250 to 300 words on heart disease

Video Links
The Single Biggest Health Threat Women Face

Go Red for Women Presents Just a Little Heart Attack

Instructor Guidance
Discussion 2 covers cardiovascular health. You will particularly look at how heart disease
affects women and the programs available to help women identify heart disease and, thus
get early treatment for the condition. The signs and symptoms of heart disease present
differently in women than what is seen in men. You can learn more details about the
symptoms of both men and women at the National Heart, Lung and Blood Institute’s
website: http://www.nhlbi.nih.gov/health/health-topics/topics/hdw/signs (Links to an
external site.)Links to an external site.. How does this information influence a person’s
life? Women are often the caretakers of others so ignore their own health care. This can be
influenced by the woman’s choices, but also by the resources within the
community. “Although the physical effects of cardiovascular disorders are seen mostly
within the individual and immediate family spheres, the physical and larger social
environment (macro perspective) can either promote or create barriers to healthpromoting activities” (Atlas, Matthews, Fritsvold, & Vinall, 2014, Section 6.2, para. 15). An
example of this is whether there is effective public transportation in a community. What
does public transportation have to do with cardiovascular health? When public
transportation is effective, people will walk a block or two to access the transportation
instead of walking out their door to the driveway and getting in the own car, driving to
their destination, and walking a few feet to the door. Far less exercise occurs when a
person drives everywhere. Small bursts of exercise like this can improve a person’s health.
6
Cardiovascular Disorders:
Congenital Heart Defects,
Heart Disease, and Stroke
Ingram Publishing/Thinkstock
Learning Objectives
1. Understand basic distinctions between heart defects, heart disease, and stroke
2. Describe how cardiovascular disorders affect different individual, familial, and social domains
3. Identify the prevalence of cardiovascular disorders within specific populations
4. Compare and contrast prevention and treatment methods for different cardiovascular disorders
5. Describe societal elements that influence diagnosis and care of cardiovascular disorders
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CHAPTER 6
Section 6.1 Introduction to Cardiovascular Disorders
6.1 Introduction to Cardiovascular Disorders
T
he literature about cardiovascular disorders can be confusing. It abounds with abbreviations and different names for the same disorder or procedure. Let’s begin by saying that the
cardiovascular system comprises the heart (cardio) plus the blood vessels, or circulatory
(vascular) system. The most common cardiovascular disorder is high blood pressure, or hypertension, which is covered in Chapter 5.
It is estimated that 83.6 million adults in the United States (or more than one in every three) had
a cardiovascular disorder in 2010 (Go et al., 2013). Table 6.1 shows how many people were diagnosed with different cardiovascular disorders in the United States in 2010, or the prevalence of
various cardiovascular disorders.
Table 6.1: Prevalence of cardiovascular disorders in the United States, 2010
Condition
Prevalence (in millions)
Hypertension
77.9
Angina (chest pain)
7.8
Myocardial infarction (heart attack)
7.6
Stroke (all types)
6.8
Heart failure
6.1
Congenital cardiovascular defects
0.65 to 1.3
Prevalence of cardiovascular disorders in the United States: hypertension = systolic pressure of 140 mmHg or over, or
diastolic pressure of 90 mmHg or over.
Note that individuals may have more than one disorder, so adding up the prevalence of each disorder does not give a
total of unique individuals.
Source: Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J., Berry, J.D., & Borden, W.B. Heart disease and stroke statistics—2013
update: a report from the American Heart Association. Circulation, 127(1), p. 109. Copyright © American Heart Association. Used by
permission
As the report from the American Heart Association, “Heart Disease and Stroke Statistics—2013
Update,” makes clear in 200-plus pages, there are many different cardiovascular disorders (Go et
al., 2013). We will examine three cardiovascular disorders—briefly touching on congenital heart
defects and focusing mainly on heart disease and stroke.
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Section 6.1 Introduction to Cardiovascular Disorders
Case Study: An Example of Cardiovascular Disorders
Ken had been diagnosed with hypertension and was treated for it for many years. One day, when he
was 49 years old, Ken experienced sudden severe chest pain and was taken to the hospital, where he
was admitted. A blocked artery in his heart was opened, and a tiny mesh tube (or stent) was inserted
into it to keep it open. He was released from the hospital a few days later, feeling much better than
before his hospitalization.
