Atherosclerosis is a disease involving the hardening and narrowing of arteries from plaque buildup within the arterial wall. The document discusses the pathogenesis of atherosclerosis, which begins with endothelial injury from factors like smoking, inflammation, and hypercholesterolemia. This allows lipids like LDL to accumulate in the arterial intima, where they become oxidized and trigger an inflammatory response involving immune cells and cytokines. Over time, smooth muscle cells and macrophages are recruited, leading to the formation of atherosclerotic plaques containing lipids and cells that narrow the arteries. The document also covers risk factors, clinical implications like heart attacks, and theories of the disease process.
Lactic acidosis occurs when there is an imbalance between the production and use of lactic acid in the body. It can be caused by tissue hypoxia (type A) or other non-hypoxic factors like malignancy, liver disease, or drugs (type B). The document discusses the pathophysiology of lactic acidosis including lactate metabolism, cytokine effects, and the Warburg effect seen in cancer. Treatment focuses on resolving the underlying cause, with sodium bicarbonate used cautiously and alternatives like hemodialysis considered to correct acidosis and remove lactate when needed.
This document provides information on heart failure, including:
1. It defines heart failure as the inability of the heart to pump an adequate amount of blood to meet the body's needs.
2. It describes compensatory mechanisms the body uses in response to heart failure like increasing sympathetic activity and activating the renin-angiotensin system.
3. It discusses treatments for heart failure like diuretics, ACE inhibitors, beta-blockers, and cardiac glycosides which aim to reduce workload on the heart and improve contractility.
The document provides guidelines for the diagnosis and management of chronic stable angina, defining it as chest discomfort caused by myocardial ischemia that is typically triggered by exertion or stress. It discusses the pathophysiology, risk factors, diagnostic testing options including ECG, stress testing, and imaging, and recommendations for invasive coronary angiography. The guidelines are intended to help clinicians properly evaluate and treat patients experiencing chronic stable angina.
This document discusses bleeding, clotting, and related abnormalities. It covers the mechanisms of hemostasis, the clotting cascade, factors involved in clotting, causes of bleeding disorders, investigations for bleeding and clotting abnormalities, and treatment approaches. The key points are: bleeding can be external or internal; hemostasis involves vascular spasm, platelet plug formation, and blood clotting; clotting is a cascade of coagulation factors; abnormalities can cause excessive clotting (thrombosis) or bleeding; investigations include blood tests and imaging; treatment depends on the specific disorder but aims to replace any deficient clotting factors.
This document provides an overview of hypertension including its definition, causes, prevalence, risk factors, evaluation, treatment goals, lifestyle modifications, medication classes, and treatment targets. Some key points:
- Hypertension is defined as blood pressure over 140/90 mmHg and increases cardiovascular risk. The prevalence increases with age from 4% in children to over 60% in those over 70 years old.
- Risk factors include age, family history, obesity, sleep apnea, smoking, diet, physical inactivity, alcohol, and stress. Evaluation includes tests to identify secondary causes and assess target organ damage.
- Lifestyle modifications like weight loss, the DASH diet, sodium reduction, and exercise can significantly lower blood
This patient presents with multiple metabolic risk factors including obesity, elevated triglycerides and fasting blood glucose, and a family history of diabetes. While she does not meet the criteria for metabolic syndrome, her 10-year risk of heart disease is elevated. Her LDL cholesterol goal according to NCEP guidelines is less than 160 mg/dL. Fasting glucose would be most influential in determining her treatment plan given her risk factors.
Definition of heart failure - causes and types of heart failure - pathophysiology and risky factors for heart failure - Diagnosis clinical manifestations and investigations and classification of heart failure- treatment of chronic heart failure
Also Acute heart failure causes - clinical picture and treatment
Lactic acidosis occurs when there is an imbalance between the production and use of lactic acid in the body. It can be caused by tissue hypoxia (type A) or other non-hypoxic factors like malignancy, liver disease, or drugs (type B). The document discusses the pathophysiology of lactic acidosis including lactate metabolism, cytokine effects, and the Warburg effect seen in cancer. Treatment focuses on resolving the underlying cause, with sodium bicarbonate used cautiously and alternatives like hemodialysis considered to correct acidosis and remove lactate when needed.
This document provides information on heart failure, including:
1. It defines heart failure as the inability of the heart to pump an adequate amount of blood to meet the body's needs.
2. It describes compensatory mechanisms the body uses in response to heart failure like increasing sympathetic activity and activating the renin-angiotensin system.
3. It discusses treatments for heart failure like diuretics, ACE inhibitors, beta-blockers, and cardiac glycosides which aim to reduce workload on the heart and improve contractility.
The document provides guidelines for the diagnosis and management of chronic stable angina, defining it as chest discomfort caused by myocardial ischemia that is typically triggered by exertion or stress. It discusses the pathophysiology, risk factors, diagnostic testing options including ECG, stress testing, and imaging, and recommendations for invasive coronary angiography. The guidelines are intended to help clinicians properly evaluate and treat patients experiencing chronic stable angina.
This document discusses bleeding, clotting, and related abnormalities. It covers the mechanisms of hemostasis, the clotting cascade, factors involved in clotting, causes of bleeding disorders, investigations for bleeding and clotting abnormalities, and treatment approaches. The key points are: bleeding can be external or internal; hemostasis involves vascular spasm, platelet plug formation, and blood clotting; clotting is a cascade of coagulation factors; abnormalities can cause excessive clotting (thrombosis) or bleeding; investigations include blood tests and imaging; treatment depends on the specific disorder but aims to replace any deficient clotting factors.
This document provides an overview of hypertension including its definition, causes, prevalence, risk factors, evaluation, treatment goals, lifestyle modifications, medication classes, and treatment targets. Some key points:
- Hypertension is defined as blood pressure over 140/90 mmHg and increases cardiovascular risk. The prevalence increases with age from 4% in children to over 60% in those over 70 years old.
- Risk factors include age, family history, obesity, sleep apnea, smoking, diet, physical inactivity, alcohol, and stress. Evaluation includes tests to identify secondary causes and assess target organ damage.
- Lifestyle modifications like weight loss, the DASH diet, sodium reduction, and exercise can significantly lower blood
This patient presents with multiple metabolic risk factors including obesity, elevated triglycerides and fasting blood glucose, and a family history of diabetes. While she does not meet the criteria for metabolic syndrome, her 10-year risk of heart disease is elevated. Her LDL cholesterol goal according to NCEP guidelines is less than 160 mg/dL. Fasting glucose would be most influential in determining her treatment plan given her risk factors.
Definition of heart failure - causes and types of heart failure - pathophysiology and risky factors for heart failure - Diagnosis clinical manifestations and investigations and classification of heart failure- treatment of chronic heart failure
Also Acute heart failure causes - clinical picture and treatment
This document defines heart failure and discusses its key characteristics. It describes how heart failure occurs when the heart is unable to pump enough blood to meet the body's needs due to problems like abnormal heart muscle function or excessive loads on the heart. The document outlines the pathophysiology and progression of heart failure, including ventricular dilation and hypertrophy as compensatory mechanisms that ultimately fail. It also covers the clinical features, diagnostic tests, medical management, and nursing care considerations for patients with heart failure.
Unstable angina is a form of ischemic heart disease where a person experiences chest pain or discomfort that occurs at rest or with minimal exertion. It is caused by decreased blood supply to the heart muscle due to partial blockage of the coronary arteries. Diagnosis involves taking a medical history, electrocardiogram, cardiac enzyme tests, and stress testing. Treatment consists of blood thinners, nitroglycerin, blood pressure medications, and cholesterol-lowering drugs medically or early cardiac catheterization and angioplasty or bypass surgery if high risk.
1) Atherosclerosis is caused by the accumulation of fatty plaques in arteries and is a leading cause of death. High cholesterol and blood pressure are major risk factors.
2) Statins are commonly used to lower cholesterol by inhibiting cholesterol synthesis in the liver. They reduce cardiovascular events but can cause side effects like muscle damage.
