The Cardiovascular System in Health and Disease

The following sections are included:

• CONTENTS

My own training in Medicine in the 1950s was of the traditional kind, beginning with two years on detailed anatomy, physiology, biochemistry and pharmacology (the “preclinical subjects”). This was followed by three years in the hospital for clinical training. I do not think that there was anything wrong with this system; it certainly stood me in a good stead for my medical career…

The following sections are included:

• Presentation

• What Happens When the Heart Stops?

• Emergency Cardiopulmonary Resuscitation

• Anatomy of the Left Ventricle

• The Circulation of the Blood

• How Circulating Blood is Oxygenated; Gas Exchange

• Cyanosis — How Blue is Blue?

• Questions, 1:2

• Acid-Base Balance

• Questions, 1:3

• The Cause of the Heart Stopping

• The Electricity of Heart Muscle Cells

• What Happens When a Depolarisation Wave Passes Over a Ventricular Cell?

• How Do the Action Potentials of the Ventricular Cells Produce Electrical Potential Differences on the Surface of the Body?

• Questions, 1:4

• Different Types of Cardiac Arrest

• Excitation-Contraction Coupling

• Questions, 1:5

The following sections are included:

• Presentation/History of the Presenting Complaint
  • Other relevant history

• Physical Examination

• Mechanism

• Differential Diagnosis
  • Cardiac
  • Vasovagal
  • Vascular
  • Cerebrovascular
  • Epilepsy
  • Hypoglycaemia

• Questions, 2:1

• Mechanisms
  • The natural pacemaker — the initiation of the heart beat
  • The transmission of depolarisation from the sinus node to the rest of the heart — the cardiac conduction system

• Questions, 2:2

• Diagnosis

• Questions, 2:3

• Emergency Treatment of Syncope

• Hydrostatic Pressure

• Starling's Law of the Heart

• Morphology of the Myocardial Cell

• Mechanism of the Length-Tension Curve

• Questions, 2:4

• Relation of Starling's Experiments to the Length-Tension Curve

• Questions, 2:5

• Why Doesn't Everyone Faint When They Stand Up?

• Questions, 2:6

• Long-Term Treatment of Patient 2.1

The following sections are included:

• Presentation

• What Happens If, Instead of Stopping, the Heart Suddenly Becomes Very Weak?

• Emergency Treatment

• Investigation

• Intermediate Treatment

• Anatomy of the Left Ventricle

• The Cardiac Cycle

• Questions, 3:1

• Reminders from Chapter 1 of Important Aspects of Sarcomere Function

• The Main Physiological Modulator of Contractility is Neural Sympathetic Nerve Activity and the Humoral Catecholamines

• Increased Extracellular Calcium also Increases Contractility

• An Acute Rise in Extracellular Carbon Dioxide Concentration (Usually Expressed in Terms of Partial Pressure, pCO₂) is an Example of a Negative Inotropic Effect — A Decrease of Contractility

• Another Negative Inotropic Effect is A Rise of Intracellular Phosphate Ion Concentration

• Accumulation of Intracellular Protons and Phosphate Ions Occurs in Myocardial Hypoxia and Ischaemia, Contributing to the Weak Contraction in this Condition

• ATP for Contraction is Produced in the Mitochondria by the Breakdown of Fuels, Consuming Oxygen with the Production of Carbon Dioxide and Water

• Questions, 3:2

• Myocardial Metabolism

• Left Ventricular Mechanics

• The End-Systolic Pressure-Volume Relationship of the Left Ventricle, Measured at a Given Level of Contractility, Demonstrates the Relationship between Mechanical Energy Output and Initial Fibre Length in the Human Heart, and Defines that Level of Contractility

• A Positive Inotropic Effect is Indicated by a Movement of the End-Systolic Pressure-Volume Curve Upwards and to the Left — More Isovolumic Pressure Development for a Given Volume

• A Negative Inotropic Effect is Indicated by a Movement of the End-Systolic Pressure-Volume Curve Downwards and to the Right — Less Isovolumic Pressure Development for a Given Volume

• Pressure-Volume Diagram of the Patient

• Consequences of Difficulty in LV Emptying

• Questions, 3:3

• Consequences of Low Cardiac Output

• Questions, 3:4

• Differential Diagnosis of Pulmonary Oedema

• Differential Diagnosis of the Causes of Acute LVF
  • Acute unstable angina
  • Acute myocarditis
  • Acute hypertension

