Cardiovascular Integrated Physicians (CVIP) provides the following general cardiology services.
Elevated blood pressure is called hypertension. Blood pressure is the amount of force that blood exerts over the surface area of blood vessels in the body, including arteries, veins, and capillaries. It should be noted, however, that the blood pressure measurements taken for patients at doctor’s offices are generally arterial blood pressure measurements, measurements of blood pressure in the arteries. Arteries are the blood vessels that carry oxygenated blood from the heart to organ systems of the body in what is called systemic circulation.
Hypertension is a serious medical condition that can result in a diverse range of health consequences. Over time, the excessive blood pressure causes vascular damage, or damage to blood vessels. For most patients, high blood pressure is asymptomatic until severe vascular damage takes place, which is why hypertension is called the “silent killer.” High arterial pressure increases afterload, the force or resistance that a ventricle has to work against in order to sufficiently contract to eject blood; afterload increase makes it difficult for the ventricles pump out blood to the different areas of the body in systemic circulation. This, in turn, makes the heart work harder to the point that it undergoes pathological, or disease-induced structural and functional changes to adapt to the extra labor, resulting in congestive heart failure. Heart, or cardiac failure is when the cardiac output is too low to maintain the blood flow the body needs to function; the term “congestive” refers to the increase in venous volume and pressure that consequently develop.
The vascular damage that hypertension can cause includes damage to cerebral, or brain blood vessels, which can cause a cerebrovascular accident commonly known as a stroke. The third-leading cause of death in the United States, a stroke is the blockage or rupture of a cerebral blood vessel that carries oxygen and nutrients to the brain. Because parts of the brain cannot receive required oxygen and nutrients due blockage or rupture, those parts as well as brain cells die.
Furthermore, uncontrolled high blood pressure can also lead to heart attack, kidney failure requiring dialysis, erectile dysfunction, and numerous other health complications. Having adequately controlled blood pressure can prevent such complications.
High Cholesterol (Hyperlipidemia)
Cholesterol is a fat-like substance classified as a lipid, a water-insoluble organic compound. The body uses cholesterol to create steroids, bile salts, and vitamin D3. Cholesterol is also a crucial component of cell membranes in the body. Having too much cholesterol, however, may cause problems. There are two sources of cholesterol: the liver, which manufactures all the cholesterol in the body, and diet. There are two types of cholesterol: low-density lipoprotein (LDL), the “bad” cholesterol, and high-density lipoprotein (HDL), the “good” cholesterol.
LDLs transport cholesterol to the arteries. They also supply cells with cholesterol by attaching to them through the cells’ protein receptors; upon attachment, the cell engulfs the LDL particles and uses the cholesterol for various purposes. Most LDL particles in the blood are removed via this engulfment by the liver. Eating a diet rich in cholesterol and saturated and trans fats will stimulate the liver into making more cholesterol, resulting in high blood concentration of LDL. This is because the liver cells do not have enough LDL receptors for the cholesterol particles to attach to, so the excess cholesterol cannot be swallowed by the cells and thus cannot be removed from the blood. This leaves more LDL present to enter the endothelial cells (inner lining) of arteries, where, when engulfed by the endothelial cells, the LDL oxidizes to oxidized LDL. Evidence indicates that this oxidized LDL plays a part in endothelial cell injury and other factors that occur in the development of atherosclerosis. Atherosclerosis is the most common type of arteriosclerosis, the hardening of arteries. In atherosclerosis, raised areas called plaques form within the intermediate layers of the arteries. Made from these cholesterol particles, other lipids, and smooth muscle cells, these plaques protrude into the lumen (cavity) of an artery, creating blockage that impedes blood flow and increases blood pressure by contributing to total peripheral resistance. These plaques also act as locations for the development of thrombi (singular: thrombus), or blood clots that can worsen blockages of blood supply to organs. In the coronary arteries, these arterial plaques can lead to heart disease.
The liver is also responsible for removing HDLs, which are usually released as excessive cholesterol into the blood from cells. Unlike with LDLs, the cholesterol in HDLs is not engulfed by arteries because artery cells do not have the receptors necessary for engulfment of HDL particles. This means that HDL cholesterol does not cause or contribute to atherosclerosis. Scientific evidence shows that having a higher proportion of HDL cholesterol than LDL cholesterol can benefit patients, as it shows that cholesterol may migrate away from blood vessels and to the liver. Furthermore, people who exercise regularly appear to have higher HDL cholesterol concentrations and lower risk for atherosclerosis compared to those who do not. A regimen of exercise and diet that minimizes consumption of foods high in saturated fat (eg, egg yolks, fatty meat) can substantially lower blood cholesterol concentration. Having high LDL, high bad cholesterol, or having low HDL or too little of good cholesterol can cause circulatory system conditions like atherosclerosis. Therefore, patients should try to lower their LDL levels and increase their HDL levels.