3) Fibrates lower triglycerides and raise HDL cholesterol to reduce cardiovascular risk, especially in patients with high triglycerides or diabetes. They carry risks of muscle and liver problems.
A presentation about DIC (Disseminated Intravascular Coagulopathy).
Done by 4th year medical students at the University of Science and Technology, Sana'a, Republic of Yemen, in October 2010.
Platelet and coagulation post graduate lecture Monkez M Yousif
This lecture is prepared for postgraduate students in Internal medicine. It presents a physiologic and basic background of the process of homeostasis followed by a practical approach to diagnosis and brief information of different causes of bleeding disorders
Complications of Myocardial Infarction (MI)Eneutron
Ischemic complications are common after acute myocardial infarction and include infarct extension, recurrent infarction, and recurrent angina. Left ventricular failure is a major predictor of mortality, ranging from mild congestive heart failure to cardiogenic shock. Other mechanical complications include ventricular septal rupture, mitral regurgitation, and cardiac wall rupture. Prompt treatment with medications, percutaneous coronary intervention, or surgery can help manage complications and reduce mortality risks.
Cardiac arrhythmias refer to irregularities in heart rhythm and can be caused by abnormalities in impulse generation, conduction, or triggered activity. Bradyarrhythmias result from issues with the sinoatrial or atrioventricular nodes and can be treated with pacemakers, while tachyarrhythmias can often be managed with drugs. There are three main mechanisms for arrhythmias - abnormal impulse generation from altered automaticity, triggered activity due to afterdepolarizations, and abnormal impulse conduction from blocks, reentry phenomena, or accessory pathways. Antiarrhythmic drugs work to suppress enhanced automaticity or abolish reentry by slowing conduction.
This document describes diseases of blood vessels. It begins by describing the basic structure and types of blood vessels. It then discusses various pathologies that can affect blood vessels including congenital anomalies, arteriosclerosis, hypertension, vasculitides, aneurysms, dissections, problems with veins and lymphatics, and tumors. Specific conditions discussed in more detail include abdominal aortic aneurysms, thoracic aortic aneurysms, berry aneurysms, aortic dissections, varicose veins, and various vasculitides such as Takayasu arteritis, polyarteritis nodosa, Kawasaki disease, Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss
Hypertensive heart disease (HHD) is a hypertrophic adaptive response of the heart to hypertension that can progress to myocardial dysfunction, cardiac dilatation, congestive heart failure, and sudden death if not controlled. The degree of hypertrophy varies depending on the underlying cause, ranging from 350-1000 grams. The pattern of hypertrophy also reflects the stimulus, with pressure overload causing a concentric thickening pattern and volume overload a dilation with increased ventricular diameter. Chronic cor pulmonale is characterized by a markedly dilated and hypertrophied right ventricle secondary to prolonged pulmonary hypertension from obstruction or compression of the lungs.
Secondary Haemostasis involves the formation of fibrin clots via the blood coagulation cascade. This involves complex sequential reactions between coagulation factors. The coagulation factors are classified based on their physical properties like molecular weight or functional properties like being substrates, cofactors, or enzymes. Vitamin K plays an important role by allowing coagulation factors to bind to phospholipid surfaces. The coagulation cascade is tightly regulated by naturally occurring inhibitors like antithrombin III and protein C to prevent excessive clotting.
The document discusses ischemic heart disease and angina. It presents 14 case scenarios describing patients presenting with chest pain and asks questions to assess the probable cause. It then defines key terms like angina, ischemic heart disease, and coronary artery disease. Tables are provided showing how coronary artery disease may present based on pathology and the recommended diagnostic tests and treatments. Angina is classified and risk factors are discussed. The document is authored by Professor Dr. Md Toufiqur Rahman and appears to be intended as an educational guide on ischemic heart disease.
The document discusses myocardial infarction (MI) including its pathogenesis, clinical features, complications, pathology findings at different time points, and case studies. It provides details on coronary artery anatomy, atherosclerosis, infarction morphology on gross and microscopic examination over time, and complications of MI such as cardiac rupture and aneurysm formation.
Microangiopathic hemolytic anemia (MAHA) is caused by damage to red blood cells as they pass through abnormally narrowed small blood vessels. This leads to fragmentation of red blood cells seen on peripheral blood smears. MAHA is associated with thrombotic microangiopathy syndromes like thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (HUS). HUS is primarily caused by endothelial injury from bacterial toxins like Shiga toxin from E. coli O157:H7, leading to platelet aggregation and blood clots in small vessels that obstruct blood flow and damage red cells. Classic HUS mostly affects children after intestinal infection and is clearly associated with Shiga-
The document discusses hypertension (high blood pressure) including its classification, pathogenesis, complications, and pathological features. It notes that essential (primary) hypertension accounts for 95% of cases and has unknown etiology, while secondary hypertension makes up 5-10% of cases and has a known cause such as renal or endocrine disorders. Complications of long-term high blood pressure include damage to organs like the heart, brain, kidneys and eyes due to reduced blood flow and vessel damage over time.
This document discusses hypercoagulable states (thrombophilia). It presents two case studies of patients presenting with deep vein thrombosis (DVT). It then defines thrombophilia as a disorder associated with an increased tendency to form blood clots. The document reviews hemostasis and coagulation mechanisms, inherited and acquired risk factors for hypercoagulability, and recommends a stepwise approach to thrombophilia testing that considers the clinical scenario and implications of testing.
This document discusses cardiac biomarkers used in the diagnosis and management of heart disease. It begins by introducing the members of a committee on cardiac biomarkers and providing definitions. It then discusses various biomarkers including creatine kinase-MB, myoglobin, cardiac troponins, B-type natriuretic peptide, and others. For each biomarker, it outlines their characteristics such as time of release, specificity, and clinical applications. It concludes by discussing the use of biomarkers in veterinary medicine to differentiate cardiac from non-cardiac causes of dyspnea.
- Ischemic heart disease is caused by a reduced blood supply to the heart muscle due to coronary artery atherosclerosis. The heart requires constant blood flow to function properly but atherosclerotic plaques can block this blood flow.
- Symptoms range from stable angina (predictable chest pain) to unstable angina (increasing chest pain) to myocardial infarction (heart attack caused by severe blockage or clot).
- Risk factors include high blood pressure, high cholesterol, smoking, obesity, and lack of exercise. Proper management can reduce the risk of further heart problems.
This document discusses leukemoid and leukoerythroblastic reactions. Leukemoid reactions involve a marked increase in white blood cell count (>50,000/cumm) in response to a stimulus like infection, with immature cells comprising less than 5% and being reversible. Leukoerythroblastic reactions involve immature cells in both the red and white cell lines in peripheral blood due to bone marrow disturbances from conditions like cancer metastases or myelofibrosis. The document differentiates these reactions from conditions like CML, CNL, and CLL based on factors like age of onset, clinical course, blood and bone marrow morphology, and presence of an underlying condition.
Atherosclerosis Definition and major and minor risk factors which will cause , and Treatment methods both surgical and pharmaceutical along with the medicine's pharmaco kinetic and dynamic properties with clinical uses , unwanted effects with simple and useful diagrams to understand better and easily.angioplasty ,bypass surgery and Stent are the surgical methods additionally explained in this presentation which are the surgical treatment methods for Atherosclerosis. classification of atherosclerosis is also explained.
Hyperlipidemia is a condition characterized by abnormally high levels of lipids in the blood. The two major types of lipids that are elevated are triglycerides and cholesterol. Hyperlipidemia can be caused by genetic factors resulting in primary hyperlipidemia or other factors like poor diet, obesity, diabetes, and medications resulting in secondary hyperlipidemia. Treatment involves lifestyle modifications like a healthy diet and exercise as well as lipid-lowering medications like statins which are the first-line treatment for lowering LDL cholesterol and reducing cardiovascular risk. Monitoring lipid levels is important for managing hyperlipidemia and reducing risk of heart disease and stroke.
