Cardiovascular, Circulatory,

and Hematologic Function

Atherosclerosis
Plaque (fatty deposits) build up in arteries is
called atherosclerosis. These deposits are
made up of cholesterol, fatty substances,
cellular waste products, calcium and fibrin (a
clotting material in the blood). SO
,Atherosclerosis refers to the buildup of fats,
cholesterol and other substances in and on
artery walls (plaque), which can restrict
blood flow.
The plaque can burst, triggering a blood clot.
Although atherosclerosis is often considered
a heart problem, it can affect arteries
anywhere in body. Atherosclerosis may be
preventable and is treatable.
• .Where plaque develops, and the type of
artery affected, varies with each person.
Plaque may partially or totally block
blood flow through large- or medium-
sized arteries in the heart, brain, pelvis,
legs, arms or kidneys. This can lead to
conditions such as:
 The complications of atherosclerosis depend on which arteries are blocked. For example:
• Coronary artery disease.- When atherosclerosis narrows the arteries close to heart, may
develop coronary artery disease, which can cause chest pain (angina), a heart attack or
heart failure.
• Carotid artery disease.- When atherosclerosis narrows the arteries close to brain,
carotid artery disease develop , which can cause a transient ischemic attack (TIA) or
stroke.
• Peripheral artery disease-. When atherosclerosis narrows the arteries in arms or legs, y
may develop circulation problems in arms and legs called peripheral artery disease. This
can make less sensitive to heat and cold, increasing your of burns or frostbite. In rare
cases, poor circulation in arms or legs can cause tissue death (gangrene).
• Aneurysms.- Atherosclerosis can also cause aneurysms, a serious complication that can
occur anywhere in body. An aneurysm is a bulge in the wall of artery.
Most people with aneurysms have no symptoms. Pain and throbbing in the area of an
aneurysm may occur and is a medical emergency. If an aneurysm bursts, you may face life-
threatening internal bleeding. Although this is usually a sudden, catastrophic event, a slow
leak is possible. If a blood clot within an aneurysm dislodges, it may block an artery at some
distant point.
• Chronic kidney disease-. Atherosclerosis can cause the arteries leading to kidneys to
narrow, preventing oxygenated blood from reaching them. Over time, this can affect r
kidney function, keeping waste from exiting body.
Symptoms
Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't
have any symptoms.pts usually won't have atherosclerosis symptoms
until an artery is so narrowed or clogged that it can't supply adequate
blood to organs and tissues. Sometimes a blood clot completely blocks
blood flow, or even breaks apart and can trigger a heart attack or stroke.

Symptoms of moderate to severe atherosclerosis depend on which

arteries are affected. For example:
• cardiovascular atherosclerosis refers to the buildup of fats,
cholesterol and other substances in and on artery walls (plaque),
which can restrict blood flow. - pain or pressure (angina).
• Cerebral atherosclerosis is a type of atherosclerosis where build-
up of plaque in the blood vessels of the brain occurs-sudden
numbness or weakness in y arms or legs, difficulty speaking or
slurred speech, temporary loss of vision in one eye, or drooping
muscles in face. These signal a transient ischemic attack (TIA),
which, if left untreated, may progress to a stroke.
• Peripheral artery disease-leg pain when walking (claudication).
• atherosclerosis in the arteries leading to kidneys-high blood
pressure or kidney failure.
Atherosclerosis
Risk Factors
Modifiable Risk Factors:
Hyperlipidemia
Cigarette smoking, tobacco use
Hypertension
Diabetes mellitus
Metabolic syndrome
Obesity
Physical inactivity
Atherosclerosis
Risk Factors

Nonmodifiable Risk Factors:

Family history of CAD (first-degree relative with
cardiovascular disease at 55 years of age or younger
for men and at 65 years of age or younger for
women)

Gender (men develop CAD at an earlier age than

women)
Race (higher incidence of heart disease in African
Americans than in Caucasians)
Atherosclerosis

