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Heart & Vascular Conditions Treated 

Heart disease is the number one cause of death in this country. But it’s also one of the most preventable. The choices you make every day - what to eat, how you respond to stress, whether or not to get up off the couch and exercise - affect how much you’re at risk. Click on a condition below to learn more.

Angina PectorisAngina de Pecho

Angina Pectoris

What is angina pectoris?

The heart and arteries, and plaque buildup in arterial wall
Click image to enlarge.

Angina pectoris (or simply angina) is recurring chest pain or discomfort that happens when some part of the heart does not receive enough blood and oxygen. Angina is a symptom of coronary artery disease (CAD), which occurs when arteries that carry blood to the heart become narrowed and blocked due to atherosclerosis or a blood clot.

What are the symptoms of angina pectoris?

Angina pectoris occurs when the heart muscle (myocardium) does not receive an adequate amount of blood and oxygen needed for a given level of work (insufficient blood supply is called ischemia). The following are the most common symptoms of angina. However, each individual may experience symptoms differently. Symptoms may include:

  • A pressing, squeezing, or crushing pain, usually in the chest under the breast bone, but may also occur in the upper back, both arms, neck or ear lobes 

  • Pain radiating in the arms, shoulders, jaw, neck, and/or back

  • Shortness of breath

  • Weakness and/or fatigue

The chest pain associated with angina usually begins with physical exertion. Other triggers include emotional stress, extreme cold and heat, heavy meals, excessive alcohol consumption, and cigarette smoking. Angina chest pain is usually relieved within a few minutes by resting or by taking prescribed cardiac medications, such as nitroglycerin.

The symptoms of angina pectoris may resemble other medical conditions or problems. Always consult your doctor for more information.

Angina pectoris and heart attack risk

An episode of angina does not indicate that a heart attack is occurring, or that a heart attack is about to occur. Angina does indicate, however, that coronary artery disease is present and that some part of the heart is not receiving an adequate blood supply. Persons with angina have an increased risk of heart attack.

A person who has angina should note the patterns of his or her symptoms--what causes the chest pain, what it feels like, how long episodes usually last, and whether medication relieves the pain. Call for medical assistance if the angina episode symptoms change sharply. This is called unstable angina.

Diagnosing angina pectoris

In addition to a complete medical history and medical exam, a doctor can often diagnose angina pectoris by noting the patient's symptoms and how/when they occur. Certain diagnostic procedures may also determine the severity of the coronary artery disease, and may include:

  • Electrocardiogram (ECG or EKG). A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.

  • Stress test (usually with ECG; also called treadmill or exercise ECG). A test that is given while a patient walks on a treadmill or pedals a stationary bicycle to monitor the heart during exercise. Breathing and blood pressure rates are also monitored. A stress test may be used to detect coronary artery disease, and/or to determine safe levels of exercise following a heart attack or heart surgery.

  • Cardiac catheterization. With this procedure, X-rays are taken after a contrast agent is injected into an artery to locate the narrowing, occlusions, and other abnormalities of specific arteries.

Treatment of angina pectoris

Specific treatment for angina pectoris will be determined by the doctor based on:

  • Your age, overall health, and medical history

  • Extent of the disease

  • Your tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the disease

  • Your opinion or preference

The underlying coronary artery disease that causes angina should be treated by controlling existing risk factors: high blood pressure, cigarette smoking, high blood cholesterol levels, high saturated fat diet, lack of exercise and excess weight.

Medications may be prescribed for people with angina. The most common is nitroglycerin which helps to relieve pain by widening the blood vessels. This allows more blood flow to the heart muscle and decreases the workload of the heart.

Other types of angina pectoris

There are two other forms of angina pectoris, including:

Variant angina pectoris
(or Prinzmetal's angina)

Microvascular angina

  • Is rare

  • Occurs almost exclusively when a person is at rest

  • Often does not follow a period of physical exertion or emotional stress

  • Attacks can be very painful and usually occur between midnight and 8 a.m.

  • Is related to spasm of the artery

  • Is more common in women

  • Can be helped by medications

  • A recently discovered type of angina

  • Patients with this condition experience chest pain but have no apparent coronary artery blockages

  • Doctors have found that the pain results from poor function of tiny blood vessels nourishing the heart as well as the arms and legs

  • Can be treated with some of the same medications used for angina pectoris

  • Was once called Syndrome X

  • Is more common in women

Angina

Angina is a type of chest discomfort caused by poor blood flow through to the heart muscle.

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AtherosclerosisAterosclerosis

Atherosclerosis

What is atherosclerosis?

View of a normal artery and an artery with plaque buildup
Click Image to Enlarge

Atherosclerosis is a type of thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery. Plaque is made up of deposits of fatty substances, cholesterol, cellular waste products, calcium, and fibrin, and can develop in medium or large arteries. The artery wall becomes thickened and stiff.

Atherosclerosis is a slow, progressive disease that may start as early as childhood. However, the disease has the potential to progress rapidly.

What causes atherosclerosis?

It is unknown exactly how atherosclerosis begins or what causes it. Some scientists think that certain risk factors may be associated with atherosclerosis, including:

  • Elevated cholesterol and triglyceride levels

  • High blood pressure

  • Smoking

  • Type 1 diabetes

  • Obesity

  • Physical inactivity

  • High saturated fat diet

How does the disease progress?

There is a gradual buildup of plaque or thickening of the inside of the walls of the artery, causing a decrease in the amount of blood flow, and a decrease in the oxygen supply to the vital body organs and extremities.

A heart attack may occur if the oxygenated blood supply is reduced to the heart. A stroke may occur if the oxygenated blood supply is cut off to the brain. Severe pain and gangrene may occur if the oxygenated blood supply is reduced to the arms and legs. 

What are the symptoms of atherosclerosis?

Signs and symptoms of atherosclerosis may develop gradually, and may be few, as the plaque builds up in the artery. Symptoms may also vary depending on the affected artery. However, when a major artery is blocked, signs and symptoms may be severe, such as those occurring with heart attack, stroke, aneurysm, or blood clot.

The symptoms of atherosclerosis may resemble other heart conditions. Consult your doctor for a diagnosis.

How is atherosclerosis diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for atherosclerosis may include any, or a combination of, the following:

  • Cardiac catheterization. With this procedure, X-rays are taken after a dye is injected into an artery to locate the narrowing, blockages, and other abnormalities of specific arteries.

  • Doppler sonography. A special probe is used to direct sound waves into a blood vessel to evaluate blood flow. An audio receiver amplifies the sound of the blood moving though the vessel. Faintness or absence of sound may indicate an obstruction in the blood flow.

  • Blood pressure comparison. Comparing blood pressure measurements in the ankles and in the arms to determine any constriction in blood flow. Significant differences may indicate a narrowing of vessels which could be caused by atherosclerosis.

  • MUGA/radionuclide angiography. A nuclear scan to see how the heart wall moves and how much blood is expelled with each heartbeat, while the person is at rest.

  • Thallium/myocardial perfusion scan. A nuclear scan given while the person is at rest or after exercise that may reveal areas of the heart muscle that are not getting enough blood.

  • Computerized tomography or CT. A type of X-ray test that can see if there is coronary calcification that may suggest a future heart problem. 

Treatment for atherosclerosis

Specific treatment will be determined by your doctor based on:

  • Your age, overall health, and medical history

  • Extent of the disease

  • The location of the blockage

  • Your signs and symptoms

  • Your tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the disease

  • Your opinion or preference

Treatment may include:

  • Modification of risk factors. Risk factors that may be modified include smoking, elevated cholesterol levels, elevated blood glucose levels, lack of exercise, poor dietary habits, and elevated blood pressure.

  • Medications. Medications that may be used to treat carotid artery disease include:

    • Antiplatelet medications. Medications used to decrease the ability of platelets in the blood to stick together and cause clots. Aspirin, clopidogrel, ticlopidine, and dipyridamole are examples of antiplatelet medications.

    • Anticoagulants. Also described as blood thinners, these medications work differently than antiplatelet medications to decrease the ability of the blood to clot. An example of an anticoagulant is warfarin.

    • Antihyperlipidemics. Medications used to lower lipids (fats) in the blood, particularly Low Density Lipid (LDL) cholesterol. Statins are a group of antihyperlipidemic medications, and include simvastatin, atorvastatin, and pravastatin, among others. Bile acid sequestrants—colesevelam, cholestyramine and colestipol—and nicotinic acid are two other types of medications that may be used to reduce cholesterol levels.

