1. Cardiovascular Disease
Chapter 15

2. Introduction
Cardiovascular disease (CVD) is the leading cause of death in the U.S.
One American dies from CVD every 33 seconds
Nearly half of all Americans will die from CVD
CVD is the leading cause of death for both men and women
45% of all heart attacks occur in people under the age of 65
Most of CVD risk is lifestyle-related
Today, much of the incidence of cardiovascular disease (CVD) is due to the American way of life. Too many Americans eat a high-fat diet, are overweight and sedentary, smoke cigarettes, manage stress ineffectively, have uncontrolled high blood pressure or high cholesterol levels, and don’t know the signs of CVD. Not all the risk factors for CVD are controllable, but many are and can be changed, treated, or modified. Therefore, you have the power to significantly reduce your risk of CVD.

3. The Cardiovascular System
Pulmonary circulation
Blood to and from the lungs.
Systemic circulation
Left side of the heart pumps blood through the rest of the body.
For a detailed description of the cardiovascular system, please see the text.
Pulmonary circulation – The part of the circulatory system governed by the right side of the heart; the circulation of blood between the heart and the lungs.
Systemic circulation – The part of the circulatory system governed by the left side of the heart; the circulation of flood between the heart and the rest of the body.
Atria – The two upper chambers of the heart in which blood collects before passing to the ventricles; also called auricles.
Ventricles – The two lower chambers of the heart from which blood flows through arteries to the lungs and other parts of the body.
Vena cava – The large vein though which blood is returned to the right atrium of the heart.
Aorta – The large artery that receives blood from the left ventricle and distributes it to the body.
Systole – Contraction of the heart.
Diastole – Relaxation of the heart.
Veins – Vessels that carry blood to the heart.
Arteries – Vessels that carry blood away from the heart.
Coronary arteries –Two arteries branching from the aorta that provide blood to the heart muscle.
Capillaries – Very small blood vessels that distribute blood to all parts of the body.

6. Cardiovascular System
Heart, blood vessels, hormones, enzymes and wastes.
Four chambers (size of a fist).
Upper chambers (Atriums).
Lower chambers (Ventricles).
Vena cava
Pulmonary Artery and Vein.
Aorta.
Coronary Arteries.

8. Cardiovascular System
Systole and Diastole.
action of the heart is controlled by an electrical signal which originates in the right atrium.
Veins carry blood back to the heart.
Arteries carry blood away from the heart.
Capillaries

9. Risk Factors Major Risk factors Contributing Risk Factors
Six Major Risk Factors that can be changed.
Tobacco use.
Physical inactivity.
Obesity
High blood pressure.
Diabetes
High levels of cholesterol.
LDL’s and HDL’s
Researchers have identified a variety of factors associated with an increased risk of developing cardiovascular disease. They are grouped into two categories: major (also called primary, causal or direct) risk factors and contributing (also called secondary, associative, or indirect) risk factors. The major risk factors can then be subdivided into two more categories: controllable and uncontrollable.
Major risk factors that CAN be changed – These include tobacco use, high blood pressure, cholesterol, physical inactivity, obesity, and diabetes. See slides 4 to 6.
Contributing risk factors that CAN be changed – These include triglyceride levels, and psychological and social factors, such as: stress; chronic hostility and anger; suppressing psychological distress; depression and anxiety; social isolation; and low socioeconomic status. See slides 7 and 8 for details.
Major risk factors that CAN’T be changed – These include heredity, aging, being male, and ethnicity. Slide 9 has more information.
Possible risk factors currently being studied – In recent years, a number of other possible risk factor for CVD have been identified. Research is ongoing and results are inconclusive at this time. The factors being studied include homocysteine, specific types of cholesterol, various infectious agents, inflammation, fibrinogen, blood viscosity and iron, uric acid, and syndrome X. Homocysteine is an amino acid. Elevated levels of it may cause damage to the lining of blood vessels, resulting in inflammation and the development of fatty deposits in the artery walls. Lipoprotein(a) is a specific type of LDL that has strong genetic links and has been identified as a possible risk factor for CHD. LDL particle size, specifically pattern B (a small density LDL) has been indicated as a factor in CVD. Various infectious agents such as certain kinds of bacteria and viruses have been linked to increased risk. Inflammations and chemicals released in the inflammatory response have shown elevated risk for heart attack and stroke. Fibrinogen is a protein that is essential for the formation of blood clots, but high levels may be linked to risk of CHD. High blood viscosity (thickness) and excess stores of iron have been associated with higher risk of CVD. Elevated levels of uric acid found in the blood may raise CVD risk by increasing inflammation and platelet aggregation or influencing hypertension. Researchers have found that certain CVD risk factors are often found in a cluster. These are high blood pressure, high triglycerides, low HDL, abdominal obesity, and glucose intolerance and grouped together, they are called syndrome X.