Risk Factors
In addition, a cluster of metabolic abnormalities known as metabolic
syndrome has emerged as a major risk factor for cardiovascular
disease. A diagnosis of this syndrome includes three of the following
conditions:
Insulin resistance (fasting plasma glucose more than
100 mg/dL or abnormal glucose tolerance test)
Central obesity (waist circumference more than 35 inches in women,
more than 40 inches in men)
Dyslipidemia (triglycerides more than 150 mg/dL, HDL less than 50
mg/dL in women, less than 40 mg/dL in men)
Blood pressure persistently greater than 130/85 mm Hg
Proinflammatory state (high levels of C-reactive protein)
Prothrombotic state (high fibrinogen level)
 Metabolic syndrome Metabolic syndrome is the name for
a group of risk factors that raises your risk for heart
disease and other health problems, such as diabetes
 and stroke. The five conditions described below are
metabolic risk factors.  You must have at least three
metabolic risk factors to be diagnosed with metabolic
syndrome.
 1) A large waistline. Excess fat in the stomach area is
a greater risk factor for heart disease than excess fat
in other parts of the body, such as on the hips.
 2) A high triglyceride level
 3) High blood pressure
 4) A low HDL cholesterol level
• 5) High fasting blood sugar (or you're on medicine to
treat high blood sugar). Mildly high blood sugar may
be an early sign of diabetes.
 Prevention
Controlling Cholesterol Abnormalities
Promoting Cessation of Tobacco Use
Physical Activity
Managing Hypertension
Controlling Diabetes Mellitus
Dietary Measures

A fasting lipid profile should demonstrate the following values:

 LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very
high-risk patients)
 Total cholesterol less than 200 mg/dL
 HDL cholesterol greater than 60 mg/dL
 Triglyceride less than 150 mg/dL
Myocardial ischemia -occurs when the blood flow through one or
more of coronary arteries is decreased. The low blood flow
decreases the amount of oxygen your heart muscle receives.
• Myocardial ischemia can develop slowly as arteries become
blocked over time. Or it can occur quickly when an artery
becomes blocked suddenly.
Conditions that can cause myocardial ischemia include:
• Coronary artery disease (atherosclerosis). Plaques made up
mostly of cholesterol build up on your artery walls and restrict
blood flow. Atherosclerosis is the most common cause of
myocardial ischemia.
• Blood clot. The plaques that develop in atherosclerosis can
rupture, causing a blood clot. The clot might block an artery and
lead to sudden, severe myocardial ischemia, resulting in a heart
attack. Rarely, a blood clot might travel to the coronary artery
from elsewhere in the body.
• Coronary artery spasm. This temporary tightening of the
muscles in the artery wall can briefly decrease or even prevent
blood flow to part of the heart muscle. Coronary artery spasm is
an uncommon cause of myocardial ischemia.
 Coronary artery disease (atherosclerosis). Arteries are 
blood vessels that carry blood from the heart throughout
the body. They're lined by a thin layer of cells called the
endothelium. The endothelium works to keep the inside of
arteries toned and smooth, which keeps blood flowing.
Atherosclerosis begins with damage to the endothelium.
It’s caused by high blood pressure, smoking, or high 
cholesterol. That damage leads to the formation of plaque.
When bad cholesterol, or LDL, crosses the damaged
endothelium, the cholesterol enters the wall of the artery.
That causes white blood cells to stream in to digest the 
LDL. Over years, cholesterol and cells become plaque in
the wall of the artery.
Atherosclerosis -- hardening and narrowing of the arteries
 -- silently and slowly blocks arteries, putting blood flow
at risk.
It’s the usual cause of heart attacks, strokes, and
peripheral vascular disease -- what together are called 
cardiovascular disease.
Atherogenesis
Myocardial ischemia
occurs when blood flow to
the heart muscle
(myocardium) is
obstructed by a partial or
complete blockage of a
coronary artery by a
buildup of plaques
(atherosclerosis). If the
plaques rupture, pts can
have a heart attack
(myocardial infarction).
 Obstruction of coronary artery
When plaque builds up,
they narrow your coronary
arteries, decreasing blood
flow to your heart.
Eventually, the decreased
blood flow may cause chest
pain (angina), shortness of
breath, or other coronary
artery disease signs and
symptoms. A
complete blockage can
cause a heart attack.
  coronary artery spasm
A coronary artery
spasm is a temporary
tightening (constriction) of
the muscles in the wall of
one of the arteries that
supplies blood flow to your
heart muscle. ... If the
spasm lasts long enough, it
can lead to chest pain
(angina) and even a heart
attack (myocardial
infarction).
 Angina Pectoris
Angina pectoris is a clinical syndrome usually characterized by
episodes or paroxysms of pain or pressure in the anterior
chest.
Angina pectoris commonly known as angina (chest
pain), is the sensation of chest pain, pressure, or
squeezing, often due to not enough blood flow to
the heart muscle as a result of obstruction or 
spasm of the coronary arteries
The cause is insufficient coronary blood flow, resulting in a
decreased oxygen supply when there is increased myocardial
demand for oxygen in response to physical exertion or
emotional stress. In other words, the need for oxygen exceeds
the supply.
Types of Angina:
• Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest
and/or nitroglycerin

