PATHO-PHYSIOLOGY

Dr. Tanzeela Rehman (PT)

DPT, MS-SPT
Lecturer
Cardiovascular Diseases
• The term ‘cardiovascular disease’ encompasses all diseases and conditions of the
heart (cardiac disease) and vascular system.
• The health burden of cardiovascular disease is immense; cardiovascular disease is
the single largest cause of death worldwide (responsible for approximately 30% of
all deaths) and one of the leading contributors to lost disability-adjusted life-years
Ischemic Heart Disease
• The human heart comprises a pair of functionally separate, valved muscular pumps,
contained structurally as a single organ.
• atrial muscle,
• ventricular muscle
• specialized excitatory and conductive muscle Fibers.
• As with all muscle tissue, the myocardium (the cardiac muscle) requires energy to
produce contractile force.
• Uniquely, the myocardium relies almost exclusively on oxidative metabolism for its
function; even at rest the heart operates at near maximal oxygen extraction.
• Ischemic heart disease (IHD) is characterized by a relative decrease in myocardial
perfusion, such that perfusion is inadequate to meet the metabolic demands of the
myocardium.
• As IHD is most commonly caused by atherosclerosis of the coronary arteries, the
terms ‘IHD’, ‘coronary heart disease’ and ‘coronary artery disease’ are often used
interchangeably.
• Atherosclerosis is a chronic and progressive inflammatory disease of the arterial
endothelium.
• atherosclerotic ‘plaques’,
• Coronary atherosclerosis presents clinically as IHD.
Ischemic Cardiac Condition
• Coronary artery disease, also called coronary heart disease, or ischemic heart
disease, is a type of heart disease involving the reduction of blood flow to the
cardiac muscle due to a build-up of atheromatous plaque in the arteries of the heart.
It is the most common of the cardiovascular diseases.
• 1) Unstable angina (UA).
• 2) Non–ST-segment elevation myocardial infarction (NSTEMI).
• 3) ST-segment elevation myocardial infarction (STEMI).
• 4) Unspecified myocardial infarction (MI)
Risk Factor
• Smoking
• Hypertension
• Diabetes mellitus
• Dyslipidemia
• Diet
• Physical inactivity
• Obesity
• Social isolation
• Depression
Non-Modifiable
• Advanced age
• Male gender
• Family history of ischemic heart disease
• Poor socioeconomic status
• Indigenous/ aboriginal
Angina
• Angina is chest pain caused by reduced blood flow to the heart muscles. It's not
usually life threatening, but it's a warning sign that you could be at risk of a
heart attack or stroke.
• Here are 2 main types of angina patient can be diagnosed with:
• Stable Angina
• Unstable Angina
Stable Angina
• Stable angina (more common) – attacks have a trigger (such as stress or exercise)
and stop within a few minutes of resting.
• Stable angina is ‘associated with a (temporary) disturbance in myocardial function,
(but) without myocardial necrosis’, and typically presents as retrosternal
pain/discomfort (angina pectoris) that is relieved by rest or nitrate medications.
• Other symptoms of stable IHD include exertional dyspnea and a reduced exercise
capacity.
• Some individuals, particularly those with diabetes mellitus, may be asymptomatic.
Unstable Angina
• Unstable angina (more serious) – attacks are more unpredictable (they may not have
a trigger) and can continue despite resting.
• UA and AMI, collectively referred to as ‘acute coronary syndromes’, can be
life-threatening and occur when physical disruption of an atherosclerotic plaque
triggers thrombosis.
• The formation of thrombus (blood clot) within the artery leads to subtotal or total
occlusion
• UA typically presents as frequent and prolonged episodes of retrosternal pain or
discomfort, often at rest or with minimal exertion; myocardial necrosis is absent.
Feature Stable Angina Unstable Angina
Chest pain or discomfort that occurs Chest pain that occurs unpredictably,
Definition predictably, often triggered by often at rest or with minimal exertion,
physical exertion or stress. and can worsen over time.

