenosis, pulmonic stenosis,
mitral stenosis, or aortic stenosis.
II.

Valvular insufficiency :

Also called regurgitation, incompetence, or "leaky valve," this occurs when a valve does not
close tightly. If the valves do not seal, some blood will leak backwards across the valve. As
the leak worsens, the heart has to work harder to make up for the leaky valve, and less blood
may flow to the rest of the body. Depending on which valve is affected, the condition is
called tricuspid regurgitation, pulmonary regurgitation, mitral regurgitation, or aortic
regurgitation.
Valve involved

Stenotic disease

Insufficiency/regurgitation disease

Aortic valve

Aortic valve stenosis

Aortic insufficiency/regurgitation

Mitral valve

Mitral valve stenosis

Mitral insufficiency/regurgitation

Tricuspid valve

Tricuspid valve stenosis

Tricuspid insufficiency/regurgitation

Pulmonary valve

Pulmonary valve stenosis

Pulmonary insufficiency/regurgitation

Figure: Stenosis and Regurgitation

37

Heart valve disease can develop before birth (congenital) or can be acquired sometime
during one's lifetime. This causes two typesI.

Congenital Heart Defect

A congenital heart defect is a defect in the

development of the heart as an organ that is usually
first noticed at birth although some are not found
until adulthood. There are many types of congenital
heart defects and a few need no treatment but others
may need surgical repair. Congenital heart defects
put those patients at higher risk to develop
arrhythmias, heart failure, heart valve infections, and other problems. However, this risk can be
reduced by specialized treatments.
II.

Acquired valve disease.

This includes problems that develop with valves that were once normal. These may involve
changes in the structure or your valve due to a variety of diseases or infections, including
rheumatic fever or endocarditis.

Symptoms

Warning signs of a heart attack include the

following:

Chest pain

Pain that may spread to the back, arms,

neck, and jaw

Shortness of breath

Nausea, vomiting

Figure: Chest Pain

38

Rapid or irregular heartbeats

Palpitations.

Swelling of ankles, feet or abdomen (edema).

Rapid weight gain

Other symptoms such as weakness, anxiety, indigestion, and heartburn may occur.

Some individuals may have only one or two symptoms. Symptoms do not always relate to the
seriousness of our valve disease. We may have no symptoms at all and have severe valve
disease, requiring prompt treatment. Or, as with mitral valve prolapsed, we may have severe
symptoms, yet tests may show valve leak is not significant.
Symptoms in Women
Heart attack symptoms in some women may differ from those
usually seen in men. For example, many women may have
predominant symptoms of heartburn, malaise, heart beat
abnormalities (heart flutters), cough, and loss of appetite.
Ignoring such symptoms may cause treatment delays and more
damage to heart tissue.

Figure: Symptoms in women

Causes:
Heart valve disease can develop before birth (congenital) or can be acquired sometime during
one's lifetime. Sometimes, the cause of valve disease is unknown.
Congenital valve disease:
This form of valve disease most often affects the aortic or pulmonic valve. Valves may be the
wrong size, have malformed leaflets, or have leaflets that are not attached correctly.

39

Bicuspid aortic valve disease:

A congenital valve disease that affects the aortic valve. Instead of the normal three leaflets or
cusps, the bicuspid aortic valve has only two. Without the third leaflet, the valve may be stiff
(unable to open or close properly) or leaky (not able close tightly).
Acquired valve disease:
This includes problems that develop with valves that were once normal. These may involve
changes in the structure of valve due to a variety of diseases or infections, including rheumatic
fever or endocarditis.

Rheumatic fever is caused by an untreated bacterial infection (usually strep throat).

Luckily, this infection was much more common before the introduction of antibiotics to
treat it in the 1950s. The initial infection usually occurs in children and causes
inflammation of the heart valves. However, symptoms associated with the inflammation
may not be seen until 20-40 years later.

Endocarditis occurs when germs, especially bacteria, enter the bloodstream and attack
the heart valves, causing growths and holes in the valves and scarring. This can lead to
leaky valves. The germs that cause endocarditis can enter the blood during dental
procedures, surgery, IV drug use, or with severe infections. People with valve disease can
be at higher risk for developing endocarditis.

Mitral valve prolapse (MVP) is a very common condition, affecting 1% to 2% of the

population. MVP causes the leaflets of the mitral valve to flop back into the left atrium
during the heart's contraction. MVP also causes the tissues of the valve to become
abnormal and stretchy, causing the valve to leak. However, the condition rarely causes
symptoms and usually doesn't require treatment.