Patients with a history of coronary artery disease, heart attack, diabetes, and stroke benefit from lowering their cholesterol, and they should have cholesterol goals that are stricter compared to those of patients without these known diagnoses. Medications known as statins, or PCKS9 inhibitors, or other types of cholesterol lowering agents are prescribed to patients to help prevent further cholesterol buildup.
Heart failure is a result of the inability of the heart to pump blood efficiently throughout the body. It is characterized by insufficient cardiac output that cannot sustain the level of blood blow required by the body to function. When the heart cannot maintain adequate performance, it tries to compensate by growing in size for more strength to meet the increased demand in blood pumping, which requires it to contract more strongly. The heart also tries to increase its output by pumping blood at a faster speed. Sometimes used interchangeably with “heart failure,” if applicable, there is a heart failure subtype called congestive heart failure (CHF). With CHF, not only does the heart fail to deliver sufficient cardiac output to maintain proper bodily blood flow, but when blood returns to the heart, the veins through which the blood returns get clogged, resulting in congestion in body tissues that manifests as edema, or swelling in various parts of the body like the legs. When these compensatory functions no longer help, patients typically experience symptoms including fatigue, shortness of breath, cough, weight gain, and swelling of the legs and feet. Heart failure evaluation includes detailed history documentation and physical examination coupled with various tests including ECG, ultrasound of the heart (echocardiogram), and magnetic resonance imaging (MRI) scans, among others.
Some causes of heart failure include coronary artery disease, heart valve problems, heart rhythm abnormalities, uncontrolled hypertension, diabetes, obesity, medical conditions associated with deposition of substances within heart muscles (eg, Amyloid), and alcohol and tobacco use. There are several different strategies for treatment of heart failure that include medications according to evidence-based guidelines, in addition to advanced measures including treatment of underlying causes such as coronary artery disease with stents or bypass surgery, valve treatment (either catheter-based or surgical), heart rhythm management, pacemaker and/or defibrillator implantation, and additional measures depending on the cause.
Ischemic Heart Disease and Heart Attack (Myocardial Infarction)
The heart is a muscular organ that sends blood and oxygen supply to the body through the arteries that surround the heart, referred to as coronary arteries. A heart attack is defined as severe or complete interruption of blood flow to the heart muscle. A heart attack typically originates from ischemia, a condition in which a tissue becomes ischemic when insufficient blood flow causes oxygen supply deficiency. The most common cause of ischemia in myocardial (heart muscle) tissue is atherosclerosis of the coronary arteries. Atherosclerosis leads to plaque formation and narrowing in a coronary artery. When the plaque breaks open, a blood clot forms that obstructs the artery and consequently leads to reduced or complete cessation of blood flow to the heart muscle. Because of the absence of adequate oxygen supply for aerobic respiration, myocardial ischemic tissue must instead perform anaerobic respiration, which yields lactic acid that increases lactic acid concentrations in the blood. The lactic acid can cause substernal pain, which is pain in the left shoulder and arm typically called angina pectoris, a major symptom of a heart attack. Nitroglycerin or similar medications are often taken by patients suffering with angina to relieve both the ischemia and pain. Such drugs produce vasodilation of blood vessels, enhancing heart circulation and lowering the ventricle workload for blood ejection into the arteries.
The cells of myocardial tissues are designed to respire aerobically and cannot do anaerobic respiration for longer than a few minutes. Consequently, prolonged anaerobic respiration and ischemia can cause necrosis, or cellular death, to develop in the most oxygen-deprived areas of tissue. This necrosis is an irreversible injury known as a myocardial infarction (MI), known commonly as a “heart attack.”
Symptoms of a heart attack include chest pain, shortness of breath, passing out, and nausea. Heart attacks require immediate medical attention with emergency procedures like cardiac catheterization and coronary angiogram, blood clot removal, and stent placement to keep the coronary artery open. Formulating a prevention strategy to lower risk of heart attacks is our goal with every patient evaluation.