• Unstable angina (also called preinfarction angina or

crescendo angina). the decrease in oxygen results in heart muscles that don't work the way
they should. This change may be temporary or permanent. When acute coronary syndrome
doesn't result in cell death, it is called unstable angina. symptoms increase in frequency and
severity; may not be relieved with rest or nitroglycerin

• Intractable or refractory angina: severe

chest pain-

• Variant angina (also called Prinzmetal’s angina): pain at

rest with reversible ST-segment elevation; thought to be
caused by coronary artery vasospasm

• Silent ischemia: objective evidence of ischemia (such as

electrocardiographic changes with a stress test), but patient
reports no pain
Several factors are associated with typical anginal
pain:
Physical exertion, which can precipitate an attack
by increasing myocardial oxygen demand
Exposure to cold, which can cause
vasoconstriction and elevated blood pressure, with
increased oxygen demand
Eating a heavy meal, which increases the blood
flow to the mesenteric area for digestion, thereby
reducing the blood supply available to the heart
muscle
Stress or any emotion-provoking situation,
Blood tests.-
• Blood Chemistry,
• Coagulation Studies  (also known as clotting)- is the process by
which blood changes from a liquid to a gel, forming a blood clot)
• Lipid Profile--Total cholesterol, LDL (low-density lipoprotein cholesterol, also
called "bad" cholesterol(can build up on the walls of your arteries and increase your
chances of getting heart disease.) HDL cholesterol -- "good" cholesterol - a higher
number means lower risk. This is because HDL cholesterol ) protects against heart
disease by taking the "bad" cholesterol out of your blood and keeping it from
building up in your arteries . Triglycerides are the form in which most fat exists in
food and the body. A high triglyceride level has been linked to higher risk
of coronary artery LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very
high-risk patients)
• Total cholesterol less than 200 mg/dL
• HDL cholesterol greater than 60 mg/dL
• Triglyceride less than 150 mg/dL
• disease. 
Diagnosis
Electrocardiogram (ECG). -Electrodes attached to
skin record the electrical activity of heart. Certain
changes in heart's electrical activity may be a sign
of heart damage.
Stress test. - heart rhythm, blood pressure and
breathing are monitored while pts walk on a
treadmill or ride a stationary bike. Exercise makes
heart pump harder and faster than usual, so a stress
test can detect heart problems that might not be
noticeable otherwise.
Echocardiogram . Sound waves directed at heart
from a wand-like device held to chest produce
video images of heart. An echocardiogram can help
identify whether an area of heart has been damaged
and isn't pumping normally.
• Chest X-Ray Fluid in or around lungs, Enlarged heart, Blood vessel problems, such as an 
aortic aneurysm. Congenital heart disease (heart problems you’re born with, Calcium build-
up in the heart or blood vessels, which could make a heart attack)