The chordae tendinae or papillary muscles can stretch or tear; the annulus of the valve
can dilate (become wide); or the valve leaflets can become fibrotic (stiff) and calcified.

Other causes of valve disease include: coronary artery disease, heart attack, cardiomyopathy
(heart muscle disease), syphilis (a sexually transmitted disease), high blood pressure, aortic

40

aneurysms, and connective tissue diseases. Less common causes of valve disease include
tumors, some types of drugs, and radiation..

Diagnosis
Physical test
Heart doctors can tell if we have valve disease by talking about our symptoms, performing a
physical exam, and giving us other tests.
During a physical exam, our doctor will listen to our heart to hear the sounds the heart makes as
the valves open and close. A murmur is a swishing sound made by blood flowing through a
stenotic or leaky valve. Your doctor can also tell if our heart is enlarged or if our heart rhythm is
irregular.
The doctor will listen to your lungs to hear if we are retaining fluid in our lungs, which shows
our heart is not able to pump as well as it should.
By examining our body, the doctor can find clues about our circulation and the functioning of
other organs.
After the physical exam, the doctor may order diagnostic tests. These may include:

Electrocardiogram (EKG)
The heart's electrical activity can be seen with an EKG
(also termed ECG or electrocardiogram). EKGs are tests
that provide important information to the physician about
the heart rhythm, damage to the heart, or a heart attack, and
may provide several other important pieces of information
or clues to the patient's condition. In addition, EKGs can be
compared to past and future EKGs to see changes in the

Figure: Electrocardiogram (EKG)

41

hearts electrical activity.

Chest X-ray
Chest X-rays are used to provide the doctor with a
view of both the heart and lungs to help determine if
any abnormalities are present. These two X-rays show
a relatively normal heart on the left. In the right Xray, an enlarged heart (mainly the left ventricle) is
easily seen and suggests the heart's main pumping
chamber is not functioning normally.

Figure1: Chest X-ray

Cardiac CT
Specialized cardiac computerized tomography (CT) scans or cardiac CTs can provide detailed 3D images of the heart. The images can be manipulated to look for calcium buildup (plaque) in
coronary arteries or provide images of such internal structures of the heart such as the valves.
The information can provide information about several heart disease problems.
Holter Monitor
A Holter monitor is similar to a stress test but it
is worn for 1 or 2 days and provides a continual
EKG-like recording of the heart's electrical
activity during those days. Most doctors will ask
the patient to keep a logbook of the time they do
certain activities (for example, walking a mile
starting at 7:20 AM and ending at 7:40 AM) and
list any symptoms (for example, "experienced
shortness of breath or rapid irregular heartbeats
at 7:35 AM"). The Holter monitor's recordings
can then be examined when certain symptoms

Figure: Holter Monitor

42

occur.
Other tests include

Transesophageal echocardiography

Cardiac catheterization (also called an angiogram)

Radionuclide scans

Magnetic resonance imaging (MRI)

By looking at the results, repeated over time, your doctor can also see the progress of your valve
disease. This will help him or her make decisions about your treatment.

43

Angina Pectoris
Angina pectoris is the result of myocardial
ischemia caused by an imbalance between
myocardial blood supply and oxygen demand.
It is a common presenting symptom (typically,
chest pain) among patients with coronary
artery disease (CAD). The main cause of
angina pectoris is improper contractivity of the
heart muscle andcoronary artery disease, due
to atherosclerosis of the arteries feeding the
heart.

The

term

derives

from

the Latin angina ("infection

of

the

throat")

from

the Greek ankhon ("strangling"), and the Latin pectus ("chest"), and can, therefore, be
translated as "a strangling feeling in the chest".

Classification
1. Stable Angina / Angina Pectoris
2. Unstable Angina
3. Variant (Prinzmetal) Angina
4. Microvascular Angina

Stable angina
Also known as effort angina, this refers to the more common understanding of angina related to
myocardial ischemia. Typical presentations of stable angina is that of chest discomfort and
associated symptoms precipitated by some activity (running, walking, etc.) with minimal or nonexistent symptoms at rest or with administration of sublingual nitroglycerin.