    • Antihypertensives. Medications used to lower blood pressure. There are several different groups of medications which act in different ways to lower blood pressure

View od artery showing plaque build up and balloon catheter
Click Image to Enlarge

  • Coronary angioplasty. With this procedure, a balloon is used to create a bigger opening in the vessel to increase blood flow. Although angioplasty is performed in other blood vessels elsewhere in the body, percutaneous coronary intervention (PCI) refers to angioplasty in the coronary arteries to permit more blood flow into the heart. PCI is also called percutaneous coronary intervention. There are several types of PCI procedures, including:

    • Balloon angioplasty. A small balloon is inflated inside the blocked artery to open the blocked area.

    • Atherectomy. The blocked area inside the artery is shaved away by a tiny device on the end of a catheter.

    • Laser angioplasty. A laser used to vaporize the blockage in the artery.

    • Coronary artery stent. A tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open.

Part of an artery showing plaque build up. A catheter and stent are in place.
Click Image to Enlarge

  • Coronary artery bypass. Most commonly referred to as simply bypass surgery, this surgery is often performed in people who have angina (chest pain) due to coronary artery disease (where plaque has built up in the arteries). During the surgery, a bypass is created by grafting a piece of a vein above and below the blocked area of a coronary artery, enabling blood to flow around the obstruction. Veins are usually taken from the leg, but arteries from the chest or arm may also be used to create a bypass graft.

Arteriosclerosis

Arteriosclerosis occurs when fatty material collects along the walls of arteries, leading to blocked arteries.

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Heart Attack Dolor en el Pecho / Síntomas de Ataque al Corazón

Heart Attack

What is a heart attack (myocardial infarction)?

A heart attack, or myocardial infarction, occurs when one or more regions of the heart muscle experience a severe or prolonged lack of oxygen caused by blocked blood flow to the heart muscle.

Normal heart and artery; artery with plaque buildup
Click image to enlarge

The blockage is often a result of atherosclerosis—a buildup of plaque composed of fat deposits, cholesterol, and other substances. When a plaque ruptures, a blood clot quickly forms. The blood clot is the actual cause of the heart attack.

If the blood and oxygen supply is cut off, muscle cells of the heart begin to suffer damage and start to die. Irreversible damage begins within 30 minutes of blockage. The result is dysfunction of the heart muscle in the area affected by the lack of oxygen or cell death.

What are the risk factors for heart attack?

There are two types of risk factors for heart attack, including the following:

Inherited (or genetic)

Acquired

Inherited or genetic risk factors are risk factors you are born with that cannot be changed, but can be improved with medical management and lifestyle changes.

Acquired risk factors are caused by activities that we choose to include in our lives that can be managed through lifestyle changes and clinical care.

Inherited (genetic) factors: Who is most at risk?

  • People with inherited hypertension (high blood pressure)

  • People with inherited low levels of HDL (high-density lipoproteins), high levels of LDL (low-density lipoprotein) blood cholesterol or high levels of triglycerides

  • People with a family history of heart disease (especially with onset before age 55)

  • Aging men and women

  • People with type 1 diabetes

  • Women, after the onset of menopause (generally, men are at risk at an earlier age than women, but after the onset of menopause, women are equally at risk)

Acquired risk factors: Who is most at risk?

  • People with acquired hypertension (high blood pressure)

  • People with acquired low levels of HDL (high-density lipoproteins), high levels of LDL (low-density lipoprotein) blood cholesterol, or high levels of triglycerides

  • Cigarette smokers

  • People who are under a lot of stress

  • People who drink too much alcohol

  • People who lead a sedentary lifestyle

  • People overweight by 30 percent or more

  • People who eat a diet high in saturated fat

  • People with type 2 diabetes

A heart attack can happen to anyone—it is only when we take the time to learn which of the risk factors apply to us, specifically, can we then take steps to eliminate or reduce them.

Managing heart attack risk factors

Managing your risks for a heart attack begins with:

  • Examining which of the risk factors apply to you, and then taking steps to eliminate or reduce them.

  • Becoming aware of conditions like hypertension or abnormal cholesterol levels, which may be "silent killers."

  • Modifying risk factors that are acquired (not inherited) through lifestyle changes. Consult your doctor as the first step in starting right away to make these changes.

  • Consulting your health care provider soon to determine if you have risk factors that are genetic or inherited and cannot be changed, but can be managed medically and through lifestyle changes.

What are the warning signs of a heart attack?

The following are the most common symptoms of a heart attack. However, each individual may experience symptoms differently. Symptoms may include:

  • Severe pressure, fullness, squeezing, pain and/or discomfort in the center of the chest that lasts for more than a few minutes

  • Pain or discomfort that spreads to the shoulders, neck, arms, or jaw

  • Chest pain that increases in intensity

  • Chest pain that is not relieved by rest or by taking nitroglycerin

  • Chest pain that occurs with any/all of the following (additional) symptoms:

    • Sweating, cool, clammy skin, and/or paleness

    • Shortness of breath

    • Nausea or vomiting

    • Dizziness or fainting

    • Unexplained weakness or fatigue

    • Rapid or irregular pulse

Although chest pain is the key warning sign of a heart attack, it may be confused with indigestion, pleurisy, pneumonia, or other disorders.

The symptoms of a heart attack may resemble other medical conditions or problems. Always consult your health care provider for a diagnosis.

Responding to heart attack warning signs

If you or someone you know exhibits any of the above warning signs, act immediately. Call 911, or your local emergency number.

Treatment for a heart attack

The goal of treatment for a heart attack is to relieve pain, preserve the heart muscle function, and prevent death.

Treatment in the emergency department may include:

Image of a man on a gurney being wheeled down a hallway at a hospital

  • Intravenous therapy such as nitroglycerin and morphine.

  • Continuous monitoring of the heart and vital signs.

  • Oxygen therapy improves oxygenation to the damaged heart muscle.

  • Pain medication decreases pain, and, in turn, decreases the workload of the heart, thus, the oxygen demand of the heart decreases.

  • Cardiac medication, such as beta-blockers, promote blood flow to the heart, improve the blood supply, prevent arrhythmias, and decrease heart rate and blood pressure.

  • Fibrinolytic therapy is the intravenous infusion of a medication which dissolves the blood clot, thus, restoring blood flow.

  • Antithrombin/antiplatelet therapy is used to prevent further blood clotting.

  • Antihyperlipidemics are medications used to lower lipids (fats) in the blood, particularly Low Density Lipid (LDL) cholesterol. Statins are a group of antihyperlipidemic medications, and include simvastatin (Zocor), atorvastatin (Lipitor), and pravastatin (Pravachol), among others. Bile acid sequestrants—colesevelam, cholestyramine, and colestipol—and nicotinic acid (niacin) are two other types of medications that may be used to reduce cholesterol levels.

Additional procedures to restore coronary blood flow may be used. Those procedures include:

  • Coronary angioplasty. With this procedure, a balloon is used to create a bigger opening in the vessel to increase blood flow. This is often followed by the insertion of a stent into the coronary artery to help keep the vessel open. Although angioplasty is performed in other blood vessels elsewhere in the body, percutaneous coronary intervention (PCI) refers to angioplasty in the coronary arteries to permit more blood flow into the heart. PCI is also called percutaneous transluminal coronary angioplasty (PTCA). There are several types of PTCA procedures, including:

    • Balloon angioplasty. A small balloon is inflated inside the blocked artery to open the blocked area.

    • Coronary artery stent. A tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open.

    • Atherectomy. The blocked area inside the artery is cut away by a tiny device on the end of a catheter.

    • Laser angioplasty. A laser used to "vaporize" the blockage in the artery.

  • Coronary artery bypass. Most commonly referred to as simply "bypass surgery" or CABG (pronounced "cabbage"), this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). During the surgery, a bypass is created by grafting a piece of a vein above and below the blocked area of a coronary artery, enabling blood to flow around the obstruction. Veins are usually taken from the leg, but arteries from the chest or arm may also be used to create a bypass graft.

Heart Attack

Heart attacks are caused by a blockage of blood flow to the heart, usually as a result of plaque build up in the arteries.

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High Blood Pressure/HypertensionPresión Sanguínea Alta / Hipertensión

High Blood Pressure/Hypertension

What is blood pressure?

Blood pressure is the force of the blood pushing against the artery walls. The force is generated with each heartbeat as blood is pumped from the heart into the blood vessels. The size and elasticity of the artery walls also affect blood pressure. Each time the heart beats (contracts and relaxes), pressure is created inside the arteries.

