Chapter 30
Alterations of Cardiovascular
Function
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Overview
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Leading cause of disease
Genetic, neurohumoral, and inflammatory
mechanisms
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Underlie tissue and cellular processes
• Endothelial injury, remodeling, stunning, reperfusion
injury, and autoimmune disease
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Diseases of the Veins
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Varicose veins
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A vein in which blood has pooled
Distended, tortuous, and palpable veins
Cause: trauma or gradual venous distention
Chronic venous insufficiency
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Inadequate venous return over a long period due
to varicose veins, valvular incompetence
Venous stasis ulcers
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Diseases of the Veins
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Deep venous thrombosis (DVT)
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Obstruction of venous flow leading to increased
venous pressure
Factors
• Venous stasis
• Venous endothelial damage
• Hypercoagulable states
Post-thrombotic syndrome
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Diseases of the Arteries and
Veins
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Thrombus formation
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Blood clot that remains attached to the vessel wall
Thromboembolus
Thrombophlebitis
Arterial thrombi
Venous thrombi
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Diseases of the Arteries and
Veins
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Aneurysm
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Local dilation or outpouching of a vessel wall or
cardiac chamber
True aneurysms
• Fusiform aneurysms
• Circumferential aneurysms
False aneurysms
• Saccular aneurysms
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Aneurysm
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Aneurysm
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Diseases of the Arteries
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Embolism
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Bolus of matter that circulates in the bloodstream,
then lodges, obstructing blood flow
• Dislodged thrombus (often DVT), air bubble, amniotic
fluid, aggregate of fat, bacteria, cancer cells, or a foreign
substance
• Many arterial emboli are from the heart

Post myocardial infarction (MI), valve disease,
endocarditis, dysrhythmias, heart failure
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Peripheral Artery Disease (PAD)
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Atherosclerotic disease of arteries that
perfuse the limbs, especially lower
extremities
Affects 12 million people
Risk factors same as atherosclerotic disease
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Especially prevalent in individuals with diabetes
Often asymptomatic
Intermittent claudication
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Obstruction of arterial blood flow in the iliofemoral
vessels resulting in pain with ambulation
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Peripheral Artery Disease
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Thromboangiitis obliterans (Buerger disease)
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Occurs mainly in young men who smoke
Inflammatory disease of peripheral arteries
resulting in nonatherosclerotic lesions
• Digital, tibial, plantar, ulnar, and palmar arteries
Obliterates the small- and medium-sized arteries
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Peripheral Artery Disease
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Thromboangiitis obliterans (Buerger disease)
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Causes pain, tenderness, and hair loss in the
affected area
Symptoms are caused by slow, sluggish blood
flow
Can often lead to gangrenous lesions
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Peripheral Artery Disease
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Raynaud phenomenon and Raynaud disease
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Episodic vasospasm (ischemia) in arteries and
arterioles of the fingers, less commonly the toes
Raynaud phenomenon is secondary to other
systemic diseases or conditions
• Collagen vascular disease (scleroderma), smoking,
pulmonary hypertension, myxedema, and environmental
factors (cold and prolonged exposure to vibrating
machinery)
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Raynaud disease is a primary vasospastic
disorder of unknown origin
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Hypertension
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Prehypertension 120-139/80-90
Hypertension
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Sustained elevation of 140/90 or higher
Primary hypertension
• Essential or idiopathic hypertension
• Genetic and environmental factors
• Affects 90% to 95% of individuals with hypertension
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Risk Factors for Hypertension
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Family history
Advancing age
Gender: female <55; male >74
Black race
Na+
Glucose intolerance
Heavy alcohol use
Obesity
Cigarettes
K+, Mg++, Ca++
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Primary Hypertension
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Hypertension
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Secondary hypertension
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Isolated systolic hypertension
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Caused by systemic disease that raises peripheral
vascular resistance/cardiac output
Elevations of systolic pressure caused by
increases in cardiac output, total peripheral
vascular resistance, or both
Complicated hypertension
Malignant hypertension
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Hypertension
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Complicated hypertension
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Chronic hypertensive damage to the walls of
systemic blood vessels
 Smooth muscle cells undergo hypertrophy and
hyperplasia with fibrosis of the tunica intima and
media
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Malignant hypertension
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Rapidly progressive hypertension
Diastolic pressure is usually >140 mmHg
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Treatment for Hypertension
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Hypotension
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Orthostatic (postural) hypotension
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Decrease in systolic (by 20 mmHg or more) and
diastolic (by 10 mmHg or more) blood pressure on
standing
Lack of normal blood pressure compensation in
response to gravitational changes on the
circulation
Acute orthostatic hypotension
Chronic orthostatic hypotension
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Diseases of the Arteries
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Arteriosclerosis
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Chronic disease of the arterial system
• Abnormal thickening and hardening of the vessel walls
• Smooth muscle cells and collagen fibers migrate to the
tunica intima
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Diseases of the Arteries
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Atherosclerosis
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Form of arteriosclerosis
Thickening and hardening caused by
accumulation of lipid-laden macrophages in the
arterial wall
Plaque development
Process occurring throughout the body
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Diseases of the Arteries
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Atherosclerosis
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Progression
• Inflammation of endothelium
• Cellular proliferation
• Macrophage migration
• LDL oxidation (foam cell formation)
• Fatty streak
• Fibrous plaque
• Complicated plaque
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Endothelial Injury
Lipid deposition
Endothelium stops making normal
antithrombic and vasodilatory substances,
like nitric oxide and prostaglandins
Leukocytes and macrophages
adhere to the endothelium
and release cytokines
Inflammation
Oxidation and phagocytosis of
LDL (foam cells)
Smooth muscle
proliferation
Abnormal
vasoconstriction
Fatty streak accumulates
foam cells
Progressive vessel damage
Fibrosis and calcification
Plaque
Ulceration
Rupture
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Thrombosis
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Atherosclerosis
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Atherosclerosis
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Coronary Artery Disease
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Any vascular disorder that narrows or occludes
the coronary arteries
Atherosclerosis is the most common cause
Risk factors
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Dyslipidemia
Hypertension
Cigarette smoking
Diabetes mellitus
Obesity/sedentary lifestyle
Defect in the production of precursor endothelial cells
• Precursor cells not available to repair injured endothelium
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Coronary Artery Disease
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Nontraditional risk factors
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Markers of inflammation and thrombosis
• C-reactive protein, fibrinogen, protein C, and
plasminogen activator inhibitor
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Hyperhomocysteinemia
Infection
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Lipids
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Strong link between lipoproteins and coronary
artery disease
Fat metabolism
Dietary fat packaged into chylomicrons for
absorption in small intestine
 Triglycerides: in chylomicrons
 VLDL: mainly triglycerides + carrier protein
 LDL: mainly cholesterol + carrier protein
 HDL: mainly phospholipids + carrier protein
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Coronary Artery Disease
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Myocardial ischemia
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Local, temporary deprivation of the coronary blood
supply
 Stable angina
 Prinzmetal angina
 Silent ischemia
 Angina pectoris
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Myocardial Ischemia
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Myocardial Ischemia
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Coronary Artery Disease
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Acute coronary syndromes
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Transient ischemia
Unstable angina
Sustained ischemia
MI
Myocardial inflammation and necrosis
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Myocardial Infarction
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Coronary Artery Disease
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Myocardial infarction
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Sudden and extended obstruction of the
myocardial blood supply
Subendocardial infarction
Transmural infarction
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Myocardial Infarction
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Cellular injury
Cellular death
Structural and functional changes
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Myocardial stunning
Hibernating myocardium
Myocardial remodeling
Repair
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Clinical Evaluation
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ECG changes
Cardiac enzymes
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Troponins: most specific
• See in 2-4 hours, remains elevated for 7-10 days
CK-MB: see in 2-4 hours, peaks in 24 hours
LDH
• Hyperglycemia 72 hours post MI
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Disorders of the Heart Wall
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Disorders of the pericardium
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Acute pericarditis
Pericardial effusion
• Tamponade
Constrictive pericarditis
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Pericarditis
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Disorders of the Myocardium
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Cardiomyopathies
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Dilated cardiomyopathy (congestive
cardiomyopathy)
Hypertrophic cardiomyopathy
• Asymmetric septal hypertrophy
• Hypertensive (valvular hypertrophic) cardiomyopathy
Restrictive cardiomyopathy
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Cardiomyopathy
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Disorders of the Endocardium
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Valvular dysfunction
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Valvular stenosis
• Aortic stenosis
• Mitral stenosis
Valvular regurgitation
• Aortic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
Mitral valve prolapse syndrome
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Valvular Dysfunction
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Acute Rheumatic Fever and
Rheumatic Heart Disease
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Rheumatic fever
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Diffuse, inflammatory disease caused by a
delayed immune response to infection by the
group A beta-hemolytic streptococci
Febrile illness
• Inflammation of the joints, skin, nervous system, and
heart

