Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Pathophysiology The Cardiovascular System

2 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Heart Disease  Heart disease (which includes Heart Disease, Stroke and other Cardiovascular Diseases) is the No. 1 cause of death in the United States, killing nearly 787,000 people alone in  Heart disease is the leading cause of death for people of most racial/ethnic groups in the United States, including African Americans, Hispanics and Whites. For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer  More people die of heart disease than all forms of cancer combined.

3 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Symptoms of a Heart Attack  Dyspnea – difficulty in breathing.  Chest Pain – Pressure / pain  Left Arm/ shoulder pain –  Dizziness / Sweating  Tired / fatigue /insomnia

4 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Medical Treatment for Heart Attacks  First Aid: Maintain life with CPR / Defibrillation Defibrillation  Medical interventions:  Clot busting medications. Video Video  Stints inserted into the coronary arteries. Video Video  Coronary Artery by pass Surgery. Video Video

5 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Chambers of Normal Heart

6 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Peripheral Vascular System

7 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Overview of Major Diseases   Congenital heart diseases- Birth defects linklink   Ischemic vascular disease - Ischemia means a "reduced blood supply". Ischemic Vascular Disease (IVD) is where a waxy substance called plaque (plak) builds up inside blood vessels, and restricts the normal flow of blood linklink   Hypertension-related disease. linklink   Infectious diseases linklink   Autoimmune disorders linklink   Metabolic diseases linklink

8 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Incidence of Fatal Cardiovascular Diseases

9 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Causes of Cardiac Diseases

10 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Congenital Heart Disease   Approximately 25,000 babies per year born with heart defects   Defect may be:   Minor: asymptomatic or related to only minor clinical symptoms   Major: associated with major clinical problems or may be lethal

11 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Causes of Congenital Heart Disease   Cause unknown (most often)   Viruses   Alcohol   Chromosomal abnormalities

12 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Most Common Congenital Heart Diseases   Ventricular septal defect   Atrial septal defect   Tetralogy of Fallot link videolinkvideo ____________________________________ Note: Isolated septal defects are initially acyanotic, but later may become cyanotic when direction of blood flow through a shunt is reversed. Tetralogy of Fallot presents with early cyanosis.

13 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Ventricular Septal Defect

14 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Tetralogy of Fallot Tetralogy of Fallot (TOF) is a congenital heart defect which is classically understood to involve four anatomical abnormalities of the heart (although only three of them are always present). It is the most common cyanotic heart defect, and the most common cause of blue baby syndrome. [1] TOF is usually a right-to-left shunt, in which higher resistance to right ventricular outflow results in more severe cyanosis symptoms. [2] congenital heart defectcyanoticblue baby syndrome [1]right-to-left shuntcyanosis [2]

15 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Atherosclerosis   Generalized videovideo   Localized   Coronary heart disease   Cerebrovascular disease videovideo   Atherosclerosis of aorta   Peripheral vascular disease

16 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Forms of Atherosclerosis

17 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Pathogenesis of Atherosclerosis

18 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Pathogenesis of Atherosclerosis (Cont’d)

19 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Complications of Atheroma

20 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Risk Factors of Atherosclerosis Risk Factors That Cannot Be Changed Risk Factors That Can Be Changed Protective Factors AgeLipid metabolism- related factors: diet, obesity, hyperlipidemia, diabetes mellitus Exercise GenderHypertensionEstrogen HeredityClotting factors Cigarette smoking Behavior

21 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Endothelial Cell Injury Leading to Atherosclerosis

Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Atherosclerosis: Gross Appearance of Aorta 22 T = thrombi

23 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Aneurysms videovideo

24 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Peripheral Vascular Disease   Atherosclerosis of renal arteries   Atherosclerosis of intestinal arteries   Atherosclerosis of extremities   Dry gangrene   Wet gangrene

25 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Clinical Presentations of Coronary Heart Disease   Asymptomatic – No symptoms observed   Angina pectoris- heart pain videovideo   Congestive heart disease – heart failure. video video   Myocardial infarction- heart attack… blood flow blockage… heart muscle death. videovideo

26 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Coronary Artery Disease

27 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Distribution of Myocardial Infarcts

28 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Coronary Occlusion by Thrombus

29 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Complications of Myocardial Infarct

30 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Hematopericardium Due to heart attack or aneurysm the heart bleeds into the pericardial sack and squeezes the heart.

