This document discusses peripheral arterial disease (PAD), which is usually caused by atherosclerosis and shares risk factors with coronary artery disease such as smoking, diabetes, hyperlipidemia, and hypertension. PAD can present as intermittent claudication (pain in the leg muscles brought on by walking) or critical limb ischemia (rest pain and tissue loss). Treatment depends on the severity and location of the disease. Other vascular conditions mentioned include aneurysms, arterial dissections, and various forms of arteritis.
This document provides information on peripheral vascular disease (PVD). It defines PVD as a circulation disorder caused by narrowing or blockage of blood vessels outside the heart. Common risk factors include atherosclerosis, smoking, hypertension, and obesity. Symptoms vary depending on the type of PVD but may include leg pain, skin changes, and ulceration. Diagnostic tests include Doppler ultrasound, angiography, and measuring ankle-brachial index. Treatment involves lifestyle changes, medications, procedures like angioplasty or bypass surgery, and sometimes amputation for severe cases. Nursing care focuses on wound prevention, exercise, smoking cessation education, and monitoring for complications.
definition of heart failure, classification of heart failure, risk factors for heart failure, clinical features, general physical examination findings in heart failure
Coronary artery disease results from the development of atherosclerosis, where plaque builds up in the coronary arteries, reducing blood flow to the heart. Risk factors include elevated cholesterol, smoking, hypertension, diabetes, and family history. Diagnosis involves tests like electrocardiograms, stress tests, and imaging of the arteries. Treatment options include lifestyle changes, medications, angioplasty and stenting, atherectomy, and coronary artery bypass grafting. Nursing care focuses on monitoring for complications, educating on risk factor management, and supporting recovery.
Peripheral vascular disease (PVD) refers to narrowed, blocked, or spasming blood vessels outside the heart and brain. It is commonly caused by atherosclerosis which leads to the buildup of fatty plaques in the arteries (atherosclerotic plaques). Symptoms range from mild intermittent leg pain with walking (intermittent claudication) to severe leg or foot pain at rest or skin ulcers/gangrene of the lower leg or foot. Treatment involves lifestyle changes, medications to reduce pain, plaque, or blood clotting, and potentially minimally invasive or open surgical procedures to restore blood flow if more conservative options are ineffective.
This document provides information about infective endocarditis:
- Infective endocarditis is a microbial infection of the heart valves, heart lining, or blood vessels that is usually caused by bacteria.
- It can affect both native and prosthetic heart valves. Staphylococcus aureus is now the most common cause.
- Diagnosis is based on modified Duke criteria using clinical findings, blood cultures, and echocardiography findings. Treatment involves prolonged antibiotic therapy and may require surgery to remove infected tissues.
- Complications can include heart valve damage, embolic events, heart failure, and extension of the infection. Proper antibiotic prophylaxis is important for those at high risk
The document discusses peripheral vascular diseases, which occur when blood flow to the peripheral vessels is reduced, potentially leading to ischemia and tissue damage. It describes the layers of arteries and veins, and compares arterial and venous disorders. Specific conditions covered include atherosclerosis, arterial insufficiency, venous insufficiency, thromboangitis obliterans (Buerger's disease), Raynaud's phenomenon, aneurysms, arterial embolism, and thrombophlebitis. Risk factors, clinical manifestations, diagnostic tests, and management approaches are discussed for each condition.
This document discusses congenital heart diseases (CHDs). It begins by describing fetal circulation and the contents include fetal circulation, incidence and classification of CHDs, hemodynamics of common CHDs like atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), tetralogy of fallot, and transposition of the great vessels. For each condition, the document discusses clinical presentation, diagnosis, and management. The classification divides CHDs into acyanotic and cyanotic types. The document provides an overview of several major CHDs, their presentations, and treatment approaches.
Aortic stenosis is a narrowing of the aortic valve that obstructs blood flow from the left ventricle to the aorta. It is most commonly caused by calcification and fibrosis of the aortic valve. Symptoms include dyspnea, exertional dizziness, and exertional angina as the left ventricle has to work harder to maintain adequate cardiac output against the increased resistance. On examination, the carotid pulse is weak and delayed while auscultation reveals a crescendo-decrescendo systolic murmur best heard at the right upper sternal border that radiates to the carotid arteries. Management involves prompt aortic valve replacement for symptomatic severe aortic stenosis.
This document provides information on peripheral vascular disease (PVD). It defines PVD as a circulation disorder caused by narrowing or blockage of blood vessels outside the heart. Common risk factors include atherosclerosis, smoking, hypertension, and obesity. Symptoms vary depending on the type of PVD but may include leg pain, skin changes, and ulceration. Diagnostic tests include Doppler ultrasound, angiography, and measuring ankle-brachial index. Treatment involves lifestyle changes, medications, procedures like angioplasty or bypass surgery, and sometimes amputation for severe cases. Nursing care focuses on wound prevention, exercise, smoking cessation education, and monitoring for complications.
definition of heart failure, classification of heart failure, risk factors for heart failure, clinical features, general physical examination findings in heart failure
Coronary artery disease results from the development of atherosclerosis, where plaque builds up in the coronary arteries, reducing blood flow to the heart. Risk factors include elevated cholesterol, smoking, hypertension, diabetes, and family history. Diagnosis involves tests like electrocardiograms, stress tests, and imaging of the arteries. Treatment options include lifestyle changes, medications, angioplasty and stenting, atherectomy, and coronary artery bypass grafting. Nursing care focuses on monitoring for complications, educating on risk factor management, and supporting recovery.
Peripheral vascular disease (PVD) refers to narrowed, blocked, or spasming blood vessels outside the heart and brain. It is commonly caused by atherosclerosis which leads to the buildup of fatty plaques in the arteries (atherosclerotic plaques). Symptoms range from mild intermittent leg pain with walking (intermittent claudication) to severe leg or foot pain at rest or skin ulcers/gangrene of the lower leg or foot. Treatment involves lifestyle changes, medications to reduce pain, plaque, or blood clotting, and potentially minimally invasive or open surgical procedures to restore blood flow if more conservative options are ineffective.
This document provides information about infective endocarditis:
- Infective endocarditis is a microbial infection of the heart valves, heart lining, or blood vessels that is usually caused by bacteria.
- It can affect both native and prosthetic heart valves. Staphylococcus aureus is now the most common cause.
- Diagnosis is based on modified Duke criteria using clinical findings, blood cultures, and echocardiography findings. Treatment involves prolonged antibiotic therapy and may require surgery to remove infected tissues.
- Complications can include heart valve damage, embolic events, heart failure, and extension of the infection. Proper antibiotic prophylaxis is important for those at high risk
The document discusses peripheral vascular diseases, which occur when blood flow to the peripheral vessels is reduced, potentially leading to ischemia and tissue damage. It describes the layers of arteries and veins, and compares arterial and venous disorders. Specific conditions covered include atherosclerosis, arterial insufficiency, venous insufficiency, thromboangitis obliterans (Buerger's disease), Raynaud's phenomenon, aneurysms, arterial embolism, and thrombophlebitis. Risk factors, clinical manifestations, diagnostic tests, and management approaches are discussed for each condition.
This document discusses congenital heart diseases (CHDs). It begins by describing fetal circulation and the contents include fetal circulation, incidence and classification of CHDs, hemodynamics of common CHDs like atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), tetralogy of fallot, and transposition of the great vessels. For each condition, the document discusses clinical presentation, diagnosis, and management. The classification divides CHDs into acyanotic and cyanotic types. The document provides an overview of several major CHDs, their presentations, and treatment approaches.
Aortic stenosis is a narrowing of the aortic valve that obstructs blood flow from the left ventricle to the aorta. It is most commonly caused by calcification and fibrosis of the aortic valve. Symptoms include dyspnea, exertional dizziness, and exertional angina as the left ventricle has to work harder to maintain adequate cardiac output against the increased resistance. On examination, the carotid pulse is weak and delayed while auscultation reveals a crescendo-decrescendo systolic murmur best heard at the right upper sternal border that radiates to the carotid arteries. Management involves prompt aortic valve replacement for symptomatic severe aortic stenosis.
This document discusses peripheral vascular disease and its management. It covers topics such as thrombosis, varicose veins, deep vein thrombosis, peripheral artery disease, aneurysms, Raynaud's phenomenon, Buerger's disease, venous disease, blood clots, lymphedema, risk factors, symptoms, diagnostic tests including Doppler ultrasound, ankle-brachial index, angiography and treatments including medications, surgery, and lifestyle changes like exercise and smoking cessation.
Falls are a common and serious problem for older adults. They can cause physical injuries like hip fractures as well as psychological issues like a fear of falling. A multifactorial assessment and intervention approach is recommended to prevent falls, which includes assessing vision, medications, home hazards, and exercise programs to improve balance and strength. Healthcare providers should routinely ask older patients about falls and recommend prevention strategies.
This document discusses various types of cardiomyopathies:
- Dilated cardiomyopathy is caused by an unknown etiology and results in left ventricular dilatation and systolic dysfunction. It is a common cause of heart failure.
- Hypertrophic cardiomyopathy involves abnormal thickening of the heart muscle and can lead to outflow obstruction. It is a common cause of sudden death in young athletes.
- Restrictive cardiomyopathy causes stiff ventricles and impaired ventricular filling due to disorders like amyloidosis. It presents with symptoms of right and left heart failure.
- Other rare types discussed include arrhythmogenic right ventricular dysplasia and obliterative cardiomyopathy. Diagnosis involves imaging and endomyocardial biopsy
Peripheral vascular disease (PVD) is a circulation disorder causing narrowing of blood vessels outside the heart and brain. There are two types: functional PVD involves no structural damage while organic PVD causes inflammation and tissue damage. Common causes include atherosclerosis, blood clots, diabetes, and vasculitis. Risk factors are family history of heart disease, age over 50, smoking, obesity, and diabetes. Symptoms range from leg pain with walking to sores or color changes. Diagnosis involves blood pressure tests and imaging of blood vessels. Treatment includes lifestyle changes, medications, surgery such as stents and bypass grafts, and preventing complications like amputation.
Ischemic heart disease is caused by a decreased supply of oxygenated blood to the heart muscle, usually due to atherosclerotic narrowing of one or more coronary arteries. It results in an imbalance between myocardial oxygen supply and demand. Treatment involves aggressively modifying risk factors, stabilizing plaques, and restoring blood flow through revascularization or pharmacotherapy to balance oxygen supply and demand. Pharmacotherapy includes agents that reduce myocardial oxygen demand such as beta-blockers and calcium channel blockers, as well as those that increase supply such as nitrates, statins, and renin-angiotensin system inhibitors. Close monitoring is needed to optimize therapy and prevent complications.
