4/28/2016

ANATOMY, PHYSIOLOGY, & PATHOPHYSIOLOGY CARDIAC SYSTEM

FOR CODERS

• Understand medical terms • Synthesize clinical findings • Comprehensive view of patient care • See problems and procedures in your mind’s eye

1 4/28/2016

ANATOMY • Chambers • Valves • Conduction System • Cardiac Circulation

HEART CHAMBERS

"Diagram of the human heart (cropped)" by Own work. Licensed under CC BY‐SA 3.0 via Commons ‐

2 4/28/2016

HEART CHAMBERS • Left Ventricle ▫ Pumps blood to body (high resistance) ▫ More muscular ▫ Pressure 120mmHg systolic, 0‐10mmHg diastolic • Right Ventricle ▫ Pumps blood to lungs (low resistance) ▫ Less muscular ▫ Pressure <25mmHg systolic, <5mmHg diastolic

HEART CHAMBERS

"Heart ant wall infarction" by Patrick J. Lynch, medical illustrator ‐ Patrick J. Lynch, medical illustrator. Licensed under CC BY 2.5 via Commons ‐

3 4/28/2016

HEART CHAMBERS • Right Atrium ▫ Receives blood from body (SVC&IVC) ▫ Fills riihtght ventiltricle ▫ Site of sinoatrial node ▫ Central line/Pacemaker placement • Left Atrium ▫ Receives blood from lungs ▫ Fills left ventricle ((atrial“atrial kick”) ▫ Potential site for clot formation

HEART CHAMBERS

• Atrial Action ▫ Prefill Ventricles ▫ Frank‐Starling Law ▫ “Atrial Kick”

• Ventricular ▫ Relaxation = diastole ▫ Contraction = systole

4 4/28/2016

HEART VALVES

"2011 Heart Valves" by OpenStax College ‐ Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.. Licensed under CC BY 3.0 via Commons

HEART VALVES

• Stenosis (narrowing) ▫ Ventricles can’ t fill (mitral, tricuspid) ▫ Ventricles can’t empty (aortic, pulmonic) ▫ = poor cardiac output • Regurgitation/Insufficiency (leaking) ▫ Wasted ventricular effort (aortic, pulmonic) ▫ Duplicated ventricular effort (mitral, tricuspid) ▫ = poor cardiac output

5 4/28/2016

AORTIC INSUFFICIENCY

• Aortic backflow wastes effort • Overfills left ventricle • Impairs inflow from left atrium

"Blausen 0039 AorticRegurgitation" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. ‐ Own work. Licensed under CC BY 3.0 via Commons

MITRAL STENOSIS

• Left ventricular cannot fully fill • Causes: ▫ Rheumatic fever ▫ Calcification ▫ Endocarditis

"Blausen 0648 MitralValveStenosis" by Blausen Medical Communications, Inc. ‐ Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

6 4/28/2016

MITRAL STENOSIS

AORTIC STENOSIS

• Left ventricular cannot fully empty • Causes: o Hypertension o Cholesterol o Diabetes o Endocarditis

"Blausen 0040 AorticStenosis" by BruceBlaus ‐ Own work. Licensed under CC BY 3.0 via

7 4/28/2016

AORTIC STENOSIS

VALVULAR DISEASE TREATMENT

• Stenosis ▫ Balloon valvuloplasty ▫ Valve replacement • Insufficiency ▫ Valve replacement ▫ Valve repair

8 4/28/2016

BALLOON VALVULOPLASTY

"Blausen 0889 MitralValvuloplasty" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

VALVE REPLACEMENT

"Mechanical heart valves" by Z22 - Own work. Licensed under CC BY-SA 4.0 via Commons

9 4/28/2016

CONGENITAL DEFECTS ‐ ASD

VENTRICULAR SEPTAL DEFECT

10 4/28/2016

SEPTAL DEFECT REPAIR

SEPTAL DEFECT PLUG

11 4/28/2016

BLUE BABY SYNDROME

BLUE BABY SYNDROME • Blalock‐Taussig Shunt

"Blalock shuntWiki" by Pezard - Own work. Licensed under CC BY-SA 3.0 via Commons

12 4/28/2016

BLUE BABY SYNDROME

• Vivien Thomas • Assistant to Dr. Alfred Blalock • Primarily developed Blalock‐Taussig techniques • Job title and pay: janitor • Honorary doctor 1976