10. Tobacco Use Smokers have 2-3 times higher risk of heart attack
Reduces HDL’s
CO displaces O2
Causes platelets to become sticky and increases blood thickness
Tobacco use – Nearly 1 in 5 deaths from CVD are attributed to smoking. People who smoke a pack of cigarettes a day have twice the risk of heart attack than nonsmokers; smoking two or more packs a day triples the risk. And when smokers do have heart attacks, they are 2-4 times more likely than nonsmokers to die from them. Women who smoke and use oral contraceptives are up to 39 times more likely to have a heart attack and up to 22 times more likely to have a stroke than women who don’t smoke. Smoking harms the cardiovascular system and raises risk for CVD in several ways. Nicotine, a CNS stimulant, increases blood pressure and heart rate; the carbon monoxide in cigarette smoke displaces oxygen in the blood, reducing the amount of oxygen available to the heart and other parts of the body. Smoking damages the linings of arteries, and it contributes to unhealthy blood fat levels by reducing levels of HDL and raising levels of LDL and triglycerides. Smoking causes platelets in the blood to become sticky and cluster, promoting clotting. Smoking also permanently accelerates the rate at which fatty deposits are laid down in arteries. You don’t have to smoke to be affected. The risk of death from CHD increases up to 30% among those exposed to environmental tobacco smoke (ETS – secondhand smoke) at home or at work. Researchers estimate that 62,000 nonsmokers die from CVD each year as a result of exposure to ETS.

11. High Blood Pressure Too much pressure against arterial walls
Heart has to work harder, weakens, enlarges, arteries scar and harden
High blood pressure – High blood pressure, or hypertension, is a risk factor for many forms of CVD, but is also considered a disease itself. High blood pressure occurs when too much force or pressure is exerted against the walls of the arteries. If your blood pressure is high, your heart has to work harder to push the flood forward. Over time, a strained heart weakens and tends to enlarge, which weakens it further. Increased blood pressure also scars and hardens arteries, making them less elastic. Heart attacks, strokes, atherosclerosis, and kidney failure can result. Hypertension usually has no early warning signs, so it’s important to have your blood pressure tested at least once every 2 years (more often if you have CVD factors). If your blood pressure is consistently high, your physician can help you lower it through diet, weight management, exercise, and; if necessary, medication.

12. High Blood Pressure Tachycardias. 100 or more beats per minute.
Compromises the ability of the heart to pump effectively.
Ventricles can not completely fill.

13. Low Blood Pressure Bradychardia 60 or less beats per minute
Poor circulation of the blood
Lack of 02 throughout to body and brain

14. Cholesterol Clogs the arteries Increased risk of CVD
LDL’s - less than 120 dl/mg
HDL’s - greater than 60 dl/mg
Total cholesterol should be below 200 dl/mg
Levels over 240 indicates high risk of CVD
Cholesterol is a fatty, waxlike substance that circulates through the bloodstream and is an important component of cell membranes, sex hormones, vitamin D, the fluid that coat the lungs, and the protective sheaths around nerves. Adequate cholesterol is essential for the proper functioning of the body. However, excess cholesterol can clog arteries and increase the risk of CVD. Our bodies obtain cholesterol in two ways: from the liver, which manufactures it, and from the foods we eat. Cholesterol levels vary depending on age, sex, heredity, and other factors.
Good versus bad cholesterol – Cholesterol is carried in the blood in protein-lipid packages called lipoproteins. Lipoproteins can be thought of as shuttles that transport cholesterol to and from the liver through the circulatory system. Low-density lipoproteins (LDLs) shuttle cholesterol from the liver to the organs and tissues that require it. LDL is known as “bad” cholesterol because if there is more than the body can use, the excess is deposited in the blood vessels. LDL that accumulates and becomes trapped in artery walls may be oxidized by free radicals, speeding inflammation and damage to artery walls and increasing the likelihood of a blockage. If coronary arteries are blocked, the result may be a heart attack. If an artery carrying blood to the brain is blocked, a stroke may occur. High-density lipoproteins (HDLs), or “good” cholesterol, shuttle unused cholesterol back to the liver for recycling. By removing cholesterol from blood vessels, HDL helps protect against atherosclerosis.
Recommended cholesterol levels – The risk for CVD increases with rising blood cholesterol levels. The first step in managing your cholesterol is to be tested. The National Cholesterol Education Program (NCEP) recommends testing at least once every 5 years for all adults, beginning at age 20, or at least every 3 years for people with a family history of heart disease. A total cholesterol level below 200 mg/dl (milligrams per deciliter) is considered desirable and indicates a relatively low risk of CVD. High levels over 240 mg/dl carry approximately double the CVD risk of desirable levels. An estimated 99 million American adults – over half the adult population – have total cholesterol levels of 200 mg/dl or higher. Total cholesterol levels do not tell the whole story; however, knowing your HDL and LDL levels can also be very helpful. In general, high LDL levels and low HDL levels are associated with a high risk for CVD; low levels of LDL and high levels of HDL are associated with lower risk; HDL is especially important because a high HDL level seems to offer protection from CVD even in cases where total cholesterol is high. On the other hand, low total cholesterol may be associated with high CVD risk if HDL is also very low. For this reason, some experts use the ratio of total cholesterol to HDL to evaluate CVD risk.
Benefits of controlling cholesterol – Experts calculate that people can cut their heart attack risk by 2% for every 1% that they reduce their total blood cholesterol. In addition, studies indicate that lowering total blood cholesterol levels not only reduces the likelihood that arteries will become clogged, but can also reverse deposits on artery walls, thereby actually helping clean out diseased arteries. Important dietary changes include substituting unsaturated for saturated and trans fats and increasing soluble fiber intake. Decreasing your intake of saturated and trans fat is particularly important because they promote the production and excretion of cholesterol by the liver. Exercising regularly and eating more fruits, vegetables, and whole grains also helps. You can raise your HDL levels by exercising regularly and, if you smoke, quit. Weight loss, if you are overweight, and altering the amount and type of fat you consume can also help raise your HDL.