Deep vein thrombosis occurs when a blood clot forms in one of the deep veins, usually in the legs. It can cause leg pain and swelling but sometimes has no symptoms. The clots are dangerous because they can break off, travel to the lungs, and block blood flow. Nursing care for deep vein thrombosis focuses on preventing clot growth and migration, providing comfort measures like leg elevation and compression stockings, and educating patients about anticoagulant medications and the need for follow up blood tests and lifestyle changes.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
Rheumatic heart disease is a condition that results from rheumatic fever, which causes inflammation and scarring of the heart valves, usually the mitral and aortic valves. It is most common in children ages 5-15 from low socioeconomic backgrounds living in crowded conditions. Long term antibiotic prophylaxis is needed to prevent recurrent streptococcal infections and further heart damage. For those with valve damage, treatment focuses on reducing cardiac workload through bed rest, medications, and possibly surgery such as valve repair or replacement.
Myocarditis is an inflammatory disease of the heart muscle that can be caused by infectious or non-infectious triggers. It has a variable clinical presentation ranging from mild symptoms to life-threatening conditions. The diagnosis is challenging due to the heterogeneity of symptoms but can involve electrocardiogram, cardiac biomarkers, echocardiogram, cardiac MRI and endomyocardial biopsy. About half of acute cases resolve in 2-4 weeks but some develop heart failure or arrhythmias. Treatment focuses on supporting heart function and managing symptoms while the disease runs its course.
Cerebellar infarction is a rare type of stroke accounting for 2-3% of cases. It can cause serious complications due to the cerebellum's location. Symptoms include nausea, vomiting, dizziness and headache. Common causes are cardiac embolism, atherosclerosis and arterial dissection. Complications include swelling, mass effect and brainstem compression. Patients require close monitoring and may need decompressive surgery. With proper management, prognosis can be good in the absence of additional brainstem injury.
Congenital heart disease (CHD) occurs in 1 in 125 live births and is the most common birth defect. The majority of cases have no known cause and are thought to be due to a combination of genetic and environmental factors. Common types of CHD include atrial septal defects, ventricular septal defects, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot. Treatment options include medical management, interventional procedures such as catheterization, and surgical repair. Without treatment, CHD can lead to heart failure, lung problems, and other issues.
This document discusses vasculitis, which is inflammation of blood vessels. It defines vasculitis and describes the different types including large vessel, medium vessel, and small vessel vasculitis. Specific conditions are discussed such as giant cell arteritis, granulomatosis with polyangiitis, Churg-Strauss syndrome, Behcet's disease, thromboangiitis obliterans, and infectious vasculitis. The pathology, clinical features, morphology, and treatment of some of these conditions are summarized. Images are also included showing histological features.
The document discusses cardiomyopathy, which refers to diseases of the heart muscle. There are three main types - dilated, hypertrophic, and restrictive. Dilated cardiomyopathy involves an enlarged and weakened left ventricle. Causes include viral infections, toxins, and genetic factors. Symptoms range from fatigue to breathing difficulties. Diagnosis involves echocardiography, ECG, and cardiac catheterization. Treatment focuses on medications and lifestyle changes to manage symptoms.
SHOCK - PATHOPHYSIOLOGY, TYPES, APPROACH, TREATMENT.DR K TARUN RAO
1. Shock is defined as a state of poor tissue perfusion and cellular metabolism due to circulatory failure and hypoperfusion.
2. The main causes of shock include hypovolemic, cardiogenic, septic, anaphylactic, neurogenic, and respiratory etiologies.
3. The pathophysiology of shock involves a low cardiac output state leading to vasoconstriction and redistribution of blood flow away from non-vital organs to preserve perfusion of vital organs. Persistent shock can progress to cellular damage, organ dysfunction, and death.
Transposition of the great arteries (TGA) is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, causing parallel instead of serial circulation. TGA accounts for 5-7% of congenital heart diseases and has an annual incidence of 20-30 per 100,000 live births. Without treatment, TGA is incompatible with long-term survival due to lack of oxygen supply. Initial treatment involves prostaglandin E1 to maintain ductal patency and increase pulmonary blood flow. Later procedures include the Rastelli operation or arterial switch operation to correct the defect.
Pulmonary stenosis (also called pulmonic stenosis) is when the pulmonary valve (the valve between the right ventricle and the pulmonary artery) is too small, narrow, or stiff. Symptoms of pulmonary stenosis depend on how small the narrowing of the pulmonary valve is
1) Acute coronary syndromes (ACS) describe conditions caused by coronary plaque rupture and include ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina.
2) Plaque rupture triggers blood clot formation, which can partially or completely block blood flow to the heart. STEMI involves complete blockage, while NSTEMI and unstable angina involve partial blockages.
3) Diagnosis involves ECG, cardiac enzyme tests, and angiography. Treatment depends on diagnosis but commonly includes aspirin, blood thinners, beta-blockers, and procedures like thrombolysis or angioplasty to restore blood flow.
This document defines pericardial effusion and cardiac tamponade, discusses their pathophysiology, etiology, clinical presentation, investigations, and management. Pericardial effusion is an abnormal amount of fluid in the pericardial space, while cardiac tamponade is acute heart failure caused by compression of the heart from a large or rapidly developing effusion. Clinical manifestations depend on the rate of fluid accumulation and include chest pain, lightheadedness, and decreased pulse pressure. Investigations include echocardiography, electrocardiography, and pericardiocentesis. Management involves bed rest, medications, drainage procedures, and surgery in severe cases.
Cor pulmonale, or right heart failure, is caused by high blood pressure in the pulmonary artery and right ventricle due to conditions that restrict pulmonary blood flow such as chronic lung diseases. It develops when pulmonary hypertension leads to enlargement and failure of the right ventricle. Symptoms include shortness of breath, leg swelling, and fatigue. Diagnosis involves physical exam, imaging like echocardiogram and chest x-ray, and assessing pulmonary pressures. Treatment focuses on managing the underlying lung condition, giving diuretics and vasodilators, and may involve oxygen therapy or lung transplantation in severe cases.
Deep vein thrombosis (DVT) occurs when a blood clot forms in one of the deep veins of the body, usually in the leg. It can be caused by factors that increase venous stasis, endothelial injury, or hypercoagulability. Common symptoms include leg swelling and pain. Diagnosis is usually made using ultrasound imaging of the veins. Treatment involves blood thinners to prevent further clotting and the risk of pulmonary embolism. Long term prevention focuses on compression stockings and avoiding prolonged sitting or immobility.
The human PRNP gene is located on chromosome 20 and encodes the prion protein (PrP). Mutations in this gene can cause neurodegenerative diseases like Creutzfeldt-Jakob disease. The protein's exact function is unknown but it may be involved in copper transport, neuroprotection, and communication between neurons. Alternatively spliced variants have been identified for this gene and the mouse protein shares high sequence identity with the human protein. Clinically relevant genetic variants in PRNP have been associated with prion diseases.
El documento describe la importancia de la nutrición perioperatoria para reducir las complicaciones quirúrgicas. La malnutrición aumenta la morbilidad y mortalidad postoperatoria a través de una cicatrización deficiente, respuesta inmune alterada y mayor estancia hospitalaria. El soporte nutricional antes, durante y después de la cirugía puede prevenir estas complicaciones al mejorar el balance de nutrientes y restaurar la función tisular. La nutrición enteral temprana es preferible a la nutrición parenteral o al ayuno prolongado.
This document discusses peripheral vascular disease and its management. It covers topics such as thrombosis, varicose veins, deep vein thrombosis, peripheral artery disease, aneurysms, Raynaud's phenomenon, Buerger's disease, venous disease, blood clots, lymphedema, risk factors, symptoms, diagnostic tests including Doppler ultrasound, ankle-brachial index, angiography and treatments including medications, surgery, and lifestyle changes like exercise and smoking cessation.
Falls are a common and serious problem for older adults. They can cause physical injuries like hip fractures as well as psychological issues like a fear of falling. A multifactorial assessment and intervention approach is recommended to prevent falls, which includes assessing vision, medications, home hazards, and exercise programs to improve balance and strength. Healthcare providers should routinely ask older patients about falls and recommend prevention strategies.
This document discusses various types of cardiomyopathies:
- Dilated cardiomyopathy is caused by an unknown etiology and results in left ventricular dilatation and systolic dysfunction. It is a common cause of heart failure.
- Hypertrophic cardiomyopathy involves abnormal thickening of the heart muscle and can lead to outflow obstruction. It is a common cause of sudden death in young athletes.
- Restrictive cardiomyopathy causes stiff ventricles and impaired ventricular filling due to disorders like amyloidosis. It presents with symptoms of right and left heart failure.
- Other rare types discussed include arrhythmogenic right ventricular dysplasia and obliterative cardiomyopathy. Diagnosis involves imaging and endomyocardial biopsy
Peripheral vascular disease (PVD) is a circulation disorder causing narrowing of blood vessels outside the heart and brain. There are two types: functional PVD involves no structural damage while organic PVD causes inflammation and tissue damage. Common causes include atherosclerosis, blood clots, diabetes, and vasculitis. Risk factors are family history of heart disease, age over 50, smoking, obesity, and diabetes. Symptoms range from leg pain with walking to sores or color changes. Diagnosis involves blood pressure tests and imaging of blood vessels. Treatment includes lifestyle changes, medications, surgery such as stents and bypass grafts, and preventing complications like amputation.
Ischemic heart disease is caused by a decreased supply of oxygenated blood to the heart muscle, usually due to atherosclerotic narrowing of one or more coronary arteries. It results in an imbalance between myocardial oxygen supply and demand. Treatment involves aggressively modifying risk factors, stabilizing plaques, and restoring blood flow through revascularization or pharmacotherapy to balance oxygen supply and demand. Pharmacotherapy includes agents that reduce myocardial oxygen demand such as beta-blockers and calcium channel blockers, as well as those that increase supply such as nitrates, statins, and renin-angiotensin system inhibitors. Close monitoring is needed to optimize therapy and prevent complications.
Deep vein thrombosis occurs when a blood clot forms in one of the deep veins, usually in the legs. It can cause leg pain and swelling but sometimes has no symptoms. The clots are dangerous because they can break off, travel to the lungs, and block blood flow. Nursing care for deep vein thrombosis focuses on preventing clot growth and migration, providing comfort measures like leg elevation and compression stockings, and educating patients about anticoagulant medications and the need for follow up blood tests and lifestyle changes.
The aortic valve has three cusps that open and close to regulate blood flow from the heart to the aorta. Aortic stenosis occurs when the valve opening narrows due to calcium buildup on the cusps. In the elderly, aortic stenosis is usually caused by age-related degeneration and calcification of the valve. Symptoms include chest pain, shortness of breath, and fainting. Diagnosis involves echocardiogram, Doppler ultrasound and cardiac catheterization. Treatment options include medications, balloon valvuloplasty, open-heart surgery to replace the valve, and newer transcatheter aortic valve replacement procedures for high-risk elderly patients.
Rheumatic heart disease is a condition that results from rheumatic fever, which causes inflammation and scarring of the heart valves, usually the mitral and aortic valves. It is most common in children ages 5-15 from low socioeconomic backgrounds living in crowded conditions. Long term antibiotic prophylaxis is needed to prevent recurrent streptococcal infections and further heart damage. For those with valve damage, treatment focuses on reducing cardiac workload through bed rest, medications, and possibly surgery such as valve repair or replacement.
