1. Chapter 19 Disorders of Cardiac Function
Essentials of Pathophysiology
Chapter 19 Disorders of Cardiac Function

2. PRE-LECTURE QUIZ F T
Pericarditis represents an inflammatory process of the myocardium.
All types of angina represent an acute myocardial infarction, also known as a heart attack.
The heart extracts and uses 60% to 80% of the oxygen in blood flowing through the coronary arteries.
Atherosclerosis is by far the most common cause of coronary heart disease.
Stable atherosclerotic plaques tend to rupture more than unstable atherosclerotic plaques and lead to acute coronary syndromes, ranging from unstable angina to ST-segment elevation myocardial infarction.

3. PRE-LECTURE QUIZ
 Cardiac __________ is a life-threatening, slow or rapid compression of the heart due to the accumulation of fluid, pus, or blood in the pericardial sac.
Rheumatic heart disease, a disorder that follows a group A _____________ throat infection, is of great concern because of the potential effects of chronic valvular disorders that produce permanent cardiac dysfunction and sometimes fatal heart failure years later.
__________ refers to a narrowing of the valve orifice and failure of the valve leaflets to close properly. 
Creatine kinase, myoglobin, and troponin are known as serum cardiac __________ and are useful for acute myocardial infarction determination and classification.
Coronary heart disease is a disorder of impaired __________ blood flow, usually caused by atherosclerosis.
corornary
Markers
Stenosis
Streptococcal
Tamponade

4. Disorders That Affect the Whole Heart
Pericardial disorders
Coronary heart disease
Myocardial diseases
These disorders can cause symptoms of both right- and left-sided heart failure

5. The Pericardium Surrounds the Heart

6. Inflammation of the pericardium causes:
Pericarditis
Inflammation of the pericardium causes:
Pain
Exudate
Serous  pericardial effusion
Cardiac tamponade: rapid accumulation of exudate compresses the heart
Fibrous  friction rub; adhesions
ECG changes

7. Pericarditis (cont.)
Inflammation of the pericardium may restrict the heart’s movement due to:
Serous exudate filling the pericardial cavity (pericardial effusion)
Fibrous scar tissue making the pericardium stick to the heart (constrictive pericarditis)

8. Consequences of Pericardial Effusion
fluid in pericardial
Consequences of Pericardial Effusion
cavity
restricts heart
expansion
left ventricle
right ventricle
cannot accept
cannot accept
enough blood
enough blood
decreased
increased venous
cardiac
pressure; jugular
output
distension
decreased blood
pressure and
shock

9. Question
What is the immediate treatment for severe cardiac tamponade?
Oxygen
Cardiac drugs
Surgery
Pericardiocentesis (removal of fluid from the sac with a needle)

10. Inflammation of the pericardium causes:
Pericarditis
Inflammation of the pericardium causes:
Pain
Exudate
Serous  pericardial effusion
Cardiac tamponade: rapid accumulation of exudate compresses the heart
Fibrous  friction rub; adhesions
ECG changes

11. Pericarditis (cont.)
Inflammation of the pericardium may restrict the heart’s movement due to:
Serous exudate filling the pericardial cavity (pericardial effusion)
Fibrous scar tissue making the pericardium stick to the heart (constrictive pericarditis)

12. Consequences of Pericardial Effusion
fluid in pericardial
cavity
Consequences of Pericardial Effusion
restricts heart
expansion
left ventricle
right ventricle
cannot accept
cannot accept
enough blood
enough blood
decreased
increased venous
cardiac
pressure; jugular
output
distension
decreased blood
pressure and
shock

13. (removal of fluid from the sac with a needle)
Question
What is the immediate treatment for severe cardiac tamponade?
Oxygen
Cardiac drugs
Surgery
Pericardiocentesis
(removal of fluid from the sac with a needle)

14. Answer
Pericardiocentesis (removal of fluid from the sac with a needle)
Rationale: In severe cardiac tamponade, there is so much fluid in the pericardial sac compressing the heart that its function declines rapidly. The fluid must be removed quickly by inserting a needle into the pericardial space and aspirating the accumulated fluid.