The pressure is greatest when blood is pumped out of the heart into the arteries. When the heart relaxes between beats (blood is not moving out of the heart), the pressure falls in the arteries.

Two numbers are recorded when measuring blood pressure.

  • The top number, or systolic pressure, refers to the pressure inside the artery when the heart contracts and pumps blood through the body.

  • The bottom number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood.

Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury). This recording represents how high the mercury column in the blood pressure cuff is raised by the pressure of the blood.

Blood pressure is measured with a blood pressure cuff and stethoscope by a nurse or other health care provider. You can also take your own blood pressure with an electronic blood pressure monitor available at most pharmacies.

High blood pressure, or hypertension, directly increases the risk of heart attack and stroke. With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood. Usually, high blood pressure has no signs or symptoms. However, you can know if your blood pressure is high by having it checked regularly by your health care provider.

The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) has determined two levels of high blood pressure for adults:

  • Stage 1

    • 140 mm Hg to 159 mm Hg systolic pressure—higher number

      and

    • 90 mm Hg to 99 mm Hg diastolic pressure—lower number 

  • Stage 2

    • 160 mm Hg or higher systolic pressure

      and

    • 100 mm Hg or higher diastolic pressure

The NHLBI defines prehypertension as:

  • 120 mm Hg to 139 mm Hg systolic pressure

    and

  • 80 mm Hg to 89 mm Hg diastolic pressure

The NHLBI guidelines define normal blood pressure as follows:

  • Less than 120 mm Hg systolic pressure

    and

  • Less than 80 mm Hg diastolic pressure

These numbers should be used as a guide only. A single elevated blood pressure measurement is not necessarily an indication of a problem. Your health care provider will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of high blood pressure and starting treatment. If you normally run a lower-than-usual blood pressure, you may be diagnosed with high blood pressure with blood pressure measurements lower than 140/90.

What are the risk factors for high blood pressure?

Nearly one-third of all Americans have high blood pressure, but it  is particularly prevalent in:

  • People who have diabetes, gout, or kidney disease

  • African Americans (particularly those who live in the southeastern United States)

  • People in their early to middle adult years; men in this age group have higher blood pressure more often than women in this age group

  • People in their middle to later adult years; women in this age group have higher blood pressure more often than men in this age group (more women have high blood pressure after menopause than men of the same age)

  • Middle-aged and elderly people; more than half of all Americans age 60 and older have high blood pressure

  • People with a family history of high blood pressure

  • Obese people

  • Heavy drinkers of alcohol

  • Women who are taking oral contraceptives

How does blood pressure increase?

The following conditions contribute to high blood pressure:

  • Being overweight

  • Excessive sodium intake

  • A lack of exercise and physical activity

How is high blood pressure controlled?

High blood pressure can be controlled by:

  • Taking prescribed medications exactly as ordered by your health care provider

  • Choosing foods that are low in sodium (salt)

  • Choosing foods low in calories and fat

  • Choosing foods high in fiber

  • Maintaining a healthy weight, or losing weight if overweight

  • Limiting serving sizes

  • Increasing physical activity

  • Reducing or omitting alcoholic beverages

Sometimes daily medication is needed to control high blood pressure. If you have high blood pressure, have your blood pressure checked routinely and see your doctor to monitor the condition.

Hypertensive Heart Disease

Hypertensive heart disease (high blood pressure) occurs when a person's blood pressure is consistently higher than the normal range.

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PericarditisPericarditis

Pericarditis

What is pericarditis?

View of the heart and pericardium
Click image to enlarge

Pericarditis is inflammation of the pericardium, the thin sac (membrane) that surrounds the heart. There is a small amount of fluid between the inner and outer layers of the pericardium. Often, when the pericardium becomes inflamed, the amount of fluid between its two layers increases. This is called a pericardial effusion. If the amount of fluid increases quickly, the effusion can impair the ability of the heart to function properly. This complication of pericarditis is called cardiac tamponade and is a serious emergency.

What are the symptoms of pericarditis?

The following are the most common indicators of pericarditis. However, individuals may experience symptoms differently. Symptoms may include:

  • Chest pain that:

    • Can especially be felt behind the breastbone, sometimes felt beneath the clavicle (collarbone), neck, and left shoulder.

    • Is a sharp, piercing pain over the center or left side of the chest that increases if the person takes a deep breath and usually decreases if the person sits up or leans forward.

  • Fever

  • Pain when swallowing

  • Palpitations (irregular heart beats)

The symptoms of pericarditis may resemble other conditions or medical problems. Consult your health care provider for a diagnosis.

What causes pericarditis?

Usually, the cause of pericarditis is unknown, but may include any or all of the following:

  • Infection (viral, bacterial, fungal, parasitic)

  • Autoimmune disorders (i.e., systemic lupus erythematosus, rheumatoid arthritis, scleroderma)

  • Inflammation after a heart attack

  • Chest trauma or injury

  • Cancer, tuberculosis, or kidney failure  

  • Medical therapies (certain medications, radiation therapy) 

  • Heart surgery

Treatment for pericarditis

Your health care provider will determine your specific treatment, based on:

  • Your age, overall health, and medical history

  • Severity of the disease

  • Cause of the disease

  • Your tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the disease

  • Your opinion or preference

The goal of treatment for pericarditis is to determine and eliminate the cause of the disease. Treatment may include:

  • Medication (i.e., analgesics, anti-inflammatory drugs, or antibiotics)

  • Aspiration or removal of excess fluid

  • Surgery

Pericarditis may last from two to six weeks, and there may be a recurrence of the disorder.

Pericardial Disorders

Pericarditis means the protective sac around the heart becomes inflamed. Pericarditis is usually a complication stemming from viral, fungal or bacterial infections.

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ArrhythmiasArritmias

Arrhythmias

What is an arrhythmia?

An arrhythmia is an abnormal heart rhythm.

Some arrhythmias can cause problems with contractions of the heart chambers by:

  • Not allowing the ventricles (lower chambers) to fill with an adequate amount of blood because an abnormal electrical signal is causing the heart to pump too fast or too slow.

  • Not allowing a sufficient amount of blood to be pumped out to the body because an abnormal electrical signal is causing the heart to pump too slowly or too irregularly.

  • Not allowing the top chambers to work properly. 

In any of these situations, the body's vital organs may not receive enough blood to meet their needs.

What are the symptoms of arrhythmias?

The effects on the body are often the same, however, whether the heartbeat is too fast, too slow, or too irregular. Some symptoms of arrhythmias include, but are not limited to:

  • Palpitations (a sensation of fluttering or irregularity of the heartbeat) 

  • Weakness

  • Fatigue

  • Low blood pressure

  • Dizziness

  • Fainting

  • Heart failure

  • Collapse and cardiac arrest

  • Difficulty feeding (in babies)

The symptoms of arrhythmias may resemble other conditions. Consult your doctor for a diagnosis.

To better understand arrhythmias, is it helpful to understand the heart's electrical conduction system.

The heart's electrical system

The heart is, in the simplest terms, a pump made up of muscle tissue. The heart's pumping action is regulated by an electrical conduction system that coordinates the contraction of the various chambers of the heart.

How does the heart beat?

Illustration of a cross section of the heart and electrical pathways. Inset box shows normal heart rhythm
Click Image to Enlarge

An electrical stimulus is generated by the sinus node (also called the sinoatrial node, or SA node), consisting of a small mass of specialized tissue located in the right atrium (right upper chamber) of the heart. The sinus node generates a regular electrical stimulus, which for adults, is usually 60 to 100 times per minute under normal conditions. This electrical stimulus travels down through the conduction pathways (similar to the way electricity flows through power lines from the power plant to your house) and causes the heart's lower chambers to contract and pump out blood. The right and left atria (the two upper chambers of the heart) are stimulated first and contract a short period of time before the right and left ventricles (the two lower chambers of the heart). 

The electrical impulse travels from the sinus node to the atrioventricular node (also called AV node), where impulses are slowed down for a very short period, then allowed to continue down the conduction pathway via an electrical channel called the bundle of His into the ventricles. The bundle of His divides into right and left pathways to provide electrical stimulation to the right and left ventricles. Each contraction of the ventricles represents one heartbeat. 

Each day the heart beats about 100,000 times, on average. Any abnormality in the heart's electrical conduction system can make the heartbeat too fast, too slow, or at an uneven rate, thus, causing an arrhythmia.