Five years later, when Ken was 54, he was working in his construction company office as usual one
morning. His coworkers could hear him talking on the phone when suddenly the talking stopped and
they heard a loud thump. They rushed in and found him unconscious on the floor. Luckily Ken’s coworkers were knowledgeable and alert; one knew cardiopulmonary resuscitation (CPR), and the other one
called 911. Ken didn’t seem to be responding to the CPR, but just a few minutes after the phone call,
they could hear the ambulance siren and the emergency medical technicians arrive. They administered
care and took Ken to the emergency room of the local hospital, where physicians tried to revive him,
but efforts were unsuccessful and he was pronounced dead. As the physician explained to Ken’s wife,
Judith, an electrical problem in his heart caused it to suddenly stop pumping blood. This is known as
cardiac arrest, or sudden cardiac arrest.
History of the Heart
Both the ancient Egyptians and Greeks believed the
heart was the center of human life, both physically
and spiritually. Later, the Romans understood the
central role of the heart in sustaining life. It was in
the second century CE that Roman physician Claudius Galen made several important observations
about the heart based on experiments in monkeys.
Galen’s work, including observations on blood circulation, valves, veins, and arteries, became the basis
for understanding heart function for the next millennium and more. However, his theory about the
four humors in the body needing to be in balance
was later disproven.
Leonardo da Vinci (1452–1519) accurately described
and sketched the four chambers of the heart, the
coronary vascular system, and the heart valves.
He also described arteriosclerosis in great detail
and asked
Leonardo da Vinci/©Bettmann/Corbis
Leonardo da Vinci was able to accurately
describe and sketch the heart.
why the vessels in the old acquire great
length and those which used to be straight
become bent and the coat thickens so much as to close up and stop the movement of the blood, and from this arises the death of the old. (Keele, 1951, p. 212)
He also noted an atrial septal defect, which he found in the course of his dissections. However, he
accepted Galen’s view of heart function (Keele, 1951).
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Section 6.1 Introduction to Cardiovascular Disorders
CHAPTER 6
In 1628, William Harvey first described blood circulation, correctly surmising that the heart
pumps blood throughout the body. In the next century, blood pressure was first measured by
Stephen Hales in 1733, and inventions of the stethoscope (in 1816 by Rene Laennec) and the
electrocardiogram (in 1903 by Willem Einthoven) made possible great strides in our understanding of the heart. Einthoven received the 1924 Nobel Prize in medicine for his invention.
The first major surgery on the great vessels near the heart was performed by Robert Gross in
1938 in an attempt to repair a pulmonary artery defect. This much-heralded operation opened
the modern era of cardiac surgical intervention. World War II probably did much to further the
cause of cardiac surgery, which was performed in the field under less than ideal conditions. The
first successful attempt to repair the hearts of “blue babies” (babies born with tetralogy of Fallot,
a heart defect that causes poor oxygenation of the blood and a resulting bluish tint, or cyanosis,
in the skin) was made by the team of Alfred Blalock, Helen Taussig, and Vivien Thomas at Johns
Hopkins Hospital in 1944.
Before modern times, most people lived active lives and tended to be lean. However, after the
Industrial Revolution in the 19th century, death from cardiovascular disorders began to increase.
Toward the middle of the century, concern about the rising epidemic raised interest in studying
what might be contributing to cardiovascular disorders, including heart disease and stroke.
Congenital Heart Defects
Congenital heart defects (also known as congenital cardiovascular defects) are structural problems in the heart or major blood vessels that form during fetal development and are present at
birth. Most occur very early in development, during
the first few weeks of pregnancy, before the mother
even knows that she is pregnant. In most cases, the
causes of congenital heart defects are unknown. We
do know that maternal obesity, diabetes, and smoking are risk factors, so it is best for women who are
planning to become pregnant to lose weight if necessary, manage their diabetes, and stop smoking.