Myocarditis is an inflammatory disease of the heart muscle that can be caused by infectious or non-infectious triggers. It has a variable clinical presentation ranging from mild symptoms to life-threatening conditions. The diagnosis is challenging due to the heterogeneity of symptoms but can involve electrocardiogram, cardiac biomarkers, echocardiogram, cardiac MRI and endomyocardial biopsy. About half of acute cases resolve in 2-4 weeks but some develop heart failure or arrhythmias. Treatment focuses on supporting heart function and managing symptoms while the disease runs its course.
Cerebellar infarction is a rare type of stroke accounting for 2-3% of cases. It can cause serious complications due to the cerebellum's location. Symptoms include nausea, vomiting, dizziness and headache. Common causes are cardiac embolism, atherosclerosis and arterial dissection. Complications include swelling, mass effect and brainstem compression. Patients require close monitoring and may need decompressive surgery. With proper management, prognosis can be good in the absence of additional brainstem injury.
Congenital heart disease (CHD) occurs in 1 in 125 live births and is the most common birth defect. The majority of cases have no known cause and are thought to be due to a combination of genetic and environmental factors. Common types of CHD include atrial septal defects, ventricular septal defects, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot. Treatment options include medical management, interventional procedures such as catheterization, and surgical repair. Without treatment, CHD can lead to heart failure, lung problems, and other issues.
This document discusses vasculitis, which is inflammation of blood vessels. It defines vasculitis and describes the different types including large vessel, medium vessel, and small vessel vasculitis. Specific conditions are discussed such as giant cell arteritis, granulomatosis with polyangiitis, Churg-Strauss syndrome, Behcet's disease, thromboangiitis obliterans, and infectious vasculitis. The pathology, clinical features, morphology, and treatment of some of these conditions are summarized. Images are also included showing histological features.
The document discusses cardiomyopathy, which refers to diseases of the heart muscle. There are three main types - dilated, hypertrophic, and restrictive. Dilated cardiomyopathy involves an enlarged and weakened left ventricle. Causes include viral infections, toxins, and genetic factors. Symptoms range from fatigue to breathing difficulties. Diagnosis involves echocardiography, ECG, and cardiac catheterization. Treatment focuses on medications and lifestyle changes to manage symptoms.
SHOCK - PATHOPHYSIOLOGY, TYPES, APPROACH, TREATMENT.DR K TARUN RAO
1. Shock is defined as a state of poor tissue perfusion and cellular metabolism due to circulatory failure and hypoperfusion.
2. The main causes of shock include hypovolemic, cardiogenic, septic, anaphylactic, neurogenic, and respiratory etiologies.
3. The pathophysiology of shock involves a low cardiac output state leading to vasoconstriction and redistribution of blood flow away from non-vital organs to preserve perfusion of vital organs. Persistent shock can progress to cellular damage, organ dysfunction, and death.
Transposition of the great arteries (TGA) is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, causing parallel instead of serial circulation. TGA accounts for 5-7% of congenital heart diseases and has an annual incidence of 20-30 per 100,000 live births. Without treatment, TGA is incompatible with long-term survival due to lack of oxygen supply. Initial treatment involves prostaglandin E1 to maintain ductal patency and increase pulmonary blood flow. Later procedures include the Rastelli operation or arterial switch operation to correct the defect.
Pulmonary stenosis (also called pulmonic stenosis) is when the pulmonary valve (the valve between the right ventricle and the pulmonary artery) is too small, narrow, or stiff. Symptoms of pulmonary stenosis depend on how small the narrowing of the pulmonary valve is
1) Acute coronary syndromes (ACS) describe conditions caused by coronary plaque rupture and include ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina.
2) Plaque rupture triggers blood clot formation, which can partially or completely block blood flow to the heart. STEMI involves complete blockage, while NSTEMI and unstable angina involve partial blockages.
3) Diagnosis involves ECG, cardiac enzyme tests, and angiography. Treatment depends on diagnosis but commonly includes aspirin, blood thinners, beta-blockers, and procedures like thrombolysis or angioplasty to restore blood flow.
This document defines pericardial effusion and cardiac tamponade, discusses their pathophysiology, etiology, clinical presentation, investigations, and management. Pericardial effusion is an abnormal amount of fluid in the pericardial space, while cardiac tamponade is acute heart failure caused by compression of the heart from a large or rapidly developing effusion. Clinical manifestations depend on the rate of fluid accumulation and include chest pain, lightheadedness, and decreased pulse pressure. Investigations include echocardiography, electrocardiography, and pericardiocentesis. Management involves bed rest, medications, drainage procedures, and surgery in severe cases.
Cor pulmonale, or right heart failure, is caused by high blood pressure in the pulmonary artery and right ventricle due to conditions that restrict pulmonary blood flow such as chronic lung diseases. It develops when pulmonary hypertension leads to enlargement and failure of the right ventricle. Symptoms include shortness of breath, leg swelling, and fatigue. Diagnosis involves physical exam, imaging like echocardiogram and chest x-ray, and assessing pulmonary pressures. Treatment focuses on managing the underlying lung condition, giving diuretics and vasodilators, and may involve oxygen therapy or lung transplantation in severe cases.
Deep vein thrombosis (DVT) occurs when a blood clot forms in one of the deep veins of the body, usually in the leg. It can be caused by factors that increase venous stasis, endothelial injury, or hypercoagulability. Common symptoms include leg swelling and pain. Diagnosis is usually made using ultrasound imaging of the veins. Treatment involves blood thinners to prevent further clotting and the risk of pulmonary embolism. Long term prevention focuses on compression stockings and avoiding prolonged sitting or immobility.
The human PRNP gene is located on chromosome 20 and encodes the prion protein (PrP). Mutations in this gene can cause neurodegenerative diseases like Creutzfeldt-Jakob disease. The protein's exact function is unknown but it may be involved in copper transport, neuroprotection, and communication between neurons. Alternatively spliced variants have been identified for this gene and the mouse protein shares high sequence identity with the human protein. Clinically relevant genetic variants in PRNP have been associated with prion diseases.
El documento describe la importancia de la nutrición perioperatoria para reducir las complicaciones quirúrgicas. La malnutrición aumenta la morbilidad y mortalidad postoperatoria a través de una cicatrización deficiente, respuesta inmune alterada y mayor estancia hospitalaria. El soporte nutricional antes, durante y después de la cirugía puede prevenir estas complicaciones al mejorar el balance de nutrientes y restaurar la función tisular. La nutrición enteral temprana es preferible a la nutrición parenteral o al ayuno prolongado.
The poster uses surreal colors like purples and greys to depict a storm approaching and families ready to fight, indicating something bad may happen. At the center is the main image of the young couple kissing, with a shining heart above them symbolizing their powerful love amid the violence around them. The layout spreads out the families on either side of the couple at the center to keep the violence from overtaking the focus on their love. The tagline "My only love sprung by my only hate" helps viewers understand how the family hatred brought the couple together despite everything.
Prions are infectious proteins that have become misfolded and cause transmissible spongiform encephalopathies in mammals by converting normal prion proteins into additional misfolded prions. These prion diseases affect the brain or nervous system, are currently untreatable, and always fatal, such as mad cow disease in cattle and Creutzfeldt-Jakob disease in humans.
La psoriasis es una enfermedad inflamatoria crónica de la piel de causa desconocida, caracterizada por placas eritematosas y escamosas que pueden aparecer en cualquier parte del cuerpo. Puede ser desencadenada por factores genéticos, infecciones, fármacos o estrés. Existen diferentes tipos como la psoriasis vulgar, pustulosa, eritrodérmica o artritis psoriásica. No tiene cura pero se puede controlar con tratamientos tópicos, fototerapia o medicamentos
Este documento resume los principales mecanismos de eliminación de fármacos del organismo, incluyendo el metabolismo, la excreción renal, biliar e intestinal. Explica conceptos clave como la semivida de eliminación, el aclaramiento y la cinética de primera y cero orden. Además, destaca la importancia de entender la eliminación de fármacos para ajustar las dosis y tener en cuenta factores que pueden alterarla.
Este documento trata sobre la farmacología y el paso de fármacos a través de las membranas celulares. Explica los diferentes mecanismos de transporte como la difusión pasiva, el transporte activo y otros mecanismos. Describe factores que determinan el paso de fármacos como las características físico-químicas, el flujo sanguíneo y la variabilidad individual. También cubre conceptos clave como la curva farmacocinética y la ecuación de Henderson-Hasselbalch.
This document discusses economic and financial mechanisms for reducing disaster risk, including insurance and microfinance. It notes that poverty can increase vulnerability to hazards, so economic development and poverty reduction are important for risk reduction strategies. Livelihood diversification is key for poor people to reduce vulnerability by having multiple sources of income. However, development programs need to consider hazard risks so assets are protected. Insurance is an effective risk-sharing method, but is market-driven so mainly benefits those in developed countries where risks can be accurately calculated. Microfinance, like loans, can help build assets but borrowers risk losing assets if a disaster strikes before returns are generated.
Este documento describe varios virus que causan gastroenteritis, incluyendo rotavirus, adenovirus, calicivirus y astrovirus. El rotavirus es una de las causas principales de diarrea grave en niños menores de dos años y se transmite fácilmente de persona a persona. Los adenovirus entéricos afectan preferentemente el tracto gastrointestinal y respiratorio, mientras que los calicivirus y astrovirus son una causa común de gastroenteritis en niños y personas mayores. Todos estos virus causan síntomas como diarrea, vómitos y deshidr
2011 SMB Disaster Preparedness Global SurveySymantec
Symantec’s 2011 SMB Disaster Preparedness Survey measured the attitudes and practices of small- and mid-sized businesses (SMBs) and their customers toward disaster preparedness. The survey findings show that though SMBs are at risk, they are still not making disaster preparedness a priority until they experience a disaster or data loss. The data also reveals that the cost of not being prepared is high, putting an SMB at risk of going out of business.
The document discusses the field of microbiology and the journey of a scientist. It covers topics ranging from the basic structure and function of microbes like bacteria, viruses, and fungi, to laboratory tools, experiments, and the scientific method. The document emphasizes the importance of microbiology in areas like health, safety, and the environment. It also profiles the career of a microbiologist whose goal is to apply scientific knowledge and experience to ensure product safety through laboratory testing and quality programs.
Recommandation stratégique pour un réseau social d'artiste peintre et sculpteur
Cas d'école fictif réalisé en 2013 dans le cadre de ma 3ème année à l'ISCOM Paris
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Recommendation for a social network dedicated to artists
School case created in 2013 during my 3rd year at ISCOM Paris
Este documento describe la enfermedad ácido péptica, incluyendo la gastritis, úlcera péptica y dispepsia. Explica la fisiopatología, síntomas, diagnóstico y tratamiento de estas afecciones gástricas, señalando que la bacteria Helicobacter pylori desempeña un papel clave y su erradicación es parte fundamental del tratamiento.
Disaster Preparedness Questionnaire Design and Pretestmmwood
A national survey is being conducted via telephone interviews to assess disaster experiences and preparedness. Over 3,300 interviews will be randomly conducted across the US, with the sample stratified into high risk and low risk areas. The survey was developed based on previous research, then pretested in iterations to refine the questions. Preliminary results show 462 interviews completed so far, but terrorism fatigue and refusals remain issues.