What is an electrocardiogram (ECG)?

The electrical activity of the heart is measured by an electrocardiogram (ECG or EKG). By placing electrodes at specific locations on the body (chest, arms, and legs), a graphic representation, or tracing, of the electrical activity can be obtained. Changes in an ECG from the normal tracing can indicate arrhythmias, as well as other heart-related conditions.

What does an ECG mean?

Almost everyone knows what a basic ECG tracing looks like. But what does it mean?

  • The first little upward notch of the ECG tracing is called the "P wave." The P wave indicates that the atria (the two upper chambers of the heart) are electrically stimulated. This causes them to contract and pump blood to the ventricles.

  • The delay in the conduction of the electrical signal from the atria to the ventricles from the beginning of the P wave to the R (or Q) wave is known as the PR interval.

  • The next part of the tracing is a short downward section connected to a tall upward section. This part is called the "QRS complex." This part indicates that the ventricles (the two lower chambers of the heart) are electrically stimulated (undergo depolarization) to pump out blood to the body via the aorta or to the lungs via the pulmonary artery. 

  • The next short flat segment is called the "ST segment." The ST segment is a time when the ventricles are activated and the electrical signal for ventricular contraction is completed.

  • The next upward curve is called the "T wave." The T wave is the electrical recovery period of the ventricles (ventricular repolarization). After the ventricles repolarize, they can then depolarize again. 

When your doctor studies your ECG, he or she looks at the size, length, and appearance of each part of the ECG. Variations in size and length of the different parts of the tracing may be significant. The tracing for each lead of a 12-lead ECG will look different, but will have the same basic components as described above. Each lead of the 12-lead is "looking" at a specific part of the heart, so variations in a lead may indicate a problem with the part of the heart associated with the lead.

What are the different types of arrhythmias?

An arrhythmia can occur in the sinus node, the atria, or the atrioventricular node. These are supraventricular arrhythmias.

A ventricular arrhythmia is caused by an abnormal electrical focus within the ventricles, resulting in abnormal conduction of electrical signals within the ventricles.

 Arrhythmias can also be classified as slow (bradyarrhythmia) or fast (tachyarrhythmia). "Brady-" means slow, while "tachy-" means fast.

Listed below are some of the more common arrhythmias:

Atrial arrhythmias

Ventricular arrhythmias

Sinus arrhythmia. A common condition in which the heart rate varies with breathing. Sinus arrhythmia is commonly found in children; adults may often have it as well. This is a benign (not dangerous) condition.

Premature ventricular contractions (PVCs). A condition in which an electrical signal originates in the ventricles and causes the ventricles to contract before receiving the electrical signal from the atria. PVCs are common and typically do not cause symptoms or problems. However, if the frequency of the PVCs increases significantly, symptoms such as weakness, fatigue, dizziness, fainting, or palpitations may be experienced. Heart failure may develop. 

Sinus tachycardia. A condition in which the heart rate is faster than normal because the sinus node is sending out electrical impulses at a rate faster than usual. Most commonly, sinus tachycardia occurs as a normal response of the heart to exercise when the heart rate increases to cope with increased energy requirements. Sinus tachycardia can be completely appropriate and normal, such as when a person is exercising vigorously. Sinus tachycardia is often temporary, also occurring when the body is under stress from strong emotions, infection, fever, hyperthyroidism, or dehydration, to name a few causes. It may cause symptoms, such as weakness, fatigue, dizziness, or palpitations, if the heart rate becomes too fast to pump an adequate supply of blood to the body. Once the stress is removed, the heart rate will return to its usual rate.

Ventricular tachycardia (VT). A potentially life-threatening condition in which an electrical signal is sent from the ventricles at a very fast, but often regular rate. If the heart rate is sustained at a high rate for more than 30 seconds, symptoms, such as weakness, fatigue, dizziness, fainting, or palpitations, may be experienced. Cardiac arrest may occur. A person in VT may require an electric shock or medications to convert the rhythm back to normal sinus rhythm. 

Sick sinus syndrome. A condition in which the sinus node sends out electrical signals too slowly. There may be alternation between too-fast and too-slow rates (tachy brady syndrome). This condition may cause symptoms if the rate becomes too slow for the body to tolerate.

Ventricular fibrillation (VF). A condition in which many electrical signals are sent from the ventricles at a very fast and erratic rate. As a result, the ventricles are unable to fill with blood and pump. This rhythm is life-threatening because there is no pulse and complete loss of consciousness. A person in VF requires prompt defibrillation to restore the normal rhythm and function of the heart. It will result in sudden cardiac death if not treated within seconds.

Premature supraventricular contractions or premature atrial contractions (PAC). A condition in which an atrial pacemaker site above the ventricles sends out an electrical signal early. The ventricles are usually able to respond to this signal, but the result is an irregular heart rhythm, which is typically benign. PACs are common and may occur as the result of stimulants such as coffee, tea, alcohol, cigarettes, or medications.

Supraventricular tachycardia (SVT). A condition in which the heart rate speeds up due to abnormal tissue above the ventricles. There are several different forms of SVT arrhythmias. A couple of the more common examples include arrhythmias caused by an abnormal electrical connection between the top and bottom chambers of the heart, such as atrioventricular node reentry tachycardia also referred to as paroxysmal SVT, or atrioventricular reentry tachycardia due to an extra conduction pathway between the atria and the ventricles. If that pathway conducts signals from the atria to the ventricles, it is known as Wolff-Parkinson-White Syndrome. Another common SVT form can be caused by a site in the atria that fires rapidly called atrial tachycardia. SVT usually begins and ends rapidly, occurring in repeated periods. These arrhythmias can cause symptoms, such as weakness, fatigue, dizziness, fainting, or palpitations if the heart rate becomes too fast. They can cause shortness of breath or chest discomfort.

Atrial flutter. A condition in which the electrical signals come from the atria at a fast but regular rate, often causing the ventricles to contract faster and increase the heart rate. When the signals from the atria are coming at a faster rate than the ventricles can respond to, the ECG pattern typically (but not always) develops a signature "sawtooth" pattern, showing two or more flutter waves between each QRS complex. The number of waves between each QRS complex is expressed as a ratio, for example, a two-to-one atrial flutter means that two waves are occurring between each QRS.

Atrial fibrillation. A condition in which the electrical signals come from the atria at a very fast and erratic rate. The ventricles contract in an irregular manner because of the erratic signals coming from the atria A condition in which the electrical signals come from the atria at a very fast and erratic rate. The ventricles contract in an irregular manner because of the erratic signals coming from the atria that activate the AV node. 

The symptoms of various arrhythmias may resemble other medical conditions. Consult your doctor for a diagnosis.

How are arrhythmias diagnosed?

There are several different types of procedures that may be used to diagnose arrhythmias. Some of these procedures include the following:

  • Electrocardiogram (ECG or EKG). An electrocardiogram is a measurement of the electrical activity of the heart. By placing electrodes at specific locations on the body (chest, arms, and legs), a graphic representation, or tracing, of the electrical activity can be obtained as the electrical activity is received and interpreted by an ECG machine. An ECG can indicate the presence of arrhythmias, damage to the heart caused by ischemia (lack of oxygen to the heart muscle) or myocardial infarction (MI, or heart attack), a problem with one or more of the heart valves, or other types of heart conditions.

There are several variations of the ECG test:

  • Resting ECG. For this procedure, the clothing on the upper body is removed and small sticky patches called electrodes are attached to the chest, arms, and legs. These electrodes are connected to the ECG machine by wires. The ECG machine is then started and records the heart's electrical activity for a minute or so. The patient is lying down during this ECG.

  • Exercise ECG, or stress test. The patient is attached to the ECG machine as described above. However, rather than lying down, the patient exercises by walking on a treadmill or pedaling a stationary bicycle while the ECG is recorded. This test is done to assess changes in the ECG during stress, such as exercise.

  • Signal-averaged ECG. This procedure is done in the same manner as a resting ECG, except that the heart's electrical activity is recorded over a longer period of time, usually 15 to 20 minutes. Signal-averaged ECGs are done when arrhythmia is suspected but not seen on a resting ECG. The signal-averaged ECG has increased sensitivity to abnormal ventricular activity called "late potentials." Signal-averaged ECG is used in research and seldom used in clinical practice.

  • Electrophysiologic studies (EPS). A test in which a small, thin tube (catheter) is inserted in a large blood vessel in the leg or arm and advanced to the heart. This gives the doctor the capability of finding the site of the arrhythmia's origin within the heart tissue, thus determining how to best treat it. Sometimes an attempt to treat the arrhythmia may be made by doing an ablation at the time of the study. 

