HMM 4401– Cardiovascular Diseases

HMM 4401– Cardiovascular diseases

Ett sykehus - nær deg og dine Hanne Thürmer PhD, MD, Specialist internal medicine Cardiology interest and practice Physician at Blefjell Hospital

Ett sykehus - nær deg og dine Ringerike

Buskerud og Telemark

Nore og Uvdal Blefjell Sykehus:

Tinn Sigdal Rollag Kongsberg Vinje 50.000 innb. Flesberg Drammen Øvre Hjartdal Eiker Notodden Notodden 35.000 innb. Seljord Kongs- Sau- berg Kvites- Rjukan Tokke Bø herad eid 13.000 innb. Nome

Skien Mission

Municipalities Blefjell hospital is a community hospital caring for the Kongsberg inhabitants of 16 municipalities. Sigdal

Rollag Blefjell hospital offers emergency and elective care and diagnostics in internal medicine, psychiatry, orthopedics and general surgery. Øvre Eiker Gynecological and obstetric services are differentiated between the Flesberg three units; Kongsberg, Notodden and Rjukan. Nore og

Private practice specialists offer services in eye diseases, ear, nose and Uvdal throat diseases, pediatrics etc. Notodden Diagnostic services to in- and outpatients include clinical labs, X-ray departments, physical therapy and a patient support unit (LMS) Nome Bø

Sauherad

Tinn

Hjartdal

Seljord

Kviteseid

Tokke

Vinje Admissions to inpatient hospital, > 70 yrs

Main diagnoses Blefjell hospital, all dep Patient admissions

Cancer and cancer related 500

Cardiovascular 1500

Lung, COPD 600

Digestion, hepatology 500

Gynecology, urology 300

Trauma 800

Cerebrovascular disease 460 Main cardiovascular diseases!

• Atherosclerosis • Hypertension • Ischaemic Heart Disease • Angina • Stable Angina • Unstable Angina • Myocardial Infarction • Heart Failure • Cerebrovascular Accident • Peripheral vascular disease Who are you? Function of the cardiovascular system

• What is the best metaphor for the heart?

• What is the best metaphor for the blood vessels?

• What is the best metaphor for the blood? Function of the heart

• What is the best metaphor for the heart?

• ????? Function of the heart

• What is the best metaphor for the heart? • Pump, pressure regulator, stressor, hormone producer The heart

Wall of muscle Cavities Valves Coronary arteries Aorta Vena Cava Lung arteries Lung veins Make a fist!! The heart

Wall of muscle Cavities Valves Coronary arteries Aorta Vena Cava Lung arteries Lung veins Function of the blood vessels

• What is the best metaphor for the blood vessels?

• ????? Function of the vessels

• What is the best metaphor for the blood vessels? • Rivers, roads, telephone wires, fish net, irrigation system Blood vessels

•Arteries from the heart •Veins to the heart •Capillaries supply oxygen and nutrients, collect carbondioxide and waste •Capillaries in lung collect oxygen and deliver carbondioxide •Two separate circulations with cross-over Blood pressure

• When heart contracts blood pressure is at its highest, this is the systolic blood pressure • When heart relaxes, elastic forces prevent blood pressure from dropping to 0, the lowest level before the next beat is diastolic blood pressure • Blood pressure is described with highest and lowest number, ie 120/80, 150/90 • Unit is mmHg or mm Mercury • kPa is the SI-unit, still not widely used Measure your own blood pressure

• Old fashioned method, still widely used • Measure your own, then each others BP • Do some exercise, measure again • Uncertainty?? • Each 5 mmHg change in indication may be 50-100 million NOK Function of the blood

• What is the best metaphor for the blood?

• ????? Function of the blood

• What is the best metaphor for the blood? • Grape juice, coca cola, coke with parcels, coke with fish? Blood Blood Function of the cardiovascular system

• What is the best metaphor for the heart? • Pump

• What is the best metaphor for the blood vessels? • irrigation system

• What is the best metaphor for the blood? • coke with fish?

• Pump and regulator, pumping thick fluids with solid particles in a closed system Function of the cardiovascular system

• Supply oxygen to the body • Rid the body of waste products

• Lungs supply oxygen • Digestion supply nutrients • Liver and kidneys detoxify • Lungs exhale carbondioxide

• Closed system, blood stays in blood vessels Function of the cardiovascular system

• Supply oxygen to the body • Rid the body of waste products

• Lungs supply oxygen • Digestion supply nutrients • Liver and kidneys detoxify • Lungs exhale carbondioxide

• Closed system, blood stays in blood vessels Function of the cardiovascular system

• Supply oxygen to the body • Rid the body of waste products

• Lungs supply oxygen • Digestion supply nutrients • Liver and kidneys detoxify • Lungs exhale carbondioxide

• Closed system, blood stays in blood vessels Main cardiovascular diseases?

• Disease of the muscular arteries (not veins) • coronary • cerebral vessels • Progressive deposition of cholesterol esters • Accounts indirectly for half of annual mortality • Ischaemic heart disease MI • Cerebrovascular disease Stroke What is atherosclerosis?