16. Physical Inactivity Exercise reduces risk by: Lowering LDL’s
Controlling Blood pressure
Increasing HDL’s
Maintaining weight
Helps prevent or controls Diabetes
Physical inactivity – An estimated million Americans are so sedentary that they are at high risk for developing CVD. Exercise is thought to be the closest thing we have to a “magic bullet” against heart disease. It lowers CVD risk by helping decrease blood pressure, increase HDL levels, maintain desirable weight, and prevent or control diabetes. Exercise also improves the functioning of the endothelial cells that line coronary arteries. One recent study found that women who accumulated at least 3 hours of brisk walking each week cut their risk of heart attack and stroke by more than half. A minimum of 30 minutes per day of moderate physical activity is recommended and more intense or longer-duration exercise has even greater benefits. Refer to chapter 13 for more information on the benefits of physical activity and guidelines for creating an exercise program.

17. Other Contributing Factors
Obesity
More than 30% above recommended weight.
Increase strain on the heart.
Diabetes
Having doubles the risk of CVD.
Obesity – A person whose body weight is more than 30% above the recommended level is at higher risk for heart disease and stroke, even if no other risk factors are present. Excess weight increases the strain on the heart by contributing to high blood pressure and high cholesterol. It can also lead to diabetes. For someone who is overweight, even modest weight reduction can reduce CVD risk by lowering blood pressure, improving cholesterol levels and reducing risk of diabetes. See chapter 12 for more on the benefits of weight reduction and weight management.
Diabetes – Diabetes is a disorder characterized by elevated blood glucose levels due to either insufficient supply or action of insulin. Having diabetes doubles the risk of CVD for men and triples the risk for women. Most people with diabetes die of CVD, and they usually die at younger ages than people without diabetes. The reason for the increased CVD risk among people with diabetes is complex. Diabetics have higher rate of other CVD risk factors, including hypertension, obesity, and unhealthy blood lipid levels (typically, high triglyceride levels and low HDL levels). The elevated blood glucose levels that occur in diabetes can damage the lining of arteries, making them more vulnerable to atherosclerosis. Diabetics also often have platelet and blood coagulation abnormalities that increase the risk of heart attacks and strokes. Careful control of glucose levels is beneficial, but even people whose diabetes is under control face an increased risk of CVD. For that reason, careful control of other CVD risk factors is critical for people with diabetes.

18. Body Weight More than 30% High cholesterol levels High blood pressure
Excessive strain on the heart
Fat collected in the torso more dangerous

19. Contributing Risk Factors That Can Be Changed
High Triglyceride Levels
Psychological factors
Chronic hostility and anger
Suppressing psychological disorders
Depression and anxiety
Social factors
Social isolation
Low socioeconomic status
Various other factors that can be changed have been identified as contributing to CVD risk:
Elevated triglyceride levels – Like cholesterol, triglycerides are blood fats that are obtained from food and manufactured by the body. High triglyceride levels are a reliable predictor of heart disease, especially if associated with other risk factors, such as low HDL levels, obesity, and diabetes. Elevated triglyceride levels are specially dangerous for women and for people who smoke. Much of the picture regarding triglycerides remains unclear, however. Studies have yet to show whether lowering triglyceride levels will actually decrease heart disease. Elevated triglyceride levels are most often seen in people with other lipid abnormalities and lifestyle modifications that help lower cholesterol also help decrease triglycerides, making it difficult to identify any potential independent benefits of lower triglyceride levels. Physicians often recommend that people with other risk factors for CVD have their total triglyceride level measured. If it is high (400 mg/dl or more) , steps should be taken to bring levels down into the healthy range (below mg/dl). The best ways to reduce triglycerides seem to be weight loss, regular exercise, and a diet that is high in fiber, fruits, and vegetables and that favors unsaturated over saturated fats. Being moderate in the use of alcohol is important because alcohol elevates triglyceride levels. Medications can also be used to lower triglyceride levels.
Psychological and social factors – Many of the psychological and social factors that influence other areas of wellness are also important risk factor for CVD. They include stress, chronic hostility and anger, suppressing psychological distress, depression and anxiety, social isolation, and low socioeconomic class. These are described in more detail on the next slide.