 Trans esophageal EchocardiographyDoctors use TEE to find problems

in your heart’s structure and function. TEE can give clearer pictures
of the upper chambers of the heart, and the valves between the
upper and lower chambers of the heart, than standard
echocardiograms. Doctors may also use TEE if you have a thick
chest wall,
A cardiac CT scan is a painless imaging test that uses
 Computed Tomography
x rays to take many detailed pictures of your heart and its blood vessels.
Computers can combine these pictures to create a three-dimensional
(3D) model of the whole heart. This imaging test can help doctors detect
or evaluate coronary heart disease, calcium buildup in the coronary
arteries, problems with the aorta, problems with heart function and
valves
 Magnetic ResonanceAngiography MRA can find problems with the blood vessels
that may be causing reduced blood flow. With MRA, both the blood flow and
the condition of the blood vessel walls can be seen. The test is often used to
look at the blood vessels that go to the brain, kidneys, and legs
Myocardial ischemia
Stress echocardiogram.- A stress echocardiogram is
similar to a regular echocardiogram, except the test is
done after pts exercise in the doctor's office on a
treadmill or stationary bike.
Nuclear stress test. Small amounts of radioactive
material are injected into your bloodstream. While you
exercise, doctor can watch as it flows through heart
and lungs — allowing blood-flow problems to be
identified.
Coronary angiography. -is a procedure that uses
contrast dye, usually containing iodine, and x ray
pictures to detect blockages in the coronary arteries that
are caused by plaque buildup. A dye is injected into the
blood vessels of a heart. Then a series of X-ray images
(angiograms) are taken, showing the dye's path. This
test gives doctor a detailed look at the inside of your
blood vessels.
Cardiac CT scan-. This test can determine if pts have
a buildup of calcium in your coronary arteries — a sign
of coronary atherosclerosis. The heart arteries can also
be seen using CT scanning (coronary CT angiogram).
CT Coronarography. Definition. A computerized tomography (CT)
coronary angiogram is a minimally invasive imaging test to look at
the arteries that supply your heart muscle with blood. Unlike a
traditional coronary angiogram, CT angiograms don't use a catheter
threaded through your blood vessels to your heart.
A coronary catheterization is (an X-ray with radiocontrast agent
in the coronary arteries) Coronary angiograms are part of a general
group of procedures known as heart (cardiac) catheterizations.
Cardiac catheterization procedures can both diagnose and treat
heart and blood vessel conditions. A coronary angiogram, which
can help diagnose heart conditions, is the most common type of
cardiac catheterization procedure.
During a coronary angiogram, a type of dye that's visible by an X-ray
machine is injected into the blood vessels of a heart. The X-ray
machine rapidly takes a series of images (angiograms), offering a
look at blood vessels. If necessary, doctor can open clogged heart
arteries (angioplasty) during coronary angiogram.Specifically,
coronary catheterization is a visually interpreted test performed to
recognize occlusion, stenosis, restenosis, thrombosis or
aneurysmal enlargement of the coronary artery lumens; heart
chamber size; heart muscle contraction performance; ..
 Acute coronary syndrome- is a term used to describe a
range of conditions associated with sudden, reduced blood
flow to the heart.
•
• Acute coronary syndrome usually results from the buildup
of fatty deposits (plaques) in and on the walls of coronary
arteries, the blood vessels delivering oxygen and nutrients
to heart muscles.

• When a plaque deposit ruptures or splits, a blood clot

forms. This clot blocks the flow of blood to heart muscles.

• When the supply of oxygen to cells is too low, cells of the

heart muscles can die. The death of cells — resulting in
damage to muscle tissues — is a heart attack (myocardial
infarction).
• Even when there is no cell death, the decrease in oxygen
still results in heart muscles that don't work the way they
should. This change may be temporary or permanent.
When acute coronary syndrome doesn't result in cell death,
it is called unstable angina.
Symptoms
The signs and symptoms of acute coronary syndrome usually begin abruptly. They include:
• Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning
• Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw
• Nausea or vomiting
• Indigestion
• Shortness of breath (dyspnea)
• Sudden, heavy sweating (diaphoresis)
• Lightheadedness, dizziness or fainting
• Unusual or unexplained fatigue
• Feeling restless or apprehensive
• Hypotension: Indicates ventricular dysfunction due to myocardial ischemia, myocardial
infarction (MI), or acute valvular dysfunction
• Hypertension: May precipitate angina or reflect elevated catecholamine levels due to anxiety
• Palpitations