La nutrición parenteral es un método seguro y fiable de alimentación que puede ser imprescindible para evitar la desnutrición o mantener un estado nutricional adecuado en pacientes quirúrgicos. Puede indicarse en pacientes que no pueden comer o no comen lo suficiente debido a su enfermedad o cirugía, así como en aquellos con estrés metabólico elevado o desnutrición preoperatoria. La nutrición enteral es preferible cuando es posible, mientras que la nutrición parenteral total o periférica pueden us
Chronic lower limb arterial disease is commonly caused by atherosclerosis and presents as intermittent claudication (IC) or critical limb ischemia (CLI). IC involves pain in the calf on walking that resolves with rest, while CLI includes tissue loss and gangrene. Treatment focuses on risk factor modification and exercise, with revascularization considered if best medical therapy fails. Endovascular procedures and bypass surgery aim to restore blood flow and relieve symptoms. Amputation may be necessary in advanced CLI if revascularization is not possible.
Peripheral Arterial Disease (PAD) is a chronic atherosclerotic disease affecting arteries outside the heart, most commonly in the lower limbs. It shares common risk factors with coronary artery disease such as smoking, diabetes, high cholesterol, and hypertension. PAD can cause intermittent claudication pain in calf muscles with walking that resolves with rest, or critical limb ischemia with rest pain and tissue loss. Diagnosis involves clinical examination, ankle-brachial pressure index measurement, and imaging tests. Treatment focuses on risk factor modification through lifestyle changes and medications to improve blood flow and prevent limb loss.
Presentation1.pptx, radiological imaging of upper limb ischemia.Abdellah Nazeer
This document discusses radiological imaging techniques for evaluating upper limb ischemia. It begins by providing background on upper limb ischemia, noting it has varied etiologies including atherosclerosis, arteritis, and trauma. CT angiography is described as the preferred initial imaging technique, providing high-quality images of the entire arterial tree to precisely plan revascularization. Other techniques discussed include Doppler ultrasound, MRI, and invasive angiography. The document then provides several examples of upper limb CT angiography findings, demonstrating various pathologies like thrombosis, aneurysms, occlusions, and fistulas. In summary, the document outlines radiological evaluation and various pathologies of upper limb ischemia visualized on CT angiography.
D. Fadhil Vasculitis-7 (Muhadharaty) (1).pptxhussainAltaher
Vasculitides are a group of rare diseases characterized by inflammation and necrosis of blood vessels. They are classified based on the size of affected vessels into large, medium, and small vessel vasculitis. Some of the main types discussed in the document include giant cell arteritis/polymyalgia rheumatica, Takayasu's arteritis, polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, and Henoch Schonlein purpura. The document provides details on clinical features, investigations, treatments, and prognosis for each type of vasculitis.
PAD can be diagnosed in asymptomatic individuals by a combination of physical examination and simple, noninvasive Doppler ultrasonography to measure the ankle–brachial index
This document provides an overview of acute limb ischemia (ALI), including its diagnosis and management. ALI is a sudden decrease in blood flow to the limbs caused by thrombus or embolism. Diagnosis involves assessing the patient's history, symptoms of pain and reduced pulses, and imaging tests like duplex ultrasound, CT angiography, or digital subtraction angiography to identify clot location. Treatment may involve anticoagulation, thrombolysis drugs, endovascular procedures to remove clots, or surgical revascularization procedures to restore blood flow if limbs are severely threatened. Both pharmacological and interventional techniques are discussed as options to reperfuse ischemic limbs within 24 hours and prevent limb loss.
This review discusses the diagnosis and management of acute limb ischemia (ALI). ALI is a medical emergency associated with high mortality and amputation rates. The review summarizes the typical etiologies of ALI such as embolism and arterial thrombosis. It describes the steps for emergency diagnosis, emphasizing the roles of clinical examination, duplex ultrasound, CT angiography, and digital subtraction angiography. A variety of treatment techniques are discussed including pharmacological thrombolysis, endovascular procedures like thrombectomy, and open surgical revascularization procedures. Post-procedure management including risks of reperfusion injury and compartment syndrome are also reviewed.
Stanford Type A Aortic Dissection: a Complex Disease for Patients and Cardiot...Crimsonpublisherssmoaj
Acute type A aortic dissection is a catastrophic event in which blood exits the vascular lumen and dissects the media, creating a false lumen. Surgery is the best possible treatment but it is complex. The surgical team needs to understand the anatomy and physiopathology before dealing with the repair. While there are just a few surgical solutions for the repair of the dissected ascending aorta, debate is still ongoing about the best surgical option for the disease involving the arch and the descending aorta. Late reoperations are relatively common on the aortic valve and/or the distal aorta after primary repair. Results are excellent in specialized centers with high volume and complexity. Lifelong follow-up is required in survivors.
1. The document provides recommendations for students on the topic of arterial thrombosis and embolism, including classification of acute limb ischemia, clinical stages, diagnosis, and surgical treatment methods.
2. It outlines the educational objectives which are to teach students to recognize symptoms, differentiate embolism and thrombosis, determine locations of vascular lesions, choose surgical methods, and conduct conservative therapy.
3. The summary section classifies acute ischemic limb by degree of ischemia and main features, and outlines variants of clinical progression and complications that can occur.
This document discusses peripheral arterial diseases of the extremities. It notes that the prevalence increases with age and risk factors like atherosclerosis. Peripheral arterial disease is defined as an ankle-brachial index of less than 0.9. Risk factors include atherosclerosis, smoking, diabetes, and hypertension. Symptoms range from intermittent claudication to critical limb ischemia with ulcers or gangrene. Diagnosis involves medical history, physical exam, and tests like ABI. Treatment focuses on risk factor modification and revascularization for severe symptoms.
This document provides an overview of carotid artery stenosis. It discusses the anatomy of the carotid arteries and how stenosis can increase the risk of stroke by reducing blood flow to the brain. Symptoms of stenosis range from transient ischemic attacks to full strokes, depending on the location and severity of the blockage. Imaging plays a key role in detecting and evaluating carotid artery stenosis. Treatment may involve medications, lifestyle changes, or carotid endarterectomy surgery to remove plaque buildup.
The document discusses coronary artery disease and myocardial infarction. It begins by describing normal coronary anatomy and physiology. It then defines ischemic heart disease and discusses its epidemiology and etiopathogenesis, focusing on atherosclerosis and other causes. It describes coronary syndromes like stable angina, unstable angina, and acute myocardial infarction. It provides details on pathogenesis, clinical features, and complications of myocardial infarction.
This document outlines a presentation on stroke. It begins with an introduction and classification of stroke, followed by sections on risk factors, pathophysiology, signs and symptoms, differential diagnosis, and approach to patients. It discusses that stroke is caused by a lack of blood flow to the brain and defines different types of stroke, including ischemic and hemorrhagic. Risk factors highlighted include age, hypertension, cardiac issues, and genetic factors. Signs and symptoms vary depending on the location and type of stroke.
1) Atherosclerosis of the carotid arteries can lead to stenosis and cause 8-15% of ischemic strokes. Clinical trials found stenting carried a higher risk of non-disabling stroke compared to endarterectomy, but endarterectomy carried higher risks of other complications.
2) For symptomatic stenosis, both treatments effectively prevent future stroke in the medium to long term. Endarterectomy provides a modest benefit for preventing stroke in asymptomatic stenosis, while the role of stenting is still uncertain.
3) Advances in medical therapy have reduced atherosclerosis risks, making the benefits of invasive treatments uncertain. Risk modeling including plaque imaging will be important for selecting patients for interventions.
Stroke is caused by interrupted blood flow to the brain and can be either hemorrhagic or ischemic. Ischemic strokes are more common and can be caused by thrombosis, embolism, or hypoperfusion. The brain requires a lot of oxygen and glucose which can be cut off by these events, triggering a damaging cascade within brain cells. Imaging like CT and MRI are used to diagnose stroke and determine if damaged areas can still be salvaged. Risk factors include conditions like high blood pressure, atrial fibrillation, and lifestyle factors. Treatment focuses on restoring blood flow as quickly as possible if the patient presents within the approved time window.
Stroke occurs when blood flow to the brain is interrupted, depriving brain cells of oxygen and nutrients. There are two main types of stroke - ischemic, caused by blockage of a blood vessel, and hemorrhagic, caused by bleeding. Risk factors include hypertension, diabetes, smoking, heart disease, and age. Diagnosis involves medical history, physical exam, and imaging tests like CT scan or MRI. Treatment depends on the type and severity of stroke, with the goal of restoring blood flow and preventing further brain damage.
Stroke occurs when blood flow to the brain is interrupted, depriving brain cells of oxygen and nutrients. There are two main types of stroke - ischemic, caused by blockage of a blood vessel, and hemorrhagic, caused by bleeding. The loss of blood flow triggers a damaging cascade within brain cells. Some brain areas may survive on minimal blood flow in the ischemic penumbra region, but cells in the core die quickly. Risk factors include age, hypertension, diabetes, smoking, prior heart disease, and family history. Stroke is a leading cause of death and disability in the United States.
1. Acute limb ischemia occurs due to a sudden decrease in blood flow to a limb, threatening the viability of the extremity. It requires prompt diagnosis and treatment to determine if the limb is viable, threatened, or irreversibly ischemic.
2. Initial management involves analgesia, oxygen, intravenous heparin, and urgent referral to a vascular specialist. Further imaging and either surgical or endovascular revascularization may be needed depending on the classification of ischemia.
3. The prognosis depends on factors like etiology and severity of ischemia. With timely treatment, limb salvage is possible in the majority of patients.
Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke.
Arthropathy in haematological disorders in childrendattasrisaila
This document discusses various hematological disorders that can present with rheumatological symptoms in children. It describes benign disorders like sickle cell disease, thalassemias, and hemophilia that can cause joint pain, swelling, and damage. It also covers malignant disorders like leukemic arthritis and how certain cancers like leukemia can initially manifest as musculoskeletal complaints. For each condition, it provides details on presentations, treatments, and long term complications involving the bones and joints.
High-yield principles in psychiatry provide concise summaries of essential psychiatric topics and conditions. Key concepts include the major psychiatric disorders, their symptoms, diagnostic criteria and initial treatment approaches. These principles aim to efficiently convey critical clinical information for psychiatrists and other medical professionals.
The document summarizes the history, epidemiology, virology, immunology, transmission, clinical progression, and global impact of HIV/AIDS. It notes that HIV was first recognized in 1981 but has since been traced to 1959. It is caused by HIV-1 and HIV-2 viruses and is transmitted via bodily fluids. Left untreated, it progresses from primary infection to asymptomatic infection to AIDS as it depletes CD4 cells and allows opportunistic infections. Currently over 30 million people are living with HIV globally, with sub-Saharan Africa most severely impacted.