20. Elevated Triglycerides
Combines with LDL’s
Causes lowered HDL’s
Linked with Obesity
Linked with Diabetes
Reliable predictor of CVD
Best means of Reduction: Exercise weight loss, and dietary changes

21. Factors Not Controllable
Heredity - CVD has genetic component; high cholesterol levels, blood clotting and obesity
Age - Over the age of 65
Sex - Men have higher risk earlier in life
Ethnicity - African Americans have higher risk of hypertension; Hispanics greater risk of HBP and Angina; Asians Lower rates of CVD
A number of major risk factors for CVD cannot be changed. They include:
Heredity (family history) – The tendency to develop CVD seems to be inherited. If one of your parents has had heart or blood vessel disease, you have a greater risk of developing CVD yourself. High cholesterol levels, hypertension, abnormal blood-clotting problems, diabetes, and obesity are other CVD risk factors that have genetic links. But it’s important to remember that people who inherit a tendency for CVD are not destined to develop it. They may; however, have to work harder than other people to prevent CVD.
Aging – The risk of heart attack increases dramatically after age 65. About 70% of all heart attack victims are age 65 and older, and more than 4 out of 5 who suffer fatal heart attacks are over 65. For people over 55, the incidence of stroke more than doubles in each successive decade. However, many people in their 30’s and 40’s, especially men, have heart attacks.
Being male –Although CVD is the leading killer of both men and women in the U.S., men face a greater risk of heart attack than women, especially earlier in life. Until age 55, men also have a greater risk of hypertension than women. The incidence of stroke is bout 19% higher for males than females. Estrogen production, which is highest during the childbearing years, may offer premenopausal women some protection against CVD. By age 75, the gender gap nearly disappears.
Ethnicity – Death rates from heart disease vary among ethnic groups in the U.S., with African Americans having much higher rates of hypertension, heart disease, and stroke than other groups. Puerto Rican Americans, Cuban Americans, and Mexican Americans are also more likely to suffer from high blood pressure and angina than non-Hispanic white Americans. These differences may be due to education, income, and other socioeconomic factors. Asian Americans historically have had far lower rates of CVD than white Americans. However, cholesterol levels among Asian Americans appear to be rising, presumably because of the adoption of a high-fat diet.

22. Possible Risk Factors Currently Being Studied
Homocysteine
Lipoprotein(a)
LDL Particle size.
Infectious agents
Inflammation and C-Reactive Protein
Fibriongen
Blood Viscosity and Iron
Uric Acid
Syndrome X

24. Major Forms of Cardiovascular Disease
Hypertension - may cause damage even before it is ever detected.
Atherosclerosis - narrowed by fatty deposits. Starts during childhood fat.
Heart Attack - Coronary thrombosis, coronary occlusion or myocardial infarction. Vessels in the heart become blocked.
Stroke - Impeded blood supply to a part of the brain.
Congestive Heart Failure - Blood backs up in the veins leading to the heart, causing fluid retention in various body parts.
Collectively, the various forms of CVD kill more Americans that the next four leading causes of death combined. The financial burden of CVD, including the costs of medical treatments and lost productivity, exceeds $320 billion annually. There are many forms of CVD. Although the following conditions are discussed independently, the many forms of CVD are interrelated and have common elements.
Hypertension – Hypertension occurs when blood pressure exceeds normal limits most of the time. It weakens the heart, scars and hardens arteries,and can damage the eyes and kidneys. See slide 11 for more information.
Atherosclerosis – Atherosclerosis is a progressive hardening and narrowing of arteries that can lead to restricted blood flow and even complete blockage. Slide number 12 provides details on atherosclerosis.
Heart disease and heart attacks – Heart attacks are usually the result of a long-term process. Warning signs of a heart attack include chest discomfort, light-headedness, nausea, and sweating. Slide number 13 describes issues related to heart disease and heart attack, while slide 14 discusses the detection and treatment of heart disease.
Stroke – A stroke occurs when the blood supply to the brain is cut off by a blood clot or hemorrhage. A transient ischemic attack (TIA) is a warning sign of a stroke. Refer to slides 15 and 16 for more details.
Congestive heart failure – Congestive heart failure occurs when the heart’s pumping action becomes less efficient and fluid collects in the lungs or in other parts of the body. Slide number 17 provides more information on this disease.
Other forms of heart disease – Other common forms of CVD are congenital defects, rheumatic heart disease, and heart valve disorders. These conditions are discussed on slide 18.

25. Major Forms of Cardiovascular Disease
Angina Pectoris - Chest pain; heart doesn’t get enough O2. (Kehr’s sign.).
Arrhythmia’s - Abnormal Heartbeat - Disruption of the electrical system - can lead to sudden death.
Every year, about 1.1 million Americans have a heart attack. Although a heart attack or myocardial infarction (MI), may come with out warning, it is usually the end result of a long-term disease process. The most common form of heart disease is coronary artery disease (CAD or CHD) caused by atherosclerosis. When one of the coronary arteries, the arteries that branch off the aorta and supply blood directly to the heart muscle (myocardium), becomes blocked, a heart attack results. A heart attack caused by a clot is call a coronary thrombosis. Turing a heart attack, part of the heart muscle may die from lack of oxygen. If an ME is not fatal, the heart muscle may sometimes partially repair itself.
Symptoms – The symptoms of MI may include: chest pain or pressure; arm, neck, or jaw pain; difficulty breathing; nausea and vomiting; and loss of consciousness. Although chest pain occurs in the majority of MI victims, a recent study of over 750,000 MI patients revealed that about one-third of people having a heart attack do not experience chest pain. Women, minorities, older adults, and people with diabetes were the most likely groups to experience heart attack without chest pain.
Angina – Arteries narrowed by disease may still be open enough to deliver blood to the heart. At times, however – primarily during emotional excitement, stress, or physical exertion – the heart requires more oxygen than narrowed arteries can accommodate. When the need for oxygen exceeds the supply, chest pain called angina pectoris, may occur. Angina pain is felt as an extreme tightness in the chest and heave pressure behind the breastbone or in the should, neck, arm, hand, or back. This pain, although not actually a heart attack, is a warning that the load on the heart must be reduced. Angina may be controlled in a number of ways (with drugs or surgical procedures), but its course is unpredictable. Over a period ranging from hours to years, the narrowing may go on to full blockage and a heart attack.
Arryhthmias and sudden cardiac death – The pumping of the heart is controlled by electrical impulses that maintain a regular heartbeat of beats per minute. If this electrical conduction system is disrupted, the heart may beat too quickly, too slowly, or in an irregular fashion, a condition know as arrhythmia. Arrhythmia can cause symptoms ranging from imperceptible to severe and even fatal. Sudden cardiac death is most often caused by an arrhythmia called ventricular fibrillation, a kind of “quivering” of the ventricle that makes it ineffective in pumping blood. If ventricular fibrillation continues for more than a few minutes, it is fatal. Cardiac defibrillation, in which an electrical shock is delivered to the heart, can be effective in jolting the heart into a more efficient rhythm. Sudden cardiac death most often occurs in people with CHD, and serious arrhythmias frequently develop during or after a heart attack and are often the actual cause of death in cases of fatal MI. Some arrhythmias cause no problems while others are more serious and require treatment. Treatments usually include medication or a surgically implanted pacemaker that delivers appropriate electrical stimulation to the heart.