31 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Coronary Heart Disease: Clinical Features

32 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Chronic Congestive Heart Disease

33 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Outcome of Myocardial Infarct (MI)

34 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Diagnosis of Myocardial Infarction

35 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Arterial Hypertension   Primary hypertension (>90%); cause unknown videovideo   Secondary hypertension   Renal; kidney blockage   Endocrine – hormonal changes - adrenaline   Neurogenic- psychological stress.   Drugs- legal and illegal drugs can increase BP

36 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Blood Pressure  Systolic pressure – the internal arterial pressure when the heart is compressing.  Diastolic pressure – the internal pressure of the arteries between heart beats.  Normal: 120/80 mm/Hg Measurement video Measurement videoMeasurement video  Measured by soundings: technique video video  Heartbeat rate: How many beats / minute.  Normal: bpm  Tachycardia: rate > 100 bpm  Bradycardia: rate < 60 bpm

37 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Regulation of Arterial Pressure

38 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Pathogenesis of Hypertension

39 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Complications of Hypertension   Cardiac hypertrophy- swelling of heart muscle due to chronic high pressure.   Congestive heart disease- decreased efficiency of heart pumping.   Renal insufficiency – kidney failure. VideoVideo   Hypertensive encephalopathy- brain swelling and pain due to high blood pressure. videovideo   Hypertensive retinopathy- eye damage due to high blood pressure. VideoVideo

40 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Rheumatic Heart Disease: Pathogenesis RHD is a chronic heart condition caused by rheumatic fever that can be prevented and controlled. Rheumatic fever is caused by a preceding group A streptococcal (strep) infection. Treating strep throat with antibiotics can prevent rheumatic fever. Moreover, regular antibiotics (usually monthly injections) can prevent patients with rheumatic fever from contracting further strep infections and causing progression of valve damage. Consequences of rheumatic heart disease Acute rheumatic fever primarily affects the heart, joints and central nervous system. The major importance of acute rheumatic fever is its ability to cause fibrosis of heart valves, leading to crippling valvular heart disease, heart failure and death

41 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Chronic Rheumatic Endocarditis

42 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Infectious Diseases of the Heart   Endocarditis- an infection of the innermost layer of the heart due to bacteria or viruses.   Myocarditis- the infection of the heart muscle in between the inside and outside membranes.   Pericarditis- an infection of the outer layer membrane of the heart.

43 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Bacterial Endocarditis

44 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Bacterial Endocarditis (Cont’d)

45 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Complications of Endocarditis

46 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Causes of Infectious Myocarditis   Viruses (most common)   Bacteria (immunosuppressed persons or in sepsis)   Parasites & protozoa (e.g., Trypanosoma cruzi)

47 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Causes of Pericarditis   Viruses (most common)   Bacteria   Fungi (rare)   Rheumatic heart disease   Uremia   Open heart surgery

48 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Pericarditis

49 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Cardiomyopathy video video   Heart Muscle Disease: Dilated: viral infection, alcohol, cardiotoxic drug   Hypertrophic: genetic   Restrictive: amyloidosis, endomyocardial fibrosis

50 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Cardiomyopathy (Cont’d)

51 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Cardiac Tumors   Rare   Most common primary tumor: atrial myxoma, which is benign; can be removed surgically   Metastases: most often from lung cancer; involve pericardium

52 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Artificial Valve Video

53 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Arterial Diseases   Atherosclerosis   Arteritis   Polyarteritis nodosa is a vasculitis of medium and small- sized arteries, which become swollen and damaged from attack by rogue immune cells. Small aneurysms are strung like the beads of a rosaryvasculitisarteriesimmune cellsrosary   Giant cell arteritis is an inflammatory disease of blood vessels most commonly involving large and medium arteries of the head, predominantly the branches of the external carotid artery.inflammatoryblood vessels arteries external carotid artery   Raynaud’s Disease -is excessively reduced blood flow in response to cold or emotional stress, causing discolouration of the fingers, toes, and occasionally other areas

54 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Polyarteritis Nodosa

55 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Diseases of Veins   Varicose veins - are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg. Veins have pairs of leaflet valves to prevent blood from flowing backwards.veins   Thrombi – blood clots.   Thrombophlebitis- inflammation of veins that causes blood clots.

56 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Varicose Veins

57 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Electrocardiogram Measurement  The quickest and easiest test to check for MI’s is the EKG or ECG. Video Video  It measures the wave of electrical energy through the heart nervous system and muscle. Career link Career linkCareer link

58 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Typical Heartbeat on EKG P-wave - atrial contraction/ depolarization QRS wave – ventricular contraction T wave – repolarization of the ventricles EKG Course Link

59 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Systematic Approach  Rate - How fast is the heart beating?  Rhythm- is the sequence sequential?  Axis- which way is the electrical impulse moving through the heart?  Wave Morphology  P, T, and U waves and QRS complex  Intervals  PR, QRS, QT  ST-T wave/Search for Infarction

60 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Determine the Rate

61 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Determine the Rhythm  Is the rhythm regular or irregular?  What is the atrial rate?  What is the ventricular rate?  Is AV conduction normal?  Are there any unusual complexes?  Is the rhythm dangerous?