  • Holter monitor. A continuous ECG recording done over a period of 24 or more hours. Electrodes are attached to the patient's chest and connected to a small portable ECG recorder by lead wires. The patient goes about his or her usual daily activities (except for activities such as taking a shower, swimming, or any activity causing an excessive amount of sweating that would cause the electrodes to become loose or fall off) during this procedure. Holter monitoring may be done when an arrhythmia is suspected but not seen on a resting ECG, since arrhythmias may be transient in nature and not seen during the shorter recording times of the resting ECG.

  • Event monitor. This is similar to a Holter monitor, but the ECG is recorded only when the patient starts the recording when symptoms are felt. Event monitors are typically worn longer than Holter monitors. The monitor can be removed to allow for showering or bathing. 

  • Mobile cardiac monitoring. This is similar to both a Holter and event monitor. The ECG is monitored constantly to allow for detection of arrhythmias, which are recorded and sent to your doctor regardless of whether symptoms are experienced. Recordings can also be initiated by the patient when symptoms are felt. These monitors can be worn up to 30 days. 

Illustration showing a male torso. Leads are attached to his chest. They are connected to a holter monitor that is clipped to the waistband of his pants.
Click Image to Enlarge

How are arrhythmias treated?

Some arrhythmias may be present but cause few, if any, problems. In this case, the doctor may elect not to treat the arrhythmia. However, when the arrhythmia causes symptoms, there are several different options for treatment. The doctor will choose an arrhythmia treatment based on the type of arrhythmia, the severity of symptoms being experienced, and the presence of other conditions (such as, diabetes, kidney failure, or heart failure) which can affect the course of the treatment.

Some treatments for arrhythmias include:

  • Lifestyle modification. Factors, such as stress, caffeine, or alcohol, can cause arrhythmias. The doctor may order the elimination of caffeine, alcohol, or any other substances believed to be causing the problem. If stress is suspected as a cause, the doctor may recommend stress-reduction measures, such as meditation, stress-management classes, an exercise program, or psychotherapy.

  • Medication. There are various types of medications that may be used to treat arrhythmias. If the doctor chooses to use medication, the decision of which medication to use will be determined by the type of arrhythmia, other conditions which may be present, and other medications already being taken by the patient.

  • Cardioversion. In this procedure, an electrical shock is delivered to the heart through the chest to stop certain very fast arrhythmias such as atrial fibrillation, supraventricular tachycardia, or atrial flutter. The patient is connected to an ECG monitor which is also connected to the defibrillator. The electrical shock is delivered at a precise point during the ECG cycle to convert the rhythm to a normal one.

  • Ablation. This is an invasive procedure done in the electrophysiology laboratory, which means that a catheter (a very thin, flexible hollow tube) is inserted into the heart through a vessel in the groin or arm. The procedure is done in a manner similar to the electrophysiology studies (EPS) described above. Once the site of the arrhythmia has been determined by EPS, the catheter is moved to the site. By use of a technique, such as radiofrequency ablation (very high frequency radio waves are applied to the site, heating the tissue until the site is destroyed) or cryoablation (an ultra-cold substance is applied to the site, freezing the tissue and destroying the site), the site of the arrhythmia may be destroyed.

  • Pacemaker. A permanent pacemaker is a small device that is implanted under the skin (most often in the shoulder area just under the collar bone), and sends electrical signals to start or regulate a slow heart beat. A permanent pacemaker may be used to make the heart beat if the heart's natural pacemaker (the SA node) is not functioning properly and has developed an abnormal heart rate or rhythm or if the electrical pathways are blocked. Pacemakers are typically used for slow arrhythmias such as sinus bradycardia, sick sinus syndrome, or heart block.

  • Implantable cardioverter defibrillator. An implantable cardioverter defibrillator (ICD) is a small device, similar to a pacemaker, that is implanted under the skin, often in the shoulder area just under the collarbone. An ICD senses the rate of the heartbeat. When the heart rate exceeds a rate programmed into the device, it delivers an electrical shock to the heart in order to correct the rhythm to a slower more normal heart rhythm. ICDs are combined with a pacemaker to deliver an electrical signal to regulate a heart rate that is too slow. ICDs are used for life-threatening fast arrhythmias such as ventricular tachycardia or ventricular fibrillation.

  • Surgery. Surgical treatment for arrhythmias is usually done only when all other appropriate options have failed. Surgical ablation is a major surgical procedure requiring general anesthesia. The chest is opened, exposing the heart. The site of the arrhythmia is located, the tissue is destroyed or removed in order to eliminate the source of the arrhythmia.

Arrhythmias

Arrhythmias occur when there is a disruption in the normal pace of the heartbeat.

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Congenital Heart DefectsDefectos Congénitos del Corazón

Congenital Heart Defects

What is a congenital heart defect?

When the heart or blood vessels near the heart do not develop normally before birth, a condition called congenital heart defect occurs (congenital means "existing at birth").

Congenital heart defects occur in close to 1 percent of infants. Most young people with congenital heart defects are living into adulthood now.

In most cases, the cause is unknown. Sometimes a viral infection in the mother causes the condition. The condition can be genetic (hereditary). Some congenital heart defects are the result of alcohol or drug use during pregnancy.

Most heart defects either cause an abnormal blood flow through the heart, or obstruct blood flow in the heart or vessels (obstructions are called stenoses and can occur in heart valves, arteries, or veins). A hole between two chambers of the heart is an example of a very common type of congenital heart defect.

More rare defects include those in which:

  • The right or left side of the heart is incompletely formed (hypoplastic)

  • Only one ventricle is present.

  • Both the pulmonary artery and aorta arise from the same ventricle.

  • The pulmonary artery and aorta arise from the "wrong" ventricles. 

Types of congenital heart defects

There are many disorders of the heart that require clinical care by a doctor or other health care professional. Listed below are some of the conditions, for which we have provided a brief overview.

Obstructive defects:

  • Aortic stenosis (AS). In this condition, the aortic valve between the left ventricle and the aorta did not form properly and is narrowed, making it difficult for the heart to pump blood to the body. A normal valve has three leaflets or cusps, but a stenotic valve may have only one cusp (unicuspid) or two cusps (bicuspid).

    In some children, chest pain, unusual tiring, dizziness, or fainting may occur. Otherwise, most children with aortic stenosis have no symptoms. But, even mild stenosis may worsen over time, and a catheter-based procedure or surgery may be needed to correct the blockage or the valve may need to be replaced with an artificial one.

  • Pulmonary stenosis (PS). The pulmonary, or pulmonic, valve, located between the right ventricle and the pulmonary artery, opens to allow blood to flow from the right ventricle to the lungs. When a defective pulmonary valve does not open properly, it causes the heart to pump harder than normal to overcome the obstruction. Usually, the obstruction can be corrected by a catheter-based procedure known as balloon valvuloplasty, although in some patients, open heart surgery may be needed.

  • Bicuspid aortic valve. In this condition, an infant is born with a bicuspid valve which has only two flaps. (A normal aortic valve has three flaps that open and close). If the valve becomes narrowed, it is more difficult for the blood to flow through, and often the blood leaks backward. Symptoms usually do not develop during childhood, but are often detected during the adult years.

  • Subaortic stenosis. This condition refers to a narrowing of the left ventricle just below the aortic valve. Normally, blood passes through it to go into the aorta. However, subaortic stenosis limits the blood flow out of the left ventricle, often resulting in an increased workload for the left ventricle. Subaortic stenosis may be congenital or caused by a form of cardiomyopathy.

  • Coarctation of the aorta (coarct). In this condition, the aorta is narrowed or constricted, obstructing blood flow to the lower part of the body and increasing blood pressure above the constriction. Usually there are no symptoms at birth, but they can develop as early as the first week after birth. If severe symptoms of high blood pressure and congestive heart failure develop, surgery is necessary. Less severe cases may not be detected until a child is older but can result in long-term health problems if not corrected.

Septal defects

Some congenital heart defects allow blood to flow between the right and left chambers of the heart because an infant is born with an opening in the wall (or septum) that separates the right and left sides of the heart.

  • Atrial septal defect (ASD). In this condition, there is an opening between the two upper chambers of the heart--the right and left atria--causing an abnormal blood flow through the heart. Children with ASD have few symptoms. The ASD may be closed by catheter-based techniques or open-heart surgery. Closing the atrial defect by open heart surgery in childhood can often prevent serious problems later in life.