This document discusses hypertension (high blood pressure). It defines hypertension and describes its history, types, causes, epidemiology, pathophysiology, clinical presentation, diagnosis, treatment including lifestyle changes and pharmacotherapy, complications, and risk factors. The summary focuses on the key points:
Hypertension is defined as blood pressure over 140/90 mmHg. It has been documented as far back as 2600 BC. Primary hypertension has no known cause, while secondary hypertension has identifiable medical causes. Lifestyle changes and medication are used to treat hypertension and lower blood pressure to reduce health risks like heart disease, stroke, kidney damage, and more. Proper diagnosis involves medical history, exams, and lab tests to evaluate the patient's case of
This document defines heart failure and discusses its key characteristics. It describes how heart failure occurs when the heart is unable to pump enough blood to meet the body's needs due to problems like abnormal heart muscle function or excessive loads on the heart. The document outlines the pathophysiology and progression of heart failure, including ventricular dilation and hypertrophy as compensatory mechanisms that ultimately fail. It also covers the clinical features, diagnostic tests, medical management, and nursing care considerations for patients with heart failure.
Unstable angina is a form of ischemic heart disease where a person experiences chest pain or discomfort that occurs at rest or with minimal exertion. It is caused by decreased blood supply to the heart muscle due to partial blockage of the coronary arteries. Diagnosis involves taking a medical history, electrocardiogram, cardiac enzyme tests, and stress testing. Treatment consists of blood thinners, nitroglycerin, blood pressure medications, and cholesterol-lowering drugs medically or early cardiac catheterization and angioplasty or bypass surgery if high risk.
1) Atherosclerosis is caused by the accumulation of fatty plaques in arteries and is a leading cause of death. High cholesterol and blood pressure are major risk factors.
2) Statins are commonly used to lower cholesterol by inhibiting cholesterol synthesis in the liver. They reduce cardiovascular events but can cause side effects like muscle damage.
3) Fibrates lower triglycerides and raise HDL cholesterol to reduce cardiovascular risk, especially in patients with high triglycerides or diabetes. They carry risks of muscle and liver problems.
A presentation about DIC (Disseminated Intravascular Coagulopathy).
Done by 4th year medical students at the University of Science and Technology, Sana'a, Republic of Yemen, in October 2010.
Platelet and coagulation post graduate lecture Monkez M Yousif
This lecture is prepared for postgraduate students in Internal medicine. It presents a physiologic and basic background of the process of homeostasis followed by a practical approach to diagnosis and brief information of different causes of bleeding disorders
Complications of Myocardial Infarction (MI)Eneutron
Ischemic complications are common after acute myocardial infarction and include infarct extension, recurrent infarction, and recurrent angina. Left ventricular failure is a major predictor of mortality, ranging from mild congestive heart failure to cardiogenic shock. Other mechanical complications include ventricular septal rupture, mitral regurgitation, and cardiac wall rupture. Prompt treatment with medications, percutaneous coronary intervention, or surgery can help manage complications and reduce mortality risks.
Cardiac arrhythmias refer to irregularities in heart rhythm and can be caused by abnormalities in impulse generation, conduction, or triggered activity. Bradyarrhythmias result from issues with the sinoatrial or atrioventricular nodes and can be treated with pacemakers, while tachyarrhythmias can often be managed with drugs. There are three main mechanisms for arrhythmias - abnormal impulse generation from altered automaticity, triggered activity due to afterdepolarizations, and abnormal impulse conduction from blocks, reentry phenomena, or accessory pathways. Antiarrhythmic drugs work to suppress enhanced automaticity or abolish reentry by slowing conduction.
This document describes diseases of blood vessels. It begins by describing the basic structure and types of blood vessels. It then discusses various pathologies that can affect blood vessels including congenital anomalies, arteriosclerosis, hypertension, vasculitides, aneurysms, dissections, problems with veins and lymphatics, and tumors. Specific conditions discussed in more detail include abdominal aortic aneurysms, thoracic aortic aneurysms, berry aneurysms, aortic dissections, varicose veins, and various vasculitides such as Takayasu arteritis, polyarteritis nodosa, Kawasaki disease, Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss
Hypertensive heart disease (HHD) is a hypertrophic adaptive response of the heart to hypertension that can progress to myocardial dysfunction, cardiac dilatation, congestive heart failure, and sudden death if not controlled. The degree of hypertrophy varies depending on the underlying cause, ranging from 350-1000 grams. The pattern of hypertrophy also reflects the stimulus, with pressure overload causing a concentric thickening pattern and volume overload a dilation with increased ventricular diameter. Chronic cor pulmonale is characterized by a markedly dilated and hypertrophied right ventricle secondary to prolonged pulmonary hypertension from obstruction or compression of the lungs.
Secondary Haemostasis involves the formation of fibrin clots via the blood coagulation cascade. This involves complex sequential reactions between coagulation factors. The coagulation factors are classified based on their physical properties like molecular weight or functional properties like being substrates, cofactors, or enzymes. Vitamin K plays an important role by allowing coagulation factors to bind to phospholipid surfaces. The coagulation cascade is tightly regulated by naturally occurring inhibitors like antithrombin III and protein C to prevent excessive clotting.
The document discusses ischemic heart disease and angina. It presents 14 case scenarios describing patients presenting with chest pain and asks questions to assess the probable cause. It then defines key terms like angina, ischemic heart disease, and coronary artery disease. Tables are provided showing how coronary artery disease may present based on pathology and the recommended diagnostic tests and treatments. Angina is classified and risk factors are discussed. The document is authored by Professor Dr. Md Toufiqur Rahman and appears to be intended as an educational guide on ischemic heart disease.
The document discusses myocardial infarction (MI) including its pathogenesis, clinical features, complications, pathology findings at different time points, and case studies. It provides details on coronary artery anatomy, atherosclerosis, infarction morphology on gross and microscopic examination over time, and complications of MI such as cardiac rupture and aneurysm formation.
Microangiopathic hemolytic anemia (MAHA) is caused by damage to red blood cells as they pass through abnormally narrowed small blood vessels. This leads to fragmentation of red blood cells seen on peripheral blood smears. MAHA is associated with thrombotic microangiopathy syndromes like thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (HUS). HUS is primarily caused by endothelial injury from bacterial toxins like Shiga toxin from E. coli O157:H7, leading to platelet aggregation and blood clots in small vessels that obstruct blood flow and damage red cells. Classic HUS mostly affects children after intestinal infection and is clearly associated with Shiga-
The document discusses hypertension (high blood pressure) including its classification, pathogenesis, complications, and pathological features. It notes that essential (primary) hypertension accounts for 95% of cases and has unknown etiology, while secondary hypertension makes up 5-10% of cases and has a known cause such as renal or endocrine disorders. Complications of long-term high blood pressure include damage to organs like the heart, brain, kidneys and eyes due to reduced blood flow and vessel damage over time.
This document discusses hypercoagulable states (thrombophilia). It presents two case studies of patients presenting with deep vein thrombosis (DVT). It then defines thrombophilia as a disorder associated with an increased tendency to form blood clots. The document reviews hemostasis and coagulation mechanisms, inherited and acquired risk factors for hypercoagulability, and recommends a stepwise approach to thrombophilia testing that considers the clinical scenario and implications of testing.
This document discusses cardiac biomarkers used in the diagnosis and management of heart disease. It begins by introducing the members of a committee on cardiac biomarkers and providing definitions. It then discusses various biomarkers including creatine kinase-MB, myoglobin, cardiac troponins, B-type natriuretic peptide, and others. For each biomarker, it outlines their characteristics such as time of release, specificity, and clinical applications. It concludes by discussing the use of biomarkers in veterinary medicine to differentiate cardiac from non-cardiac causes of dyspnea.
- Ischemic heart disease is caused by a reduced blood supply to the heart muscle due to coronary artery atherosclerosis. The heart requires constant blood flow to function properly but atherosclerotic plaques can block this blood flow.
- Symptoms range from stable angina (predictable chest pain) to unstable angina (increasing chest pain) to myocardial infarction (heart attack caused by severe blockage or clot).
- Risk factors include high blood pressure, high cholesterol, smoking, obesity, and lack of exercise. Proper management can reduce the risk of further heart problems.