44

Characteristics of stable angina

Develops when your heart works harder, such as when you exercise or climb stairs

Can usually be predicted and the pain is usually similar to previous types of chest pain
you've had

Lasts a short time, perhaps five minutes or less

Disappears sooner if you rest or use your angina medication

Unstable angina
Unstable angina (UA) (also "crescendo angina"; this is a form of acute coronary syndrome) is
defined as angina pectoris that changes or worsens.
It has at least one of these three features:
1. it occurs at rest (or with minimal exertion), usually lasting 35 minutes
2. it is severe and of new onset (i.e., within the prior 46 weeks)
3. it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than
before).

Braunwald Classification of Unstable Angina*

Classification Description

Designation

Severity
I

New

onset

of

severe

angina

or

increasing angina
No angina during rest
II

Angina during rest within past month but not Subacute angina
within preceding 48 h

at rest

45

III

Angina during rest within 48 h

Acute angina at
rest

Clinical situation
A

Develops secondary to an extracardiac condition Secondary UA

that worsens myocardial ischemia

Develops when no contributory extracardiac Primary UA

condition is present

Develops within 2 wk of acute MI

Post-MI UA

Characteristics of unstable angina (a medical emergency)

Occurs even at rest

Is a change in your usual pattern of angina

Is unexpected

Is usually more severe and lasts longer than stable angina, maybe as long as 30 minutes

May not disappear with rest or use of angina medication

Might signal a heart attack

Variant angina
Variant angina is also known as Prinzmetals angina. It often occurs while someone is resting
(usually between midnight and 8:00 in the morning), and it has no predictable patternthat is, it
is not brought on by exercise or emotion. This kind of angina may cause severe pain, and is
usually the result of a spasm in a coronary artery. Most people who have variant angina have
severe atherosclerosis (hardening of the arteries), and the spasm is most likely to occur near a
buildup of fatty plaque in an artery
Characteristics of variant angina (Prinzmetal's angina)

Usually happens when you're resting

Is often severe

46

May be relieved by angina medication

Microvascular angina
Microvascular Angina or Angina Syndrome X is characterized by angina-like chest pain, but the
cause is different. The cause of Microvascular Angina is unknown, but it appears to be the result
of spasm in the tiny blood vessels of the heart, arms, and legs. Since microvascular angina is not
characterized by arterial blockages, it is harder to recognize and diagnose, but its prognosis is
excellen

Signs and symptoms

Patients should be asked about the frequency of angina, severity of pain, and number of
nitroglycerin pills used during episodes. Symptomatology reported by patients with angina
commonly includes the following:

Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking

sensation) as opposed to frank pain

Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders

Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for
about 1-5 minutes and relieved by rest or nitroglycerin

Pain intensity that does not change with respiration, cough, or change in position

Angina decubitus (a variant of angina pectoris that occurs at night while the patient is
recumbent) may occur.

47

Pathophysiology

Diagnosis

Chest radiography: Usually normal in angina pectoris but may show cardiomegaly in
patients with previous MI, ischemic cardiomyopathy, pericardial effusion, or acute
pulmonary edema

Graded exercise stress testing: This is the most widely used test for the evaluation of
patients presenting with chest pain and can be performed alone and in conjunction with
echocardiography or myocardial perfusion scintigraphy

Coronary artery calcium (CAC) scoring by fast CT: The primary fast CT methods for this
application are electron-beam CT (EBCT) and multidetector CD (MDCT)

Other tests that may be useful include the following:

ECG: If typical exertional symptoms are present, ECG is indicated. Because angina resolves
quickly with rest, ECG rarely can be done during an attack except during stress testing. If done
during an attack, ECG is likely to show reversible ischemic changes: T wave discordant to the

48

QRS vector, ST-segment depression (typically), ST-segment elevation, decreased Rwave height, intraventricular or bundle branch conduction disturbances, and arrhythmia (usually
ventricular extrasystoles).
Angiography: Coronary angiography is the standard for diagnosing CAD but is not always
necessary to confirm the diagnosis. It is indicated primarily to locate and assess severity of
coronary artery lesions when revascularization (percutaneous intervention [PCI] or coronary
artery bypass grafting [CABG]) is being considered. Angiography may also be indicated when
knowledge of coronary anatomy is necessary to advise about work or lifestyle needs (eg,
discontinuing job or sports activities).
Imaging: Electron beam CT can detect the amount of Ca present in coronary artery plaque. The
Ca score (from 1 to 100) is roughly proportional to the risk of subsequent coronary events.
However, because Ca may be present in the absence of significant stenosis, the score does not
correlate well with the need for angioplasty or CABG.