HEART FAILURE • = Cardiac output which is insufficient for the needs of the body. • Systolic – decreased ejection fraction ▫ Failure of pumping action • Diastolic –normal ejection fraction ▫ Failure of filling action • Congestive ▫ Venous return (preload) exceeds cardiac output

13 4/28/2016

HEART FAILURE • Causes –any acute or chronic condition which insults, stresses, or damages myocardium: ▫ Hypertension ▫ Valvular disease ▫ Ischemic disease ▫ Myocardial infarction ▫ Cardiomyopathy ▫ Myocarditis

HEART FAILURE • Normal end‐diastolic volume 140ml • Normal ejection fraction >50% • Normal stroke volume >70ml • Systolic heart failure ▫ EDV 140ml ▫ EF 25% ▫ SV 35ml • Diastolic heart failure ▫ EDV 70ml ▫ EF 50% ▫ SV 35ml

14 4/28/2016

HEART FAILURE • Symptoms ▫ Dyspnea ▫ Tiredness ▫ Swelling • Treatment ▫ Diuretics (furosemide) ▫ Decrease vascular resistance (ACEI’s) ▫ Cardiac stimulants (digoxin)

CONGESTIVE HEART FAILURE

"Elevated JVP" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons"Combinpedal" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons

15 4/28/2016

CONGESTIVE HEART FAILURE

"Pulmonaryedema09" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons

CONDUCTION MECHANISM • Specialized, conductive heart cells • Not nerves • Sinoatrial node –primary pacemaker • Atrioventricular node –relay station, 2nd pacemaker • Right bundle branch • Left bundle branch ▫ Left anterior branch/fascicle ▫ Left posterior branch/fascicle

16 4/28/2016

CONDUCTION MECHANISM

"ConductionsystemoftheheartwithouttheHeart-en" by Madhero88 (original files); Angelito7

CONDUCTION MECHANISM

17 4/28/2016

CONDUCTION MECHANISM • Electrocardiogram (EKG)

CONDUCTION MECHANISM

• 12‐lead EKG • Axis of conduction

"EKG leads" by Npatchett - Own work. Licensed under CC BY-SA 4.0 via Commons -

18 4/28/2016

CONDUCTION MECHANISM

CONDUCTION PROBLEMS • Atrial Fibrillation • Atrioventricular Blocks ▫ 1st, 2nd, 3rd degree • Bundle Branch Blocks • Left, right, bifascicular, left hemi • Re‐entrant pathways

19 4/28/2016

ATRIAL FIBRILLATION

"Atrial Fibrillation" by BruceBlaus - Own work. Licensed under CC BY-SA 4.0 via Commons –

ATRIAL FIBRILLATION

20 4/28/2016

ATRIAL THROMBUS

ATRIAL THROMBUS

• Source of embolic CVA • Treated with anticoagulants

21 4/28/2016

HEART CONDUCTION BLOCKS • AV Blocks ▫ 1st degree –delay ▫ 2nd degree – missed conductions ▫ 3rd degree –total lack of conduction • Bundle Blocks ▫ 1, 2, or 3 fascicles (bundles) blocked ▫ Conduction becomes incidental ▫ Contraction is less organized

HEART BLOCKS

• 1st Degree

• 2nd Degree

• 3rd Degree

22 4/28/2016

Wolf‐Parkinson‐White Syndrome

CORONARY CIRCULATION

Blausen 0260 CoronaryVessels Anterior" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

23 4/28/2016

CORONARY CIRCULATION

Blausen 0260 CoronaryVessels Anterior" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

CORONARY CIRCULATION Latin “corona” = crown

"Blausen 0256 CoronaryArteries 02" by BruceBlaus - Own work. Licensed under CC BY 3.0 via Commons -

24 4/28/2016

CORONARY CIRCULATION

• Left (main) ▫ Left anterior descending ▫ Circumflex ▫ Left marginal • Right ▫ Posterior descending ▫ Right marginal • Fill during diastole

"Blausen 0256 CoronaryArteries 02" by BruceBlaus - Own work. Licensed under CC BY 3.0 via Commons

