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8
Cardiovascular
System Diseases
and Disorders
Key Terms
Angina (p. 140)
Angiocardiography
(p. 142)
Angioplasty (p. 153)
Ankle-brachial index
(ABI) test (p. 142)
Arrhythmia (p. 140)
Arteriography (p. 142)
Arteriosclerosis (p. 146)
Auscultation (p. 142)
Cardiac catheterization
(p. 142)
Cardiac palpitations
(p. 140)
Cyanosis (p. 140)
Diastolic (p. 142)
Doppler (p. 142)
Echocardiography (p. 142)
Electrocardiogram
(p. 142)
Embolus (p. 149)
Endarterectomy (p. 150)
Exsanguination (p. 162)
Fibrillation (p. 159)
Hemorrhage (p. 162)
Hemothorax (p. 162)
Intermittent claudication
(p. 151)
Ischemia (p. 140)
Lumen (p. 145)
Murmur (p. 159)
Myocardial infarction
(p. 154)
Patency (p. 142)
Perfusion (p. 163)
Plaque (p. 148)
Systolic (p. 142)
Tachycardia (p. 140)
Thrombus (p. 153)
Venography (p. 142)
Learning Objectives
Upon completion of the chapter, the learner should be able to:
1. Define the terminology common to the
cardiovascular system and the disorders of the system.
2. Discuss the basic anatomy and physiology of the
cardiovascular system.
3. Identify the important signs and symptoms
associated with common cardiovascular system
disorders.
4. Describe the common diagnostics used to
determine the type and cause of cardiovascular
system disorders.
5. Identify the common disorders of the
cardiovascular system.
6. Describe the typical course and management of
common cardiovascular system disorders.
7. Describe the effects of aging on the cardiovascular
system and the common disorders associated with
aging of the system.
Overview
T
he cardiovascular system is often regarded as the major body system because the individual cannot live
without a functioning heart and circulatory system. The heart is responsible only for pumping blood,
whereas the vascular system transports the blood throughout the body. Disorders of the system often share
137
138 Chapter 8
common symptoms and problems. Other systems are affected when the cardiovascular system is malfunc
tioning because it is responsible for delivering necessary nutrients and oxygen to the body. Diseases of the
cardiovascular system are a major cause of morbidity and mortality in all ages, but especially in older adults.
Heart disease is also the leading cause of death overall in women. ■
Anatomy and Physiology
The heart, arteries, and veins, along with the blood,
make up the cardiovascular system. The heart is a four
chambered muscular structure. It is about the size of a
man’s fist and weighs about 300 grams. The heart is sit
uated approximately in the middle of the chest, slightly
to the left, behind the sternum (breastbone). The heart is
composed of the cardiac muscle, the chambers, and the
valves. The heart is surrounded by the pericardium, a
two-layered sac with fluid between the layers. The wall of
the heart is divided into three layers. The epicardium is
the outermost layer, the myocardium is the middle layer,
and the endocardium is the innermost layer.
The four chambers in the heart are the right
atrium, right ventricle, left atrium, and left ventricle.
The tricuspid valve is between the right atrium and
ventricle, the mitral valve is between the left atrium
and ventricle, the pulmonary valve is between the right
ventricle and pulmonary artery, and the aortic valve is
between the left ventricle and the aorta.
Blood enters the heart from the superior and infe
rior vena cava and then passes through the right atrium
and the tricuspid valve into the right ventricle. It then
passes through the pulmonary valve into the pulmonary
artery and travels to the lungs, where carbon dioxide is
exchanged for oxygen. The oxygenated blood returns to
the heart through the pulmonary vein and is pumped
into the left atrium through the mitral valve and into
the left ventricle. It then passes through the aortic valve
into the aorta and to the body (Figure 8-1). The heart
itself is supplied with blood by the coronary arteries.
Right
pulmonary
veins
Right atrium
Pulmonary
semilunar valve
Tricuspid valve
Right ventricle
Inferior vena cava
Superior
vena cava
Right
pulmonary
artery
Aorta
Left
pulmonary
artery
Left atrium
Left
pulmonary
veins
Aortic semilunar
valve
Mitral valve
Interventricular
septum
Left ventricle
Figure 8-1 The heart: four chambers and great vessels.
