Pathophysiology

Cardiovascular system
(CVS)
 Components of the CVS
1-Heart:

• A pump: contracts to push blood through vessels

• 4 chambers: 2 atria and 2 ventricles

2-Blood vessels:

• Tubes through which blood moves, include arteries, arterioles,

capillaries, venules and veins.

3-Blood:

• Fluid→ composed of blood cells suspended in plasma.

• Blood cells include: RBCs, WBCs and Platelets

 The vascular system
• Arteries
Control of blood flow to organs and tissues

• Capillaries
Exchange of nutrients, waste, and fluid between the blood and
interstitium

• Veins
Return blood to the heart

Regulation of blood flow

• Sympathetic control of vascular smooth muscle
↑sympathetic activity→ vasoconstriction.
↓sympathetic activity→ vasodilation.
 Blood pressure measures
• Systolic blood pressure: the pressure in the arteries when the
ventricles are contracting.

• Diastolic blood pressure: the pressure in the arteries when the

ventricles are relaxed.

• Pulse pressure : The difference between the systolic and diastolic

pressures.

• Mean arterial pressure: diastolic pressure + 1/3 pulse pressure.

• cardiac output: The volume of blood pumped from the

ventricle/min.

• Stroke volume (SV): Volume of blood pumped by the

ventricle / beat.

• The venous return: The volume of blood returned to the atria

/min.

• Cardiac output = Stroke volume x Heart rate

• CO = SV x HR = 70 ml x 70 ~ 5 L/min
BP α cardiac output (C.O.P) × peripheral vascular resistance (PVR)
BP: Blood pressure
Where, C.O.P is controlled by:
1. Heart contractility
2. Heart rate (HR)
3. Venous return.

Also, PVR is controlled by:

1. Diameter of the arterioles
2. Viscosity of blood.
 1. Hypertension

Hypertension is defined as a elevation of arterial pressure above

the normal range expected for a particular age group.

Normal blood pressure in adults 120/80 mmHg.

A patient is considered hypertensive, if blood pressure

measurements ≥ 140 mmHg for systolic pressure and ≥ 90 mmHg
for diastolic pressure at two successive measurements.
 Stages of hypertension

• Pre-hypertension.
Systolic between 120 –139 mmHg, diastolic between 80-89 mmHg.
Have high risk of developing HTN.

• Stage 1 hypertension.
Systolic between 140 –159 mmHg, diastolic between 90-99 mmHg.
Most hypertensive patients are in this group.

• Stage 2 hypertension.
Systolic >160 mmHg, diastolic >100 mmHg.
 Types of hypertension
A. Primary hypertension (essential or idiopathic): Its etiology is
uncertain.

B. Secondary hypertension: in which the cause of the elevated

blood pressure is clearly defined (another disease).

A. Primary or essential hypertension

May be due to :

1. Chronic increases in fluid volume.

2. Enhanced sympathetic activity.

3. Abnormal salt and water excretion by the kidneys.

A number of genetic, environmental and dietary factors are associated

with an increased risk for the development of essential hypertension:

• Familial history of hypertension

• Increasing age and obesity

• Cigarette smoking

• Low dietary intake of potassium, calcium and magnesium

• Race and gender: incidence of hypertension is significantly higher

in black men

• High dietary salt intake

• Heavy alcohol consumption

 Manifestations of essential hypertension
• Although a small percentage of patients with essential
hypertension may present with frequent headaches, most are
asymptomatic.
• Unless diagnosed early, chronic essential hypertension can
progressively damage tissue and organs, including:
1. Blood vessels
2. Heart
3. Kidneys
4.Eyes
 1. Blood vessels
• Prolonged high BP in the arteries and arterioles lead to
thickening of walls of the blood vessels to compensate for the
excess shear stress. The chronic increased shear forces may
predispose walls of blood vessels to atherosclerosis and
aneurysm.

• If left untreated coronary artery disease, cerebrovascular

disease and renal vascular disease.
 2. Heart
• Chronic elevation of arterial pressure obligate the heart to pump
blood out against a continually elevated afterload. As
compensation for this increased afterload, left ventricular
hypertrophy occurs. The hypertrophied ventricle will require
increased blood, oxygen and nutrient supplies and will be at
greater risk for arrhythmia.
• When the ventricular enlargement reaches a certain point,
contractile function will no longer be supported and pump failure
(congestive heart failure, CHF) will ensue.
 3. Kidneys
• Chronically elevated pressure can damage the renal
vasculature and decrease renal blood flow, oxygen delivery
and filtration.
• As a result, renal insufficiency can occur that may eventually
progress to renal failure. Decreased renal blood flow can lead
to activation of the renin–angiotensin system and contribute to
a cycle of increasing blood pressure and decreasing renal
function.
 4. Eyes
• Vision can suffer in a patient with chronic hypertension as a
result of increased arteriolar pressure in the eyeball or from
vascular sclerosis, both of which can damage the retina and
eye as a whole.
 Treatment

1. Lifestyle modifications
• Weight loss

• Exercise

• Sodium-restricted diet

• Cessation of smoking

• Limiting alcohol intake

2. Pharmacologic
a. Diuretics (thiazides, furosemide) —Lower blood pressure by
reducing vascular volume. They inhibit sodium reabsorption in the
distal convoluted tubules of the kidney and in the thick ascending
portion of the loop of Henle, respectively.
b. β-Blockers (selective β1and nonselective)
Lower blood pressure by decreasing heart rate and cardiac output.
c. ACE (angiotensin-converting enzyme) inhibitors (captopril,
enalapril) — Block the formation of angiotensin II, which is a
powerful vasoconstrictor. Also reduces the formation of aldosterone ,
an adrenal hormone that stimulates salt and water retention.
d. Calcium channel blockers (nifedipine, diltiazem) — Reduce blood
pressure by relaxing vascular smooth muscle around blood vessels.
Some calcium channel blockers may also reduce cardiac output.

e. Direct-acting vasodilators (hydralazine, diazoxide) - Directly relax

smooth muscle around peripheral blood vessels.

f. Central-acting agents (methyldopa) — Reduce blood pressure by

decreasing sympathetic output from the brain.
 Secondary hypertension
Represents only a small fraction of all cases of hypertension. The
underlying cause can usually be clearly elucidated and as a result can
often be corrected or cured.

causes
1. renal artery stenosis, which is a narrowing of the renal arteries due
to atherosclerosis. As a result, the kidney responds by activating the
renin–angiotensin system that in turn leads to vasoconstriction and
salt and water retention.
This case may be resolved with angioplasty or surgical

intervention to reopen the occluded renal blood vessels.

2. Hyperaldosteronism (excess aldosterone production)

3. Pheochromocytoma (tumor of the adrenal medulla).

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