This document discusses leukemoid and leukoerythroblastic reactions. Leukemoid reactions involve a marked increase in white blood cell count (>50,000/cumm) in response to a stimulus like infection, with immature cells comprising less than 5% and being reversible. Leukoerythroblastic reactions involve immature cells in both the red and white cell lines in peripheral blood due to bone marrow disturbances from conditions like cancer metastases or myelofibrosis. The document differentiates these reactions from conditions like CML, CNL, and CLL based on factors like age of onset, clinical course, blood and bone marrow morphology, and presence of an underlying condition.
Atherosclerosis Definition and major and minor risk factors which will cause , and Treatment methods both surgical and pharmaceutical along with the medicine's pharmaco kinetic and dynamic properties with clinical uses , unwanted effects with simple and useful diagrams to understand better and easily.angioplasty ,bypass surgery and Stent are the surgical methods additionally explained in this presentation which are the surgical treatment methods for Atherosclerosis. classification of atherosclerosis is also explained.
Hyperlipidemia is a condition characterized by abnormally high levels of lipids in the blood. The two major types of lipids that are elevated are triglycerides and cholesterol. Hyperlipidemia can be caused by genetic factors resulting in primary hyperlipidemia or other factors like poor diet, obesity, diabetes, and medications resulting in secondary hyperlipidemia. Treatment involves lifestyle modifications like a healthy diet and exercise as well as lipid-lowering medications like statins which are the first-line treatment for lowering LDL cholesterol and reducing cardiovascular risk. Monitoring lipid levels is important for managing hyperlipidemia and reducing risk of heart disease and stroke.
This document discusses hypertension (high blood pressure). It defines hypertension and describes its history, types, causes, epidemiology, pathophysiology, clinical presentation, diagnosis, treatment including lifestyle changes and pharmacotherapy, complications, and risk factors. The summary focuses on the key points:
Hypertension is defined as blood pressure over 140/90 mmHg. It has been documented as far back as 2600 BC. Primary hypertension has no known cause, while secondary hypertension has identifiable medical causes. Lifestyle changes and medication are used to treat hypertension and lower blood pressure to reduce health risks like heart disease, stroke, kidney damage, and more. Proper diagnosis involves medical history, exams, and lab tests to evaluate the patient's case of
Basics of hyperlipoproreinemia in an easy and understandable way.gives a brief picture of the disease , it's cauusitive agents and clinical sequelae following it.
Metabolic syndrome is a collection of risk factors that increases the risk of cardiovascular disease and diabetes. It involves having at least three of the following: central obesity, high blood pressure, high blood sugar, high triglycerides, or low HDL cholesterol. An estimated 50 million Americans have metabolic syndrome. Risk factors include obesity, physical inactivity, stress, aging, and genetic predisposition. Symptoms include central obesity, high blood pressure, and abnormal cholesterol and blood sugar levels. Management focuses on lifestyle changes like diet, exercise, weight loss, and medication to control risk factors. Complications can include heart disease, stroke, diabetes, and kidney disease.
Hyperlipidemia, also known as high cholesterol, occurs when there are abnormally high levels of fats like cholesterol and triglycerides in the blood. It can be caused by genetic factors, diseases of the liver, thyroid or kidneys, smoking, excess alcohol intake, or an unhealthy diet. If left untreated, hyperlipidemia can lead to a buildup of fats in the arteries and increase the risk of heart attack or stroke. It is typically diagnosed through a blood test, and treatment focuses on lifestyle changes and medications like statins to lower cholesterol levels.
Lipid Profile Dyslipidemia and others.pptxAmruth32
A lipid profile is a blood test that measures cholesterol and triglyceride levels. It provides information about cardiovascular health and risk of heart disease. The test typically measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Abnormal levels can indicate increased risk and are addressed through lifestyle changes or medication.
This document discusses atherosclerosis and cardiovascular disease. It covers:
- Atherosclerosis is the leading cause of morbidity and mortality in Western societies. Major risk factors include hypertension, smoking, and hypercholesterolemia.
- Risk factors such as dyslipidemia, smoking, hypertension, and diabetes can damage the endothelium and promote atherosclerotic plaque formation through various mechanisms. Managing these risk factors can help halt disease progression.
- Complications of advanced atherosclerosis include vessel occlusion, thrombosis, ulceration, hemorrhage, narrowing of the lumen, and weakening of the vessel wall which can lead to aneurysm.
Heart is the most important organ of a human body. It circulates oxygen and other vital nutrients through blood to different parts of the body and helps in the metabolic activities. Apart from this it also helps in removal of the metabolic wastes. Thus, even minor problems in heart can affect the whole organism. Researchers are diverting a lot of data analysis work for assisting the doctors to predict the heart problem. So, an analysis of the data related to different health problems and its functioning can help in predicting with a certain probability for the wellness of this organ. In this paper we have analysed the different prescribed data of 1094 patients from different parts of India. Using this data, we have built a model which gets trained using this data and tries to predict whether a new out-of-sample data has a probability of having any heart attack or not. This model can help in decision making along with the doctor to treat the patient well and creating a transparency between the doctor and the patient. In the validation set of the data, it’s not only the accuracy that the model has to take care, rather the True Positive Rate and False-Negative Rate along with the AUC-ROC helps in building/fixing the algorithm inside the model.
High levels of LDL cholesterol and lipoprotein a in the bloodstream, along with conditions like diabetes and hypothyroidism, can lead to the development of atherosclerosis over time. Atherosclerosis occurs when fat, cholesterol, and other substances build up in the arteries in the form of plaque. This plaque hardens and narrows the arteries, reducing blood flow. If a plaque breaks off a coronary artery, it can cause a heart attack. Blood tests can detect high LDL and lipoprotein a levels, and low HDL, as markers for risk of atherosclerosis and coronary heart disease. Lifestyle changes like exercise, diet, weight control and limiting alcohol/saturated fats can help lower cholesterol and reduce risk.
The document discusses the diagnosis and classification of lipid disorders. Lipid disorders can be caused by genetic abnormalities, environmental factors, or as a consequence of other diseases. They are generally diagnosed based on a patient's clinical presentation and laboratory tests measuring lipids and lipoproteins. Abnormal lipid levels are associated with conditions like coronary artery disease. Lipid disorders include both overproduction and deficiencies of lipoproteins and are classified into primary categories of hyperlipoproteinemia and hypolipoproteinemia. Common genetic lipid disorders discussed include familial hypercholesterolemia and hypertriglyceridemia.
This document summarizes the key guidelines from the Adult Treatment Panel III (ATP III) on cholesterol treatment and prevention. The guidelines focus on multiple risk factors like diabetes, which is considered a cardiovascular disease risk equivalent. It modifies lipid classification cut-offs and recommends a complete lipoprotein profile for screening. It provides LDL cholesterol goals and criteria for lifestyle changes or drug therapy based on a patient's risk category of having cardiovascular disease, multiple risk factors, or 0-1 risk factor. The metabolic syndrome is highlighted as a secondary target of therapy beyond LDL lowering. Case examples are given to demonstrate how the guidelines would be applied.
Hyperlipidemia is high levels of lipids in the blood. The document discusses hyperlipidemia including types of lipids in the body, lipoproteins, causes of hyperlipidemia, diagnosis, and management. Specifically, it covers primary and secondary causes, Frederickson classification of lipid disorders, diagnostic tests and criteria, physical signs, lifestyle management including diet and exercise, and drug therapies such as statins, fibrates, nicotinic acid, and bile acid sequestrants.
Coronary artery disease is caused by atherosclerosis and is a leading cause of death worldwide. As atherosclerosis progresses, fatty deposits build up in the arteries and restrict blood flow. Over many years, risk factors such as high cholesterol, hypertension, smoking, and obesity can cause plaque to build up and rupture, restricting blood flow. Managing modifiable risk factors through lifestyle changes, medication, and medical treatment can help prevent complications from coronary artery disease.
This Will Give Detail Information On HYPERTENSION likes Types, Sign and Symptoms, Causes , Identification Test, Treatment, Drug Use for It .
Plz Share and Give Suggestions for Improvement.