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Cardiovascular System Diseases and Disorders 139
(A)
Sinoatrial
(SA) node
Atrioventricular
(AV) node
(AV) Bundle
Q wave is a negative deflection or wave.
R wave is a positive deflection or wave.
S wave is a negative wave.
T wave is a positive wave and represents
ventricular repolarization.
U wave (occasionally seen in some patients)
is a positive deflection and associated with
repolarization.
Bundle of His
Right and left
bundle branches
Purkinje fibers
Figure 8-2 (A) The conduction system. (B) ECG reading — the PQRST cycle.
Cardiac muscle normally contracts continually
throughout one’s lifetime. Designated areas of the
heart produce electrical stimulation, causing the heart
muscle to contract and pump the blood to the body.
This sequence of events is termed the cardiac cycle and
begins in the sinoatrial (SA) node, then passes to the
atrioventricular (AV) node to the bundle of His and
the Purkinje fibers (Figure 8-2).
Consider This...
The heart beats approximately 100,000
times a day, pumping 2,000 gallons of
blood with enough pressure to squirt blood
30 feet into the air.
One sequence of the conduction pathway is one car
diac cycle. This is represented on the electrocardiogram
as the PQRST cycle. The P wave represents the electrical
stimulation beginning and passing over the atria (depo
larization). The QRS wave is caused by the stimulation
passing over the ventricles. The T wave represents the
recovery of the ventricles (repolarization). The cardiac
cycle repeats itself approximately 60 to 100 times per
minute in the average adult. One cycle is one heartbeat.
The pulsation (heartbeat) felt with the hand over the
chest or the fingertips placed over an artery (such as at
the wrist or neck) is called the pulse (Figure 8-3). The
pulse rate is the number of pulsations felt in a minute.
The closing of the heart valves produces the sounds
heard when listening with a stethoscope over the heart.
The circulatory component of the cardiovascular sys
tem includes the arteries and veins (Figure 8-4). The three
major subsystems include the portal unit, the pulmonary
unit, and the systemic unit. Each of these circulatory sub
systems has special functions in addition to delivering
blood to the body. The portal unit, or subsystem, includes
the circulation to the stomach, spleen, intestine, and
140 Chapter 8
(A) Temporal
(D) Radial
(B) Carotid
(E) Femoral
(C) Brachial
(F) Popliteal
(G) Dorsalis pedis
Figure 8-3 Pulse points of the body.
pancreas.
Blood from these organs goes through the liver
before returning to the heart. The pulmonary subsystem
includes the pulmonary artery and its divisions, leading
from the heart to the lungs, the circulation through the
lungs, and the pulmonary vein leading from the lungs
back to the heart. In this subsystem, non-oxygenated
blood from the systemic circulation passes through the
lungs, where an exchange of carbon dioxide for oxygen
occurs. The oxygenated blood returns to the heart to be
pumped throughout the body. The systemic subsystem
includes all the arteries and veins and their capillaries
not already included in the previously mentioned sub
systems. This subsystem carries the oxygen and nutrients
to the body cells and removes waste products.
The level of pressure of the blood pushing against
the walls of the vessels as it is delivered throughout the
body is referred to as blood pressure. Most individu
als are familiar with the arterial blood pressure taken
with a sphygmomanometer on the arm over the bra
chial artery. The pressure measured with this instru
ment is divided into two parts. The systolic pressure,
caused by the contraction of the ventricles, is the first
number recorded. The second number is the diastolic
pressure, reflecting the relaxation of the ventricles. The
average adult pressure is 120/80 mm Hg (millimeters
of mercury).
Common Signs and Symptoms
Common symptoms of heart disease include
angina (an-JIGH-nah) or chest pain, shortness of
breath, fatigue, and arrhythmias (uh-RITH-me-uh)
most often in the form of tachycardia (TAK-ee-
KAR-dee-ah; tachy = rapid, cardia = heart). Chest
pain might be described as a severe, crushing pressure
as though someone is crushing the chest, or the pain
might be milder and described as a constant feeling of
indigestion. Pain also can radiate down the left arm or
into the jaw. Shortness of breath is also a common symp
tom because a lack of oxygen to the tissues stimulates
the respiratory system. Individuals with heart disease
often feel fatigued and experience episodes of tachy
cardia. Other symptoms include cardiac palpitations
(an unusually strong, rapid, or irregular heart rate so
abnormal that the individual “can feel” it), sweating
(diaphoresis), edema in the extremities, and nausea
and vomiting.