Causes of Angina
1. Most of the time, angina is caused by coronary artery disease (CAD). The coronary
arteries are the heart muscle's blood and oxygen supply. In CAD, the coronary arteries
become narrowed by fatty, fibrous deposits. This means that less blood can pass through
them. During exercise or exertion, the cells in the heart (the myocardium) may need more
oxygen (and therefore more blood) than the coronary arteries can handle. As these cells
are forced to work without enough oxygen, the nervous system complains by sending
pain signals to the brain
2. Heart attacks are normally brought on by events that completely block blood flow
in a coronary artery. These events may include travelling blood clots or peeling off of
fatty plaques inside the arteries. In angina, there's no sudden blockage, but the artery has
become so narrow that it cannot carry the blood needed to handle the demands of
strenuous exercise. This usually means it has narrowed to less than half of its original

49

width. It follows that people who suffer from angina are at higher risk of heart
attack. For unknown reasons, angina seems to have a better prognosis in women than in
men.

3. Risk factors for angina are basically the same as risk factors for coronary artery
disease. They include:

being male

being postmenopausal

diabetes

excessive alcohol use

family history of early CAD, stroke, or other circulation-related medical

conditions

high blood pressure

high salt intake

50

Hypertensive Heart Disease[1,2,30,31]]

Definition:
In general sense, the diseases associated with hypertension that is called Hypertensive Heart
Disease. It refers to a group of disorders that includes heart failure, ischemic heart disease, and
left/right ventricular hypertrophy.

Heart Failure:
It means that the heart's pumping power is
weaker than normal or the heart has become
less elastic. With heart failure, blood moves
through the heart's pumping chambers less
effectively, and pressure in the heart increases,
robbing our body of oxygen and nutrients.
To compensate for reduced pumping power, the
heart's chambers respond by stretching to hold
more blood. This keeps the blood moving, but over time, the heart muscle walls weaken and are
unable to pump as strongly. As a result, the kidneys often respond by causing the body to retain
fluid (water) and sodium. The resulting fluid buildup in the arms, legs, ankles, feet, lungs, or
other organs, is called congestive heart failure.

Ventricular hypertrophy:
High blood pressure brings on heart failure by causing left ventricular hypertophy, a thickening
of the heart muscle that results in less effective muscle relaxation between heart beats. This
makes it difficult for the heart to fill with enough blood to supply the bodys organs, especially
during exercise, leading your body to hold onto fluids and our heart rate to increase.

51

Figure: Ventricular hypertropy

Symptoms of heart failure include:

Shortness of breath
Swelling in the feet, ankles, or
abdomen
Difficulty sleeping flat in bed
Bloating

Irregular pulse
Nausea
Fatigue
Greater need to urinate at night

Ischemic Heart Disease:

High blood pressure can also cause ischemic
heart disease. This means that the heart
muscle isn't getting enough blood. Ischemic
heart

disease

is

usually

the

result

of

atherosclerosis or hardening of the arteries

(coronary artery disease), which impedes blood

52

flow to the heart.

Figure: Mechanism of atherosclerosis, heart failure and myocardial ishchemia

Symptoms of ischemic heart disease may include:

Chest pain which may radiate (travel) to the arms, back, neck, or jaw

Chest pain with nausea, sweating, shortness of breath, and dizziness; these associated
symptoms may also occur without chest pain

Irregular pulse

Fatigue and weakness

Hypertensive Heart Disease Diagnosis:

Physician will look for certain signs of hypertensive heart disease, including:

High blood pressure

Enlarged heart and irregular heartbeat

Fluid in the lungs or lower extremities

53

Unusual heart sounds

Physician may perform tests to determine if we have hypertensive heart disease, including an
electrocardiogram, echocardiogram, cardiac stress test, chest X-ray, and coronary angiogram.

Blood Pressure Complications

High blood pressure itself usually causes no symptoms, so it is easy to ignore. Left untreated,
however, it can quietly damage our body for years. Eventually, it can lead to serious
complications, such as heart attack, heart failure, stroke, kidney damage, and vision loss.
Fortunately, lifestyle changes and medication can usually get blood pressure under control and
reduce the risk of developing these problems.