Some congenital heart defects are minor and disappear as the child grows; some are more serious and
may result in death before birth or require surgery
before birth or soon after birth for survival. More
than one fourth of infants who have died of a birth
defect have had a heart defect (Go et al., 2013).
Some congenital heart defects are not diagnosed
until adolescence or adulthood. In this section, we
briefly cover a few of the more common congenital
heart defects.
iStock/Thinkstock
The human heart.
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Major cardiovascular defects may be identified at
birth because the infant appears blue or has low
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CHAPTER 6
Section 6.1 Introduction to Cardiovascular Disorders
blood pressure. Others are identified within the first few months of life because of breathing difficulties, feeding problems, or lack of normal weight gain. Most major defects require intervention;
some operations can be done without opening the chest, and others require open-heart surgery.
Most children with major defects have to be seen periodically by a pediatric cardiologist. After
surgery, some children lead normal lives, whereas others have limitations to their physical activity.
Table 6.2 shows the prevalence of some of the more common major congenital heart defects. To
fully understand the biology of congenital heart defects, review how a normal heart works. Visit
the American Heart Association at http://www.heart.org/HEARTORG/ to review the basics about
healthy heart functions.
Table 6.2: Prevalence of select congenital heart defects per 10,000 births
Defect
No./10,000 births
Atrioventricular septal defect
4.7
Tetralogy of Fallot
4.0
Transposition of the great arteries
3.0
Hypoplastic left heart syndrome
2.3
Truncus arteriosus
0.7
Source: Go, A.S., Mozaffarian, D., Roger, V.L., Benjamin, E.J., Berry, J.D., & Borden, W.B. Heart disease and stroke statistics—2013
update: a report from the American Heart Association. Circulation, 127(1), p. 153. Copyright © American Heart Association. Used by
permission.
Ventricular Septal Defect
Ventricular septal defect (VSD) is the most common congenital heart defect. It is an opening or
hole in the wall (or septum; the plural is septa) between the two lower heart chambers (or ventricles). The opening allows extra blood to be pumped to the lung arteries and creates extra work
for both the lung and the heart. A small VSD does not need intervention, but a larger one causes
problems and has to be closed through open-heart surgery, usually while the child is quite young
(American Heart Association [AHA], 2009b).
Atrial Septal Defect
Atrial septal defect (ASD) is an opening or hole in the wall between the two upper heart chambers (or atria; the singular is atrium). However, all children are born with this hole, which allows
blood to bypass the lungs while the child is in the womb (in utero) and receiving oxygenated blood
from the mother through the placenta. Normally, the ASD closes within a few months after birth,
but sometimes it does not. A small ASD is probably not a problem, but a large ASD needs to be
mechanically closed (AHA, 2009a).
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Section 6.1 Introduction to Cardiovascular Disorders
CHAPTER 6
Case Study: Marfan Syndrome
Ben was adopted when he was 1 day old. Diane and David had talked to his birth mother at length,
although they hadn’t actually met her before Ben was born. Diane remembers thinking that Ben’s
birth mother had unusually long slender fingers. When Ben was 4 months old, his pediatrician told
Diane that she thought he had some features of Marfan syndrome, a rare genetic disorder caused by
a defect in the gene for a connective tissue protein that affects many parts of the body, including the
aorta and heart valves. People with Marfan syndrome are often unusually tall and slender. The pediatrician made arrangements for Ben to be seen by a genetic counselor, who became their base for all
ensuing medical procedures.
Ben was 5 months old when he was examined by a Marfan specialist who confirmed the characteristic
physical traits and tested his blood. He was indeed positive for Marfan, so they arranged for Ben to be
seen by an ophthalmologist, a cardiologist, an orthopedic surgeon, and a pulmonologist. Ben is at the
more severe end of the syndrome, and will probably need cardiac surgery within the next two years.
He has worn glasses since he was 2 years old and has been getting physical and occupational therapy
every week, first at home and later at the school he attends for special needs children.