Pain, edema, and cyanosis are symptoms of diseases
of the vascular system. Pain is often associated with
poor blood perfusion to the tissues, leading to ischemia
(iss-KEE-me-ah; lack of oxygen) of the organ. Edema of
the extremities is commonly due to poor venous return,
leading to congestion of blood and fluids in the tissues.
Tissues that lack oxygen often exhibit a characteristic
blue color called cyanosis (SIGH-ah-NO-sis; cyano =
blue, osis = condition).
Consider This...
The heart pumps about 212 million liters of
blood in the average lifetime.
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A.
Right external carotid A.
Right common carotid A.
Left common carotid A
.
Brachiocephalic A.
Left subclavian (to arms) A.
ARCH OF AORTA
Left axillary A.
Common hepatic A.
Left brachial A.
Superior mesenteric A.
ABDOMINAL AORTA
Right common iliac A.
Right internal iliac A.
Right digitals A.
Right subclavian A.
ASCENDING AORTA
Right internal carotid
Left deep palmar arch A.
Right femoral A.
Left popliteal A.
Right external jugular
Right peroneal A.
Right internal jugular
SUPERIOR VENA CAVA
Left superficial
palmar arch A.
Left dorsalis
pedis A.
Left dorsal
arch A.
Left posterior
tibial A.
Left radial A.
Left ulnar A.
------ Left anterior
tibial A.
THORACIC AORTA
Celiac (to liver, spleen, stomach, pancreas) A.
-Splenic A.
Left gastric A.
Left renal (to kidney) A.
Left testicular/ovarian
(gonadal) A.
Inferior mesenteric A.
Right common iliac V.
V.
Inferior sagittal sinus V.
Straight sinus V.
V.
V.
Brachiocephalic V.
Left axillary V.
Left basilic V.
Left brachial V.
Right hepatic V.
INFERIOR VENA CAVA
Superior mesenteric V.
Right renal V.
Right palmar arch V.
Right ovarian
or testicular V.
Splenic V.
- Left renal V.
Left hepatic V.
Hepatic portal V.
Superior sagittal sinus
Left femoral V.
Right great saphenous V.
Left great saphenous V.
Right femoral V.
Left popliteal V.
Right small saphenous V.
Left posterior tibial V.
Left anterior tibial V.
Left dorsal venous arch V.
Left palmar
digitals V.
Left ovarian
or testicular V.
Left external
iliac V.
Left subclavian V.
Left cephalic V.
Great cardiac V.
Inferior
mesenteric V.
Figure 8-4 The circulatory system.
142 Chapter 8
Diagnostic Tests
Noninvasive procedures of the cardiovascular system
involve listening to the heart and movement of blood
in the vessels with a stethoscope in a procedure called
auscultation (aws-kul-TAY-shun). During auscul
tation, the stethoscope may be placed on the chest to
listen to the heart and over various arteries to listen for
blood flow. Murmurs can be auscultated in the heart
area and indicate abnormal flow through the heart
valves. A Doppler device can be placed over arteries
to magnify the sound of blood flow. Decreased blood
flow can be due to heart disease, vessel disease, or both.
Arterial blood pressure is simply referred to as
blood pressure and is measured by a sphygmoma
nometer, a cuff and pressure gauge used to measure
pressure when the heart beats (systolic; sis-TALL-ick)
and when it rests (diastolic; dye-as-TOL-ick). Venous
blood pressure is an important measure of the heart’s
pumping ability and can be determined by examining
the individual for edema. Edema in the extremities and
distention of the jugular veins in the neck are common
indicators of increased venous pressure.
The action of the heart may be drawn or graphed
by an electrocardiograph, a machine that receives elec
trical information and draws a graph of heart action.
The picture produced is an electrocardiogram (ECG or
EKG) (ee-LECK-troh-KAR-dee-oh-GRAM; electro =
electrical, cardio = heart, gram = drawing, writing).