This document summarizes several types of parasitic helminths (worms) that can infect humans. It describes the life cycles, geographical distribution, clinical presentation, diagnosis, and treatment of important nematode infections including hookworms, Strongyloides, ascariasis, enterobiasis, trichuriasis, and filariasis. Key points are that these soil-transmitted helminths typically have complex life cycles involving larval stages in soil that infect via skin penetration or ingestion, causing anaemia, pulmonary symptoms, or intestinal obstruction in heavy infections. Diagnosis involves finding eggs or larvae in stool or tissue samples, and treatment consists of anthelmintic medications like albendazole or me
This document discusses several types of fungal infections including superficial mycoses, subcutaneous mycoses, systemic mycoses, and opportunistic mycoses. It describes the classification, causative organisms, clinical presentations, diagnoses, and treatments for various specific fungal infections including candidiasis, cryptococcosis, aspergillosis, fusariosis, mucormycosis, and penicilliosis.
Protozoa can cause important infectious diseases like malaria. Malaria is caused by Plasmodium parasites and transmitted via mosquito bites. It affects millions annually, especially in sub-Saharan Africa. Drug resistance has emerged, necessitating new treatments. Prevention relies on chemoprophylaxis and reducing mosquito exposure.
The document discusses various bacterial infections of the skin and soft tissues caused by staphylococci and streptococci. It describes how staphylococci are commonly found on the skin and nose and can cause infections like cellulitis, abscesses and toxic shock syndrome. Methicillin-resistant Staphylococcus aureus is an increasing problem. Streptococci also cause skin infections like cellulitis, impetigo and scarlet fever, and can result in toxic shock. Other bacterial infections mentioned include yaws, tropical ulcer and Buruli ulcer.
This document provides information about sexually transmitted infections (STIs), including their modes of transmission, common types of STIs, global prevalence estimates, and STI screening and management practices in clinical settings. Key points covered include the most common curable STIs worldwide being trichomoniasis, chlamydia, and gonorrhea; chlamydia and gonorrhea being the most frequently diagnosed STIs in the UK; and STIs requiring comprehensive screening and partner notification due to the risk of concurrent infections. Diagnosis and treatment approaches are described for various STIs affecting different anatomical sites.
19. presenting problems in infectious diseasesAhmad Hamadi
This document discusses the evaluation and management of fever. It notes that the differential diagnosis for fever is broad and initial screening investigations should include blood tests, imaging, and cultures of potential sites of infection depending on symptoms. For patients where the cause is not obvious, further targeted investigations are needed. The document also discusses considerations for evaluating fever in people who inject drugs, including risks related to injection practices and common infections in this population.
This document discusses the treatment of infections, including antimicrobial therapy and adjuvant therapies. It covers selecting appropriate antimicrobial agents based on the infecting organism and patient factors. The mechanisms of action, pharmacokinetics, and resistance patterns of various classes of antibacterial agents such as beta-lactams, macrolides, and lincosamides are described. Factors contributing to antimicrobial resistance and strategies to prevent resistance are also addressed.
17. epidemiology, control and prevention of infectionAhmad Hamadi
This document discusses endemic, emerging, and reemerging infectious diseases. It explains that endemic diseases have a constant presence within a given population or geographic area, while emerging diseases are newly appearing or increasing. Factors like human migration, climate change, and breakdown of public health services can influence whether a disease is restricted to a certain area or population. The document also covers reservoirs of infection, modes of disease transmission, and principles of controlling outbreaks and preventing healthcare-associated infections.
Microbiological tests detect microorganisms or the host immune response to infection. They can identify infectious agents, provide information to guide antimicrobial therapy, and assess drug susceptibility. Test results must be interpreted carefully based on factors like specimen type, test characteristics, clinical findings, and communication between clinician and microbiologist. A variety of methods are used, including microscopy, culture, antigen and antibody detection, and nucleic acid amplification tests.
This document discusses congenital heart disease, including causes, presentation, and treatment. Some key points:
- Congenital heart defects are present from birth but may not cause symptoms until adulthood. Defects can now often be corrected through surgery allowing survival into adulthood.
- Fetal circulation, where blood passes through the foramen ovale without the lungs, helps explain some defects. Failures in changes at birth from fetal to post-natal circulation can cause problems.
- Common defects include atrial and ventricular septal defects from failures in heart development, and transposition of the great arteries from failures in vessel alignment.
- Defects may be asymptomatic or cause breathlessness, poor
15. principles of infectious disease 1Ahmad Hamadi
This document discusses infection and infectious diseases. It defines infection as the establishment of foreign organisms in a human host, which can result in colonization or infectious disease. It describes the different types of infectious agents (prions, viruses, bacteria, fungi, protozoa, helminths) and discusses their characteristics. It also covers the normal human flora, factors that influence pathogenesis, and the host immune response to infection.
The normal pericardium contains a small amount of fluid that lubricates the heart. Inflammation of the pericardium can be caused by various conditions and may produce an effusion. A large or rapidly developing effusion can cause cardiac tamponade, where the heart is compressed. Tuberculous pericarditis can lead to thickening and scarring of the pericardium, causing constrictive pericarditis where the heart cannot fill properly. Surgical removal of the diseased pericardium may help but is not always successful.
This document discusses myocarditis and various types of cardiomyopathy. It defines myocarditis as an acute inflammatory condition of the heart muscle that is usually due to infections, toxins, or autoimmune causes. The most common causes are viral infections. Myocarditis can lead to dilated cardiomyopathy over time in some cases. Dilated cardiomyopathy is characterized by enlarged, weakened heart ventricles. Causes include genetic factors, alcohol use, and prior viral myocarditis. Hypertrophic cardiomyopathy causes abnormal thickening of the heart muscle and can lead to heart failure or arrhythmias. Arrhythmogenic right ventricular cardiomyopathy primarily affects the right ventricle and can cause arrhythmias or sudden death.
This document discusses valvular heart disease and rheumatic heart disease. It describes how valves can become narrowed or fail to close adequately, leading to regurgitation. Doppler echocardiography is useful for assessing valvular disease. Rheumatic fever is triggered by streptococcal infection and causes inflammation of the heart valves, most commonly affecting the mitral valve and causing mitral stenosis over time. Chronic rheumatic heart disease develops in at least half of rheumatic fever patients and causes progressive fibrosis and calcification of the valves.
Coronary heart disease (CHD) is the most common cause of death worldwide. It is caused by a buildup of fatty deposits called atheroma in the coronary arteries which supply the heart with blood. Symptoms include angina or chest pain that occurs with exertion or stress. Diagnosis is based on symptoms and tests like exercise tolerance tests, myocardial perfusion scans, or coronary angiography. Treatment involves lifestyle changes, medications like aspirin, nitrates, beta-blockers or calcium channel blockers to relieve symptoms, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) to improve blood flow.
Atherosclerosis is a progressive inflammatory disease where fatty deposits called atheromas build up in the arteries. Over time it can restrict blood flow and cause complications like heart attacks or strokes. It begins early in life with fatty streaks in the arteries. Clinical symptoms often do not appear until later in life. Key risk factors include age, smoking, high blood pressure, high cholesterol, diabetes, obesity, lack of exercise, diet, stress, alcohol use, and family history. Both population-wide and targeted prevention strategies are used to modify risk factors and reduce the burden of atherosclerotic vascular disease.
The document summarizes information about cardiac arrhythmias and the heart's electrical conduction system. It describes how the sinus node initiates heartbeats and how electrical signals pass through the heart. It then defines different types of arrhythmias including tachycardias and bradycardias, and covers their underlying mechanisms and potential causes. Treatment options for various arrhythmias are also discussed.
The document discusses hypertension and cardiac arrest. It states that hypertension is predominantly asymptomatic and its definition is arbitrary. Treatment of hypertension aims to reduce cardiovascular risk factors. Cardiac arrest is the sudden loss of cardiac output due to arrhythmias or mechanical issues. It commonly results from coronary artery disease and sudden cardiac death claims many lives each year. Prompt treatment of cardiac arrest, such as defibrillation for ventricular fibrillation, can help restore cardiac output.
Panchkula offers a wide array of dining experiences. From traditional North Indian flavors to global cuisine, the city’s restaurants cater to every taste bud. Let’s dive into some of the best restaurants in Panchkula
Ang Chong Yi’s Culinary Revolution: Pioneering Plant-Based Meat Alternatives ...Ang Chong Yi Singapore
In the heart of Singapore’s bustling culinary scene, a visionary chef named Ang Chong Yi is quietly revolutionizing the way we think about food. His mission? To create delectable Ang Chong Yi Singapore — Plant-based meat: Next-gen food alternatives that not only tantalize our taste buds but also contribute to a more sustainable future.
A Review on Recent Advances of Packaging in Food IndustryPriyankaKilaniya
Effective food packaging provides number of purposes. It functions as a container to hold and transport the food product, as well as a barrier to protect the food from outside contamination such as water, light, odours, bacteria, dust, and mechanical damage by maintaining the food quality. The package may also include barriers to keep the product's moisture content or gas composition consistent. Furthermore, convenience is vital role in packaging, and the desire for quick opening, dispensing, and resealing packages that maintain product quality until fully consumed is increasing. To facilitate trading, encourage sales, and inform on content and nutritional attributes, the packaging must be communicative. For storage of food there is huge scope for modified atmosphere packaging, intelligent packaging, active packaging, and controlled atmosphere packaging. Active packaging has a variety of uses, including carbon dioxide absorbers and emitters, oxygen scavengers, antimicrobials, and moisture control agents. Smart packaging is another term for intelligent packaging. Edible packaging, self-cooling and self-heating packaging, micro packaging, and water-soluble packaging are some of the advancements in package material.
Cacao, the main component used in the creation of chocolate and other cacao-b...AdelinePdelaCruz
Cacao, the main component used in the creation of chocolate and other cacao-based products is cacao beans, which are produced by the cacao tree in pods. The Maya and Aztecs, two of the earliest Mesoamerican civilizations, valued cacao as a sacred plant and used it in religious rituals, social gatherings, and medical treatments. It has a long and rich cultural history.
The Menu affects everything in a restaurant; as our friend and FCSI consultant Bill Main says, “The Menu is your blueprint for profitability.”
Let’s start with the segment. What will be your marketing and brand positioning? It depends on what menu items you serve. What type of cooking methods and equipment will you use? GUEST EXPERIENCE = FACILITY (Space) DESIGN + MENU + SERVPOINTS™
W.H. Bender & Associates
408-784-7371
whb@whbender.com
www.whbender.com
San Jose, California
FOOD PSYCHOLOGY CHARLA EN INGLES SOBRE PSICOLOGIA NUTRICIONALNataliaLedezma6
Our decisions about what to put on our plate are far more intricate than simply following hunger cues. Food psychology delves into the fascinating world of why we choose the foods we do, revealing a complex interplay of emotions, stress, and even disorders.
3. In developed countries, almost all peripheral
arterial disease (PAD) is due to atherosclerosis
and so shares common risk factors with coronary
artery disease (CAD): namely, smoking, diabetes
mellitus, hyperlipidaemia and hypertension.
As with CAD, plaque rupture is responsible for
the most serious manifestations of PAD, and not
infrequently occurs in a plaque that hitherto has
been asymptomatic.
4. Approximately 20% of middle-aged (55–75
years) people in the UK have PAD but only one-
quarter of them will have symptoms.