27. Helping a Heart Attack Victim
Most die within 2 hours from time of first symptoms.
Cardiopulmonary resuscitation (CPR)
Helping a heart attack victim – Most people who die from a heart attack do so within 2 hours from the time they experience the first symptoms. Unfortunately, half of all heart attack victims wait more than 2 hours before getting help. Recognizing signals and responding immediately by initiating emergency medical services is critical. If a person loses consciousness, cardiopulmonary resuscitation (CPR) should be performed. Damage to heart muscle increases with time. If the victim receives emergency care quickly enough, a clot-dissolving drug can be used to break up the clot.

28. Detecting and Treating Heart Disease
Electrocardiogram (ECG or EKG)
Magnetic Resonance Imaging (MRI)
Angiogram
Balloon Angioplasty
Coronary Bypass Surgery
Detecting heart disease - Physicians have several methods to evaluate the condition of the heart and arteries including several new techniques. Currently, the most common initial screening tool is the stress test (also called an exercise stress test), in which a patient runs or walks on a treadmill or pedals a stationary cycle while being monitored for abnormalities with an electrocardiogram (ECG or EKG). Certain characteristic changes in the heart’s electrical activity while under stress can reveal particular heart problems, such as restricted blood flow. Exercise testing can also be performed in conjunction with techniques such as ultrasonography and X ray that provide further information about the heart and arteries. Recently, several non-invasive tests for detecting CVD have become available. These include: electron-beam computed tomography (EBCT) which uses a sweeping electron beam to produce computerized cross-sectional images. It can detect calcium in the arteries, which is a marker for atherosclerosis; echocardiography, which utilize sound waves to exam the heart; and magnetic resonance imaging (MRI), which uses powerful magnets to look inside the body. If symptoms of non-invasive tests suggest coronary artery disease, the next step is usually a coronary angiogram. In this test, a catheter is threaded through an artery, usually in the groin, and a special dye is injected into the bloodstream. X rays are then used to trace the flow of blood through the coronary arteries and heart.
Treatments – Various treatments, ranging from changes in diet to major surgery are available if a problem is detected. Along with a low-fat diet, regular exercise, and smoking cessation, one frequent non-surgical recommendation for people at high risk for CVD is to take half an aspirin a day. Aspirin has an anti-clotting effect, discouraging platelets in the blood from sticking to arterial plaques and forming clots. Aspirin also reduces inflammation. Prescription drugs can help control heart disease symptoms and may prevent heart attack, thus raising both the quality and quantity of life in heart patients. A common surgical procedure for CHD is balloon angioplasty. This technique involves threading a catheter with an inflatable balloon tip through the artery until it reaches the area of blockage. The balloon is then inflated, flattening the fatty plaque and widening the arterial opening. However, repeat clogging of the artery, known as restenosis, is common. To keep arteries open following angioplasty, may surgeons also permanently implant coronary stents – flexible, stainless steel mesh tube that remains in place as a framework to prop the artery open and prevent restenosis. Every year, coronary bypass surgery is performed on over 500,000 men and women, about half of whom are under age 65. Surgeons remove a healthy blood vessel, usually a vein from one of the patient’s legs, and graft it to one or more coronary arteries to bypass a blockage. A heart-lung machine maintains circulation during the surgery.