The procedure involving the use of a machine to make
this picture is called electrocardiography. ECG or EKG
is also used as an abbreviation to name the machine
and the procedure. ECG is helpful in determining most
cardiac arrhythmias and heart diseases.
The use of ultrasound for diagnostic pur
poses is valuable for both heart and vessel diseases.
Echocardiography (ECK-oh-KAR-dee-OG-rah-fee)
and ultrasound arteriography (AR-tee-ree-OG-rah-
fee) both use sound waves to produce pictures of the
heart and arteries, respectively. These procedures are
noninvasive.
Positron emission tomography (PET) scanning
is a diagnostic test that involves imaging of radioac
tive positron emission. Prior to testing, a radioactive
substance is administered as an intravenous injection.
During imaging, different levels of tissue activity and
function can be determined, and these images of the
body developed by PET scanning can be used to eval
uate a variety of diseases. PET scans of the heart assist
in determining heart muscle function and blood flow
to the heart muscle.
Cardiac catheterization (KATH-eh-ter-eye-ZAY-
shun) is an invasive procedure used to sample the blood
in the chambers of the heart to determine the oxygen
content and blood pressure in the chambers. Cardiac
output also can be checked this way. This procedure
involves passing a small plastic catheter into the heart
through a vein or artery. A vein is used for right-sided
catheterization, and an artery is used for a left-sided
approach. Vessels of the arms and legs are commonly
used (Figure 8-5).
X-rays of the heart and vessels can be beneficial
in determining normal structure, size, and patency
(openness). These procedures involve injecting
dye into the system and taking pictures of the heart
and vessels. Common X-ray procedures include
angiocardiography (AN-jee-oh-KAR-dee-OG-rah-
fee; angio = vessel, cardio = heart, graphy = pro
cedure), arteriography (arterio = artery, graphy =
procedure), and venography (veno = vein, graphy =
procedure). The X-ray pictures produced are called
angiocardiograms, arteriograms, and venograms,
respectively (Figure 8-6).
The ankle-brachial index (ABI) test screens for
peripheral arterial disease (PAD) by measuring the
blood pressure at the ankle and in the arm. The result
is calculated by dividing the systolic blood pressure
in the ankle by the systolic blood pressure in the arm.
The normal ABI is 1.0. The blood pressure in the ankle
should be the same or greater than the pressure in the
arm. Less than 0.9 indicates some narrowing of the
blood vessels in the legs, which can lead to PAD.
Blood tests of this system include enzyme studies
that assist in determining whether the individual has had
a myocardial infarction (MI) (heart attack). As the heart
Cardiac Catheterization
Catheter
Alternative
site
Catheter
insertion site
Narrowed
on X-ray i
Alila Medical Media/Shutterstock.com
Figure 8-5 Cardiac catheterization.
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Cardiovascular System Diseases and Disorders 143
Pharmacology
Highlight
Common Drugs for Cardiovascular Disorders
Category Examples of Medications
Antianginals
Drugs used to treat angina
Nitrates Nitroglycerin
Beta-blockers Atenolol, betaxolol, carteolol, propranolol, or sotalol
Calcium channel blockers Amlodipine, diltiazem, nifedipine, or verapamil
Anticoagulants
Drugs used to
prevent clotting
Aspirin, clopidogrel, dabigatran, heparin, lepirudin,
rivaroxaban, or warfarin
Antihypertensives
Drugs used to treat
high blood pressure
Beta-blockers Atenolol, betaxolol, carteolol, propranolol, or sotalol
Calcium channel blockers Amlodipine, diltiazem, nifedipine, or verapamil
Diuretics Furosemide, hydrochlorothiazide, indapamide, or
spironolactone
Angiotensin-converting
enzyme inhibitors
Captopril or benazepril
144 Chapter 8
Common Drugs for Immune Disorders (continued)
Category Examples of Medications
Angiotensin II receptor
antagonists
Candesartan, eprosartan, or losartan
Aldosterone antagonists Eplerenone
Vasodilators Alprostadil, hydralazine, or nitroglycerin
a
2
Agonists
Clonidine, guanabenz, guanfazine, or methyldopa
Antiarrhythmics
Drugs used to treat
abnormal heart rhythms
Lidocaine, procainamide, propafenone, or tocainide
Beta-blockers Atenolol, betaxolol, carteolol, propranolol, or sotalol
Calcium channel blockers Amlodipine, diltiazem, felodipine, nifedipine,
nimodipine, nisoldipine, or verapamil
Cholesterol-lowering Medications
Drugs used to lower
cholesterol
Statins: atorvastatin, fluvastatin, lovastatin, pravastatin,
or ezetimibe/simvastatin
Nicotinic acid: Niacin
Cholesterol absorption inhibitor: ezetimibe
Diuretics
Drugs used to treat high
blood pressure
Furosemide, hydrochlorothiazide, indapamide, or
spironolactone
Vasodilators
Drugs used to treat a
variety of cardiovascular
conditions including such
disorders as high blood
pressure
Alprostadil, hydralazine, minoxidil, or nitroglycerin
muscle dies, enzymes are released. The enzyme levels
help determine the time and degree of the infarction.