Other Congenital Heart Defects
Atrioventricular septal defect (also known as atrioventricular canal or endocardial cushion defect)
is a large hole in the wall (septum) at the center of the heart separating the two upper chambers (atria) and the two lower chambers (ventricles). Defects in the valves that normally regulate
movement of blood from upper to lower chambers are usually present as well.
Tetralogy of Fallot has four components. The major ones are a ventricular septal defect and an
obstruction between the right ventricle and the lungs (stenosis—narrowing or constriction—of
the pulmonary valve). In addition, the aorta is misplaced over the septal defect, and the right ventricle muscle is abnormally thick.
Transposition of the great arteries reverses the aorta and pulmonary artery so that the aorta
receives oxygen-poor blood and the lungs receive oxygen-rich blood. It must be repaired for the
child to survive.
In hypoplastic left-heart syndrome, the whole left side of
the heart—including the aorta,
aortic valve, left ventricle, and
mitral valve—is underdeveloped.
This defect is fatal unless treated
within the first month of life.
Truncus arteriosus is the fusion
of two large arteries carrying
blood away from the heart in
addition to a ventricular septal defect. Surgery is needed to
repair this defect.
iStock/Thinkstock
Some children with cardiovascular defects can participate in
normal activities after repair.
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Section 6.1 Introduction to Cardiovascular Disorders
CHAPTER 6
Heart Disease
Heart disease begins with the narrowing of arteries that supply blood, oxygen, and nutrients to
the heart muscle (the coronary arteries). Narrowing results from a deposit of fats and other substances to form a thick film on the interior of the artery walls, a buildup known as plaque. The
process of plaque formation is known as atherosclerosis, or colloquially known as “hardening of
the arteries” because the arteries become stiff as plaque builds on their inner surface. As plaque
builds up, the arteries become narrower and blood flow can slow or stop, reducing the amount of
oxygen that reaches the heart muscle. As mentioned earlier, narrowing of the arteries is known
as stenosis, and the reduction of blood flow, and therefore a reduction of oxygen and nutrients, is
known as ischemia.
Coronary arteries, which branch off from the aorta near the left ventricle, supply the heart with all
the blood, oxygen, and nutrients it needs in order to pump continuously and keep blood flowing
throughout the body. Heart disease is often termed coronary heart disease or coronary artery
disease. The coronary arteries supply the blood and oxygen to the heart that allow this specialized
muscle to continue to work day in and day out. Reduced blood flow through the coronary arteries may create chest pain from reduced oxygen and buildup of waste material. This pain, known
as angina, or angina pectoris, is a symptom of heart disease. Angina is more likely to occur with
increased activity, heavy meals, stress, or emotional upset. It usually goes away with rest or treatment with nitroglycerine, a medicine that relaxes blood vessels (a vasodilator) and allows blood
flow to increase.
Cardiologists distinguish between stable angina and unstable angina. Stable angina happens predictably with exertion, emotional upset, exposure to cold, or overeating and resolves with rest or
taking nitroglycerine. Unstable angina is not predictable, may happen at rest or with light activity, does not resolve with rest or nitroglycerine, and is a warning sign of a possible heart attack.
Stable angina can go unchanged for years, but unstable angina can happen without warning,
even to those who have not experienced stable angina. Unstable angina needs to be evaluated
immediately.
In addition to angina, other common symptoms of heart disease include shortness of breath and
fatigue. Even if there is no obvious pain, reduced blood flow to the heart muscle means that some
of the heart cells die and the heart becomes weaker, which may lead to inadequacy in pumping
enough blood to meet the body’s needs (termed heart failure) or problems in the rate or rhythm
of the heartbeat (arrhythmias).
If a blood vessel to the heart becomes mostly or totally blocked, a heart attack (also known as
myocardial infarction) may result. If blood flow is not restored very quickly, a section of the heart
muscle starts to die. Depending on which coronary artery is blocked and how much of the heart
muscle becomes ischemic, a heart attack may cause permanent disability or death. The faster
blood flow can be restored, the better the outcome will be.