  • Ventricular septal defect (VSD). In this condition, a hole is present between the two lower chambers of the heart. Because of this hole, blood from the left ventricle flows back into the right ventricle, due to higher pressure in the left ventricle. This causes extra blood to be pumped into the lungs by the right ventricle, which can create congestion in the lungs. while some VSDs close on their own, others require surgery to repair the hole.

Cyanotic defects

Cyanotic defects are defects in which blood pumped to the body contains less-than-normal amounts of oxygen. It causes a blue discoloration of the skin. Infants with cyanosis are often called "blue babies."

  • Tetralogy of Fallot. This condition is characterized by four defects, including the following:

    • An abnormal opening, or ventricular septal defect, that allows blood to pass from the right ventricle to the left ventricle without going through the lungs

    • A narrowing (stenosis) at or just beneath the pulmonary valve that partially blocks the flow of blood from the right side of the heart to the lungs

    • The right ventricle is more muscular than normal

    • The aorta lies directly over the ventricular septal defect

    Tetralogy of Fallot is the most common defect causing cyanosis in people beyond 2 years of age. Most children with tetralogy of Fallot have open-heart surgery before school age (frequently in infancy) to close the ventricular septal defect and remove the obstructing muscle. Lifelong medical follow-up is needed.

  • Tricuspid atresia. In this condition, there is no tricuspid valve, therefore, no blood flows from the right atrium to the right ventricle. Tricuspid atresia is characterized by the following:

    • A small right ventricle

    • A large left ventricle

    • Diminished pulmonary circulation

    • Cyanosis

    A surgical shunting procedure is often necessary to increase the blood flow to the lungs.

  • Transposition of the great arteries. In this embryologic defect, the positions of the pulmonary artery and the aorta are reversed, thus:

    • The aorta originates from the right ventricle, so most of the blood returning to the heart from the body is pumped back out without first going to the lungs.

    • The pulmonary artery originates from the left ventricle, so that most of the blood returning from the lungs goes back to the lungs again.

    Immediate medical intervention is necessary to correct this condition.

Other defects:

  • Hypoplastic left heart syndrome (HLHS). In this condition, the left side of the heart, including the aorta, aortic valve, left ventricle, and mitral valve, is underdeveloped. Blood reaches the aorta through a patent ductus arteriosus, and if this ductus closes, as is normal, the baby will die. The baby often seems normal at birth, but the condition will become noticeable within a few days of birth, as the ductus closes. Babies with this syndrome become ashen (gray), have diminished or absent pulses in the legs, have difficulty breathing, and are unable to feed. Treatment is surgical and typically requires three operations. 

  • Patent ductus arteriosus (PDA). This condition results from failure of the PDA to close normally after birth, allowing blood to mix between the pulmonary artery and the aorta. When it does not close, extra blood may flood the lungs and cause pulmonary congestion. Patent ductus arteriosus is often seen in premature infants.

  • Ebstein's anomaly. In this defect, there is a downward displacement of the tricuspid valve (located between the upper and lower chambers on the right side of the heart) into the right bottom chamber of the heart (or right ventricle). This means the atrium is larger than normal and the ventricle is smaller than normal, which can lead to rhythm abnormalities and heart failure. It is usually associated with an atrial septal defect.  

Who treats congenital heart defects?

Babies with congenital heart problems are followed by specialists called pediatric cardiologists. These doctors diagnose heart defects and help manage the health of children before and after surgical repair of the heart problem. Specialists who correct heart problems in the operating room are known as pediatric cardiovascular or cardiothoracic surgeons.

A new subspecialty within cardiology is emerging as the number of adults with congenital heart disease (CHD) is now greater than the number of babies born with CHD, as a result of the advances in diagnostic procedures and treatment interventions that have been made since 1945. These doctors care for adults with heart problems that began in infancy or childhood, as opposed to the types of heart conditions that develop in adults as they age.

In order to achieve and maintain the highest possible level of wellness, it is imperative that those individuals born with CHD who have reached adulthood transition to the appropriate type of cardiac care. The type of care required is based on the type of CHD a person has. Those people with simple CHD can often be cared for by a community adult cardiologist. Those with more complex types of CHD will need to be cared for at a center that specializes in adult CHD.

For adults with CHD, guidance is necessary for planning key life issues such as college, career, employment, insurance, activity, lifestyle, inheritance, family planning, pregnancy, chronic care, disability, and end of life. Knowledge about specific congenital heart conditions and expectations for long-term outcomes and potential complications, and risks must be reviewed as part of the successful transition from pediatric care to adult care. Parents should help pass on the responsibility for this knowledge and accountability for ongoing care to their young adult children to help ensure the transition to adult specialty care and optimize the health status of the young adult with CHD.

Congenital Heart Disease

Congenital refers to a problem with the heart's structure and function due to abnormal heart development before birth.

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Heart Failure

Heart failure occurs when the heart cannot pump sufficient blood to the rest of body's organs.

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Peripheral Vascular DiseaseEnfermedad Vascular Periférica

Peripheral Vascular Disease

What is peripheral vascular disease (PVD)?

Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. It may involve disease in any of the blood vessels outside of the heart and diseases of the lymph vessels—the arteries, veins, or lymphatic vessels. Organs supplied by these vessels such as the brain, heart, and legs, may not receive adequate blood flow for ordinary function. However, the legs and feet are most commonly affected, thus the name peripheral vascular disease.

Circulatory system
Click image to enlarge

Conditions associated with PVD that affect the veins include deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency. Lymphedema is an example of PVD that affects the lymphatic vessels.

When PVD occurs in the arteries outside the heart, it may be referred to as peripheral arterial disease (PAD). However, the terms "peripheral vascular disease" and "peripheral arterial disease" are often used interchangeably. PVD is frequently found in people with coronary artery disease, because atherosclerosis, which causes coronary artery disease, is a widespread disease of the arteries.

Conditions associated with PAD may be occlusive (occurs because the artery becomes blocked in some manner) or functional (the artery either constricts due to a spasm or expands). Examples of occlusive PAD include peripheral arterial occlusion and Buerger's disease (thromboangiitis obliterans). Examples of functional PAD include Raynaud's disease, Raynaud's phenomenon, and acrocyanosis.

What causes peripheral vascular disease?

PVD is often characterized by a narrowing of the vessels that carry blood to the leg and arm muscles. The most common cause is atherosclerosis (the buildup of plaque inside the artery wall). Plaque reduces the amount of blood flow to the limbs and decreases the oxygen and nutrients available to the tissue. Clots may form on the artery walls, further decreasing the inner size of the vessel and potentially blocking off major arteries.

PArt of an artery showing plaque buildup
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Other causes of peripheral vascular disease may include trauma to the arms or legs, irregular anatomy of muscles or ligaments, or infection. People with coronary artery (arteries that supply blood to the heart muscle) disease are frequently found to also have peripheral vascular disease. 

What conditions are associated with peripheral vascular disease?

The term "peripheral vascular disease" encompasses several different conditions. Some of these conditions include, but are not limited to:

  • Atherosclerosis. Atherosclerosis is the build up of plaque inside the artery wall. Plaque is made up of deposits of fatty substances, cholesterol, cellular waste products, calcium, and fibrin. The artery wall then becomes thickened and loses its elasticity. Symptoms may develop gradually, and may be few, as the plaque builds up in the artery. However, when a major artery is blocked, a heart attack, stroke, aneurysm, or blood clot may occur, depending on where the blockage occurs. 

  • Buerger's disease (thromboangiitis obliterans). This is a chronic inflammatory disease in the peripheral arteries of the extremities leading to the development of clots in the small- and medium-sized arteries of the arms or legs and eventual blockage of the arteries. Buerger's disease most commonly occurs in men between ages 20 and 40 who smoke cigarettes. Symptoms include pain in the legs or feet, clammy cool skin, and a diminished sense of heat and cold.  

  • Chronic venous insufficiency. This is a prolonged condition in which one or more veins don't adequately return blood from the lower extremities back to the heart due to damaged venous valves. Symptoms include discoloration of the skin and ankles, swelling of the legs, and feelings of dull, aching pain, heaviness, or cramping in the extremities. 

  • Deep vein thrombosis (DVT). DVT is a clot that occurs in a deep vein, and has the potential to dislodge, travel to the lungs, occlude a lung artery (pulmonary embolism), and cause a potentially life-threatening event. It's found most commonly in those who have undergone extended periods of inactivity, such as from sitting while traveling or prolonged bed rest after surgery. Symptoms may be absent or subtle, but include swelling and tenderness in the affected extremity, pain at rest and with compression, and raised vein pattern.