THANK YOU
Dyslipidemia, specially high LDL cholesterol is the key risk factor for cardiovascular diseases. The presentation discusses metabolism and structure of lipoproteins, their screening and interpretation, risk assessment methods, targets for various lipoproteins and its step by step treatment.
This document provides an overview of the management of dyslipidemia. It discusses lipoprotein classification and composition. It also outlines the non-pharmacological and pharmacological treatment approaches for different dyslipidemia scenarios, including various drug classes like statins, PCSK9 inhibitors, fibrates and their effects. It discusses treatment approaches for different patient groups such as those with cardiovascular disease, diabetes, chronic kidney disease, inflammatory conditions and others. The guidelines for screening and management of dyslipidemia in various clinical situations are summarized.
The lipid profile is a group of blood tests that measure cholesterol and triglyceride levels to determine risk for heart disease. It includes measurements of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. High LDL ("bad") cholesterol increases risk of plaque buildup in arteries while high HDL ("good") cholesterol helps remove cholesterol from arteries. An abnormal lipid profile can indicate risk for conditions like atherosclerosis and help diagnose underlying issues like hyperlipidemia.
is obesity a disease seminar by iffat final (2) (1).pptxMasatDubai
The document discusses whether obesity is a disease. It defines obesity as abnormal fat accumulation that can impair health. The World Health Organization considers a BMI over 30 to be obese. Obesity is assessed using BMI and can be apple-shaped or pear-shaped. Major causes include lack of exercise, poor diet, genes, and medical conditions. Consequences involve increased risk of heart disease, diabetes, cancers, gallstones, hypertension, PCOS, and arthritis. Treatments include surgery, medication, and lifestyle changes. Obesity exacerbates COVID-19 and is linked to impaired metabolic health.
This document discusses secondary dyslipidemia, which is dyslipidemia caused by an underlying medical condition or disease. Some common causes mentioned include type 2 diabetes mellitus, cholestatic liver diseases, nephrotic syndrome, chronic renal failure, hypothyroidism, cigarette smoking, obesity, and certain drugs. The document provides details on how each of these conditions can affect lipid levels and lead to secondary dyslipidemia. It also discusses clinical presentations of dyslipidemia, diagnostic testing, and treatment approaches focused on addressing the underlying cause.
Statins are a class of drugs that lower blood cholesterol levels by inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis. They work by reducing cholesterol production in the liver and increasing uptake of LDL cholesterol from the bloodstream. Common statins include atorvastatin, simvastatin, and rosuvastatin, which can lower LDL cholesterol by 40-60% and are first-line treatments for high cholesterol. Statins are well absorbed orally and metabolized in the liver, with some variations in pharmacokinetics between different statins. They are effective for treating familial hypercholesterolemia and secondary causes of high cholesterol like diabetes. Adverse effects can include muscle
A 25 year old male presented with fever for 1 month. Blood tests showed low hemoglobin and platelet counts, and a very high white blood cell count. A bone marrow examination confirmed the diagnosis of acute myeloid leukemia (AML). AML is a type of cancer that affects the myeloid line of blood cells. It is characterized by the overproduction of immature myeloid cells called myeloblasts in the bone marrow. The patient's case is discussed in the context of defining AML, describing its subtypes and clinical features, and summarizing methods used for diagnosis and classification.
This document summarizes several case studies involving lymphomas:
Case 1 involves a 52-year-old female with enlarged lymph nodes and lung lesions. Biopsies of the lymph nodes and lung lesion were performed.
Case 2 involves a 40-year-old female with gastric pain and abnormalities found during endoscopy. A gastric biopsy was performed.
Case 3 involves a 5-year-old girl with a rapidly growing jaw swelling. Imaging and biopsies were performed to investigate.
Case 4 involves a 70-year-old male being evaluated for weakness found to have lymphadenopathy. Testing of lymph nodes and bone marrow was done.
The document discusses findings and next steps for each case
This document contains 14 case studies related to inflammation. Each case study provides brief clinical information about a patient, including descriptions of lesions, medical procedures, or test results. The cases cover a range of inflammatory conditions and injuries in different organ systems. Doctors are prompted to provide diagnoses or interpretations based on the limited information given for each case.
The document discusses the process of tumor invasion and metastasis. It describes how tumor cells must go through a series of steps called the metastatic cascade to break away from the primary tumor and form secondary tumors elsewhere. This involves invasion of the extracellular matrix and vascular dissemination. The key steps of ECM invasion are: 1) changes in cell adhesion, 2) degradation of the ECM, 3) attachment to novel ECM components, and 4) migration of tumor cells through active proteolysis and locomotion. Genetic changes can cause variations in metastatic potential between cancer types by promoting epithelial-to-mesenchymal transition or affecting signaling pathways. Tumors can spread via lymphatics, direct seeding of body cavities,
This document provides information on neoplasia (new growth) and tumor nomenclature. It defines neoplasia as abnormal and uncontrolled cell growth that exceeds normal tissues. Tumors are named based on their cell or tissue of origin, with benign tumors ending in "-oma" and malignant tumors called carcinomas for epithelial cells and sarcomas for mesenchymal cells. Common sites for teratomas are the gonads and along midline fusion lines. Hamartomas contain normal tissues for the organ, while choristomas contain ectopic tissues. Environmental exposures like coal tar were found to induce skin cancer in rabbits.
This document provides guidance on chemical safety in laboratories. It discusses the importance of understanding material safety data sheets, chemical hazards, and proper personal protective equipment. The key responsibilities are to treat all chemicals as dangerous, ensure safety is a priority for all, and to avoid haste which can compromise safety. Proper labeling, storage, hygiene and equipment are essential for preventing accidents and protecting health.
Single gene disorders with non-classic inheritance patterns can be caused by trinucleotide repeat mutations, mutations in mitochondrial genes, genomic imprinting, or gonadal mosaicism. Trinucleotide repeat disorders are caused by the expansion of repeats, usually containing G and C, which can impair gene function. Examples include fragile X syndrome and Huntington disease. Mitochondrial gene mutations are maternally inherited and affect tissues with high energy demands. Genomic imprinting involves parent-of-origin specific gene silencing through DNA methylation. Diseases caused include Prader-Willi and Angelman syndromes, which involve deletions on chromosome 15 but present differently depending on whether the paternal or maternal allele is deleted.
This document contains several quiz cases related to disorders of leucocytes. Some key details include:
- Case 1 asks about differentiating a condition from leukemoid reaction, the chromosomal abnormality involved, and treatment drugs.
- Case 3 describes a 60-year-old male with splenomegaly and anemia.
- Case 10 lists abnormal differential count findings in a 25-year-old male with fever.
- Case 11 describes test results for a 60-year-old female with bone pain and asks for the diagnosis.
- The document provides clues to identify people, medical conditions, and drugs related to hematology. It aims to test knowledge of disorders of white blood cells
The document provides guidance on evaluating endometrial biopsy specimens. It discusses that the functionalis layer of the endometrium from the fundus is ideal for diagnosis. Proliferative phase dating is not possible while secretory phase dating is. Findings of fat in the specimen indicates uterine perforation. Endometrial polyps, hyperplasia, and carcinomas are discussed along with mimics. Immunostains can help in certain cases. The clinician should be notified of significant findings and limitations of the specimen.
Vitamins are organic micronutrients found in foods that are essential for health. Vitamin A deficiency can occur due to malabsorption or other issues affecting fat absorption. Key symptoms include night blindness, keratomalacia (softening and ulceration of the cornea), papular desquamation (flaking of the skin), and frequent respiratory infections. Vitamin A is important for maintaining epithelial surfaces and its deficiency can lead to epithelial metaplasia and keratinization of tissues.
This document summarizes different types of intracellular pigments, including exogenous pigments that come from outside the body like carbon, iron, and silica, as well as endogenous pigments synthesized within the body like lipofuscin, melanin, hemosiderin, hematin, and bilirubin. It provides examples of different pigments, how they are demonstrated, their origins, locations in the body, and associations with certain diseases.