If left untreated, rheumatic fever causes rheumatic
heart disease
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Acute Rheumatic Fever and
Rheumatic Heart Disease
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Rheumatic fever
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Carditis
Polyarthritis
Chorea
Erythema marginatum
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Acute Rheumatic Fever and
Rheumatic Heart Disease
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Infective Endocarditis
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Inflammation of the endocardium
Agents
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Bacteria, viruses, fungi, rickettsiae, and parasites
Sources: prosthetic valves, indwelling catheters
open heart surgery
Pathogenesis
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“Prepared” endocardium
Blood-borne microorganism adherence
Proliferation of the microorganism
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Infective Endocarditis
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Cardiac Complications of AIDS
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Myocarditis
Endocarditis
Pericarditis
Cardiomyopathy
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Heart Failure

General term used to describe several types
of cardiac dysfunction that result in
inadequate perfusion of tissues with bloodborne nutrients
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Heart Failure
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Congestive heart failure
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Systolic heart failure
• Inability of the heart to generate adequate cardiac output
to perfuse tissues
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Diastolic heart failure
• Pulmonary congestion despite normal stroke volume and
cardiac output
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Heart Failure
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Right heart failure
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Commonly caused by a diffuse hypoxic pulmonary
disease
Can result from an increase in left ventricular filling
pressure that is reflected back into the pulmonary
circulation
High-output failure
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Inability of the heart to supply the body with bloodborne nutrients, despite adequate blood volume
and normal or elevated myocardial contractility
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Right Heart Failure
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Dysrhythmias
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Disturbance of the heart rhythm
Range from occasional “missed” or rapid
beats to severe disturbances that affect the
pumping ability of the heart
Can be caused by an abnormal rate of
impulse generation or abnormal impulse
conduction
Examples

Tachycardia, flutter, fibrillation, bradycardia,
premature ventricular contractions (PVCs),
premature atrial contractions (PACs), asystole
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