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Coronary Heart
Disease, Myocardial
Infarction,
and Heart Failure
A Review of the
Basics

Review Date 12/13


G-0967

Defining Heart
Disease
Heart disease is a broad term used to
describe a range of diseases that affect your
heart, such as:
Coronary heart disease (CHD)
Atherosclerosis
Myocardial infarction (MI)
Heart failure (formerly called congestive
heart failure)

Risk Factors for


CHD and MI
Smoking
High intake of alcohol
Obesity
Sedentary lifestyle
Diabetes
Hypertension

Risk Factors for


CHD and MI (contd)
More than 34 years of age for males and
55 years of age for females (risk increases
after menopause)
Family historygenetics
Hypertension
Stress
Chronic kidney disease

Risk Factors for


CHD and MI (contd)
High low-density lipoprotein (LDL)
cholesterol
Low high-density lipoprotein (HDL)
cholesterol
Left ventricular hypertrophy

Risk Factors
for Heart Failure
Obesity
Hypertension
Overweight or obesity
Ischemic heart disease
Changes in cardiovascular structure, such
as diseases to the heart valves or muscle

Coronary Heart
Disease: An
Blood flow
to the vessels surrounding
Overview

the heart is blocked


The major underlying cause of CHD is
atherosclerosis or a buildup of plaque
in the arteries

Plaque
Development
Many factors speed up plaque development:
Elevated cholesterol and triglyceride levels
Hypertension
Infection that initiates the inflammatory response
Elevated iron levelscarry free radicals that
damage lining
Elevated homocysteine level
Cigarette smoking
Diabetes
Obesity
Oxidized (LDL) levels

The Atherosclerotic
Process
Buildup of smooth muscle cells,
macrophages, and lymphocytes
Smooth muscle cells form a matrix of
connective tissue
Lipid and cholesterol accumulates in the
matrix

The Atherosclerotic
Process (contd)
Lipid deposits and other materials
(including cellular waste, fibrin, and
calcium) build up and form a plaque
After injury, platelets adhere to the
arterial wall and release growth factors,
which promote lesion development

Coronary Heart
Disease
Steps to development
of CHD:
Development

Fatty streaks form, often in people younger than


30 years of age
People are asymptomatic during this first stage of
CHD
Plasma LDL enters the injured endothelial wall and
forms a plaque that sometimes is prone to rupture
Acute, complicated lesions with rupture and either
nonocclusive or occlusive thrombus form (occlusive
form often results in MI and sudden death)
Hemorrhage into plaque produces thrombi
thrombus formation with arterial lumen initiated

Coronary Heart
Disease
Steps to development
of CHD (contd):
Development
(contd)
Progressive narrowing of lumen
Insufficient blood flow to myocardium (ischemia)
results
Chest pain or angina pectoris occurs

Signs and Symptoms


of Coronary Heart
Chest pain
Disease
Hypertension
Increased pulse
Increased respiration
Dyspnea on exertion
Pallor of skin
Light-headedness with exertion
Diminished peripheral pulses
Intermittent claudicationcramping of the
lower extremities

Treatment of
Coronary Heart
Antihyperlipidemic
agents
Disease
Medications that lower triglycerides
Antiplatelets (aspirin)
Antihypertensives
Antianginals (nitroglycerin)
Antimicrobials

Angina Pectoris:
An Overview
Chest pain caused by myocardial ischemia
from reduced blood flow and/or reduced
oxygen supply to the myocardium
Angina is a warning sign that a heart attack
(MI) may occur

Angina Pectoris:
An Overview (contd)
Aerobic metabolism switches to anaerobic
metabolism:

Lactic acid buildup


Release of histamine, bradykinins, and enzymes,
which stimulate nerve fibers in the myocardium,
sending pain impulses to the central nervous
system

Angina Pectoris:
An Overview (contd)
Other causes of decreased oxygen supply to
the myocardium:
Congestive heart failure
Congenital heart defects
Pulmonary hypertension
Left ventricular hypertrophy
Cardiomyopathy
Severe hypertension
Narrowing of the aortic valve