Hyaline change is defined as a homogeneous glassy pink material seen on H&E stained sections that can accumulate both intra and extracellularly. It results from the accumulation of various substances and is a descriptive histologic term, not a specific marker of cell injury. Examples of intracellular hyaline change include Mallory bodies, hyaline droplets in renal tubular cells in nephrotic syndrome, alcoholic hyaline in the liver, viral inclusions, and Russel bodies. Extracellular hyaline change occurs in connective tissue and can be seen in conditions like hyalinization of glomeruli in chronic kidney disease, hyaline arteriosclerosis of renal vessels in hypertension, and aging. Amyloid should not be considered hyaline change as
Pathologic calcification involves the abnormal deposition of calcium salts in tissues. There are two main types: dystrophic calcification occurs in dead or damaged tissues and is associated with normal calcium levels, while metastatic calcification occurs in normal living tissues and is associated with high calcium levels. Dystrophic calcification results from calcium deposition in areas of tissue damage or necrosis. Metastatic calcification is usually caused by hypercalcemia from conditions like hyperparathyroidism or certain cancers. The lungs, kidneys, and gastric mucosa are especially susceptible to metastatic calcification.
This document discusses apoptosis, or programmed cell death. It begins by describing reversible and irreversible cell injury, with apoptosis and necrosis listed as examples of irreversible injury. Apoptosis is then discussed in more detail, noting that it was initially recognized in 1972 and is a mechanism to eliminate unwanted, harmful, or damaged cells. Apoptosis involves planned self-destruction of cells and is important for survival. The document outlines the clinical implications and provides examples of apoptosis in physiological and pathological conditions. It describes the morphology, biochemical features, and mechanisms of apoptosis, including the extrinsic and intrinsic pathways. Differences between apoptosis and necrosis are also summarized.
This document discusses various types of necrosis including coagulative, liquefactive, caseous, fat, and fibrinoid necrosis. Coagulative necrosis preserves cell outlines while liquefactive necrosis completely digests dead cells. Caseous necrosis is seen in tuberculosis and has a cheesy appearance. Fat necrosis occurs in pancreatitis. Fibrinoid necrosis involves fibrin deposition in blood vessels. Gangrene and primary gangrene are also described, with primary gangrene caused specifically by Clostridium bacteria. Overall, the document provides detailed information on the morphological and pathological features of different forms of cell death.
Atrophy is the shrinkage of cells and tissues due to loss of cellular components. It can result from decreased workload, blood supply, nutrition, endocrine stimulation or aging. At the microscopic level, atrophied cells appear smaller with more autophagic vacuoles and lipofuscin accumulation. Cancer cachexia involves activation of the proteasome pathway leading to muscle wasting.
Hypertrophy is the enlargement of cells and tissues due to an increase in cellular components but without an increase in cell number. It can be physiological such as in pregnancy or pathological such as in response to hypertension. The mechanisms involve increased protein synthesis, DNA content or cellular phenotype. Over time, degenerative changes can occur.
This document discusses cell injury and adaptation. It covers various types of cell injury including ischemia/hypoxia, chemical injury, and free radical-induced injury. It describes mechanisms of injury like lipid peroxidation and ways cells can adapt through processes like hyperplasia, hypertrophy, atrophy, and metaplasia. Adaptations can be physiological or pathological in response to stresses and insults on cells. The document provides examples of cell injury and adaptation in different clinical scenarios.
Hemodynamic derangements and shock can be classified in several ways. Shock is defined as inadequate tissue perfusion resulting in cellular oxygen debt. There are four main types of shock based on hemodynamic parameters: hemorrhagic, cardiogenic, distributive, and obstructive. Etiologically, shock can be caused by hemorrhage, cardiac issues like myocardial infarction, sepsis/systemic inflammatory response syndrome, or anaphylaxis due to peripheral vasodilation. If not treated, shock can progress to organ dysfunction and failure due to hypoxic injury. Management involves identifying the cause, restoring intravascular volume and blood pressure, and treating the underlying condition.
1) Myocardial infarction, cerebral infarction, pulmonary infarction, and gangrene of limbs are common examples of infarction that result from obstruction of blood flow.
2) Infarctions are typically wedge-shaped areas of ischemic necrosis caused by occlusion of the arterial blood supply or venous drainage of a tissue.
3) The development of an infarction depends on factors like the nature of the blood supply, the rate of occlusion, the tissue's vulnerability to hypoxia, and the oxygen content of the blood. Tissues with dual blood supplies are less likely to infarct.
An embolus is a solid, liquid, or gaseous mass that breaks off and travels through the bloodstream, lodging in and blocking smaller blood vessels. Pulmonary embolisms originate from deep leg vein thrombi in 95% of cases and can cause infarction or blockage of lung tissue. Systemic embolisms originate from heart mural thrombi in 80% of cases and commonly impact the brain or lower extremities. Fat embolisms occur after bone fractures and burns, causing pulmonary insufficiency, neurological issues, and thrombocytopenia. Air embolisms enter the circulation through chest or obstetric injuries and can block major blood vessels. Amniotic fluid embolisms are a rare
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
2. Some Questions
• What are turbulent and laminar flows?
• What are ROS ?
• What is HDL cholesterol ?
• What is LDL cholesterol ?
• Name some markers of inflammation ?
• What is glycocalyx ?
• What is metabolic syndrome ?
Mar-2015-CSBRP
3. Clinical Implications of AS
• Myocardial infarction
• Stroke
• Hypertension
• Gangrene
Mar-2015-CSBRP
9. Epidemiology
• Atherosclerosis-associated ischemic heart
disease used to be the most common
cause of morbidity in developed nations
– However, implementing risk reduction and
improved therapies have reduced the
mortality
• Adoption of western style of life style led to
increased incidence of IHD in developing
countries
Mar-2015-CSBRP
10. Risk Factors
• Risk factors have been identified through
a number of prospective analyses
(e.g: The Framingham Heart Study)
• Important Risk factors:
– Hyperlipidemia
– Hypertension and
– Smoking
• These risk factors have roughly
multiplicative effect
– 2 factors – increase the risk by 4x
– 3 factors – increase risk by 7x
Mar-2015-CSBRP
13. Constitutional Risk Factors
• Genetics: Family history is the most
important independent risk factor for
atherosclerosis
• Single Mendalian disorders like Familial
Hypercholesterolemia – Constitutes only a
small percentage
• Polygenic, relating to familial clustering
constitute a major chunk
Mar-2015-CSBRP
14. Constitutional Risk Factors
• Genetics
• Age: Formation of atherosclerotic plaque
is typically a progressive process
• Hence, complications are seen usually
between ages 40 and 60
• Death rates from ischemic heart disease
rise with each decade
Mar-2015-CSBRP
15. Constitutional Risk Factors
• Genetics
• Age
• Gender: Myocardial infarction and other
complications of atherosclerosis are uncommon
in premenopausal women
• After menopause, however, the incidence of
atherosclerosis related diseases increases in
women and at older ages actually exceeds that
of men
– ? Estrogen
Mar-2015-CSBRP
17. Modifiable Major Risk Factors
Hyperlipidemia: Even in the absence of other risk factors,
hypercholesterolemia is sufficient to initiate AS
• High LDL – Increased risk
• High HDL – Reduced risk
• Diet:
– Saturated FA – rises Cholesterol
– Polyunsaturated FA – reduces Cholesterol
– Omega-3 fatty acids – beneficial
– Artificial hydrogenation of polyunsaturated oils – adversely affect
cholesterol levels
• Exercise and moderate consumption of ethanol raise
HDL levels
• Obesity and smoking lower HDL
• In the past decade statins have been used widely to
lower serum cholesterol levels
Mar-2015-CSBRP
18.