Probable complications
Blood Vessel Complications
As times goes on, untreated high blood pressure can take a toll on blood vessels. Healthy arteries
have flexible walls that stretch like elastic. When the heart pumps blood through the arteries,
their walls stretch to let it through more easily. But high blood pressure leads to overstretching,
damaging cells in the arteries inner lining. This can set off a chain of events that makes the
artery walls thick and stiff, a condition known as arteriosclerosis.
Atherosclerosis
Overstretching can also cause tiny tears in blood vessel walls. These tears and the scar tissue
they leave behind can catch debris in the blood, such as cholesterol. The result is a buildup of
fatty deposits that narrow and clog the arteries, a condition known as atherosclerosis.
Blood clots
Trapped blood can form clots that further narrow a blood vessel and sometimes block it. Blood
clots can also break off and travel through the bloodstream until they become lodged in a narrow
blood vessel elsewhere in the body, causing trouble there. Depending on the site, blood clots
sometimes lead to a heart attack or stroke.
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Aneurysm
Overstretching can create weak places in the arteries that bulge outward, a condition known as an
aneurysm. If an aneurysm bursts, it can cause life-threatening internal bleeding.

Heart Complications
High blood pressure that isnt treated can damage the heart in several ways.
Coronary artery disease
When the arteries that supply blood to the heart become narrowed, blood cant flow through
them freely. This can cause chest pain (angina) or irregular heart rhythms (arrhythmias).
Eventually, it may result in a heart attack.
Heart attack
A heart attack occurs when one of the arteries supplying blood to the heart becomes blocked by
atherosclerosis or a blood clot. When this happens, the part of the heart supplied by the artery is
deprived of nourishing blood, and that part of the heart begins to die. The longer the artery stays
blocked, the worse the damage.
Left ventricular hypertrophy
Narrowed arteries force the heart to work harder to pump blood through the body. Just as lifting
weights can make your biceps bigger, this added work can cause enlargement of the heart muscle
in the left ventricle, the hearts main pumping chamber. Enlargement and stiffening make it even
more difficult for the ventricle to do its job.
Heart failure
Over time, the added strain on the heart can cause it to get weaker and work less efficiently.
Eventually, the overwhelmed heart becomes unable to pump enough blood to meet the bodys
demands, a condition known as heart failure.
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Brain Complications
Like other parts of the body, the brain depends on a healthy blood supply for nourishment. When
high blood pressure isnt controlled, the blood supply can be compromised.
Stroke
A stroke occurs when part of the brain is deprived of the vital oxygen and nutrients in blood.
Within minutes, brain cells begin to die. In the majority of cases, a blood clot blocks one of the
arteries leading to the brain. In other cases, a blood vessel in the brain leaks or bursts, often due
to high blood pressure or an aneurysm.

Vascular dementia
Dementia is a brain disorder characterized by impairments in memory, thinking, speaking and
other mental skills. This form of dementia can be caused by a stroke or by reduced blood flow to
the brain due to narrowed arteries there.
Kidney Complications
The kidneys job is to filter excess fluid and waste from the blood, and they depend on healthy
blood vessels to do this efficiently. High blood pressure can damage blood vessels in and around
the kidneys, causing serious problems.
Kidney failure
Kidney failure refers to a loss of kidney function, which allows dangerous levels of fluid and
waste to build up in the body. High blood pressure is a double threat. It can damage both the
large arteries leading to the kidneys and the tiny blood vessels inside the kidneys.
Eye Complications
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The tiny blood vessels inside the eyes are delicate and vulnerable. When subjected to the
force from high blood pressure, they may narrow or leak, leading to vision problems.
Hypertensive retinopathy
Hypertensive retinopathy refers to damage of the retinathe light-sensitive tissue at the back of
the eyesthat is caused by high blood pressure. If blood pressure is not controlled, this can lead
to vision loss or even blindness.
Pregnancy Complications
Many women with high blood pressure have healthy pregnancies. However, for others,
uncontrolled blood pressure can cause problems. In pregnant women, it can damage the kidneys
and other organs. In their babies, it can cause premature birth and low birth weight.
Preeclampsia
The most serious form of high blood pressure in pregnancy is preeclampsia. Although the exact
cause is uncertain, blood vessel damage and insufficient blood flow to the uterus may play a role.
In this condition, which typically begins after the 20th week of pregnancy, high blood pressure is
combined with increased protein in the urine due to kidney problems. Most women with
preeclampsia deliver healthy babies.
Male Sexual Complications
Men need healthy blood flow to achieve and sustain an erection.
Erectile dysfunction
Blood vessel damage can reduce the amount of blood that reaches the penis. For some men, the
decreased blood flow interferes with their ability to have an erection, causing erectile
dysfunction.

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