Angina Pectoris:
An Overview (contd)
Other causes of decreased oxygen supply to
the myocardium (contd):
Leakage of the aortic valve
Ventricle wall thickening
Atheroma leading to arterial narrowing

Silent ischemiadecreased oxygen supply


with no pain

Causes of Increased
Oxygen Demand
Causes of increased oxygen demand on the
myocardium:
Anemia
Exercise
Thyrotoxicosis
Substance abuse, particularly cocaine
Hyperthyroidism
Emotional stress

Four Types of Angina


Stable:

Caused by specific amount of activity


Predictable
Relieved with rest and nitrates

Unstable:

Pain occurs with increasing frequency, severity,


and duration over time
Unpredictable
May occur at rest
High risk for MI

Four Types of Angina


(contd)
Prinzmetals (variant):

Has no identified cause


May occur at same time of day
May intensify or worsen over time
Is usually caused by coronary artery spasm

Angina decubitus:

Occurs when a person is lying down with no cause


Occurs because gravity redistributes body fluids

Signs and Symptoms


Pressure of
or heaviness
in chest beneath
Angina
breastbonewomen are likely to have
unusual types of chest discomfort
Pain may occur down shoulder or inside of
arms, or in the throat, jaw, or teeth
Stomach pain, especially after eating
Sweating

Signs and Symptoms


Light-headedness
of Angina
Hypotension
Pulse changes
Indigestion

(contd)

Treatment of Angina
Antianginals (nitroglycerin)
Antiplatelets (aspirin)
ACE inhibitors
Beta-blockers
Calcium channel blockers
Thrombolytic therapy (if thrombi are the
cause)
Oxygen administration
Percutaneous transluminal coronary
angioplasty or coronary artery bypass graft to
prevent MI

Myocardial
Infarction: An
Death of Overview
cells in the myocardium, usually
related to prolonged or severe ischemia
Necrosis, tissue damage, and sometimes
death results
Cause of MI include:
Sudden onset of ventricular fibrillation
Embolus (most common cause)
Thrombosis
Atherosclerotic occlusion
Prolonged vasospasm

Myocardial
Infarction
Cellular injury
occurs from lack of oxygen:
Progression
If prolonged, will lead to cell death

Scar replaces muscle, but cannot contract


or conduct impulses:

Location of damage is determined by which artery


is blocked

Damage begins at subendocardial level:

Will progress to the epicardium within 1 to 6 hours

Myocardial
Infarction
DamagedProgression
cells lead to decreased
(contd)
contractility:

Less blood ejected by left ventricle with each beat


Decreased blood pressure
Decreased tissue perfusion

Myocardial
Infarction: Signs and
Pain, typically
in middle of chest, radiating
Symptoms
to jaws, arms (usually the left), abdomen,
and/or shoulders, and lasting 20 minutes:

Possible to have no pain or atypical pan


(particularly
in females)
Sudden onset of pain, not associated with activity

Myocardial
Infarction: Signs and
Symptoms
(contd)
Tachycardia
Excessive perspiration
Painful breathing and/or difficulty breathing
Anxiety/panic
Nausea/vomiting
Fever
Stomach pain, often confused with
indigestion

Laboratory
Evaluation
Creatinine kinase
Trophin
Myoglobin

Myocardial
Infarction
If more than 50% of heart tissue is
Complications
damaged, severe disability or death will
result

Myocardial
Infarction
Pericarditis may develop up to 2 months
Complications
later:
(contd)

Fever
Pericardial effusion
Pleurisy
Pleural effusion
Joint pain
Rupture of heart muscle
Ventricular aneurysm
Blood clots
Hypotension

Treatment Following
Myocardial
Antianginals
(nitroglycerin)
Analgesics
Infarction
Electrolyte replacement
Calcium channel blockers
Beta-blockers
Antihypertensives
Anticoagulants

Treatment Following
Myocardial
Infarction
(contd)
Antiarrhythmics
Thrombolytics
Oxygen
Mild antianxiety agents