15. Pulsus Paradoxus
On inhaling, the right ventricle fills with extra blood
When the right ventricle is overfilled, the left ventricle is compressed and cannot accept much blood. Because the heart cannot fully expand
On the next heartbeat, the left ventricle does not send out much blood: systolic BP drops

16. Coronary Heart Disease
Atherosclerosis blocks coronary arteries
Ischemia may cause:
Angina
Heart attack
Cardiac arrhythmias
Conduction deficits
Heart failure
Sudden death

17. Plaque/Thrombus Formation

19. Chronic Ischemic Heart Disease
Imbalance in blood supply and the heart’s demands for oxygen
Less blood
Atherosclerosis
Vasospasm
Thrombosis
Higher oxygen demand
Stress
Exercise
Cold

21. Kinds of Angina Stable angina
Pain when heart’s oxygen demand increases
Variant angina
Pain when coronary arteries spasm
Silent myocardial ischemia
Myocardial ischemia without pain

22. Acute Coronary Syndromes
ECG changes
T-wave inversion
ST-segment depression or elevation
Abnormal Q wave
Serum cardiac markers
Proteins released from necrotic heart cells
Myoglobin, creatine kinase, troponin

23. Question
Tell whether the following statement is true or false. Chronic ischemic heart disease is more likely to result in stable angina than acute coronary syndromes.

24. Answer
True Rationale: Ischemic heart disease is characterized by stable angina, which is associated with plaques that are fixed obstructions. Unstable angina is characterized by plaques with platelets stuck to them (these are likely to form a thrombus)—they cause a range of acute coronary syndromes.

25. Acute Myocardial Infarction
Chest pain
Severe, crushing, constrictive, OR like heartburn
Sympathetic nervous system response
GI distress, nausea, vomiting
Tachycardia and vasoconstriction
Anxiety, restlessness, feeling of impending doom
Hypotension and shock
Weakness in arms and legs

26. An Acute MI (AMI) Leaves Behind an Area of Yellow Necrosis

27. Complications of AMI Heart failure Cardiogenic shock Pericarditis
Thromboemboli
Rupture of the heart
Ventricular aneurysms

28. Malfunctioning Heart Muscle
Malfunctioning heart muscle can cause heart failure if:
Ventricles are unusually thick so there is not a normal amount of room for blood inside them (hypertrophic cardiomyopathy)
Ventricles are too stiff to stretch (restrictive cardiomyopathy)
Ventricles are too weak to pump out the blood that is in them (MI, myocarditis, dilated cardiomyopathy)

29. Myocardial Disorders Myocarditis Cardiomyopathies
Dilated cardiomyopathies
Hypertrophic cardiomyopathies
Restrictive cardiomyopathies
Peripartum cardiomyopathy

30. Hypertrophic Cardiomyopathy
Defects in their contractile proteins make cells too weak
They hypertrophy to do the same amount of work as normal cells
Need more oxygen and perform less efficiently, so the person is prone to heart failure and may suffer sudden death during exertion

31. Question
Which type of cardiomyopathy is characterized by weakened ventricles?
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Peripartum cardiomyopathy

32. Answer
Dilated cardiomyopathy
Rationale: In dilated cardiomyopathy, the ventricles are too weak to pump blood, resulting in a diminished cardiac output (CO). The other types listed are caused by thick ventricles, stiff ventricles, or LV dysfunction in late pregnancy or postpartum, respectively.