Gradual, triggered by specific Sudden, without a clear trigger, and

Onset activities like exercise or emotional can occur at rest or with minimal
stress. exertion.
Can last longer, often more than 10
Typically lasts a few minutes (usually
Duration of Pain minutes, and may not resolve with rest
< 5 minutes).
or nitroglycerin.
Mild to moderate intensity, predictable Severe pain, unpredictable, and may
Pain Intensity
in nature. increase in intensity.
Relieved by rest, reduced physical Not easily relieved by rest or
Relief
activity, or nitroglycerin. nitroglycerin.
 Occurs more frequently, with
Occurs intermittently, typically
Frequency episodes that may be progressively
triggered by physical exertion.
more severe.
Low risk of immediate heart attack High risk of progressing to a heart
Risk of Heart Attack
or sudden cardiac death. attack or sudden cardiac death.
Managed with lifestyle changes, Requires urgent medical
medications (e.g., beta-blockers, intervention, including medications
Treatment
nitrates), and sometimes (e.g., antiplatelets, anticoagulants),
angioplasty. and possible angioplasty or surgery.
Caused by rupture of an
Typically due to atherosclerosis and atherosclerotic plaque, leading to
Underlying Cause stable plaques narrowing the blood clot formation and partial or
coronary arteries. complete blockage of a coronary
artery.
Acute Myocardial Infarction (AMI)
• AMI with myocardial necrosis occurs when thrombosis and reactive coronary artery
spasm cause prolonged (>20 minutes)myocardial ischemia.
• AMI may also occur without symptoms, but typically presents as prolonged ‘chest,
upper extremity, jaw or epigastric discomfort/pain with exertion or rest’ and/or
dyspnea, diaphoresis, nausea and syncope.
• AMI is presumed, and treatment instigated, when an individual presents with
prolonged and/or severe ischemic symptoms.
• If the ECG shows ST-segment elevation (a typical ECG finding of AMI) in two
contiguous ECG leads, the AMI is designated an ST-segment elevation myocardial
infarction (STEMI)
• AMI is confirmed using blood tests for biomarkers of myocardial necrosis, most
commonly cardiac troponin levels
Myocardial Infarction
• A myocardial infarction, commonly known as a heart attack, occurs when
blood flow decreases or stops in one of the coronary arteries of the heart,
causing infarction to the heart muscle.
• Non-ST-elevation myocardial infarction (NSTEMI) is a type of involving partial
blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood
to the heart muscle.
• An ST-elevation myocardial infarction (STEMI) is a type of heart attack that is
more serious and has a greater risk of serious complications and death. It gets its
name from how it mainly affects the heart's lower chambers and changes how
electrical current travels through them.
Diagnosis Of IHDS
• A provisional diagnosis of IHD is normally made on the basis of risk and the
presence of ischemic symptoms.
• As noted by the American College of Cardiology (ACCF)/AHA, ‘once a diagnosis
of IHD is established, it is necessary in most patients to assess their risk of
subsequent complications, such as AMI or death’
• A normal ECG does not exclude IHD, however, as IHD-related ECG changes may
be transient.
• In the absence of an acute coronary syndrome, a progressive exercise or ‘stress’ test
with ECG monitoring is usually conducted to confirm a provisional diagnosis of
IHD.
• Coronary angiography (i.e. arteriography) is used in both stable IHD and acute
coronary syndromes to assess coronary artery anatomy
Cardiomyopathy
• Any disorder that affects the heart muscle is called a cardiomyopathy.
• Cardiomyopathy causes the heart to lose its ability to pump blood well.
• In some cases, the heart rhythm also becomes disturbed.
• This leads to arrhythmias (irregular heartbeats).
Types of cardiomyopathy
• Hypertrophic cardiomyopathy
• Dilated cardiomyopathy
• Restrictive cardiomyopathy
• Arrhythmogenic cardiomyopathy
Hypertrophic cardiomyopathy
• Hypertrophic cardiomyopathy is a condition in which muscle tissues of the heart
become thickened without an obvious cause.
• The parts of the heart most commonly affected are the interventricular septum and
the ventricles
Restrictive cardiomyopathy
• Restrictive cardiomyopathy is a form of cardiomyopathy in which the walls of the
heart are rigid. Thus the heart is restricted from stretching and filling with blood
properly. It is the least common of the three original subtypes of cardiomyopathy
hypertrophic, dilated, and restrictive.
Dilated cardiomyopathy
• Dilated cardiomyopathy, or DCM, is when the heart chambers enlarge and lose their
ability to contract.
• It often starts in the left ventricle (bottom chamber).
• As the disease gets worse, it may spread to the right ventricle and to the atria (top
chambers).
Restrictive Lung Disease
• Restrictive lung disease, a decrease in the total volume of air that the lungs are
able to hold, is often due to a decrease in the elasticity of the lungs themselves
or caused by a problem related to the expansion of the chest wall during
inhalation.
• Examples of restrictive lung diseases include asbestosis, sarcoidosis and pulmonary
fibrosis
• Symptoms of restrictive lung disease include:
• cough,
• shortness of breath,
• wheezing and chest pain.
Obstructive Lung Disease
• Chronic obstructive pulmonary disease (COPD) is a common lung disease
causing restricted airflow and breathing problems. It is sometimes called
emphysema or chronic bronchitis.
• In people with COPD, the lungs can get damaged or clogged with phlegm.
• Symptoms include :
• cough, sometimes with phlegm,
• difficulty breathing,
• wheezing and tiredness.
• Emphysema
• Chronic bronchitis
• Chronic obstructive pulmonary disease
• Asthma
• Cystic fibrosis.
• Diagnostic testing for lung disease may include any of the following:
• Pulmonary function tests
• Chest X-ray
• CT scans
• Bronchoscopy
• Pulse oximetry
 Obstructive Lung
Feature Restrictive Lung Disease
Disease
Reduced lung volume due to
Airflow limitation due to
Definition stiffness or restriction in lung
obstruction in the airways.
expansion.
Chronic Obstructive Pulmonary Pulmonary Fibrosis, Interstitial
Examples Disease (COPD), Asthma, Lung Disease, Obesity, Pleural
Bronchiectasis, Cystic Fibrosis Effusion
Reduced Total Lung Capacity
Reduced Forced Expiratory
Spirometry Findings (TLC), Vital Capacity (VC), and
Volume in 1 second (FEV1)
FVC
Difficulty exhaling air (airflow Difficulty in inhaling air
Primary Abnormality
limitation) (restriction in lung expansion)
Increased Residual Volume (RV),
Decreased TLC, Decreased Vital
Lung Volumes Increased Total Lung Capacity
Capacity (VC)
(TLC)
Peak Expiratory Flow Rate (PEFR) Reduced, especially in severe cases Normal to reduced