Coronary Artery Disease (CAD)
Coronary artery disease (CAD) is defined as a buildup of fat, cholesterol, and other substances that leads to formation of plaque in the walls of arteries that connect to the heart, which are called coronary arteries. The plaque grows in size to the point that it narrows the artery lumen and thus hinders or obstructs blood flow to the heart. This deprives the heart of oxygen-rich blood, leading to the condition ischemia, an inadequate blood flow rate for oxygen supply and for maintenance of aerobic respiration for an organ, the heart in this case. It is likely for this reason that CAD is often used interchangeably with the terms coronary heart disease (CHD) and ischemic heart disease. However, it should be noted that these two conditions are the results of CAD, not the equivalents of it.
Because CAD blocks blood flow to the heart and other parts of the body, chest pain or discomfort, called angina, is a typical symptom of CAD. Some patients discover they have CAD when they have heart attacks. Heart attack symptoms include angina, shoulder or arm pain, shortness of breath, and weakness or nausea. Severe narrowing of coronary arteries with CAD weakens the heart muscle, creates rhythm disturbances, and produces other heart related complications such as heart failure.
Conditions associated with increased risk of developing coronary artery disease include diabetes, hypertension, high cholesterol, family history, smoking, and advanced age. Patients with coronary artery disease have increased risk of heart attack. Prevention of heart attack includes adequate blood pressure control, lowering cholesterol, management of diabetes, and smoking cessation. Medications known as antiplatelets are given to patients with a diagnosis of coronary artery disease to help prevent clotting in the coronary arteries and lower the risk of heart attack.
Atrial Fibrillation (AF or AFIB)
If any chambers of the heart (atria or ventricles) undergo very rapid rates of electrical stimulation and contraction, then flutter or fibrillation may follow. Flutter is very rapid contraction, upwards of 200 to 300 contractions per minute; despite the fast pace, these contractions maintain coordination. With fibrillation, however, myocardial fibers (heart muscle fibers) contract at different times, precluding coordination of the blood pumping function of the chambers. Atrial flutter, flutter in the atria of the heart, can quickly deteriorate into atrial fibrillation (AF or AFIB), abnormal and irregular rhythm in the atria. With AFIB, failure to coordinate blood pumping causes the heart to beat irregularly because the atria cannot contract properly. Because the atria cannot contract effectively and consequently cannot pump blood adequately into the ventricles, remaining blood that is not pumped to the ventricles starts to collect within the atria. This pooling of blood enables formation of blood clots within the left atrial appendage, a small sac in the top left atrium of the heart, increasing a patient’s risk of stroke. Patients may be placed on medications known as blood thinners (anticoagulants) to prevent stroke; examples include Warfarin (Coumadin), Xarelto, Eliquis, and Pradaxa. Risk factors of atrial fibrillation include heart valve disease, hypertension, excessive use of alcohol, aging, and tobacco use.
Aortic Valve Stenosis
The aortic valve is the valve which allows blood flow from the heart to the aorta, the body’s main artery that supplies the rest of the body with blood, oxygen, and nutrients. When the valve becomes too narrowed, which is a condition called aortic valve stenosis, it prevents blood from flowing out of the heart to the aorta. Severe aortic valve stenosis is a serious condition that can lead to shortness of breath, dizziness, passing out, heart failure, and sudden death. Treatment options include surgical aortic valve replacement (SAVR)in an open-heart surgery performed by a cardiothoracic surgeon, or the minimally invasive transcatheter aortic valve replacement (TAVR), which is performed by a structural interventional cardiologist such as Dr. Daniel as a member of a heart valve team.
Mitral Valve Regurgitation
The mitral valve is a heart valve located on the left side of the heart and has two leaflets (flaps), which is why it is also called the bicuspid valve. The mitral valve sits between the left atrium and left ventricle. Normally, blood flow returns from the lungs to the left atrium through the mitral valve; the blood then flows to the left ventricle to be pumped out to the aorta for transport to the entire body. A normal mitral valve functions by preventing blood from flowing backwards into the left atrium. In mitral valve regurgitation, however, leakage of the mitral valve results when the two leaflets do not close properly, causing some of the blood to flow backwards into the left atrium. Mitral valve regurgitation may be associated with various conditions including mitral valve prolapse, rheumatic heart disease, and cardiomyopathy. This condition may lead to symptoms of heart failure such as fatigue, shortness of breath, coughing, and swelling of the feet. Treatments for mitral valve regurgitation include mitral valve repair or replacement. Patients who may not be candidates for surgery are offered an alternative option: a minimally invasive transcatheter mitral valve repair (TMVr) procedure called MitraClip™, the attachment of an implanted clip to the mitral valve to facilitate valve closure and restore proper blood flow in the heart.