• What Further Treatment is Possible
  • “Inodilators”
  • Intra-aortic balloon pumping
  • Getting water out of the lungs
  • Maintaining renal function

• Scheme for the Management of Acute Dyspnoea

The following sections are included:

• Presentation

• Examination

• Mechanisms

• Questions, 4:1

• Differential Diagnosis of Established Dyspnoea
  • Cardiac
  • Respiratory
  • Other

• Mechanism of Dyspnoea and Tiredness on Exertion

• Cardiac Mechanics

• Echocardiography

• New York Heart Association Classification of Heart Failure Severity (NYHA Classes I–IV)

• “Diastolic Heart Failure”

• Questions, 4:2

• Myocardial Energy Cost of Heart Failure

• Questions, 4:3

• Loading and Therapeutic Unloading of the Heart in Heart Failure

• Prognosis in Heart Failure and its Modification by Treatment

• Questions, 4:4

• Pathophysiological Mechanisms Underlying the Benefit of ACE Inhibition and β-Blockade

• Molecular Mechanisms

• Questions, 4:5

The following sections are included:

• Presentation

• Examination

• Questions, 5:1
  • JVP
  • CXR
  • Echocardiography
  • Exercise tolerance

• Causes of Salt and Water Retention
  • Cardiac
  • Renal disease
  • Liver disease
  • Hypoalbuminaemia

• CHRONIC AIRWAY DISEASE PATIENT CASE NO. 5.2 CASE DESCRIPTION: OEDEMA

• Cyclical Oedema of Women

• Questions, 5:2

• Diuretics

• Localised Oedema
  • Deep venous thrombosis
  • Chronic venous leg
  • Lymphoedema
  • Bilateral oedema

• Questions, 5:3

The following sections are included:

• Presentation

• Electrocardiographic Left Axis Deviation

• Einthoven's Triangle

• Pathophysiology

• Questions, 6:1

• Differential Diagnosis
  • Viral myocarditis
  • Doxorubicin-induced myocardial disease
  • AIDS heart

• Causes of Cardiomyopathy
  • Cardiovascular
  • Infective
  • Metabolic
  • Endocrine
  • Toxic
  • Connective tissue disease
  • Neuromuscular disease
  • Infiltrative
  • Peripartum cardiomyopathy
  • Genetically determined

• The Treatment of Dilated Cardiomyopathy

• PATIENT CASE NO. 6.2 CASE DESCRIPTION: HYPERTROPHIC CARDIOMYOPATHY

• ECG Chest Leads

• Questions, 6:2

• Differential Diagnosis

• Questions, 6:3

• Genetics

• Pathophysiology

• Treatment

• PATIENT CASE NO. 6.3 CASE DESCRIPTION: RESTRICTIVE CARDIOMYOPATHY

• Pathophysiology

• Diagnosis

• Treatment

• Questions, 6:4

The following sections are included:

• Presentation

• Differential Diagnosis
  • Cardiac: myocardial infarction, angina pectoris, pericarditis (all causing central pain), prolapse of mitral valve (can be lateral pain)
  • Vascular
  • Respiratory
  • Gastrointestinal
  • Musculoskeletal
  • Neurological

• Questions, 7:1

• The Correct Management of Patient 7.1

• Explanation of Risk Factors

• Systematic Review of Risk Factors
  • Smoking
  • Blood lipids
  • Questions, 7:2
  • Insulin resistance
  • Questions, 7:3
  • Hyperhomocysteinaemia
  • Prothrombotic factors
  • Physical activity and life style
  • Age, male sex, oral contraceptives, menopause and hormone replacement therapy
  • Others

• Multivariate Risk Profiles

• Primary Prevention

The following sections are included:

• Presentation

• Differential Diagnosis
  • Syndrome X

• Mechanisms of Symptomatology

• Myocardial Metabolism

• Coronary Autoregulation and Metabolic Regulation

• Questions, 8:1

• Roles of Autonomic Nerves
  • Autonomic control of the coronary circulation
  • Afferent pathways

• Anatomy of the Coronary Arteries

• Consequence for Coronary Flow of Supplying Contracting Muscle

• Questions, 8:2

• Collateral Coronary Flow

• Coronary Veins

• Why Do Atheromatous Stenoses Occur in Coronary Arteries?