Prolonged expiratory phase due to Shallow, rapid breathing (tachypnea)

Breathing Pattern
difficulty exhaling due to reduced lung volume

Shortness of breath (dyspnea), Shortness of breath (dyspnea), dry

Symptoms
wheezing, chronic cough cough, fatigue
Corticosteroids,
Bronchodilators, steroids, oxygen immunosuppressant's, oxygen
Treatment
therapy, pulmonary rehabilitation therapy, lung transplant in severe
cases

Peak expiratory flow rate (PEFR) is the volume of air forcefully expelled from the lungs in
one quick exhalation
Cardiopulmonary Complications
• Angina
• Atrial fibrillation
• cardiac arrest
• heart attack
• heart failure
• pulmonary edema
• stroke
Atrial Fibrillation
• Atrial fibrillation is an abnormal heart rhythm characterized by rapid and irregular
beating of the atrial chambers of the heart.
• It often begins as short periods of abnormal beating, which become longer or
continuous over time.
• Graves disease
• Mitral Valve prolapse
• Atrial septal Defect
• Atrial Flutter
• Amyloidosis
Atrial Flutter
• Atrial flutter, the atria beat regularly, but faster than usual and more often than the
ventricles, so you may have four atrial beats to every one ventricular beat.
Heart Failure (HF)
• HF is a clinical syndrome that arises from
ventricular dysfunction (acute or chronic).

• In which venous return to the heart is normal but

the heart is unable to pump sufficient cardiac
output
• or can do so only at abnormally elevated diastolic
pressures or volumes
Etiology & types
Etiology:
Heart failure may develop as a result of right or left ventricular systolic dysfunction
or diastolic dysfunction, or a combination of both.
Types:
• Systolic Heart Failure
• Diastolic Heart Failure
Systolic Heart Failure
• SHF is characterized by impaired myocardial contractility and reduced ejection
fraction, leading to a large dilated heart.
• The ejection fraction (EF) equals the amount of blood pumped out of the ventricle
with each contraction (stroke volume or SV) divided by the end-diastolic volume
(EDV), the total amount of blood in the ventricle.
Increased ventricular volumes and pressures are reflected back to the atria and
antecedent vasculature, resulting in congestion and edema.
Significant ventricular dilatation often causes functional mitral regurgitation,
tricuspid regurgitation, or both.
Diastolic Heart Failure
• DHF, also referred to as heart failure with normal ejection fraction, occurs in 20% to
50% of patients with HF
• particularly women, hypertensive, and older individuals