5. The clinical
manifestations
depend upon the
anatomical site, the
presence or absence
of a collateral supply,
the speed of onset
and the mechanism of
injury.
6. PAD affects the leg eight times more often than
the arm.
The lower limb arterial tree comprises the aorto-
iliac (‘inflow’), femoro-popliteal and infra-
popliteal (‘outflow’) segments.
One or more segments may be affected in a
variable and asymmetric manner.
7. Lower limb ischaemia presents as two distinct
clinical entities: intermittent claudication (IC) and
critical limb ischaemia (CLI).
The presence and severity of ischaemia can be
determined by clinical examination and
measurement of the ankle-brachial pressure index
(ABPI), which is the ratio between the (highest
systolic) ankle and brachial blood pressures.
In health the ABPI is > 1.0, in IC typically 0.5–
0.9 and in CLI usually < 0.5.
8.
9. This term describes ischaemic pain affecting the
muscles of the leg upon walking.
The pain is usually felt in the calf because the
disease most commonly affects the superficial
femoral artery.
However, the pain may be felt in the thigh or
buttock if the iliac arteries are involved.
10. Typically, the pain comes on after a reasonably
constant ‘claudication distance’, and rapidly
subsides on stopping walking.
Resumption of walking leads to a return of the
pain.
Most patients describe a cyclical pattern of
exacerbation and resolution due to the
progression of disease and the subsequent
development of collaterals.
11. Approximately 5% of middle-aged men report IC.
Provided patients comply with ‘best medical
therapy’ (BMT), only 1–2% per year will
deteriorate to a point where amputation and/or
revascularisation is required.
However, the annual mortality rate exceeds 5%,
2–3 times higher than in an equivalent non-
claudicant population.
12.
13. This is because IC is nearly always found in
association with widespread atherosclerosis, so
that most claudicants succumb to MI or stroke.
The mainstay of treatment is BMT, including
(preferably supervised) exercise therapy.
The peripheral vasodilator, cilostazol, has been
shown to improve walking distance.
14. Intervention with angioplasty, stenting,
endarterectomy or bypass is usually only
considered after BMT has been given at least 6
months to effect symptomatic improvement, and
then only in patients who are severely disabled or
whose livelihood is threatened by their disability.
15. This is defined as rest
(night) pain, requiring
opiate analgesia, and/or
tissue loss (ulceration or
gangrene), present for
more than 2 weeks, in the
presence of an ankle BP
of < 50mmHg.
16. Rest pain only, with ankle pressures > 50mmHg,
is known as subcritical limb ischaemia (SCLI).
The term severe limb ischaemia (SLI) is used to
describe both CLI and SCLI
17. Whereas IC is usually due to single-segment
plaque, SLI is always due to multilevel disease.
Many patients with SLI have not previously
sought medical advice for IC, principally because
they have other comorbidity that prevents them
from walking to a point where claudication pain
might develop.
18. In contrast to IC, patients with SLI are at high
risk of losing their limb, and sometimes their life,
in a matter of weeks or months without surgical
bypass or endovascular revascularisation by
angioplasty or stenting.
19. However, treatment is difficult because patients
have extensive and severe (often bilateral) end-
stage disease, are usually elderly and nearly
always have significant multisystem comorbidity.
Imaging is performed using duplex
ultrasonography, MRI or CT with intravenous
injection of contrast agents.
20. Intra-arterial digital subtraction angiography (IA-
DSA) is usually reserved for those undergoing
endovascular revascularisation.
21. Approximately 5–10% of patients with PAD have
diabetes but this proportion increases to 30–40%
in those with SLI.
Diabetes does not cause obstructive
microangiopathy at the capillary level, as
previously thought, and so is not a
contraindication to lower limb revascularisation.
23. If the blood supply is adequate, then dead tissue
can be excised in the expectation that healing will
occur, provided infection is controlled and the
foot is protected from pressure.
24. However, if significant ischaemia is also present,
the priority is to revascularise the foot if possible.
Sadly, many diabetic patients present late with
extensive tissue loss, which accounts for the high
amputation rate.
25. This is an inflammatory obliterative arterial
disease that is distinct from atherosclerosis and
usually presents in young (20–30 years) male
smokers.
It is most common in those from the
Mediterranean and North Africa.
It characteristically affects distal arteries, giving
rise to claudication in the feet or rest pain in the
fingers or toes.
26. Wrist and ankle pulses are absent but brachial and
popliteal are present.
Disease also affects the veins, giving rise to
superficial thrombophlebitis.
It often remits if the patient stops smoking;
sympathectomy and prostaglandin infusions may
be helpful.
Major limb amputation is the most frequent
outcome if patients continue to smoke.
27. In the arm, the subclavian artery is the most
common site of disease, which may manifest as:
1)Arm claudication (rare).
2)Atheroembolism (blue finger syndrome): Small
emboli lodge in digital arteries and may be
confused with Raynaud’s phenomenon, but in this
case the symptoms are unilateral. Failure to make
the diagnosis may eventually lead to amputation.
28. 3) Subclavian steal:
When the arm is used, blood is ‘stolen’ from the
brain via the vertebral artery.
This leads to vertebro-basilar ischaemia, which is
characterized by dizziness, cortical blindness
and/or collapse.
Where possible, subclavian artery disease is
treated by means of angioplasty and stenting, as
surgery (e.g. carotid-subclavian bypass) can be
difficult.
29. Cold (and emotional) stimuli may trigger
vasospasm, leading to the characteristic sequence
of digital pallor due to vasospasm, cyanosis due
to deoxygenated blood, and rubor due to reactive
hyperaemia.
30. This affects 5–10% of young women aged 15–30
years in temperate climates and may be familial.
It does not progress to ulceration or infarction,
and significant pain is unusual.
The underlying cause is unclear.
No investigation is necessary.
31. The patient should be reassured and advised to
avoid exposure to cold.
Long-acting nifedipine may be helpful but
sympathectomy is not indicated.
32. This tends to occur in older people in association
with connective tissue disease (most commonly
systemic sclerosis or the CREST syndrome),
vibration-induced injury (from the use of power
tools) and thoracic outlet obstruction (e.g.
cervical rib).
33. Unlike primary disease, it is often associated with
fixed obstruction of the digital arteries, fingertip
ulceration, and necrosis and pain.
The fingers must be protected from cold and
trauma, infection requires treatment with
antibiotics, and surgery should be avoided if
possible.
34. Vasoactive drugs have no clear benefit.
Sympathectomy helps for a year or two.
Prostacyclin infusions are sometimes beneficial.
35.
36. This is most frequently caused by acute thrombotic
occlusion of a pre-existing stenotic arterial segment,
thromboembolism, and trauma which may be
iatrogenic.
Apart from paralysis (inability to wiggle
toes/fingers) and paraesthesia (loss of light touch
over the dorsum of the foot/hand), the so-called ‘Ps
of acute ischaemia’ are non-specific for ischaemia
and/or inconsistently related to its severity.
37.
38. Pain on squeezing the calf indicates muscle
infarction and impending irreversible ischaemia.
All patients with suspected acutely ischaemic
limbs must be discussed immediately with a
vascular surgeon; a few hours can make the
difference between death/amputation and
complete recovery of limb function.
39. If there are no contraindications (for example,
acute aortic dissection or trauma, particularly
head injury), an intravenous bolus of heparin
(3000–5000 U) should be administered to limit
propagation of thrombus and protect the collateral
circulation.
40. Distinguishing thrombosis from embolism is
frequently difficult but is important because
treatment and prognosis are different.
41.
42. Acute limb ischaemia due to thrombosis in situ
can usually be treated medically in the first
instance with intravenous heparin (target
activated partial thromboplastin time (APTT)
2.0–3.0), antiplatelet agents, high-dose statins,
intravenous fluids to avoid dehydration,
correction of anaemia, oxygen and sometimes
prostaglandins such as iloprost.
43. Careful monitoring is required.
Embolism will normally result in extensive tissue
necrosis within 6 hours unless the limb is
revascularised.
The indications for thrombolysis, if any, remain
controversial. Irreversible ischaemia mandates
early amputation or palliative care.
47. This is an abnormal dilatation of the aortic lumen;
a true aneurysm involves all the layers of the
wall, whereas a false aneurysm does not.
48. a) Non-specific aneurysms:
Why some patients develop occlusive vascular
disease, some aneurysmal vascular disease and
some both in response to atherosclerosis risk
factors remains unclear.
Unlike occlusive disease, aneurysmal disease
tends to run in families and genetic factors are
undoubtedly important.
49. The most common site for ‘non-specific’
aneurysm formation is the infrarenal abdominal
aorta.
The suprarenal abdominal aorta and a variable
length of the descending thoracic aorta may be
affected in 10–20% of patients but the ascending
aorta is usually spared.
50. b) Marfan’s syndrome:
This disorder of connective tissue is inherited as
an autosomal dominant trait and is caused by
mutations in the fibrillin gene on chromosome 15.
Affected systems include the skeleton
(arachnodactyly, joint hypermobility, scoliosis,
chest deformity and high arched palate), the eyes
(dislocation of the lens) and the cardiovascular
system (aortic disease and mitral regurgitation).
51. Weakening of the aortic media leads to aortic root
dilatation, aortic regurgitation and aortic
dissection.
Pregnancy is particularly hazardous.
Chest X-ray, echocardiography, MRI or CT may
detect aortic dilatation at an early stage and can
be used to monitor the disease.
52. Treatment with β-blockers reduces the rate of
aortic dilatation and the risk of rupture.
Elective replacement of the ascending aorta may
be considered in patients with evidence of
progressive aortic dilatation but carries a
mortality of 5–10%.
53. c) Aortitis:
Syphilis is a rare cause of aortitis that
characteristically produces saccular aneurysms of
the ascending aorta containing calcification.
Other rare conditions associated with aortitis
include Takayasu’s disease, Reiter’s syndrome,
giant cell arteritis and ankylosing spondylitis.
54. d) Thoracic aortic aneurysms:
These may produce chest pain, aortic
regurgitation, compressive symptoms such as
stridor (trachea, bronchus) and hoarseness
(recurrent laryngeal nerve), and superior vena
cava syndrome.
If they erode into adjacent structures e.g. aorto-
oesophageal fistula, massive bleeding occurs.
55. e) Abdominal aortic aneurysms (AAAs):
AAAs are present in 5% of men aged over 60
years and 80% are confined to the infrarenal
segment.
Men are affected three times more commonly
than women.
AAA can present in a number of ways.
The usual age at presentation is 65–75 years for
elective presentations and 75–85 years for
emergency presentations.
56.
57. Ultrasound is the best way of establishing the
diagnosis, and of following up patients with
asymptomatic aneurysms that are not yet large
enough to warrant surgical repair.
58. CT provides more accurate information about the
size and extent of the aneurysm, the surrounding
structures and whether there is any other intra-
abdominal pathology.
It is the standard pre-operative investigation but
is not suitable for surveillance because of cost
and radiation dose.
59. Until an asymptomatic AAA has reached a maximum of
5.5 cm in diameter, the risks of surgery generally
outweigh the risks of rupture.