Chest pain or discomfort is the most common symptom. However, signs and symptoms may
vary significantly depending on age, sex and other medical conditions. woman, older adult
or have diabetes more likely to have signs and symptoms without chest pain or discomfort if
you're a woman, older adult or have diabetes
Physical findings can range from normal
to any of the following:
• Hypotension: Indicates ventricular dysfunction
due to myocardial ischemia, myocardial
infarction (MI), or acute valvular dysfunction
• Hypertension: May precipitate angina or
reflect elevated catecholamine levels due to
anxiety
• Pulmonary edema and other signs of left
heart failure-Rales/crackles and wheezing on
auscultation of the lungs suggestive of left
ventricular dysfunction or mitral regurgitation)
• Cool, clammy skin and diaphoresis in
patients with cardiogenic shock
• A third heart sound (S3) and, frequently, a
fourth heart sound (S4)
• A systolic murmur related to dynamic
obstruction of the left ventricular outflow
tract
•
• Jugular venous distention--The blood flow
from the head to the heart is measured by
central venous pressure or CVP. Jugular
vein distention or JVD is when the increased
pressure of the superior vena cava causes the
jugular vein to bulge, making it most visible
on the right side of a person's neck.The
appearance of the vein is similar to a rope or
raised tube below the surface of the skin, and
its height can be measured to indicate the
CVP. This measurement will be taken when a
person is lying down with their head elevated
at an angle of 45–60 degrees.BCS, the venous
waves are visible just above the clavicle when
the patient is sitting at 30-45 degrees. A
normal jugular venous pressure should not
exceed 3-4 cm above the sternal angle.
Higher readings may signify right-sided heart
failure, constrictive pericarditis, pleural
effusion, obstructed vena cava and other
pathologies of the heart and lungs.
The immediate goals of treatment for acute coronary syndrome are:
 Relieve pain and distress
 Improve blood flow
 Restore heart function as quickly and as best as possible

Long-term treatment goals are to improve overall heart function, manage risk factors and lower the risk
of a heart attack. A combination of drugs and surgical procedures may be used to meet these goals
.Medical Management
The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium
and to increase the oxygen supply.
Pharmacologic Therapy:
 Thrombolytics (clot busters) help dissolve a blood clot that's blocking an artery.
 Nitroglycerin improves blood flow by temporarily widening blood vessels.
 Antiplatelet drugs help prevent blood clots from forming and include aspirin, clopidogrel (Plavix),
prasugrel (Effient) and others.
 Beta blockers help relax your heart muscle and slow your heart rate. They decrease the demand on your
heart and lower blood pressure. Examples include metoprolol (Lopressor, Toprol-XL) and nadolol
(Corgard).
 Angiotensin-converting enzyme (ACE) inhibitors widen blood vessels and improve blood flow, allowing
the heart to work better. They include lisinopril (Prinivil, Zestril), benazepril (Lotensin) and others.
 Angiotensin receptor blockers (ARBs) help control blood pressure and include irbesartan (Avapro),
losartan (Cozaar) and several others.
 Statins lower the amount of cholesterol moving in the blood and may stabilize plaque deposits, making
them less likely to rupture. Statins include atorvastatin (Lipitor), simvastatin (Zocor, Flolipid) and several
Surgery and other procedures
procedures to restore blood flow to heart muscles:

• Angioplasty and stenting. In this procedure, doctor

inserts a long, tiny tube (catheter) into the blocked
or narrowed part of your artery. A wire with a
deflated balloon is passed through the catheter to the
narrowed area. The balloon is then inflated, opening
the artery by compressing the plaque deposits
against artery walls. A mesh tube (stent) is usually
left in the artery to help keep the artery open.
• Coronary bypass surgery. With this procedure, a
surgeon takes a piece of blood vessel (graft) from
another part of body and creates a new route for
blood that goes around (bypasses) a blocked
coronary artery.
A coronary angioplasty also called percutaneous coronary intervention, is a
procedure used to open clogged heart arteries. Angioplasty uses a tiny balloon
catheter that is inserted in a blocked blood vessel to help widen it and improve
blood flow to the heart.
Angioplasty is often combined with the placement of a small wire mesh tube called
a stent. The stent helps prop the artery open, decreasing its chance of narrowing
again. Most stents are coated with medication to help keep artery open (drug-
eluting stents).
Coronary bypass surgery is a procedure that
restores blood flow to the heart muscle by
diverting the flow of blood around a section of
a blocked artery Coronary bypass surgery
redirects blood around a section of a blocked or
partially blocked artery by removing a blood
vessel from the chest, arms, or legs and using it
to create a detour or bypass around the
blockage
Assessment and Diagnostic Findings:
Patient’s history
12-lead electrocardiogram (ECG)
CRP and cardiac biomarker
Stress ECG
Echocardiogram
Cardiac catheterization
Coronary angiography is a procedure that uses X-ray
imaging to see your heart's blood vessels. The test is
generally done to see if there's a restriction in blood
flow going to the heart. Coronary angiograms are part of
a general group of procedures known as heart (cardiac)
catheterizations
Assessment and Diagnostic Findings
Patient History
Electrocardiogram
Echocardiogram
Laboratory Tests - Creatine Kinase and Its
Isoenzymes, Myoglobin, Troponin
Medical Management
Pharmacologic Therapy - Analgesics, Angiotensin-Converting
Enzyme Inhibitors, Thrombolytics
Emergent Percutaneous Coronary Intervention
Cardiac Rehabilitation - targets risk reduction by means of
education, individual and group support, and physical activity.