• Pathology of Atheroma

• Treatment of Patient 8.1
  • Treatment of anginal pain
  • Revascularisation
  • Secondary prevention

• Questions, 8:3

The following sections are included:

• Presentation

• Differential Diagnosis
  • Non-cardiac chest pain
  • Pericarditis
  • Severe “stable” angina pectoris
  • Low risk unstable angina
  • Sub-endocardial infarction
  • Full thickness MI
  • Dissection of the thoracic aorta
  • Pulmonary embolus
  • Connective tissue diseases

• Initiation of Acute Coronary Syndromes (ACS)

• Questions, 9:1

• Platelet Activation

• Questions, 9:2

• Treatment of Patient 9.1 (Fig. 9.3(A))

• PATIENT CASE NO. 9.2 CASE DESCRIPTION: ACUTE MYOCARDIAL INFARCTION

• Differential Diagnosis

• Pathology

• Mechanism of ST Elevation

• Limitation of Infarct Size

• Questions, 9:3

• Features of ACS
  • New bundle branch block (Chapter 2)
  • ECG Features of ACS
  • Chemical markers of myocardial damage
  • Emergency management (Fig. 9.2(B))
  • Complications

• Questions, 9:4

• Immediate Therapy (Fig. 9.3)

• Non-Urgent Investigations following MI

• Cardiac Rehabilitation

• Assessment of a Patient Presenting in Out-Patients with Previous MI

• Questions, 9:5

The following sections are included:

• Presentation

• Ventricular Tachyarrhythmia

• Post-extrasystolic Potentiation

• Questions, 10:1

• Re-entry

• Delayed After-depolarisations (DADs)

• Differential Diagnosis
  • Bundle branch block
  • Torsade
  • Junctional tachycardia

• Care Required in Managing Dysrhythmias

• PATIENT CASE NO. 10.2 CASE DESCRIPTION: JUNCTIONAL ARRHYTHMIA

• PATIENT CASE NO. 10.3 CASE DESCRIPTION: ATRIAL FIBRILLATION

• Characterisation of Atrial Fibrillation (AF)

• Pulse Variation in AF

• Causes of AF
  • Thyrotoxicosis
  • Enlargement of the left atrium, stretching the atrial wall

• Complications of AF

• Management of AF

• Paroxysmal SVT

• Consequences of an Increase in Heart Rate
  • Haemodynamic
  • The force frequency relationship (the effect of heart rate on contractility)
  • Effect of frequency on action potential duration and QT interval
  • Effect of frequency on diastolic interval

• Antiarrhythmic Drugs

• Questions, 10:2

The following sections are included:

• Presentation

• Differential Diagnosis

• Mechanism

• Anatomy of Cardiac Valves

• Rheumatic Heart Disease

• Complications of Mitral Stenosis

• Questions, 11:1

• PATIENT CASE NO. 11.2 CASE DESCRIPTION: MITRAL PROLAPSE AND REGURGITATION

• Heart-disease in Pregnancy

• Mitral Regurgitation
  • Rheumatic mitral disease
  • Rupture of chordae tendinae
  • Rupture or weakness of papillary muscles
  • Left ventricular distension
  • Subendocardial ischaemia

• Tricuspid Disease

• PATIENT CASE NO. 11.3 CASE DESCRIPTION: AORTIC VALVE DISEASE AND INFECTIVE ENDOCARDITIS

• Causes of Aortic Valve Disease
  • Degenerative aortic stenosis
  • Congenital connective tissue disorders
  • Rheumatic disease
  • Spirochetal infection
  • Infective endocarditis

• Differential Diagnosis

• Questions, 11:2

• Infective Endocarditis

The following sections are included:

• Presentation

• Right Heart Haemodynamics

• Differential Diagnosis

• Other Pulmonary Valve Disease

• PATIENT CASE NO. 12.2 CASE DESCRIPTION: ATRIAL SEPTAL DEFECT

• Foetal Circulation and the Changes at Birth

• Haemodynamics of Atrial Septal Defect

• Complications of Severe Atrial Septal Defect

• Treatment

• Questions, 12:1

• PATIENT CASE NO. 12.3 CASE DESCRIPTION: VENTRICULAR SEPTAL DEFECT

• Patent Ductus Arteriosus

• Heart Defects

• Questions, 12:2

• PATIENT CASE NO. 12.4 CASE DESCRIPTION: TETRALOGY OF FALLOT

• Other Cardiac Congenital Defects
  • Transposition
  • Tricuspid atresia
  • Ebstein's anomaly
  • Hypoplastic left ventricle
  • Situs inversus and dextrocardia

• Questions, 12:3

The following sections are included:

• Presentation

• Differential Diagnosis

• The Arterial System

• Arterial Pressure Damping

• Tube Characteristics

• Pulse Wave Velocity

• Diseases of Arteries

• Vascular Endothelium
  • Active functions of endothelium

• Complications of Peripheral Arterial Atheromatous Disease

• Questions, 13:1

• Diabetic Foot

• The Immunological Vasculitides
  • Giant cell (temporal) arteritis
  • Takayasu's disease
  • Polyarteritis nodosa
  • Kawasaki syndrome

• Blood Flow in Arteries

• Arterial Aneurysms

• Circulatory Impedance

• Organ Blood Flows

• Questions, 13:2

• Raynaud's Phenomenon

The following sections are included:

• Presentation

• Diagnosis

• PATIENT CASE NO. 14.2 CASE DESCRIPTION: SECONDARY HYPERTENSION

• Renal Artery Stenosis

• Other Causes of Raised Renin

• Other Renal Causes of Secondary Hypertension
  • Other renal disease
  • Tumours

• Questions, 14:1

• Investigation of Hypertension

• Questions, 14:2

• Hypertension in Pregnancy

• PATIENT CASE NO. 14.3 CASE DESCRIPTION: PRIMARY HYPERTENSION

• Primary (Essential) Hypertension

• The Importance of Identifying Non-Symptomatic Hypertension

• PATIENT CASE NO. 14.4 CASE DESCRIPTION: MALIGNANT HYPERTENSION

• End Organ Damage

• Antihypertensive Drugs (Fig. 14.6)

• Questions, 14:3

The following sections are included:

• Vasculitis

• Questions, 15:1

• Arterioles

• Capillaries

• Capillary Transport and Exchange

• Starling's Principle

• Interstitium

• Lymphatics

• Disease of the Lymphatic System
  • Lymphangitis
  • Lymphoedema

• Questions, 15:2

• Vascular Tumours
  • Haemangiomas
  • Glomangiomas
  • Telangiectasias
  • Naevus flammeus
  • Spider naevi
  • Rendu-Osler-Weber disease
  • Bacillary angiomatosis
  • Haemangioendotheliomas
  • Angiosarcomas
  • Haemangiopericytoma
  • Kaposi's sarcoma
  • Lymphangiomas

• PATIENT CASE NO. 15.1 CASE DESCRIPTION: VARICOSE VEINS, DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM

• Deep Vein Thrombosis

• Leg Ulcers

• Oesophageal varices

• Systemic veins (Fig. 15.3)

• Contractility of Veins

• Questions, 15:3

• The Low Pressure Circulation

• Postural Effect on Pulmonary Blood Flow

• Pulmonary Endothelium

• Effect of Hypoxia

• Effect of Exercise

• Ventilation-Perfusion Mismatching

• Questions, 15:4

• Capacitance of the Pulmonary Circulation

• Pulmonary Hypertension and Right Heart Failure

The following sections are included:

• Presentation

• Pericardial Structure and Function
  • Causes of acute pericarditis

• Dressler's Syndrome

• Investigation of Pericarditis

• Differential Diagnosis

• Treatment

• Cardiac Tamponade

• Prognosis

• Constrictive Pericarditis

• Mediastinitis

• Oesophagitis

Successful performance of life support involves a sufficient understanding of the upper airways to be able to get them clear, an ability to apply mouth-to-mouth ventilation, and an ability to apply external cardiac massage. You must become familiar with ECG displays on defibrillators, so that you can distinguish between asystole and ventricular fibrillation (the former requires pacing, the latter demands defibrillation). Practice all these aspects of the procedure on a dummy in your medical school or hospital resuscitation unit…

The following sections are included:

• INDEX