Warning signs of a heart attack include the following:
•
•
•
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chest discomfort that lasts for several minutes or that recurs—may feel like uncomfortable pressure, fullness, squeezing, or pain;
discomfort in other areas of the upper body, including arms, back, neck, jaw,
or stomach;
shortness of breath with or without chest discomfort;
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Section 6.1 Introduction to Cardiovascular Disorders
•
•
CHAPTER 6
sweating, nausea or vomiting, or lightheadedness; and
in women, more likely, shortness of breath, nausea or vomiting, and back or jaw pain
as presenting symptoms (AHA, 2013b)
Anyone experiencing any of these symptoms or witnessing them in someone else should call 911
or the local emergency response number within 5 minutes.
Web Field Trip
Women often fail to recognize heart attack symptoms or attribute them to other causes, such as the flu
or acid reflux. A video from the AHA’s Go Red for Women/ public awareness campaign exaggerates
this tendency but underlines the importance of responding to warning signs promptly: http://www
.youtube.com/watch?v=t7wmPWTnDbE.
Critical Thinking Questions
1. What do you think interferes with women’s ability to recognize their condition?
2. What are the typical images most often associated with having a heart attack?
In addition to distinguishing between the different forms of angina, cardiologists distinguish
between less severe and more severe heart attacks: non-ST-elevation myocardial infarction
(NSTEMI) and ST-elevation myocardial infarction (STEMI), respectively. The different names
reflect whether the ST segment of an electrocardiogram (ECG or sometimes EKG) tracing shows
a change from normal baseline heart electrical activity. The diagnosis of NSTEMI or STEMI affects
treatment: In NSTEMI, damage is caused by partial blockage (occlusion) of a coronary artery without extensive damage to the heart muscle. In STEMI, by contrast, more complete occlusion of a
major coronary artery results in damage that extends throughout the depth of the heart muscle.
Unstable angina, NSTEMI, and STEMI are often grouped together under the umbrella term acute
coronary syndrome (ACS), as all are medical emergencies and require immediate (acute) evaluation and treatment. However, treatment depends on which form of ACS the patient is experiencing. In 2010, approximately 625,000 people were discharged from the hospital with a diagnosis
of ACS. Of these, an estimated 363,000 were males and 262,000 were females (Go et al., 2013).
Stroke
Interruption (or severe reduction) of normal blood flow to part of the brain is known as a stroke.
Another name for stoke is cerebrovascular disease (cerebro refers to the brain). Stroke is often
termed a “brain attack,” because what happens in the brain during a stroke is similar to what
happens in the heart during a heart attack: Reduced arterial blood flow deprives the affected part
of the brain of oxygen and nutrients, and within minutes, some brain cells begin to die. Stroke is
the fourth leading cause of death in the United States and the leading cause of serious long-term
disability (National Institute of Neurological Disorders and Stroke [NINDS], n.d.-a). Key risk factors
for stroke include hypertension, smoking, atrial fibrillation (a type of arrhythmia), and physical
inactivity (American Stroke Association, 2013).
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CHAPTER 6
Everyone should be familiar with the signs of a stroke:
•
•
•
•
•
sudden numbness or weakness of the face, arm, or leg, especially on one side of the
body;
sudden confusion or trouble speaking or understanding speech;
sudden trouble seeing in one or both eyes;
sudden trouble walking, dizziness, or loss of balance or coordination; and
sudden severe headache with no known cause (NINDS, n.d.-b)
If someone experiences any of these symptoms or sees them in someone else, that person should
not hesitate to call 911, noting the time that symptoms first appeared. Stroke is always an emergency. The good news is that today, stroke is treatable, and the faster medical attention is received,
the better the chance of avoiding long-term brain damage and disability.
There are two major types of stroke: ischemic, which is caused by a blocked artery, and hemorrhagic, which is caused by a leaking or burst blood vessel. Most strokes (approximately 80%) are
ischemic. They can be triggered when a plug forms in one of the arteries that supply blood to the
brain. In someone with atherosclerosis, the plug often consists of plaque or a blood clot that forms
around a ruptured plaque, called thrombotic ischemic stroke. Another form of ischemic stroke
occurs when a blood clot or other debris formed in a distant part of the body is carried to the brain
and blocks one of the narrower brain arteries, called embolic ischemic stroke.