62 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

63 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Axis  Find the quadrant  Isolate the isoelectric lead  Smallest QRS voltage  Isolate the closest lead  Isolate the vector  Double check your findings

64 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

65 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Morphology – What do the waves look like and how long do they last?  P waves - small beginning of beat  QRS Complexes – ventricle depolarization  ST segments- ventricle contraction; key signature of a MI  T waves- ventricle repolarization

66 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. EKG Changes  Positive EKG is single most important lab test in the diagnosis of AMI:  Location  Stage  Extent  ST elevation – transmural injury  Q waves – transmural necrosis  T wave changes – hyperacute=peaked

67 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

68 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

69 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Composition of Blood  Plasma - a liquid suspending other blood components  Red blood cells - (erythrocytes) carries oxygen to the body’s cells and carbon dioxide away.  White blood cells - (leukocytes) fights disease and foreign invaders and, alone, contain cell nuclei.  Platelets – (thrombocytes) aids in blood clotting and the repair of damaged blood vessels. 69

70 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Composition of Blood 70

71 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Composition of Blood A bag containing one unit of fresh frozen plasma

72 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

73 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Forensic Serology Serology Serology – involves the study of body fluids and stains at a crime scene, particularly blood. If blood contains DNA matching: It could link a suspect to a scene It can prove a link between suspect, victim and crime 2009©Forensic Science Today73

74 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Cellular Components of Blood 2009©Forensic Science Today74

75 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Forensic Science: Blood Basics Fill out worksheet 2009©Forensic Science Today75

76 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 2009©Forensic Science Today76

77 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 2009©Forensic Science Today77

78 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 2009©Forensic Science Today78

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81 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 2009©Forensic Science Today81

82 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 2009©Forensic Science Today82

83 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Discovery of Blood Types  Discovered in 1900 by Karl Landsteiner.  Identifies the presence or absence of particular proteins embedded in the cell.  In 1901, Landsteiner described the A and B proteins found on red blood cells.  The Rh factor (protein) were also identified.  An antibody reaction test is used to identify each blood type. 83

84 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. A and B Proteins 84 42% 12% 3% 43% of the population in the United States

85 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Rh Factor 85 85% of the human population has a protein called RH factor on their red blood cells.

86 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. 86 Rhesus monkeys have an important history with humans and have aided a great deal of medical and scientific research. Rhesus antigens found in their blood enabled doctors to identify the different human blood groups. These primates also preceded humans into space.

87 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Naming of Blood Types  A person’s blood type is based on the presence or absence of the AB and Rh proteins.  The presence of different blood types was not discovered until  Wrong blood = cause clumping = death 2009©Forensic Science Today87

88 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

89 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

90 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Blood Groups Type Antigen Antibody Can Give Blood To Can Get Blood From A B AB O A B A and B Neither A nor B B A Neither A nor B A and B A, ABO, A B, ABO, B AB A, B, O, AB O 90

91 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Blood Donation 91 Video of Type and cross lab Blood donation process video

92 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Antibodies 2009©Forensic Science Today92 Antibodies are Y- shaped proteins secreted by white blood cells that attach to antigens to destroy them. Antigens are foreign molecules or cells that react to antibodies.

93 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Antigen-Antibody Response  Foreign invader is recognized by the immune system and an attack is launched against the invader.  Viruses, bacteria, or red blood cells proteins from a different blood type. 2009©Forensic Science Today93

94 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Agglutination  There are more than 300 known blood group proteins and more than 1 million different protein binding sites on each RBC.  Agglutination animation Agglutination animation Agglutination animation  An antibody reaction to surface proteins on RBC causes agglutination, or clumping, of the cells. 2009©Forensic Science Today94

95 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc. Blood Typing Tests  Blood typing is a way to identify and match blood samples.  Structure and Function of Blood -Video Structure and Function of Blood -Video Structure and Function of Blood -Video 2009©Forensic Science Today95

96 Copyright © 2012, 2006, 2000, 1996 by Saunders, an imprint of Elsevier Inc.  In addition to A, B, and Rh protein, people can have M and N proteins. ABO System MN System ABO System MN System Additional Blood Proteins and Probability TypePercentFraction A42%42/100 B12%12/100 AB3%3/100 O43%43/100 TypePercentFraction MM30%30/100 MN48%48/100 NN22%22/100 TypePercentFraction Rh +85%85/100 Rh -15%15/100 Rh System New Game