• Characterized by impaired ventricular relaxation and increased passive stiffness

(decreased compliance) with normal systolic function and a normal ejection fraction
ASSIGNMENT

• CLASSIFICATION SYSTEM
1)American system
2) New York system
Clinical Manifestation
• Dependent edema
• Weight gain
• Liver engorgement (hepatomegaly) abdominal
pain
• Ascites
• Anorexia, nausea, bloating
• Cyanosis
• Possible murmurs of pulmonary or tricuspid
valve insufficiency
Treatment of HF
• Pharmacological Therapy
• Surgical Interventions
• Physical therapy
• Patient Education
Pharmacologic therapies
• ACE inhibitors or angiotensin II receptor blockers
• β-Blockers
• Diuretics
• Vasodilators (Hydralazine)
• Diltiazem for micro vascular circulatory abnormalities
• Nitrates
• Digoxin
• Antiarrhythmic agents, as indicated
• Relief of hypoxia (e.g., oxygen therapy, corticosteroids, bronchial hygiene, and mechanical
ventilation)
• Rest, if unstable
• Low-salt diet
• Exercise training
• Continuous positive airway pressure for obstructive sleep apnea.
Drugs and Side effects
• PTs must be familiar with the side effects of medications
• Acute CHF may develop because of either inadequate or toxic drug levels
• Digoxin toxicity can cause arrhythmias,
dizziness, confusion, nausea
• Many of the drugs are associated with orthostatic and post exercise hypotension .
Surgical interventions
• Intra-aortic balloon counter pulsation
• Ventricular assist device
(LVAD, RVAD or BiVAD)
• Organ transplantation
• Pacemaker for Brady arrhythmia’s
and some tachyarrhythmia's
• Cardiac resynchronization therapy
(i.e., biventricular pacing)
Clinical Implications for Physical Therapy
Patients with CHF should be assessed for signs of decompensation at each visit:
• Sudden weight gain
• Increased shortness of breath
• More lower extremity edema or abdominal swelling
• Pain
• Pronounced cough
• Increased fatigue
• Lightheadedness or dizziness.
Clinical Monitoring
• Perform at rest and during exercise and rehabilitation activities at each patient visit.

• PTs should recognize the signs and symptoms of exercise

intolerance and Exercise should be terminated, if observed.
Treatment Modifications
• Exercise and rehabilitation activities should be
low-level initially and progress slowly.
• Isokinetic, high-intensity isometric,
and high-resistance exercises are usually not
tolerated.
• Frequent 1- to 2-minute rests interspersed with
activity
• Breath holding and the Valsalva maneuver
should be avoided
• Rating of perceived exertion (RPE)and clinical
signs and symptoms can be used to monitor
exercise/activity intensity
Exercise training
• Aerobic exercise training
• Low-level, gradually progressive
• low- to moderate intensity exercise
• Interval training with brief rest period
• Warm-up and cool down periods
• JOGGING,WALKING, RUNNING,
SWIMMING etc.
Resistance Training

• Low- to moderate-intensity
• Increases in muscle strength
• Cardiorespiratory endurance
• Improving functional ability and quality of life
• WEIGHTS, WEIGHT MACHINES, PUSH UPS,
SQUATS
Inspiratory Muscle Training

• Improvement in inspiratory muscle strength

• Endurance
• Functional capacity
• BREATHING EXERCISES: DEEP BREATHING,
ACBT’S, YOGA, SPIROMETERY Improvement in
inspiratory muscle strength
• Endurance
• Functional capacity
• BREATHING EXERCISES: DEEP BREATHING,
ACBT’S, YOGA, SPIROMETERY
Patient Education
• Patient Education regarding:
• The individual’s disease process
• Measure body weight first thing in the morning every day, and
action to take if weight increases by 3 lb. or more.
• The symptoms of decompensation and exercise
intolerance
• Side effects of medications and symptoms
of toxicity.