Coronary angioplastic Bypass surgery

• Blood test
• C-reactive protein (CRP). CRP is a marker for inflammation, and atherosclerosis has
an inflammatory component. Patients with elevated levels of CRP have an increased
risk for heart attack, stroke, sudden death, and vascular disease.
• Standard coagulation screening tests, such as
• activated partial thromboplastin time (APTT),-- is a screening test that helps evaluate a
person's ability to appropriately form blood clots. (30-40 seconds.)
• prothrombin time (PT),- is a test used to help detect and diagnose a bleeding disorder
or excessive clotting disorder ( 11 to 13.5 seconds)
• the international normalized ratio (INR)-is a calculation based on results of a PT and is
used to monitor individuals who are being treated with the blood-thinning medication
(anticoagulant) warfarin (Coumadin®). The PT and INR are used to monitor the
effectiveness of the anticoagulant warfarin. are important constituents of basic
examinations in clinical laboratories.( 2.0 to 3.0)
• CBC
Current cardiac biomarker tests (troponin, cardiac
biomarker tests (Troponin, creatine kinase (CK) and CK-MB)
that may be used to help diagnose, evaluate, and monitor
individuals suspected of having 
acute coronary syndrome (ACS) include :Troponin - this is the
most commonly ordered and most specific of the cardiac markers. It is
elevated (positive) within a few hours of heart damage and remains
elevated for up to two weeks.rising levels can help dignose heart
attack.troponin normal range is <0.1 Most patients who have had a heart
attack have increased troponin levels within 6 hours. After 12 hours, almost everyone
who has had a heart attack will have raised levels. Troponin levels may remain high
for 1 to 2 weeks after a heart attack
 Creatine kinase (CK)  expressed by various tissues and cell types,and can rise
after a heart attack, skeletal muscle injury, strenuous exercise, or drinking too much
alcohol, and from taking certain medicines or supplements. CK-MB CK-MB is one
particular form of the enzyme creatine kinase that is found mostly in
heart muscle; it rises when there is damage to the heart muscle cells
and may be used in follow up to an elevated CK and/or when the
troponin test is not available.
• Lipid profile or lipid panel is a panel of blood tests that serves as an initial
screening tool for abnormalities in lipids, such as
• Total cholesterol,
• LDL (low-density lipoprotein cholesterol, also called "bad" cholesterol(can
build up on the walls of your arteries and increase your chances of getting heart
disease.)
• HDL cholesterol -- "good" cholesterol - a higher number means lower risk.
This is because HDL cholesterol ) protects against heart disease by taking the
"bad" cholesterol out of your blood and keeping it from building up in your
arteries . Triglycerides are the form in which most fat exists in food and the
body. A high triglyceride level has been linked to higher risk of coronary artery
• LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk
patients)
• Tryglicerids
Total cholesterol less than 200 mg/dL
HDL cholesterol greater than 60 mg/dL
Triglyceride less than 150 mg/dL
disease. 
Rate
Square Counting: 300-150-100-75-60-50-42A

Count QRS in 10 second rhythm strip x 6  use this method to

determine rate when rhythm is irregular (e.g., atrial fibrillation)