19. Modifiable Major Risk Factors
• Hyperlipidemia
• Hypertension: both systolic and diastolic
levels are important
• Hypertensives show 60% increased risk of
cardiovascular events than normotensives
• Left ventricular hypertrophy is a surrogate
marker for cardiovascular risk
Mar-2015-CSBRP
20. Modifiable Major Risk Factors
• Hyperlipidemia
• Hypertension
• Cigarette smoking: Smoking of one pack
of cigarettes or more daily doubles the
death rate from ischemic heart disease
• Smoking cessation reduces that risk
substantially
Mar-2015-CSBRP
21. Modifiable Major Risk Factors
• Hyperlipidemia
• Hypertension
• Cigarette smoking
• Diabetes: induces hypercholesterolemia
– 2x prone for IHD
– 100x prone for gangrene
– Increased risk for stroke
Mar-2015-CSBRP
24. Additional Risk Factors
Inflammation:
• C-reactive protein (HS-CRP): plasma CRP
is a strong, independent marker of risk for
myocardial infarction, stroke, peripheral
arterial disease and sudden cardiac death
• CRP is also a useful marker for gauging
the effects of risk reduction measures
Mar-2015-CSBRP
26. Additional Risk Factors
• Inflammation
• Hyperhomocystinemia: is associated
with premature vascular disease
– Congenital
– Acquired
• NOTE: Supplemental vitamin ingestion
does not affect the incidence of
cardiovascular disease
Mar-2015-CSBRP
27. Additional Risk Factors
• Inflammation
• Hyperhomocystinemia
• Metabolic syndrome: characterized by insulin
resistance, hypertension, dyslipidemia (elevated
LDL and depressed HDL), hypercoagulability
and a proinflammatory state
– Hypertension, dyslipidemia contribute to IHD
– Systemic hypercoagulable and proinflammatory state
contribute to endothelial dysfunction
Mar-2015-CSBRP
28. Additional Risk Factors
• Inflammation
• Hyperhomocystinemia
• Metabolic syndrome
• Lipoprotein a [Lp(a)]: Lp(a) levels are
associated with coronary and
cerebrovascular disease risk, independent
of total cholesterol or LDL levels
Mar-2015-CSBRP
29.
30. Additional Risk Factors
• Inflammation
• Hyperhomocystinemia
• Metabolic syndrome
• Lipoprotein a [Lp(a)]
• Factors affecting hemostasis: Platelet-derived
factors, as well as thrombin—through both its
procoagulant and proinflammatory effects—are
increasingly recognized as major contributors to
vascular pathology
Mar-2015-CSBRP
31. Additional Risk Factors
• Inflammation
• Hyperhomocystinemia
• Metabolic syndrome
• Lipoprotein a [Lp(a)]
• Factors affecting hemostasis
• Other factors: lack of exercise;
competitive, stressful life style (“type A”
personality); and obesity
Mar-2015-CSBRP
32. Pathogenesis of Atherosclerosis
“Response to Injury” hypothesis:
This model views atherosclerosis as
a chronic inflammatory and healing
response of the arterial wall to
endothelial injury
Mar-2015-CSBRP
34. Pathogenesis of Atherosclerosis
• The specific factors contributing to
endothelial cell dysfunction in early
atherosclerosis are not completely
understood
• Etiologic agents may include:
– Toxins from cigarette smoke
– Elevated Homocysteine levels
– Infectious agents
– Inflammatory cytokines (eg: TNF)
What causes
endothelial injury ?
Mar-2015-CSBRP
35. Pathogenesis of Atherosclerosis
Two most important causes of endothelial
dysfunction are:
• Hemodynamic disturbances and
• Hypercholesterolemia
Mar-2015-CSBRP
36. Figure 11-10 Evolution of arterial wall
changes in the response to injury
hypothesis:
1, Normal.
2, Endothelial injury with monocyte and
platelet adhesion.
3, Monocyte and smooth muscle cell migration
into the intima, with macrophage activation.
4, Macrophage and smooth muscle cell
uptake of modified lipids, with further
activation and recruitment of T cells.
5, Intimal smooth muscle cell proliferation with
extracellular matrix production, forming a well-
developed plaque
Mar-2015-CSBRP
37. Pathogenesis of Atherosclerosis
• Hemodynamic Disturbances
Some observations:
– Plaques tend to occur at ostia of exiting
vessels, branch points
– Laminar flow stimulates the expression of
genes which inhibit atherogenesis
(Atheroprotective genes)
Mar-2015-CSBRP
38. Pathogenesis of Atherosclerosis
• Hypercholesterolemia
– Dyslipoproteinemias
• increased LDL
• decreased HDL
• increased levels of lipoprotein (a)
– Maybe due to primary or secondary causes
• Nephrotic syndrome
• Diabetes mellitus
• Hypothyroidism
• Alcoholism
Mar-2015-CSBRP
39. Pathogenesis of Atherosclerosis
Hypercholesterolemia: is Atherogenic
The evidence:
1-Cholesterol esters are the dominant lipids in
atheromatous plaques
2-Genetic defects in lipoprotein uptake and metabolism are
associated with accelerated atherosclerosis
3-Other acquired disorders of hypercholesterolemia lead to
premature atherosclerosis
4-Epidemiology: Severity of atherosclerosis and total
plasma cholesterol are directly proportional
5-Lowering of serum cholesterol has shown to reduce the
atherogenesis and cardiovascular events
Mar-2015-CSBRP
40. Pathogenesis of Atherosclerosis
The mechanisms by which hyperlipidemia
contributes to atherogenesis include the
following:
1-Hyperlipidemia, can directly impair
endothelial cell function
• By production of ROS
• Mitochondrial damage
• Degrading NO
Mar-2015-CSBRP
41. The mechanisms by which hyperlipidemia
contributes to atherogenesis
Mar-2015-CSBRP
43. Pathogenesis of Atherosclerosis
Inflammation: Chronic inflammation
contributes to the initiation and
progression of atherosclerotic lesions
– Production of IL-1
– Macrophage and lymphocyte recruitment and
activation
– Liberation of ROS by macrophages
– Oxidation of LDL
– More inflammation and elaboration of Growth
factors Mar-2015-CSBRP
56. Summary
Endothelial injury is the primary event
Intimal accumulation of lipids esp. LDL
Oxidation of LDL –>–> Modified LDL –>–> resulting in ?
Autoimmunity
Recruitment of T-cells & MØ
ROS and Cytokine liberation
More cytokines & growth factors
Recruitment of Smooth muscle cells and MØ
More lipid accumulation in extracellularly and in MØ
Atheromatous plaque formation
Mar-2015-CSBRP
59. AS – Morphology –AS – Morphology – Fatty streaks
• Multiple minute flat yellow spots or
elongated 1 cm long or longer streaks
• Distribution: Similar to AS plaques
• Composition: Lipid-filled foamy MØ
• No significant alteration in the blood flow
• Seen even in infants and adolescents
• It may / may not progress to AS plaque
Mar-2015-CSBRP
62. AS – Morphology –AS – Morphology –
Atherosclerotic Plaque
• Colour of plaque:
– White-yellow patches
– Red – Brown: When ulcerated and
superimposed by thrombus
• Involvement of the artery: Patchy
• Location: Eccentric (not circumferential)
• Size: Vary. May coalesce to form large masses
• Lesions at various stages often coexist
• Narrows the lumen of the artery
Mar-2015-CSBRP
65. AS – Morphology –AS – Morphology –
Atherosclerotic Plaque
Vessels affected (some facts)
• Lower abdominal aorta: Typically involved to a
greater degree than the thoracic aorta
• Vessels that are usually spared are: vessels of
upper extremities, the mesenteric and renal
arteries, except at their ostia
• Severity of disease in one arterial distribution
does not always predict its severity in another
Mar-2015-CSBRP
66. AS – Morphology –AS – Morphology –
Atherosclerotic Plaque
Atherosclerotic plaques have three principal
components:
1. CELLS: Smooth muscle cells, macrophages,
and T cells
2. MATRIX: Extracellular matrix, including
collagen, elastic fibers, and proteoglycans
3. LIPID: Intracellular and extracellular lipid
These components occur in varying proportions and
configurations in different lesions
Mar-2015-CSBRP
67. AS – Morphology –AS – Morphology –
Atherosclerotic Plaque
Typical plaque:
• Superficial fibrous cap: composed of smooth
muscle cells and relatively dense collagen
• The “shoulder” (sides of the cap): MØ, T-cells,
smooth muscle cells
• Necrotic core: containing lipid, debris from
dead cells, foam cells, fibrin, organized
thrombus, and other plasma proteins
• The periphery: of the lesions demonstrate
neovascularizationMar-2015-CSBRP
70. AS – Morphology –AS – Morphology –
Atherosclerotic Plaque
Atherosclerotic plaques are susceptible to
the following clinically important
pathologic changes:
• Rupture, ulceration, or erosion
• Hemorrhage into a plaque
• Atheroembolism
• Aneurysm formation
Mar-2015-CSBRP
71. The natural history, morphologic features, main pathogenic
events, and clinical complications of atherosclerosis
Mar-2015-CSBRP
73. Consequences of Atherosclerotic Disease
• Major targets vessels: Large elastic arteries,
large and medium-sized muscular arteries
• Major arteries affected resulting in Symptoms:
Arteries supplying the heart, brain, kidneys, and
lower extremities
• The major consequences of atherosclerosis:
– Myocardial infarction
– Cerebral infarction
– Aortic aneurysms and
– Peripheral vascular disease
Mar-2015-CSBRP
74. Mechanisms:Mechanisms:
AS lesions that are responsible for the
clinicopathologic manifestations
1. Atherosclerotic Stenosis
2. Acute Plaque Change
3. Thrombosis
4. Vasoconstriction
Mar-2015-CSBRP
75. 1-Atherosclerotic Stenosis1-Atherosclerotic Stenosis
• At early stages of stenosis, outward
remodeling of the vessel media tends to
preserve the size
• Eventually the expanding atheroma
impinges on the lumen causing ischemia
– Critical stenosis
• Coronaries: 70% chest pain may develop with
exertion – stable angina
Note: The effects of vascular occlusion ultimately depend on arterial
supply and the metabolic demand of the affected tissue
Mar-2015-CSBRP
76. Vulnerable and Stable AS plaque
Stable plaques tend to have a dense fibrous cap, minimal lipid accumulation
and little inflammation, whereas “vulnerable” unstable plaques have thin
caps, large lipid cores, and relatively dense inflammatory infiltrates.