Common enzyme studies measure the levels of creatine
phosphokinase (CPK) and the protein troponin (TnL)
lactic dehydrogenase. In the past, lactate dehydrogenase
(LDH) was usually measured, but research has shown
that cardiac troponin and CPK are more specific.
Common Diseases of the
Cardiovascular System
Cardiovascular disease (CVD) is the leading cause
of death in the United States today (Figure 8-7).
Approximately 659 million people per year die from
CVD, and approximately one in every four people are
affected. CVD claims more lives than all forms of can
cer combined. Heart disease alone costs approximately
$363 billion a year in health care costs and lost pro
ductivity (Centers for Disease Control and Prevention
[CDC], 2021). High blood pressure accounts for most
of these cases, but coronary heart disease, rheumatic
heart disease, and other forms of cardiovascular dis
ease also contribute to these staggering numbers. Edu
cation about lifestyle behavioral changes has helped
decrease some individuals’ risk for CVD.
Diseases of the Arteries
Arterial disorders are the most common among all
CVDs. High blood pressure (hypertension) accounts
for the largest incidence of arterial disorders, but coro
nary artery disease (coronary heart disease) is the lead
ing cause of death overall.
Hypertension
■ Description. Most people are familiar with the basic
concept that hypertension is high arterial blood pres
sure. Other concepts include the fact that hypertension
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*CLRD—Chronic Lower Respiratory Diseases
Figure 8-7 Mortality statistics comparing cardiac
disease to other diseases (Centers for Disease
Control and Prevention, 2016).
is not only a disease process but also serves as an indi
cator of the development of cerebrovascular, cardiovas
cular, and kidney disease. Hypertension is a chronic
disease affecting almost half (47%) of all American
adults (CDC, 2021). It is the leading cause of stroke and
heart failure. Life expectancy in all individuals, regard
less of age or sex, is reduced when diastolic hypertension
is greater than 90 mm Hg.
Blood pressure varies from individual to individ
ual, but average adult blood pressure is considered to
be less than 120/80 mm Hg. The top number (120) is
the systolic pressure and measures the highest amount
of pressure in the artery when the ventricles of the heart
contract. The lower number is the diastolic pressure
and measures the artery pressure when the ventricles
relax. If one could view the arteries as the heart beats,
one would see a wavelike pattern of blood flow related
to the heart beating and resting (Figure 8-8). Medical
parameters for diagnosing high blood pressure start
with prehypertension at levels above 120/80. Stage
I hypertension is recognized when the level reaches
140/90, and stage II begins with a blood pressure of
160/100 or greater.
In addition to heartbeat, blood vessel resistance
also helps determine blood pressure. One might com
pare the heart and vessels to a water pump and hose:
the amount of water being pumped and the width of
the hose help determine the amount of water flow or
water pressure. In the same way, the amount of blood
the heart pumps and the resistance of the vessel, or size
of the lumen (LOO-men; inner open space or width),
will help determine blood pressure. The larger the
lumen or the more patent the vessel, the easier it is for
the heart to pump blood and, generally, the lower the
blood pressure.
