Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
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