CORONARY ARTERY DISEASE • Arteriosclerosis = hardening of artery walls ‐> hypertension , etc. • Atherosclerosis = plaque buildup and narrowing ‐> stenosis, obstruction • Often used interchangeably, or “CAD” • ICD‐10 index prefers “arteriosclerosis” • ICD‐10 tabular prefers “atherosclerosis”

25 4/28/2016

ATHEROSCLEROSIS

"Blausen 0257 CoronaryArtery Plaque" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

ATHEROSCLEROSIS

• Plaque made of ▫ Fat/Cholesterol ▫ Inflammatory tissue ▫ WBCs ▫ Calcium • Plaque caused by: ▫ Fat, smoking, alcohol, sedentary lifestyle

"Atherosclerosis disease progression" by Npatchett ‐ Created by uploading user in Gimp based on a public domain image created by the US federal government. Licensed under CC BY‐SA 3.0

26 4/28/2016

ATHEROSCLEROSIS

• % occlusion equals % of plaque cross‐section

• “80% occlusion proximal LAD”

"RCA atherosclerosis" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Commons

ATHEROMA • Carotid endarterectomy, at bifurcation

"Carotid Plaque" by Ed Uthman. Licensed under CC BY 2.0 via Commons

27 4/28/2016

ATHEROSCLEROSIS

• Disease Progession: • Fatty streak • Atherosclerosis • Angina (+/‐ spasm) • Unstable angina • Myocardial infarction

• Microangiopathy (capillary disease)

ANGINA • Angina Pectoris • Latin “angere” = “to strangle” • Narrowing of coronary artery ▫ Atherosclerosis ▫ Spasm ▫ Stenosis • Oxygen starvation (()ischemia) of myocardium

28 4/28/2016

ANGINA

• Vagus innervation • Referral common • Degree of pain not necessarily degree of ischemia

"Angina pectoris" by Ian Furst - Own work derivative of File:Aorta scheme.jpg and File:Gray1220.png. Licensed under CC BY-SA 3.0 via Commons

ANGINA • (stable) “Angina” ▫ Increased cardiac oxygen demand ▫ On exertion, stress, stimulants, etc. ▫ Relieved by rest, vasodilators • “Unstable angina” ▫ Borderline oxygen supply ▫ At rest, severe, prolonged, unabated by rest ▫ May evolve into MI ▫ May require PTCA, CABG

29 4/28/2016

ANGINA vs. ACUTE CORONARY SYNDROME • Angina ▫ Patient flfeels it ▫ No damage • Acute coronary syndrome ▫ Spectrum of USA, NSTEMI, STEMI ▫ Dysfunction of or damage to myocardium

MYOCARDIAL INFARCTION • Ischemia = oxygen starvation • Infarction = tissue death • Atherosclerosis • Clot ▫ Inflammation ▫ Embolization ▫ Hypercoagulability ▫ Happenstance

30 4/28/2016

MYOCARDIAL INFARCTION

"Blausen 0463 HeartAttack" by Blausen Medical Communications, Inc. ‐ "Heart ant wall infarction" by Patrick J. Lynch, medical illustrator ‐ Patrick Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons J. Lynch, medical illustrator. Licensed under CC BY 2.5 via Commons

MYOCARDIAL INFARCTION • “STEMI” = ST Elevation MI ▫ Severe, complete, or permanent blockage ▫ Full‐thickness of myocardium dies • “NSTEMI” = Non‐ST Elevation MI ▫ AKA “nontransmural”, “subendocardial” ▫ Mild, partial, or temporary blockage ▫ Partial thickness of myocardium dies

31 4/28/2016

MYOCARDIAL INFARCTION • Normal

• STEMI

NSTEMI • NSTEMI ▫ Normal EKG or certain abnormalities ▫ Elevated Troponin T ▫ Elevated CK/MB fraction

32 4/28/2016

CORONARY INTERVENTIONS

• Dissolve clot ▫ Thrombolytics • Open stenosis ‐ PTCA • Bypass stenosis ▫ CABG

"Blausen 0259 CoronaryArteryDisease 02" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

PTCA

• Usually with stent • Bare metal • Drug eluting ▫ Anticoagulant drug

33 4/28/2016

CABG

"Blausen 0151 CABG 02" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

CONCLUSION

"Apikal4D" by Kjetil Lenes - Own work. Licensed under CC BY-SA 3.0 via Commons

34