60. All symptomatic AAAs should be considered for
repair, not only to rid the patient of symptoms but
also because pain often predates rupture.
Distal embolisation is a strong indication for
repair, regardless of size, because otherwise limb
loss is common.
61. Most patients with a ruptured AAA do not survive
to reach hospital, but if they do and surgery is
thought to be appropriate, there must be no delay
in getting them to the operating theatre to clamp
the aorta.
62. Open AAA repair has been the treatment of
choice in both the elective and the emergency
settings, and entails replacing the aneurysmal
segment with a prosthetic (usually Dacron) graft.
The 30-day mortality for this procedure is
approximately 5–8% for elective asymptomatic
AAA, 10–20% for emergency symptomatic AAA
and 50% for ruptured AAA.
63. However, patients who survive the operation to
leave hospital have a long-term survival which
approaches that of the normal population.
64. Increasingly, endovascular aneurysm repair
(EVAR), using a stent-graft introduced via the
femoral arteries in the groin, is replacing open
surgery.
It is cost-effective and likely to become the
treatment of choice for infrarenal AAA.
It is possible to treat many suprarenal and
thoracoabdominal aneurysms by EVAR too.
65. A breach in the integrity of the aortic wall allows
arterial blood to enter the media, which is then
split into two layers, creating a ‘false lumen’
alongside the existing or ‘true lumen’.
The aortic valve may be damaged and the
branches of the aorta may be compromised.
66. Typically, the false lumen eventually re-enters the
true lumen, creating a double-barrelled aorta, but
it may also rupture into the left pleural space or
pericardium with fatal consequences.
67. The primary event is often a spontaneous or
iatrogenic tear in the intima of the aorta; multiple
tears or entry points are common.
Other dissections appear to be triggered by
primary haemorrhage in the media of the aorta
that then ruptures through the intima into the true
lumen.
68. This form of spontaneous bleeding from the vasa
vasorum is sometimes confined to the aortic wall,
when it may present as a painful intramural
haematoma.
Disease of the aorta and hypertension are the
most important aetiological factors but a variety
of other conditions may be implicated.
69.
70. Chronic dissections may lead to aneurysmal
dilatation of the aorta, and thoracic aneurysms
may be complicated by dissection.
It is therefore sometimes difficult to identify the
primary pathology.
71. The peak incidence is in the sixth and seventh
decades of life but dissection can occur in
younger patients, most commonly in association
with Marfan’s syndrome, pregnancy or trauma;
men are twice as frequently affected as women.
72. Aortic dissection is classified anatomically and
for management purposes into type A and type B ,
involving or sparing the ascending aorta
respectively.
Type A dissections account for two-thirds of cases
and frequently also extend into the descending
aorta.
73. Involvement of the ascending aorta typically
gives rise to anterior chest pain, and involvement
of the descending aorta to intrascapular pain.
The pain is typically described as ‘tearing’ and
very abrupt in onset; collapse is common.
Unless there is major haemorrhage, the patient is
invariably hypertensive.
74. There may be asymmetry of the brachial, carotid
or femoral pulses and signs of aortic
regurgitation.
Occlusion of aortic branches may cause MI
(coronary), stroke (carotid) paraplegia (spinal),
mesenteric infarction with an acute abdomen
(coeliac and superior mesenteric), renal failure
(renal) and acute limb (usually leg) ischaemia.
75. The chest X-ray characteristically shows
broadening of the upper mediastinum and
distortion of the aortic ‘knuckle’, but these
findings are variable and are absent in 10% of
cases.
A left-sided pleural effusion is common.
The ECG may show left ventricular hypertrophy
in patients with hypertension, or rarely changes of
acute MI (usually inferior).
76. Doppler echocardiography may show aortic
regurgitation, a dilated aortic root and,
occasionally, the flap of the dissection.
Transoesophageal echocardiography is
particularly helpful because transthoracic
echocardiography can only image the first 3–4
cm of the ascending aorta.
CT and MRI angiography are both highly specific
and sensitive.
77.
78.
79.
80. The early mortality of acute dissection is
approximately 1–5% per hour so treatment is
urgently required.
Initial management comprises pain control and
antihypertensive treatment.
Type A dissections require emergency surgery to
replace the ascending aorta.
81. Type B aneurysms are treated medically unless
there is actual or impending external rupture, or
vital organ (gut, kidneys) or limb ischaemia, as
the morbidity and mortality associated with
surgery is very high.
The aim of medical management is to maintain a
mean arterial pressure (MAP) of 60–75mmHg to
reduce the force of the ejection of blood from the
LV.
82. First-line therapy is with β-blockers; the
additional α-blocking properties of labetalol make
it especially useful.
Rate-limiting calcium channel blockers, such as
verapamil or diltiazem, are used if β-blockers are
contraindicated.
Sodium nitroprusside may be considered if these
fail to control BP adequately.
83. Percutaneous or minimal access endoluminal
repair is sometimes possible and involves either
‘fenestrating’ (perforating) the intimal flap so that
blood can return from the false to the true lumen
(so decompressing the former), or implanting a
stent graft placed from the femoral artery.
84.
85. Hypertension is a condition in which arterial BP
is chronically elevated.
BP occurs within a continuous range, so cutoff
levels are defined according to their effect on
patients’ risk.
The British Hypertension Society has defined
ranges of BP which are normal and those that
indicate hypertension.
86.
87. In more than 95% of cases, a specific underlying
cause of hypertension cannot be found.
Such patients are said to have essential
hypertension.
The pathogenesis of this is not clearly
understood.
88. Many factors may contribute to its development,
including renal dysfunction, peripheral resistance
vessel tone, endothelial dysfunction, autonomic
tone, insulin resistance and neurohumoral factors.
89. Hypertension is more common in some ethnic
groups, particularly Black Americans and
Japanese, and approximately 40–60% is
explained by genetic factors.
Important environmental factors include a high
salt intake, heavy consumption of alcohol,
obesity, lack of exercise and impaired intrauterine
growth.
90. There is little evidence that ‘stress’ causes
hypertension.
In about 5% of cases, hypertension can be shown
to be a consequence of a specific disease or
abnormality leading to sodium retention and/or
peripheral vasoconstriction (secondary
hypertension).
91.
92. A decision to embark upon antihypertensive
therapy effectively commits the patient to life-
long treatment, so BP readings must be as
accurate as possible.
93. Measurements should be made to the nearest 2
mmHg, in the sitting position with the arm
supported, and repeated after 5 minutes’ rest if the
first recording is high.
94.
95. To avoid spuriously high recordings in obese
subjects, the cuff should contain a bladder that
encompasses at least two-thirds of the
circumference of the arm.
96. Exercise, anxiety, discomfort and unfamiliar
surroundings can all lead to a transient rise in BP.
Sphygmomanometry, particularly when
performed by a doctor, can cause an
unrepresentative surge in BP which has been
termed ‘white coat’ hypertension, and as many as
20% of patients with apparent hypertension in the
clinic may have a normal BP when it is recorded
by automated devices used at home.
97. The risk of cardiovascular disease in these patients is
less than that in patients with sustained hypertension
but greater than that in normotensive subjects.
A series of automated ambulatory BP measurements
obtained over 24 hours or longer provides a better
profile than a limited number of clinic readings and
correlates more closely with evidence of target organ
damage than casual BP measurements.
98. However, treatment thresholds and targets must
be adjusted downwards because ambulatory BP
readings are systematically lower (approximately
12/7mmHg) than clinic measurements.
The average ambulatory daytime (not 24-hour or
night-time) BP should be used to guide
management decisions.
99. Patients can measure their own BP at home using
a range of commercially available semi-automatic
devices.
The value of such measurements is less well
established and is dependent on the environment
and timing of the readings measured.
100. Home or ambulatory BP measurements are
particularly helpful in patients with unusually
labile BP, those with refractory hypertension,
those who may have symptomatic hypotension,
and those in whom white coat hypertension is
suspected.
101. Family history, lifestyle (exercise, salt intake,
smoking habit) and other risk factors should be
recorded.
A careful history will identify those patients with
drug- or alcohol-induced hypertension and may elicit
the symptoms of other causes of secondary
hypertension such as phaeochromocytoma
(paroxysmal headache, palpitation and sweating) or
complications such as coronary artery disease (e.g.
angina, breathlessness).
102. Radio-femoral delay (coarctation of the aorta),
enlarged kidneys (polycystic kidney disease),
abdominal bruits (renal artery stenosis) and the
characteristic facies and habitus of Cushing’s
syndrome are all examples of physical signs that
may help to identify causes of secondary
hypertension.
103. Examination may also reveal features of
important risk factors such as central obesity and
hyperlipidaemia (tendon xanthomas etc.).
Most abnormal signs are due to the complications
of hypertension.
104. Non-specific findings may include left ventricular
hypertrophy (apical heave), accentuation of the
aortic component of the second heart sound, and
a fourth heart sound.
The optic fundi are often abnormal and there may
be evidence of generalised atheroma or specific
complications such as aortic aneurysm or
peripheral vascular disease.
105. The adverse effects of hypertension on
the organs can often be detected
clinically.
106. In larger arteries (> 1mm in diameter), the
internal elastic lamina is thickened, smooth
muscle is hypertrophied and fibrous tissue is
deposited.
The vessels dilate and become tortuous, and their
walls become less compliant.
107. In smaller arteries (< 1mm), hyaline
arteriosclerosis occurs in the wall, the lumen
narrows and aneurysms may develop.
Widespread atheroma develops and may lead to
coronary and cerebrovascular disease,
particularly if other risk factors (e.g. smoking,
hyperlipidaemia, diabetes) are present.
108. These structural changes in the vasculature often
perpetuate and aggravate hypertension by
increasing peripheral vascular resistance and
reducing renal blood flow, thereby activating the
renin–angiotensin–aldosterone axis.
Hypertension is a major risk factor in the
pathogenesis of aortic aneurysm and aortic
dissection.
109. Stroke is a common complication of hypertension
and may be due to cerebral haemorrhage or
infarction.
Carotid atheroma and transient ischaemic attacks
are more common in hypertensive patients.
Subarachnoid haemorrhage is also associated
with hypertension.
110. Hypertensive encephalopathy is a rare condition
characterized by high BP and neurological
symptoms, including transient disturbances of
speech or vision, paraesthesiae, disorientation,
fits and loss of consciousness.
111. Papilloedema is common.
A CT scan of the brain often shows haemorrhage
in and around the basal ganglia; however, the
neurological deficit is usually reversible if the
hypertension is properly controlled.
112. The optic fundi reveal a gradation of changes
linked to the severity of hypertension;
fundoscopy can, therefore, provide an indication
of the arteriolar damage occurring elsewhere.
113.
114. ‘Cotton wool’ exudates are associated with retinal
ischaemia or infarction, and fade in a few weeks.
‘Hard’ exudates (small, white, dense deposits of
lipid) and microaneurysms (‘dot’ haemorrhages)
are more characteristic of diabetic retinopathy.
115. Hypertension is also associated with central retinal vein
thrombosis.