33. Valvular Disorders and Heart Defects
By interfering with normal blood flow, these often cause the signs and symptoms of left- or right-sided heart failure
body
right
left
heart
heart
lungs

34. The Endocardial Structures
The endocardial structures lining the heart can cause heart failure
If the AV valves leading into the ventricles do not work (mitral or tricuspid problems)
If the semilunar valves leading out of the ventricles do not work (aortic or pulmonary problems)

35. Arrange these steps in the proper order:
Cardiac Cycle
Discussion:
Arrange these steps in the proper order:
– Ventricles relax – First heart sound
– Start Systole – Semilunar valves open
– End Diastole – AV valves close
– AV valves open – Semilunar valves close
– Ventricles contract – Second heart sound 6 4 1 5 10 3 9 7 2 8

36. Valve Defects Each of the four valves can be defective
Stenosis: valve will not open all the way; it is harder to force blood through it
Regurgitation: valve will not close all the way; it leaks when it should be closed
Also called valvular insufficiency

37. Question
Tell whether the following statement is true or false. Mitral valve regurgitation results in a diminished stroke volume.

38. Answer
True Rationale: If the mitral valve does not close as it should, a portion of the stroke volume (amount of blood ejected by the ventricle/beat) leaks back into the left atrium, decreasing the amount of blood that is ejected during that beat (SV).

39. Discussion Defects in which valves might cause:
Severe dependent edema?
Paroxysmal nocturnal dyspnea?
Congested liver?
Distended jugular veins?
Productive cough with frothy sputum?

40. Identifying Defective Valves
The blood going through the valve makes a noise
These are called heart murmurs
You can identify them by:
Where they are—which valve are they near?
How they sound—high- or low-pitched?
When they happen—systole or diastole?

41. When Will You Hear Murmurs?
If a valve is stenotic, you will hear a murmur of blood shooting through the narrow opening when the valve is open
If a valve is regurgitant, you will hear a murmur of blood leaking back through when the valve should be closed

42. Left-sided Valvular Disorders
Mitral valve disorders
Mitral valve stenosis
Mitral valve regurgitation
Mitral valve prolapse
Aortic valve disorders
Aortic valve stenosis
Aortic valve regurgitation

43. Valvular Disorders Mitral Regurgitation Aortic Valve Stenosis
Part of SV goes back into the LA
Heart has to work harder to meet body needs
LV hypertrophy
Aortic Valve Stenosis
Aortic valve is constricted
Difficult to pump blood from the LV
LV hypertrophy
Mitral Stenosis
Incomplete LV filling
Lower CO
Aortic Regurgitation
Blood flows backward into the LV from the Aorta
LV Dilatation

44. Congenital Heart Defects
Atrial septal defects
Ventricular septal defects
Endocardial cushion defects
Patent ductus arteriosus
Pulmonary stenosis
Tetralogy of Fallot
Transposition of the great vessels
Coarctation of the aorta

45. Shunts
A shunt is an opening or connection that lets blood move from one side of the circulation to the other
Most shunts occur in the heart and move blood either from the left to the right or from the right to the left
Because the left side is stronger, blood is usually pushed from the left to the right side

46. Shunts (cont.) Shunts are normal before birth Foramen ovale
Lets blood go from the right atrium to the left atrium to bypass the lungs
Ductus arteriosus
Lets blood go from the pulmonary trunk to the aorta to bypass the lungs
Ductus venosus
Lets blood go from the visceral veins to the vena cava, bypassing the liver

47. body left right heart heart lungs Less blood goes to body
Left-to-right Shunt
Less blood goes to body
body
right
left
Blood moves from left to right
heart
heart
More blood goes to lungs
lungs

48. body left right heart heart lungs Deoxygenated blood goes to body
Right-to-left Shunt
Deoxygenated blood goes to body
body
right
Blood moves from right to left
left
heart
heart
Less blood goes to lungs
lungs

49. body left right heart heart lungs Discussion
Show how the diagram would look for:
Patent ductus arteriosus
body
right
left
heart
heart
lungs

50. body left right heart heart lungs Discussion
Show how the diagram would look for:
Transposition of the great vessels
body
right
left
heart
heart
lungs

51. body left right heart heart lungs Discussion
Show how the diagram would look for:
Tetralogy of Fallot
body
right
left
heart
heart
lungs