29. Stroke or Cerebrovascular Accident (CVA)
Ischemic stroke
Thrombotic stroke clot forms in a cerebral artery
Embolic Stroke - wandering blood clot
Hemorrhagic stroke- blood vessel ruptures in the brain
Aneurysm
For brain cells to function properly, they must have a continuous and ample supply of oxygen-rich blood. If brain cells are deprived of blood for more than a few minutes, they die. A stroke, also called a cerebrovascular accident (CVA), occurs when the blood supply to the brain is cut off. Many experts now refer to strokes as “ brain attacks” to emphasize their similarity to heart attacks and the importance of early treatment. In the past, not much could be done for stroke victims; today, however, prompt treatment of stroke can greatly decrease the risk of permanent disability. Everyone should know the warning signs for a stroke and seek immediate medical help, just as they would for the first sign of a heart attack.
Types of strokes – There are two major types of stroke: ischemic strokes, which are caused by blockages in blood vessels, and hemorrhagic strokes, which are caused by ruptured of blood vessels that lead to bleeding in the brain. One type of ischemic stroke, the thrombotic stroke, is caused by a thrombus, a blood clot that forms in a cerebral artery that has been narrowed or damaged by atherosclerosis. A second type of ischemic stroke, called an embolic stroke, is caused by an embolus, a wandering blood clot that is carried in the bloodstream and may become wedged in one of the cerebral arteries. Many embolic strokes are linked to a type of abnormal heart rhythm called atrial fibrillation; when this arrhythmia occurs, blood may pool in the artia (upper chambers of the heart) and form clots. Ischemic strokes, which account for 80% of all strokes, are potentially treatable with clot-busting drugs, so obtaining immediate medical help is critical to improve chances of recovery. The other, less common, but more severe type of stroke is the hemorrhagic stroke. It occurs when a blood vessel in the brain bursts, spilling blood into the surrounding tissue. Cells normally nourished by the artery are deprived of blood and cannot function. In addition, accumulated blood from the burst vessel may put pressure on surrounding brain tissue, causing damage and even death. In a subarachnoid hemorrhage, a blood vessel on the brain’s surface ruptures and bleeds into the space between the brain and the skull; a ruptured vessel within the brain causes an intercerebral hemorrhage. Hemorrhage can be caused by head injuries or the bursting of a malformed blood vessel or an aneurysm (a blood-filled pocket that bulges out from a weak spot in an artery wall). Aneurysms in the brain may remain stable and never break. But when they do, the result is a stroke. Aneurysms may be caused or worsened by high blood pressure.

31. The Effects of a Stroke 600,000 Americans per year
One-third die within a year
Those who survive have some lasting disability.
Effects of a stroke – The interruption of the blood supply to any area of the brain prevents the nerve cells there from functioning and in some cases, causing death. Of the 600,000 American who have strokes each year, nearly one-third die within a year. Those who survive usually have some lasting disability. Which parts of the body are affected depends on the area of the brain that has been damaged. Nerve cells control sensation and most of our body movements, and a stroke may cause paralysis, walking disability, speech impairment, memory loss, and changes in behavior. The severity of the stroke and its long-term effects depend on which brain cells have been injured, how widespread the damage is, how effectively the body can restore the blood supply, and how rapidly other areas of the brain can take over. Early treatment can significantly reduce the severity of disability resulting from a stroke.
Detecting and treating stroke – Death rates from stroke have declined significantly over the past decades. In 1950, nearly 90% of victims died; today, about two-thirds of the victims survive. Effective treatment requires the prompt recognition of symptoms and correct diagnosis of the type of stroke that has occurred. Signs or signals of a stroke are listed in your textbook. Anyone who experiences one or more of the signs of stroke should obtain emergency medical help immediately. Some stroke victims have a transient ischemic attack (TIA), or ministroke, days, weeks or months before they have a full-blown stroke. A TIA produces temporary stroke-like symptoms, such as weakness or numbness in an arm or leg, speech difficulty, or dizziness. TIA symptoms are brief, often lasting just a few minutes, and do not cause permanent damage. However, TIAs should be taken as warning signs of a stroke, and anyone with a suspected TIA should get immediate medical attention. Strokes should be treated with the same urgency as heart attacks. A person with strokes symptoms should be rushed to the hospital. A computed tomography (CT) scan, which uses a computer to construct an image of the brain from X rays, can assess brain damage and determine the type of stroke. Newer diagnostic techniques using MRI and ultrasound are becoming increasingly available and should improve the speed and accuracy of stroke diagnosis. If tests reveal that a stroke is caused by a blood clot – and if help is ought within a few hours of the onset of symptoms – the person can be treated with the same kind of clot-dissolving drugs that are used to treat coronary artery blockages. If the clot is dissolved quickly enough, brain damage is minimized and symptoms may disappear. People who have had TIAs or who are at high risk for stroke due to narrowing of the carotid arteries may undergo a procedure called carotid endarterectomy, in which plaque is surgically removed. If detection and treatment of stroke come too late, rehabilitation is the only treatment. Although damaged or destroyed brain tissue does not normally regenerate, some functions can be taken over by other parts of the brain. Some spontaneous recovery starts immediately after a stroke and continues for a few weeks. Rehabilitation consists of various types of therapy: physical therapy, which helps strengthen muscles and improve balance and coordination; speech and language therapy, which helps those whose speech has been damaged; and occupational therapy, which helps improve hand-eye coordination and everyday living skills. Progress varies from person to person and can be unpredictable. Some people recover completely in a matter of days or weeks, but most stroke victims who survive must adapt to a lifelong disability.