  • Raynaud's phenomenon. This is a condition in which the smallest arteries that bring blood to the fingers or toes constrict (go into spasm) when exposed to cold or as the result of emotional upset. Raynaud's most commonly occurs in women between ages 18 and 30. Symptoms include coldness, pain, and pallor (paleness) of the fingertips or toes. 

  • Thrombophlebitis. Thrombophlebitis is a blood clot in an inflamed vein, most commonly in the legs, but it can also occur in the arms. The clot can either be close to the skin (superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis). It may result from pooling of blood, venous wall injury, and altered blood coagulation. Symptoms in the affected extremity include swelling, pain, tenderness, redness, and warmth.

  • Varicose veins. Dilated, twisted veins are caused by incompetent valves (valves that allow backward flow of blood) allowing blood to pool. It's most commonly found in the legs or lower trunk. Symptoms include bruising and sensations of burning or aching. Pregnancy, obesity, and extended periods of standing intensify the symptoms. 

What are the risk factors for peripheral vascular disease?

A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity, diet, family history, or many other things. Risk factors for peripheral vascular disease include factors which can be changed or treated and factors that cannot be changed.

Risk factors that cannot be changed include:

  • Age (especially older than age 50)

  • History of heart disease

  • Male gender

  • Diabetes mellitus

  • Postmenopausal women

  • Family history of dyslipidemia (elevated lipids in the blood, such as cholesterol), hypertension, or peripheral vascular disease

Risk factors that may be changed or treated include:

  • Coronary artery disease

  • Impaired glucose tolerance

  • Dyslipidemia (abnormal amount of lipids in the blood)

  • Hypertension (high blood pressure)

  • Obesity

  • Physical inactivity

  • Smoking or use of tobacco products

Those who smoke or have diabetes mellitus have the highest risk of complications from peripheral vascular disease because these risk factors also cause impaired blood flow. 

What are the symptoms of peripheral vascular disease?

Up to half the people diagnosed with peripheral vascular disease are symptom free. For those experiencing symptoms, the most common first symptom is intermittent claudication in the calf (leg discomfort described as painful cramping that occurs with exercise and is relieved by rest). During rest, the muscles need less blood flow, so the pain disappears. It may occur in one or both legs depending on the location of the clogged or narrowed artery.

Other symptoms of peripheral vascular disease may include:

  • Changes in the skin, including decreased skin temperature, or thin, brittle shiny skin on the legs and feet

  • Diminished pulses in the legs and the feet

  • Gangrene (dead tissue due to lack of blood flow)

  • Hair loss on the legs

  • Impotence

  • Nonhealing wounds over pressure points, such as heels or ankles

  • Numbness, weakness, or heaviness in muscles

  • Pain (described as burning or aching) at rest, commonly in the toes and at night while lying flat

  • Pallor (paleness) when the legs are elevated

  • Reddish-blue discoloration of the extremities

  • Restricted mobility

  • Severe pain

  • Thickened, opaque toenails

The symptoms of peripheral vascular disease may resemble other conditions. Consult your physician for a diagnosis. 

How is peripheral vascular disease diagnosed? 

In addition to a complete medical history and physical examination, diagnostic procedures for peripheral vascular disease may include any, or a combination, of the following:

  • Angiogram. This is an X-ray of the arteries and veins to detect blockage or narrowing of the vessels. This procedure involves inserting a thin, flexible tube into an artery in the leg and injecting a contrast dye. The contrast dye makes the arteries and veins visible on the X-ray.

  • Ankle-brachial index (ABI). An ABI is a comparison of the blood pressure in the ankle with the blood pressure in the arm using a regular blood pressure cuff and a Doppler ultrasound device. To determine the ABI, the systolic blood pressure (the top number of the blood pressure measurement) of the ankle is divided by the systolic blood pressure of the arm. 

  • Blood lipid profile. This blood test measures the levels of each type of fat in your blood: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and others.

  • Doppler ultrasound flow studies. This uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Doppler technique is used to measure and assess the flow of blood. Faintness or absence of sound may indicate an obstruction in the blood flow.

  • Magnetic resonance angiography (MRA). This noninvasive diagnostic procedure uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of organs and structures within the body. An MRA is often used to examine the heart and other soft tissues and to assess blood flow.

  • Treadmill exercise test. This test is given while a patient walks on a treadmill to monitor the heart during exercise.

  • Photoplethysmography (PPG). This examination is comparable to the ankle brachial index except that it uses a very tiny blood pressure cuff around the toe and a PPG sensor (infrared light to evaluate blood flow near the surface of the skin) to record waveforms and blood pressure measurements. These measurements are then compared to the systolic blood pressure in the arm.

  • Pulse volume recording (PVR) waveform analysis. This technique is used to calculate blood volume changes in the legs using a recording device that displays the results as a waveform.

  • Reactive hyperemia test. This test is similar to an ABI or a treadmill test but used for people who are unable to walk on a treadmill. While a person is lying on his or her back, comparative blood pressure measurements are taken on the thighs and ankles to determine any decrease between the two sites. 

  • Segmental blood pressure measurements. This is a means of comparing blood pressure measurements using a Doppler device in the upper thigh, above and below the knee, at the ankle, and on the arm to determine any constriction in blood flow. 

What is the treatment for peripheral vascular disease?

There are two main goals for treatment of peripheral artery/vascular disease: control the symptoms and halt the progression of the disease to lower the risk for heart attack, stroke, and other complications. 

Specific treatment will be determined by your physician based on:

  • Your age, overall health, and medical history

  • Extent of the disease

  • Your signs and symptoms

  • Your tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the disease

  • Your opinion or preference

Treatment may include:

  • Lifestyle modifications to control risk factors, including regular exercise, proper nutrition, and smoking cessation

  • Aggressive treatment of existing conditions that may aggravate PVD, such as diabetes, hypertension, and hyperlipidemia (elevated blood cholesterol)

  • Medications for improving blood flow, such as antiplatelet agents (blood thinners) and medications that relax the blood vessel walls

  • Angioplasty—a catheter (long hollow tube) is used to create a larger opening in an artery to increase blood flow. Angioplasty may be performed in many of the arteries in the body. There are several types of angioplasty procedures, including:

    • Balloon angioplasty (a small balloon is inflated inside the blocked artery to open the blocked area)

    • Atherectomy (the blocked area inside the artery is "shaved" away by a tiny device on the end of a catheter)

    • Laser angioplasty (a laser is used to "vaporize" the blockage in the artery)

    • Stent (a tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open)

  • Vascular surgery—a bypass graft using a blood vessel from another part of the body or a tube made of synthetic material is placed in the area of the blocked or narrowed artery to reroute the blood flow

With both angioplasty and vascular surgery, an angiogram is often performed prior to the procedure. 

What are the complications of peripheral vascular disease? 

Complications of peripheral vascular disease most often occur because of decreased or absent blood flow. Such complications may include:

  • Amputation (loss of a limb)

  • Heart attack

  • Poor wound healing

  • Restricted mobility due to pain or discomfort with exertion

  • Severe pain in the affected extremity

  • Stroke (three times more likely in people with PVD)

By following an aggressive treatment plan for peripheral vascular disease, complications such as these may be prevented.

Can peripheral vascular disease be prevented?

Steps to prevent PVD are primarily aimed at management of the risk factors for PVD. A prevention program for PVD may include:

  • Smoking cessation, including avoidance of second hand smoke and use of tobacco products

  • Dietary modifications including reduced fat, cholesterol, and simple carbohydrates (such as sweets), and increased amounts of fruits and vegetables

  • Treatment of dyslipidemia (high blood cholesterol levels) with medications as determined by your physician

  • Weight reduction

  • Moderation in alcohol intake

  • Medications as determined by your physician to reduce your risk for blood clot formation

  • Exercise plan

  • Control of diabetes mellitus

  • Control of hypertension (high blood pressure)

A prevention plan for PVD may also be used to prevent or lessen the progress of PVD once it has been diagnosed. Consult your physician for diagnosis and treatment.

Peripheral Vascular Disease

Peripheral vascular disease(PVD) is a slow and progressive circulation disorder that involves disease in any of the blood vessels outside of the heart.

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Heart Valve DiseasesEnfermedades Valvulares del Corazón

Heart Valve Diseases

What are heart valves?