116. The excess cardiac mortality and morbidity
associated with hypertension are largely due to a
higher incidence of coronary artery disease.
High BP places a pressure load on the heart and
may lead to left ventricular hypertrophy with a
forceful apex beat and fourth heart sound.
117. ECG or echocardiographic evidence of left
ventricular hypertrophy is highly predictive of
cardiovascular complications and therefore
particularly useful in risk assessment.
Atrial fibrillation is common and may be due to
diastolic dysfunction caused by left ventricular
hypertrophy or the effects of coronary artery
disease.
118. Severe hypertension can cause left ventricular
failure in the absence of coronary artery disease,
particularly when renal function, and therefore
sodium excretion, is impaired.
119. Long-standing hypertension may cause
proteinuria and progressive renal failure by
damaging the renal vasculature.
120. This rare condition may complicate hypertension
of any aetiology and is characterized by
accelerated microvascular damage with necrosis
in the walls of small arteries and arterioles
(‘fibrinoid necrosis’) and by intravascular
thrombosis.
121. The diagnosis is based on evidence of high BP
and rapidly progressive end organ damage, such
as retinopathy (grade 3 or 4), renal dysfunction
(especially proteinuria) and/or hypertensive
encephalopathy.
Left ventricular failure may occur and, if this is
untreated, death occurs within months.
122. All hypertensive patients should undergo a limited
number of investigations:
124. QUANTIFICATION OF CARDIOVASCULAR
RISK:
The sole objective of antihypertensive therapy is
to reduce the incidence of adverse cardiovascular
events, particularly coronary heart disease, stroke
and heart failure.
125. The relative benefit of antihypertensive therapy
(approximately 30% reduction in risk of stroke
and 20% reduction in risk of coronary heart
disease) is similar in all patient groups, so the
absolute benefit of treatment (total number of
events prevented) is greatest in those at highest
risk.
126.
127. For example, to extrapolate from the Medical
Research Council (MRC) Mild Hypertension
Trial (1985), 566 young patients would have to be
treated with bendroflumethiazide for 1 year to
prevent 1 stroke, while in the MRC trial of
antihypertensive treatment in the elderly (1992),
1 stroke was prevented for every 286 patients
treated for 1 year.
128. A formal estimate of absolute cardiovascular risk
which takes account of all the relevant risk
factors may help to determine whether the likely
benefits of therapy will outweigh its costs and
hazards.
A variety of risk algorithms are available for this
purpose.
129. Most of the excess morbidity and mortality
associated with hypertension is attributable to
coronary heart disease and many treatment
guidelines are therefore based on estimates of the
10-year coronary heart disease risk.
130. Total cardiovascular risk can be estimated by
multiplying coronary heart disease risk by 4/3
(i.e. if coronary heart disease risk is 30%,
cardiovascular risk is 40%).
131. THRESHOLD FOR INTERVENTION:
Systolic BP and diastolic BP are both powerful
predictors of cardiovascular risk.
The British Hypertension Society management
guidelines therefore utilize both readings, and
treatment should be initiated if they exceed the
given threshold.
132.
133. Patients with diabetes or cardiovascular disease
are at particularly high risk and the threshold for
initiating antihypertensive therapy is therefore
lower (≥ 140/90mmHg) in these patient groups.
The thresholds for treatment in the elderly are the
same as for younger patients.
134.
135. TREATMENT TARGETS:
The optimum BP for reduction of major
cardiovascular events has been found to be
139/83mmHg, and even lower in patients with
diabetes mellitus.
Moreover, reducing BP below this level causes no
harm.
The targets suggested by the British Hypertension
Society are ambitious.
136.
137. Primary care strategies have been devised to
improve screening and detection of hypertension
that, in the past, remained undetected in up to half
of affected individuals.
Application of new treatment guidelines should
help establish patients on appropriate treatment,
and allow step-up of treatment if lifestyle
modification and first-line drug therapy fail to
control patients’ BP.
138. Patients taking antihypertensive therapy require
follow-up at 3-monthly intervals to monitor BP,
minimise side-effects and reinforce lifestyle
advice.
139. NON-DRUG THERAPY:
Appropriate lifestyle measures may obviate the
need for drug therapy in patients with borderline
hypertension, reduce the dose and/or the number
of drugs required in patients with established
hypertension, and directly reduce cardiovascular
risk.
140. Correcting obesity, reducing alcohol intake,
restricting salt intake, taking regular physical
exercise and increasing consumption of fruit and
vegetables can all lower BP.
Moreover, quitting smoking, eating oily fish and
adopting a diet that is low in saturated fat may
produce further reductions in cardiovascular risk.
141. ANTIHYPERTENSIVE DRUGS:
a) Thiazide and other diuretics:
The mechanism of action of these drugs is
incompletely understood and it may take up to a
month for the maximum effect to be observed.
An appropriate daily dose is 2.5mg
bendroflumethiazide or 0.5mg cyclopenthiazide.
142. More potent loop diuretics, such as furosemide
40mg daily or bumetanide 1mg daily, have few
advantages over thiazides in the treatment of
hypertension unless there is substantial renal
impairment or they are used in conjunction with
an ACE inhibitor.
143. b) ACE inhibitors:
For example enalapril 20mg daily, ramipril
5–10mg daily or lisinopril 10–40mg daily, these
inhibit the conversion of angiotensin I to
angiotensin II and are usually well tolerated.
144. They should be used with particular care in
patients with impaired renal function or renal
artery stenosis because they can reduce the
filtration pressure in the glomeruli and precipitate
renal failure.
145. Electrolytes and creatinine should be checked
before and 1–2 weeks after commencing therapy.
Side-effects include first-dose hypotension,
cough, rash, hyperkalaemia and renal
dysfunction.
146. c) Angiotensin receptor blockers:
For example irbesartan 150–300mg daily,
valsartan 40–160mg daily), these block the
angiotensin II type I receptor and have similar
effects to ACE inhibitors; however, they do not
cause cough and are better tolerated.
147. :d) Calcium channel antagonists
The dihydropyridines (e.g. amlodipine 5–10 mg
daily, nifedipine 30–90 mg daily) are effective
and usually well-tolerated antihypertensive drugs
that are particularly useful in older people.
Side-effects include flushing, palpitations and
fluid retention.
148. The rate-limiting calcium channel antagonists
(e.g. diltiazem 200–300 mg daily, verapamil 240
mg daily) can be useful when hypertension
coexists with angina but they may cause
bradycardia.
The main side-effect of verapamil is constipation.
149. e) Beta-blockers:
These are no longer used as first line
antihypertensive therapy, except in patients with
another indication for the drug (e.g. angina).
Metoprolol (100–200mg daily), atenolol (50–
100mg daily) and bisoprolol (5–10mg daily)
preferentially block cardiac β1-adrenoceptors, as
opposed to the β2-adrenoceptors that mediate
vasodilatation and bronchodilatation.
150. f) Labetalol and carvedilol:
Labetalol (200mg–2.4g daily in divided doses)
and carvedilol (6.25–25mg 12-hourly) are
combined β- and α-adrenoceptor antagonists
which are sometimes more effective than pure β-
blockers.
Labetalol can be used as an infusion in malignant
phase hypertension.
151. g) Other drugs:
A variety of vasodilators may be used.
These include the α1-adrenoceptor antagonists (α-
blockers), such as prazosin (0.5–20mg daily in
divided doses), indoramin (25–100mg 12-hourly)
and doxazosin (1–16mg daily), and drugs that act
directly on vascular smooth muscle, such as
hydralazine (25–100mg 12-hourly) and minoxidil
(10–50mg daily).
152. Side-effects include first-dose postural
hypotension, headache, tachycardia and fluid
retention.
Minoxidil also causes increased facial hair and is
therefore unsuitable for female patients.
153. CHOICE OF ANTIHYPERTENSIVE DRUG:
Trials that have compared thiazides, calcium
antagonists, ACE inhibitors and angiotensin
receptor blockers have not shown consistent
differences in outcome, efficacy, side-effects or
quality of life.
Beta-blockers, which previously featured as first-
line therapy in guidelines, have a weaker
evidence base.
154. The choice of antihypertensive therapy is initially
dictated by the patient’s age and ethnic
background, although cost and convenience will
affect the exact drug and preparation used.
Response to initial therapy and side-effects
dictate subsequent treatment.
155. Comorbid conditions also have an influence on
initial drug selection; for example, a β-blocker
might be the most appropriate treatment for a
patient with angina.
156.
157. Thiazide diuretics and dihydropyridine calcium
channel antagonists are the most suitable drugs
for the treatment of high BP in older people.
Although some patients can be satisfactorily
treated with a single antihypertensive drug, a
combination of drugs is often required to achieve
optimal BP control.
158.
159. Combination therapy may be desirable for other
reasons; for example, low-dose therapy with two
drugs may produce fewer unwanted effects than
treatment with the maximum dose of a single
drug.
Some drug combinations have complementary or
synergistic actions; for example, thiazides
increase activity of the renin–angiotensin system
while ACE inhibitors block it.
160. EMERGENCY TREATMENT OF ACCELERATED
PHASE OR MALIGNANT HYPERTENSION:
In accelerated phase hypertension, lowering BP
too quickly may compromise tissue perfusion
(due to altered autoregulation) and can cause
cerebral damage, including occipital blindness,
and precipitate coronary or renal insufficiency.
161. Even in the presence of cardiac failure or
hypertensive encephalopathy, a controlled
reduction to a level of about 150/90 mmHg over a
period of 24–48 hours is ideal.
In most patients, it is possible to avoid parenteral
therapy and bring BP under control with bed rest
and oral drug therapy.
162. Intravenous or intramuscular labetalol (2mg/min
to a maximum of 200mg), intravenous glyceryl
trinitrate (0.6–1.2mg/hour), intramuscular
hydralazine (5 or 10mg aliquots repeated at half-
hourly intervals) and intravenous sodium
nitroprusside (0.3–1.0 μg/kg body weight/min)
are all effective but require careful supervision,
preferably in a high-dependency unit.
163. REFRACTORY HYPERTENSION:
The common causes of treatment failure in
hypertension are non-adherence to drug therapy,
inadequate therapy, and failure to recognise an
underlying cause such as renal artery stenosis or
phaeochromocytoma; of these, the first is by far
the most prevalent.
164. There is no easy solution to compliance problems
but simple treatment regimens, attempts to
improve rapport with the patient and careful
supervision may all help.
165. ADJUVANT DRUG THERAPY:
a) Aspirin:
Antiplatelet therapy is a powerful means of
reducing cardiovascular risk but may cause
bleeding, particularly intracerebral haemorrhage,
in a small number of patients.
166. The benefits are thought to outweigh the risks in
hypertensive patients aged 50 or over who have
well-controlled BP and either target organ
damage, diabetes or a 10-year coronary heart
disease risk of ≥ 15% (or 10-year cardiovascular
disease risk of ≥ 20%).
167. b) Statins:
Treating hyperlipidaemia can produce a
substantial reduction in cardiovascular risk.
These drugs are strongly indicated in patients
who have established vascular disease, or
hypertension with a high (≥ 20% in 10 years) risk
of developing cardiovascular disease.