32. Stroke Warning Signs
Sudden numbness or weakness of face, arm, leg or one side of the body
Loss of Speech or difficulty speaking
Dimming or loss of vision in one eye
Unexplained dizziness in relation to other symptoms

33. Detecting and Treating Stroke
Transient ischemic attack (TIA)
Computed tomography (CT)
Rehabilitation
Physical therapy
Speech and Language therapy
Occupational therapy
Detecting and treating stroke – Death rates from stroke have declined significantly over the past decades. In 1950, nearly 90% of victims died; today, about two-thirds of the victims survive. Effective treatment requires the prompt recognition of symptoms and correct diagnosis of the type of stroke that has occurred. Signs or signals of a stroke are listed in your textbook. Anyone who experiences one or more of the signs of stroke should obtain emergency medical help immediately. Some stroke victims have a transient ischemic attack (TIA), or ministroke, days, weeks or months before they have a full-blown stroke. A TIA produces temporary stroke-like symptoms, such as weakness or numbness in an arm or leg, speech difficulty, or dizziness. TIA symptoms are brief, often lasting just a few minutes, and do not cause permanent damage. However, TIAs should be taken as warning signs of a stroke, and anyone with a suspected TIA should get immediate medical attention. Strokes should be treated with the same urgency as heart attacks. A person with strokes symptoms should be rushed to the hospital. A computed tomography (CT) scan, which uses a computer to construct an image of the brain from X rays, can assess brain damage and determine the type of stroke. Newer diagnostic techniques using MRI and ultrasound are becoming increasingly available and should improve the speed and accuracy of stroke diagnosis. If tests reveal that a stroke is caused by a blood clot – and if help is ought within a few hours of the onset of symptoms – the person can be treated with the same kind of clot-dissolving drugs that are used to treat coronary artery blockages. If the clot is dissolved quickly enough, brain damage is minimized and symptoms may disappear. People who have had TIAs or who are at high risk for stroke due to narrowing of the carotid arteries may undergo a procedure called carotid endarterectomy, in which plaque is surgically removed. If detection and treatment of stroke come too late, rehabilitation is the only treatment. Although damaged or destroyed brain tissue does not normally regenerate, some functions can be taken over by other parts of the brain. Some spontaneous recovery starts immediately after a stroke and continues for a few weeks. Rehabilitation consists of various types of therapy: physical therapy, which helps strengthen muscles and improve balance and coordination; speech and language therapy, which helps those whose speech has been damaged; and occupational therapy, which helps improve hand-eye coordination and everyday living skills. Progress varies from person to person and can be unpredictable. Some people recover completely in a matter of days or weeks, but most stroke victims who survive must adapt to a lifelong disability.

34. Congestive Heart Failure
Number of conditions
Pulmonary edema - Fluid accumulates in the lungs.
Heart can not maintain regular pumping rate; fluid backs up.
Controlled by: Reducing cardiac load, eliminating excess fluid, restriction of salt and drug therapy.
A number of conditions – high blood pressure, heart attack, atherosclerosis, rheumatic fever, birth defects – can damage the heart’s pumping mechanism. When the heart cannot maintain its regular pumping rate and force, fluids begin to back up. When extra fluid seeps through capillary walls, edema (swelling) results, usually in the legs and ankles, but sometimes in other parts of the body as well. Fluid can collect in the lungs and interfere with breathing, particularly when a person is lying down. This condition is called pulmonary edema, and the entire process is known as congestive heart failure. Congestive heart failure can be controlled. Treatment includes reducing the workload on the heart, modifying salt intake, and using drugs that help the body eliminate excess fluid. Drugs used to treat congestive heart failure include digitalis, which increases the pumping action of the heart, and diuretics, which help the body eliminate excess salt and water. Several other drugs have recently been shown to help prolong survival and improve the quality of life for people with congestive heart failure. This is an important area of research because the incidence of this disease is rising as our population ages.