Heart Failure:
An Overview

Inability of the heart to pump sufficiently to


meet metabolic needs, leading to decreased
tissue perfusion as a result of decreased
cardiac output
Acute or chronic
Left sided or right sided
Systolic or diastolic

Causes of Heart
Failure

Hypertension
MI
Cardiomyopathies
Congenital heart disease
Valve disorders
Side effect of medication or alcohol

Types of Heart
Failure
Systolic dysfunction:

Heart contracts with less force and cannot pump


out as much blood to the rest of the body as
normal
Blood accumulates in the ventricles and veins

Diastolic dysfunction:

Heart is stiff and does not relax after contracting


Heart does not allow as much blood to enter its
chambers from the veins, and the blood
accumulates in the veins

Types of Heart
Failure (contd)
Left sided:

More common
Fluid backs into lungs
Signs and symptoms include:
Fatigue
Activity
intolerance
Dizziness
Syncope
Dyspnea
Coughing

Pulmonary
crackles
Tacycardia
urine output
Shortness of
breath when
lying down

Types of Heart
Failure (contd)
Right sided:

Caused by pulmonary hypertension or right


ventricular infarction
Fluid backs into rest of body, with abdominal
organ congestion and peripheral edema
Signs and symptoms include:
Lower extremity edema
in the ambulatory
Sacral edema in the
bedridden

Liver engorgement and right


upper quadrant pain
Anorexia and nausea
Jugular venous distension

Types of Heart
Failure (contd)
Biventricular (signs and symptoms of both
left and right heart failure):
Signs and symptoms include:
All symptoms of right
and left heart failure
Dyspnea at rest
Hepatomegaly and
splenomegaly
Abdominal pressure
Ascites
Anorexia

Nausea and vomiting


digestion and absorption
of nutrients
Dysrhythmias
Cardiogenic shock or acute
pulmonary edema

Cardiac Cachexia
10% to 15% of patients with heart failure
develop cardiac cachexia
Loss of 6% of nonedematous body weight
over 6 months
Concurrent loss of cardiac muscle mass as
a result

Cardiac Cachexia
(contd)
Many other metabolic changes:

Increased catabolic catecholamines


Tumor necrosis factor is increased, contributing to
a lower body mass index and catabolic state

Treatment of
Coronary Heart
Diuretics Disease
Dopamine
Analgesics
Antihypertensives
ACE inhibitors
Direct vasodilators
Antidysrhythmics
Cardiac glycosides (digitalis)
Aldosterone agonists

Treatment of
Coronary Heart
Antibiotics,
if necessary(contd)
Disease
Iron supplementation, if necessary
Supplemental oxygen
Nitrates
Beta-blockers
Anticoagulants

References
Academy of Nutrition and Dietetics. Nutrition Care Manual
[by subscription]. Nutrition Care Manual Web site.
www.nutritioncaremanual.org. Accessed December 1, 2013.

Cleveland Clinic. Acute myocardial infarction. Cleveland Clinic


Center of Continuing Education Web site.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanage
ment/cardiology/acute-myocardial-infarction/
. Accessed
December 1, 2013.
Cleveland Clinic. Heart failure. Cleveland Clinic Center for
Continuing Education Web site.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanag
ement/cardiology/heart-failure
. Accessed December 1, 2013.

References (contd)
Raymond JL, Couch SC. Medical nutrition therapy for
cardiovascular disease. In: Mahan, LK, Escott-Stump S,
Raymond JL. Krauses Food and the Nutrition Care Process. 13th
ed. St Louis, MO: Elsevier Saunders; 2012:742-781.
The Merck Manual for Health Care Professionals. Cardiovascular
disorders. Merck Manuals Web site.
http://www.merckmanuals.com/professional/cardiovascular_diso
rders.html
. Accessed December 1, 2013.
What is angina? National Heart, Lung, and Blood Institute Web
site.
http://www.nhlbi.nih.gov/health/health-topics/topics/angina/.
Accessed December 1, 2013.