The heart consists of four chambers--two atria (upper chambers) and two ventricles (lower chambers). There is a valve through which blood passes before leaving each chamber of the heart. The valves prevent the backward flow of blood. They act as one-way inlets of blood on one side of a ventricle and one-way outlets of blood on the other side of a ventricle. The four heart valves include the following:

Illustration of the heart and heart valves
Click on Image to Enlarge

  • Tricuspid valve. Located between the right atrium and the right ventricle.

  • Pulmonary valve. Located between the right ventricle and the pulmonary artery.

  • Mitral valve. Located between the left atrium and the left ventricle.

  • Aortic valve. Located between the left ventricle and the aorta.

How do the heart valves function?

As the heart muscle contracts and relaxes, the valves open and close, letting blood flow into the ventricles and out to the body at alternate times. The following is a step-by-step illustration of how the valves function normally in the left ventricle:

  • After the left ventricle contracts, the aortic valve closes and the mitral valve opens to allow blood to flow from the left atrium into the left ventricle.

  • The left atrium contracts and more blood flows into the left ventricle.

  • When the left ventricle contracts, the mitral valve closes and the aortic valve opens so blood flows into the aorta and out into the systemic circulation to the rest of the body.

What is heart valve disease?

Heart valve disorders can arise from two main types of malfunctions:

  • Regurgitation (or leakage of the valve). The valve(s) does not close completely, causing the blood to flow backward through the valve. The heart is forced to pump more blood on the next beat, making it work harder.

  • Stenosis (or narrowing of the valve). The valve(s) opening becomes narrowed, limiting the flow of blood out of the ventricles or atria. The heart is forced to pump blood with increased force in order to move blood through the narrowed or stiff (stenotic) valve(s).

Heart valves can develop both malfunctions at the same time (regurgitation and stenosis). Also, more than one heart valve can be affected at the same time. When heart valves fail to open and close properly, the implications for the heart can be serious, possibly hampering the heart's ability to pump blood adequately through the body. Heart valve problems are one cause of heart failure.

What are the symptoms of heart valve disease?

Mild heart valve disease may not cause any symptoms. The following are the most common symptoms of heart valve disease. However, each individual may experience symptoms differently. Symptoms may vary depending on the type of heart valve disease present and may include:

  • Chest pain

  • Palpitations caused by irregular heartbeats

  • Fatigue

  • Dizziness

  • Low or high blood pressure, depending on which valve disease is present

  • Shortness of breath

  • Abdominal pain due to an enlarged liver (if there is tricuspid valve malfunction)

Symptoms of heart valve disease may resemble other medical conditions and problems. Always consult your doctor for a diagnosis.

What causes heart valve damage?

The causes of heart valve damage vary depending on the type of disease present, and may include the following:

  • A history of rheumatic fever, a condition characterized by painful fever, inflammation, and swelling of the joints. Rheumatic fever is now rare in North America due to effective antibiotic treatment.

  • Damage resulting from a heart attack

  • Damage resulting from an infection

  • Changes in the heart valve structure due to the aging process

  • Congenital birth defect

  • Syphilis, a disease characterized by progressive symptoms if not treated. Syphilis is a sexually-transmitted infection. Symptoms may include small, painless sores that disappear, followed by a skin rash, enlarged lymph nodes, headache, aching bones, loss of appetite, fever, and fatigue.

  • Myxomatous degeneration, an inherited connective tissue disorder that weakens the heart valve tissue.

The mitral and aortic valves are most often affected by heart valve disease. Some of the more common heart valve diseases include:

Heart valve disease

Symptoms and causes

Bicuspid aortic valve

This congenital birth defect is characterized by an aortic valve that has only two flaps (a normal aortic valve has three flaps). If the valve becomes narrowed, it is more difficult for the blood to flow through, and often the blood leaks backward. Symptoms usually do not develop during childhood, but are often detected during the adult years.

Mitral valve prolapse (also known as click-murmur syndrome, Barlow's syndrome, balloon mitral valve, or floppy valve syndrome)

This disease is characterized by the bulging of one or both of the mitral valve flaps during the contraction of the heart. One or both of the flaps may not close properly, allowing the blood to leak backward. This may result in a mitral regurgitation murmur.

Mitral valve stenosis

Often caused by a past history of rheumatic fever, this condition is characterized by a narrowing of the mitral valve opening, increasing resistance to blood flow from the left atrium to the left ventricle.

Aortic valve stenosis

This type of valve disease occurs primarily in the elderly and is characterized by a narrowing of the aortic valve opening, increasing resistance to blood flow from the left ventricle to the aorta.

Pulmonary stenosis

This condition is characterized by a pulmonary valve that does not open sufficiently, causing the right ventricle to pump harder and enlarge.

How is heart valve disease diagnosed?

Heart valve disease may be suspected if the heart sounds heard through a stethoscope are abnormal. This is usually the first step in diagnosing a heart valve disease. A characteristic heart murmur (abnormal sounds in the heart due to turbulent blood flow across the valve) can often indicate valve regurgitation or stenosis. To further define the type of valve disease and extent of the valve damage, doctors may use any of the following diagnostic procedures:

  • Electrocardiogram (ECG or EKG). A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and can sometimes detect heart muscle damage.

  • Echocardiogram (echo). A noninvasive test that uses sound waves to evaluate the heart's chambers and valves. The echo sound waves create an image on a monitor as an ultrasound transducer is passed over the heart.

  • Transesophageal echocardiogram (TEE). A diagnostic procedure that involves passing a small ultrasound transducer down into the esophagus. The sound waves create an image of the valves and chambers of the heart on a computer monitor without the ribs or lungs getting in the way.

  • Chest X-ray. A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. An X-ray can show enlargement in any area of the heart.

  • Cardiac catheterization. This diagnostic procedure involves the insertion of a tiny, hollow tube (catheter) through a large artery in the leg or arm leading to the heart in order to provide images of the heart and blood vessels. This procedure is helpful in determining the type and extent of certain valve disorders.

  • Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

What is the treatment for heart valve disease?

In some cases, the only treatment for heart valve disease may be careful medical supervision. However, other treatment options may include medication, surgery to repair the valve, or surgery to replace the valve. Specific treatment will be determined by your doctor based on:

  • Your age, overall health, and medical history

  • Extent of the disease

  • The location of the valve

  • Your signs and symptoms

  • Your tolerance for specific medications, procedures, or therapies

  • Expectations for the course of the disease

  • Your opinion or preference

Treatment varies, depending on the type of heart valve disease, and may include one, or a combination of, the following:

  • Medication. Medications are not a cure for heart valve disease, but in many cases are successful in the treatment of symptoms caused by heart valve disease. These medications may include:

    • Medications such as beta-blockers, digoxin, and calcium channel blockers to reduce symptoms of heart valve disease by controlling the heart rate and helping to prevent abnormal heart rhythms.

    • Medications to control blood pressure, such as diuretics (medications that remove excess water from the body by increasing urine output) or vasodilators (medications that relax the blood vessels, decreasing the force against which the heart must pump) to ease the work of the heart.

  • Surgery. Surgery may be necessary to repair or replace the malfunctioning valve(s). Surgery may include:

    • Heart valve repair. In some cases, surgery on the malfunctioning valve can help alleviate symptoms. Examples of heart valve repair surgery include remodeling abnormal valve tissue so that the valve functions properly, or inserting prosthetic rings to help narrow a dilated valve. In many cases, heart valve repair is preferable, because a person's own tissues are used.

    • Heart valve replacement. When heart valves are severely malformed or destroyed, they may need to be replaced with an entirely new replacement valve. Replacement valve mechanisms fall into two categories: tissue (biologic) valves, which include animal valves and donated human aortic valves, and mechanical valves, which can consist of metal, plastic, or another artificial material.

Another treatment option that is less invasive than valve repair or replacement surgery is balloon valvuloplasty, a nonsurgical procedure in which a special catheter (hollow tube) is threaded into a blood vessel in the groin and guided into the heart. The catheter, which contains a deflated balloon, is inserted into the narrowed heart valve. Once in place, the balloon is inflated to stretch the valve open, and then removed. This procedure is sometimes used to treat pulmonary stenosis and, in some cases, aortic stenosis. There are also some special cases where a new valve can be inserted through the groin into the heart and opened up with a balloon like a stent. This is called total aortic valve replacement. 

Valve Disease & Disorders

A condition where one or more of the heart's valves do not work properly due to disease or structural defect.

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