Hemorrhagic stroke occurs when a blood vessel in the brain leaks or bursts; bleeding occurs into
or around the brain, which stops or decreases blood flow to other areas of the brain. Hemorrhagic
stroke often occurs in people with hypertension, but it also can result from vascular defects in the
brain. Normally, brain cells are not in direct contact with blood; nutrients and oxygen pass across
the smallest blood vessels, the capillaries, to the brain cells or neurons, and waste material passes
from the neurons into the capillaries. The presence of blood around neurons is toxic and interrupts their normal function.
Sometimes people have one or more symptoms of a stroke that appear to clear up within minutes
or up to an hour without leaving any noticeable disability. Known as a transient ischemic attack
(TIA), also called a mini-stroke, it is caused by a temporary decrease in the brain’s blood supply.
Because there is no way of knowing whether the signs of a stroke indicate a full stroke or a TIA,
all stroke symptoms should be treated as an emergency. In addition, people who have had a TIA
are at increased risk for having a more serious stroke. Indeed, having any type of stroke puts a
person at risk for having another one: About one quarter of those who have had a stroke will have
another one within 5 years (NINDS, 2013e). Most recurrent strokes happen within two years of
the first one, and the risk of stroke decreases with time. However, if it does strike, recurrent stroke
increases the risk for disability and death.
After a person survives a stroke, the next question concerns disability: how bad and for how long.
The degree of disability depends on both the location of the stroke within the brain (the critical
functions controlled by that part of the brain) and the size of the area affected. A stroke on the left
side of the brain affects functioning on the right side of the body, and vice versa.
The most common disabilities from stroke include:
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•
•
•
•
•
•
CHAPTER 6
complete paralysis on one side of the body (hemiplegia) or weakness in the muscles
on one side of the body (hemiparesis); paralysis or weakness confined to one area,
such as an arm, leg, or side of the face;
cognitive deficits, including memory loss and problems with higher levels of thinking
such as planning and making judgments, also known as executive function;
speech and language problems, which may include both the inability to form words
because the muscles of the mouth aren’t working properly (dysarthria) and the inability to understand and form language (aphasia);
emotional difficulties, including problems with depression or the ability to control
feelings;
problems in activities of daily living such as walking, dressing, eating, and personal
hygiene; and
pain, numbness, or other sensations in parts of the body affected by stroke.
After being released from the hospital, most people who have had a stroke go into intensive rehabilitation before going home. Rehabilitation is discussed in the section on treatment.
Common Misperceptions About Heart Disease and Stroke
A number of misconceptions and misperceptions persist about heart disease and stroke that may
contribute to inaction or inappropriate action.
People Are Reluctant to Call 911
People tend to wait much too long, often more than two hours, before getting help. They may
think they are experiencing a false alarm, or they may be afraid to admit that they or their loved
one is having a heart attack or stroke. Although it is easy to understand why this happens, it is
dangerous to wait.
A related misperception is to think it’s better to drive or have someone else drive to the
emergency room rather than calling 911 when emergency services are available in the region.
Emergency medical personnel can begin lifesaving measures well before a person reaches
the emergency room, which may save a life or lessen the severity of a resulting disability.
Cardiac Arrest Is the Same as a Heart Attack
Cardiac arrest is caused by a malfunction in the heart’s electrical system that stops the heart
from beating; it often results in death within a few minutes unless immediate treatment is available (see about treatment, below). In contrast, a heart attack is a blockage in blood flow to the
heart muscle; the heart keeps beating, so the attack does not usually result in immediate death.
Confusion arises because sometimes a heart attack can trigger cardiac arrest, but there are other
triggers as well.
Heartbeat Is a Reliable Indicator of Heart Health
Resting heart rate in adults is generally between 50 and 90 beats per minute. Some people think
that an occasional fast (tachycardia) or erratic heartbeat (arrhythmia) is an indicator of a heart
attack, which is almost never the case unless there is accompanying chest pain, shortness of
breath, or another symptom of heart attack. However, it is a good idea to have an erratic heartbeat
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