• Blood vessels clog up • Injured vessel stimulate clotting • Slow flow enhance clot formation • Slow and fast occlusion • Heart infarction • Angina pectoris • Stroke • Leg and kidney circulation Heart

• Too

What is atherosclerosis? What is atherosclerosis, step by step How is CABG done? Atherosclerosis comes before disease

• Angina pectoris (where is the sclerosis?) • Kidney disease ? • Stroke ? • Heart attack ? • Heart attack, High blood pressure leads to • Heart failure • Aneurysms • Heart failure leads to • Disability, nursing home, need for caretaker • Heart transplantation Main symptoms of angina or infarction

• Chest discomfort—pressure, squeezing, fullness, or pain in center of chest • Discomfort in one or both arms, back, neck, jaw, or stomach • Shortness of breath, may come before or with chest discomfort • Breaking out in a cold sweat • Nausea • Light-headedness What Is a Heart Attack Really Like?

• Heart attacks often begin with vague symptoms that slowly intensify. • Pain or discomfort can be relatively mild. • Symptoms may come and go. • Variety of symptoms may signal danger.

Only sometimes is heart attack or heart infarction dramatic! • Crushing chest pain • Sudden, intense, falls to the floor—like in the movies Angina and heart attack

• 113 • Ambulance – with prehospital thrombolysis • Hospital with 24 hour PCI service • Stents of platinum, covered in gold (10-15 000 each) • CABG if extensive disease • Often recurrent disease Extensive part of medical departments and outpatient • Exercise testing • Angiography • Medication to prevent disease Atherosclerosis comes before disease

• Think FACES... • Fatigue • Activities limited • Chest congestion • Edema or ankle swelling • Shortness of breath

• Blue bloater or pink puffer!! What makes a good /bad pump?

• Pressure • Normal blood pressure is … • Shock is …. • High blood pressure is above…. • Volume per beat • Stroke volume is about… • Minute volume is about… • Frequency of beats • Resting pulse is about…. • Maximum pulse is about … • Viscosity and volume of pumped fluid What makes a good/bad pump?

• Pressure • Normal blood pressure is 120/80 (mm Hg) • Shock is pressure too low to perfuse organs (brain, kidneys) • High blood pressure is above 140/90, depending on age • Volume per beat • Stroke volume is about 60-100 ml per beat • Minute volume is about 4-20 liters/minute • Frequency of beats • Resting pulse is about 60-80 beats per minute • Maximum pulse is about 220 minus age (180 beats per minute) • Viscosity and volume of pumped fluid • Dehydration, blood clots in large vessels, emboli from fat, air, IV drugs Heart disease can give arrhytmias

• Too slow - bradycardia • Too fast - tachycardia • Too irregular –flutter, flimmer • Life threatening – heart starters in every shopping centre What makes a good rhytm?

Electric currency in wiring Cords can break, switches disconnect, fuses blow Many reserve pacemaker in the heart, stop is rare Some are pacemaker dependent, turn off the pacemaker and they die. Cardiology is technology intensive

• Measurements • X-ray, Ekko-doppler, ECG, brain scans, MRI, PET • Decision trees • Algorithms • Evidence based medication • Small increments in benefit • Large increases in costs • High status disease – but hits low status people • Developing world – will be #1 killer • Developed world, - higher age groups Heart diagnostics

• ECG - electrocardiogram Life threatening arrytmias – ICD (0,4 Mill)

• Decision tree Heart death survivors Risk factors abound – life style

• Too Heart disease risk factors

• Smoking • Smoking • Smoking • Smoking • Smoking • Smoking • Genetics • Lipids • Exercise Heart

• Too Cholesterol and fat

• Too Prevention costs, and saves?

• Too Drugs over time, DDD Main killer and disabler

• 50% of all deaths, 50% of acute admissions to hospital • Norway: 14 500 deaths of cardiovascular causes • 7 300 deaths from ischemic heart disease • 12-15 000 suffer from a heart attack /year • Falling mortality; particularly in the 1990’s • Stroke also decreasing, still major killer • Men die 10 years earlier than women • “Smoking women = non-smoking man” • Medications to prevent = 2,8 billion NOK /year Mortality is decreasing

Ischemic heart disease mortality, men and women, 1951 - 2002

• Peak mortality 1960 • Men > women • Causes?? Sale of cholesterol lowering drugs, DDD

1,1 billion NOK /year Cost effect analyses

• Cost minimization: • Cheapest method if same effect, • Benefit is not part of analyses • Cost effectiveness: • Cost for single effect • NOK/ mmHg, /year saved, /avoided heart attack • Cost utility • Standardized effect; DALY eller QALY • NOK/ DALY/QALY • Cost-benefit • All is money • Estimate profitability Disease costs more than direct costs Heart transplantation (>1 mill)

• Strong indications and absence of contraindications • Lack of donors Clinical services

• Internal medicine in general hospital • Cardiology department • Cardiovascular surgery department • Intensive care or cardiac care units • Team work with radiology, perfusionist, surgeon and cardiologist + intensive care nurses, physiotherapy etc. • Heart rehabilitation institutions • Patient organizations Future advances

• Even more specific and costly lifestyle drugs • Genetic therapy • Infection/Antibiotic theories • 24 hours service within 1 hour from start of symptoms • Ambulance and air lift planning • Decentralized high specialized care • Reversal of the big hospital in big cities theorem? • Thrombolysis of stroke, invasive stroke care? • Tailor made prevention – genetic testing Summary

• Cardiovascular disease is a “world wide” disease • Life style and genetic causes • Prevention, treatment, secondary prevention, retreatment is possible, but costly • Chronic disease • Economics play major role • Men > women, middle age and older • High visibility of care and patients • 1 of 3 in this class room will experience CV disease