35. Heart Disease in Children Congenital Heart Disease
Most common are holes between the ventricles.
Congenital narrowing of the aorta.
Hypertrophic Cardiomyopathy
Rheumatic Heart Disease - Streptococcal infections causes damage to the heart muscle and valves.
Strep throat needs to be treated, primary cause if not treated.
Heart Valve Disorders
Mitral valve prolapse
Congenital heart disease – About 32,000 children born each year in the U.S. have a defect or malformation of the heart or major blood vessels. These conditions are collectively called congenital heart disease, and cause about 5000 deaths each year. The most common congenital defects are holes in the wall that divides the chambers of the heart. With these defects the heart produces a distinctive sound, making diagnosis relatively simple. Another defects is coarctation of the aorta, a narrowing, or constriction, of the aorta. Heart failure may result unless the constriction is repaired by surgery. Most of the common congenital defects can now be accurately diagnosed and treated with medication or surgery. Important in saving lives is early recognition that the newborn, who has a bluish appearance or respiratory difficulty or who fails to thrive, may be suffering from congenital heart disease. Hypertrophic cardiomyopathy is the most common cause of sudden death among athletes younger than 35 years of age. It is an inherited condition that causes the heart muscle to become enlarged, primarily in the area between the two ventricles.
Rheumatic heart disease (RHD) – Worldwide, a leading cause of heart trouble is rheumatic fever, a consequence of certain types of untreated streptococcal infections (group A beta-hemolytic). Rheumatic fever can damage the heart muscle and heart valves causing rheumatic heart disease. Many of the approximately 70,000 operations on heart valves performed annually are related to RHD, and about 5000 Americans die each year from RHD. Rheumatic fever can be prevented by treating strep throat when it occurs. Symptoms of strep throat are the sudden onset of a sore throat, painful swallowing, fever, swollen glands, headache, nausea, and vomiting. Laboratory diagnosis is important because strep throat is treated with antibiotics, which are not useful in the treatment of viral sore throats, which are much more common. Symptoms of rheumatic fever are generally vague, but in children they include weight loss or a failure to gain weight, fever, poor appetite, repeated nosebleed, jerky body movements; fatigue, weakness, and pain in the arms, legs, or abdomen.
Heart valve disorders – Congenital defects and certain types of infections can cause abnormalities in the valves between the chambers of the heart. Heart valve problems generally fall into two categories: the valve fails to open fully, or it fails to close completely. In either case, blood flow through the heart is impaired. Treatment for heart valve disorders depends on their location and severity. Serious valve problems may require surgery to repair or replace the valve. People with certain types of heart valve defects are advised to take antibiotics prior to some types of dental and surgical procedures in order to prevent bacteria (which may be dislodged into the bloodstream during the procedure) from infecting the defective valve. The most common valve disorder is mitral valve prolapse (MVP), which occurs in about 4% of the population. MVP is characterized by a “billowing” of the mitral valve (the mitral valve separates the left ventricle and left atrium) during ventricle contraction. In some cases, blood leaks from the ventricle into the atrium. Most people with MVP have no symptoms and have the same ability to exercise and live as long as people without MVP. The condition is often diagnosed during a routine medical exam when an extra heart sound (a click) or murmur is heard. The diagnosis can be confirmed with echocardiography. Treatment is usually unnecessary, although surgery may be needed in the rare cases where leakage through the faulty valve is severe. Experts disagree over whether patients with MVP should take antibiotics prior to dental procedures; most often, only those patients with significant blood leakage are advised to take antibiotics.

36. Protecting Yourself Against CVD
Total Fats less than 30%
Low Saturated Fats
Increased Dietary Fiber
Moderation of Alcohol
No smoking
Omega-3 fatty acids, vitamin E, folic acid, vitamin B-6 & B-12,soy protein, and total calories.
There are several important steps you can take now to lower your risk of developing CVD in the future. If you are a young adult, you may be wondering how CVD prevention advice applies to you, since most cases of CVD show up in people who are decades older. Evidence is mounting that the development of CVD begins very early in life. For example, young adults with relatively low cholesterol levels go on to live substantially longer than those with higher levels. Reducing CVD risk factors when you are young can pay off with many extra years of life and health.
Eat heart-healthy – For most Americans, changing to a heart-healthy diet involves cutting total fat intake, substituting unsaturated fats for saturated and trans fats, and increasing fiber. Such changes can lower a person’s blood levels of total cholesterol, LDL, and triglycerides. See the next slide for more information on a heart-healthy diet.
Exercise regularly – You can significantly reduce your risk of CVD with a moderate amount of physical activity. You can start by accumulating at least 30 minutes of moderate-intensity physical activity every day. Follow the guidelines for physical activity and exercise described in chapter 13.
Avoid tobacco – Remember: The number-one risk factor for CVD (and all preventable deaths) that you can control is smoking. If you smoke, kick the habit (It’s not easy, but you can do it, just like the thousands other people who have quit. And, the results are worth it). If you don’t smoke, never start. The majority of people who start don’t believe they will become hooked, but most do.
Know and manage your blood pressure – Currently, only about 18% of Americans with hypertension have their blood pressure under control. If you have no CVD risk factors, have your blood pressure measured at least once every 2 years. If you have other risk factors, yearly or more often, tests are recommended. Self-administered blood pressure tests in pharmacies and other public places are OK, but they may be misleading and there is no substitute for a test performed by a trained professional.
Know and manage your cholesterol levels – Have your blood cholesterols measured if you’ve never had it done. Everyone age 20 and over should have their total and HDL cholesterol checked at least once every five years. Finger-prick tests at health fairs and other public places are generally accurate, especially if they offered by a hospital or other reputable health group. When you know your “number,” follow the Guidelines from the NCEP: Total cholesterol below 200 mg/dl – low risk for CVD; mg/dl – moderate risk if your HDL is under 35 mg/dl; and 240 mg/dl and above – high risk. In addition, don’t forget to control LDL and triglyceride levels.
Develop effective ways to handle stress & anger – To reduce the psychological and social risk factors for CVD, develop effective coping strategies for handling stress in your life. Shore up you social support network and try some the relaxation techniques describes in chapter 2
Manage other risk factors and medical conditions – Know your CVD risk factors and follow you physician’s advice for testing, lifestyle modification, and any drug treatments. If you are a postmenopausal woman, discuss the health risks and benefits of hormone replacement therapy.

37. Protecting Yourself Moderate physical activity
Blood pressure monitored twice a year
Control Cholesterol levels
Effective means of controlling stress

39. DASH Dietary Approaches to Stop Hypertension DASH DIET
DASH – DASH stands for Dietary Approaches to Stop Hypertension. It is a dietary plan that reflects many of the findings and suggestions of a research study by the same name. The DASH study found that a diet low in fat and high in fruits, vegetables, and low-fat dairy products reduced blood pressure.

40. Thank You!