HMM 4401–Cardiovascular diseases

Ett sykehus - nær deg og dine

Hanne ThürmerPhD, MD, Specialist internal medicineCardiology interest and practicePhysician at Blefjell Hospital

Ett sykehus - nær deg og dine

Blefjell Sykehus:

Kongsberg50.000 innb.

Notodden35.000 innb.

Rjukan13.000 innb.

Buskerud og Telemark

Kongs-berg

Nore og Uvdal

ØvreEiker

Rollag

Flesberg

SigdalTinn

Vinje

Tokke

NotoddenHjartdal

Seljord

Kvites-eid

Sau-heradBø

Nome

Ringerike

Skien

Drammen

Mission

Blefjell hospital offers emergency and elective care and diagnostics in internal medicine, psychiatry, orthopedics and general surgery. Gynecological and obstetric services are differentiated between thethree units; Kongsberg, Notodden and Rjukan.Private practice specialists offer services in eye diseases, ear, nose and throat diseases, pediatrics etc. Diagnostic services to in- and outpatients include clinical labs, X-ray departments, physical therapy and a patient support unit (LMS)

Kongsberg

Sigdal

Rollag

Øvre Eiker

Flesberg

Nore og

Uvdal

Notodden

Nome

Bø

Sauherad

Tinn

Hjartdal

Seljord

Kviteseid

Tokke

Vinje

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

Municipalities

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 staysin 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 staysin 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 staysin blood vessels

Main cardiovascular diseases?

• Atherosclerosis• Hypertension• Ischaemic Heart Disease• Angina

• Stable Angina• Unstable Angina

• Myocardial Infarction• Heart Failure• Cerebrovascular Accident• Peripheral vascular disease

Atherosclerosis

• 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 diseaseExtensive part of medical departments and outpatient• Exercise testing• Angiography• Medication to prevent disease

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

Heart failure - symptoms

• 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 thepacemaker 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

• Peak mortality 1960• Men > women• Causes??

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

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