Specialized nerve receptors in the body help con
trol pressure by bringing about vasoconstriction and
vasodilation at appropriate times. For example, when
an individual stands up suddenly, the blood pressure to
the head drops, often causing momentary dizziness. To
correct this situation, nerves react and constrict blood
vessels, raising blood pressure and restoring normal
pressure in the head. If blood pressure is too high, these
nerve receptors dilate vessels leading to the kidneys.
This increased blood flow leads to greater urine forma
tion and output. Increased urine production decreases
blood volume and thus lowers blood pressure. In this
way, the kidneys play a vital role in blood pressure. If
pressure is too low—as often occurs in shock—blood
flow to the kidneys is diminished, urine output is min
imal, blood fluid is maintained, and blood pressure is
maintained or restored.
■ Etiology. Because blood pressure and the kidneys
have such a close relationship, any disease of the kid
neys can cause an alteration in blood pressure, and
any change in blood pressure can have an adverse
effect on the kidneys. The kidneys play a vital role in
the elimination of salt and water, two substances that
also have a great effect on blood pressure. Retention of
salt and water increases blood pressure, whereas elim
ination of these substances reduces blood pressure.
Hypertension caused by kidney disease or some other
146 Chapter 8
Quercetin for
Cardiovascular
Disease
Complementary and Alternative Therapy
Q
uercetin is a plant pigment. It is an important flavonoid that is found in many
plants and foods such as green tea, apples, berries onions, buckwheat tea, red wine,
and other foods. It has an antioxidant and anti-inflammatory effect, so it has some ther
apeutic potential as an anti-atherosclerotic agent in cardiovascular disease. Research has
shown that quercetin can decrease the development of fatty plaques in the wall of arter
ies thus reducing damage to the arteries and interrupted blood flow. Quercetin may also
be beneficial in thalassemia, asthma, exercise-induced muscle damage, high cholesterol,
and high blood pressure disorders. Further research is needed to determine the dosages
needed to get the maximum antioxidant and anti-inflammatory effect.
Source: Deng et al (2020)
type of disease process is called secondary hyperten
sion. Only 10% of all hypertensive cases are due to
secondary problems.
Primary or essential hypertension accounts for
approximately 90% of all hypertensive cases. This type
of hypertension is idiopathic, or due to an unknown
cause, and usually has a gradual onset over a number
of years.
Some identified genetic and environmental risk
factors are known to cause primary hypertension:
■ Heredity Hypertension affects Black people twice
as often as White people.
■ Diet High salt and fat intake increases the risk of
hypertension.
■ Age Blood pressure tends to rise with age.
■ Obesity Obesity causes an increased workload on
the heart.
■ Smoking Nicotine causes vasoconstriction.
■ Stress Stress causes a rise in blood pressure due to
vasoconstriction.
■ Type A personality traits This type of personality
tends to experience more stress.
■ Symptoms. Symptoms usually do not occur until sig
nificant heart and vessel damage has already occurred.
If left untreated, high blood pressure overworks the
heart. Because the left ventricle works harder to pump
blood, it is the area most often affected, leading to left
ventricle hypertrophy (muscle enlargement). The vas
cular system, or blood supply, to the left ventricle does
not increase with this enlargement of muscle, so this
extra tissue does not have an adequate blood supply,
often leading to bouts of angina or chest pain due to
ischemia. This condition often leads to myocardial
infarction (MI), or heart failure, and death.
Hypertension not only affects the heart but also
adversely affects the vessels. Over a period of years, the
vessels become hardened (sclerotic) and lose elastic
ity, a contributing factor in arteriosclerosis (arterio =
artery, sclero = hardened, osis = condition of). Sclerotic
(hardened) vessels are also more likely to form thrombi
and to rupture, which can cause damage or death to the
involved organs.
■ Diagnosis. Blood pressure screening is very import
ant in diagnosing hypertension before the cardiovas
cular system is damaged. A random blood pressure
of greater than 140/90 might be physiologic; thus,
screening with frequent blood pressure readings
under varied conditions is needed to confirm the
diagnosis.
Further evaluation for hypertension consists pri
marily of
1. taking a medical and family history because
hypertension tends to run in families.
2. completing a physical examination.
3. testing blood for
■ cholesterol: should be under 200.
■ LDL (low-density lipoprotein—bad choles
terol): should be under 100.
■ HDL (high-density lipoprotein—good choles
terol): should be over 60.
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