Mar-2015-CSBRP
77. 2-Acute Plaque Change2-Acute Plaque Change
Plaque changes fall into three general
categories:
• Rupture/fissuring, exposing highly
thrombogenic plaque constituents
• Erosion/ulceration, exposing the
thrombogenic subendothelial basement
membrane to blood
• Hemorrhage into the atheroma, expanding
its volume
Mar-2015-CSBRP
79. 4-Vasoconstriction4-Vasoconstriction
Vasoconstriction compromises lumen size and can
potentiate plaque disruption:
• Vasoconstriction at sites of atheroma may be
stimulated by
1. Circulating adrenergic agonists
2. Locally released platelet contents
3. Endothelial cell dysfunction with imbalance between
nitric oxide & endothelin and
4. Mediators released from perivascular inflammatory cells
Mar-2015-CSBRP
Genetics. Family history is the most important independent risk factor for atherosclerosis. Certain Mendelian
disorders are strongly associated with atherosclerosis (e.g., familial hypercholesterolemia; Chapter 5), but
these account for only a small percentage of cases. The well-established familial predisposition to atherosclero-
sis and ischemic heart disease is usually polygenic, relating to familial clustering of other established risk
factors, such as hypertension or diabetes, or to inherited variants that influence other pathophysiologic processes,
Such as inflammation.
Age is a dominant influence. Although the development of atherosclerotic plaque is typically a progressive
process, it does not usually become clinically manifest until lesions reach a critical threshold in middle age or later (see later). Thus, between ages 40 and 60, the incidence of myocardial infarction increases five-fold. Death rates from ischemic heart disease rise with each
decade even into advanced age.
Gender: Other factors being equal, premenopausal women are relatively protected against atherosclerosis and its consequences compared to age-matched men. Thus, myocardial infarction and other complications of atherosclerosis are uncommon in premenopausal women unless they are otherwise predisposed by diabetes, hyperlipidemia, or severe hypertension. After menopause, however, the incidence of atherosclerosisrelated diseases increases in women and at older ages actually exceeds that of men. Although a favorable influence of estrogen has long been proposed to explain this effect, clinical trials of estrogen replacement have not been shown to protect against vascular disease; indeed, in some studies, post-menopausal estrogen replacement actually increased cardiovascular risk. The atheroprotective effect of estrogens may be related to the age at which the therapy is initiated; in younger postmenopausal women, coronary atherosclerosis is diminished by estrogen therapy, while older women appear not to benefit.
Hyperlipidemia—and more specifically hypercholesterolemia—is a major risk factor for atherosclerosis; even in the absence of other risk factors, hypercholesterolemia is sufficient to initiate lesion development. The major component of serum cholesterol associated with increased risk is low-density lipoprotein (LDL) cholesterol (“bad cholesterol”). LDL is the com plex that delivers cholesterol to peripheral tissues; in contrast, high-density lipoprotein (HDL) is the complex that mobilizes cholesterol from the periphery (including atheromas) and transports it to the liver for excretion in the bile. Consequently, higher levels of HDL (“good cholesterol”) correlate with reduced
risk. Understandably, dietary and pharmacologic approaches that lower LDL or total serum cholesterol, or raise serum HDL, are of considerable interest. High dietary intake of cholesterol and saturated fats (present in egg yolks, animal fats, and butter, for example) raises plasma cholesterol levels. Conversely, diets low in cholesterol and/or high in polyunsaturated fats lower plasma cholesterol levels. Omega-3 fatty acids (abundant in fish oils) are beneficial, whereas (trans)unsaturated fatsproduced by artificial, hydrogenation of polyunsaturated oils (used in baked goods and margarine) adversely affect cholesterol profiles. Exercise and moderate consumption of ethanol raise HDL levels whereas obesity and smoking lower it. Statins are a class of drugs that lower circulating cholesterol levels by inhibiting hydroxymethylglutaryl coenzyme A (HMG CoA) reductase, the rate-limiting enzyme in hepatic cholesterol biosynthesis (Chapter 5). In the past two decades, statins have been used widely to lower serum cholesterol levels, arguably one of the most significant success stories of translational research.
Hypertension (see earlier) is another major risk factor for atherosclerosis; both systolic and diastolic levels are important. On its own, hypertension can increase the risk of ischemic heart disease by approximately 60% versus normotensive populations (Fig. 11-8). Chronic
hypertension is the most common cause of left ventricular hypertrophy, and hence the latter
is also a surrogate marker for cardiovascular risk.
Cigarette smoking is a well-established risk factor in men and likely accounts for the increasing incidence and severity of atherosclerosis in women. Prolonged (years) smoking of one pack of cigarettes or more daily doubles the death rate from ischemic heart disease. Smoking cessation reduces that risk substantially.
Diabetes mellitus induces hypercholesterolemia (Chapter 24) and markedly increases the risk of atherosclerosis. Other factors being equal, the incidence of myocardial infarction is twice as high in patients with diabetes than in those without. There is also an increased risk of stroke
and a 100-fold increased risk of atherosclerosis-induced gangrene of the lower extremities.
Figure 11-9 C reactive protein (CRP) predicts cardiovascular risk. Relative risk (y-axis) refers to the risk of a cardiovascular event (e.g., myocardial infarction). The x-axis is the 10-year risk of a cardiovascular event derived from established risk factors identified in the Framingham Heart Study. In each risk group, CRP values further stratify patients. (Data from Ridker PM, et al: Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med 347:1557, 2002.)
Hyperhomocystinemia. Serum homocysteine levels correlate with coronary atherosclerosis, peripheral vascular disease, stroke, and venous thrombosis. Homocystinuria, due to rare inborn errors of metabolism, results in elevated circulating homocysteine (>100 µmol/L) and is
associated with premature vascular disease. Although low folate and vitamin B levels can increase homocysteine, supplemental vitamin ingestion does not affect the incidence of cardiovascular disease.
Metabolic syndrome. Associated with central obesity
(Chapter 9), this entity is characterized by insulin resis-
tance, hypertension, dyslipidemia (elevated LDL and
depressed HDL), hypercoagulability, and a proinflammatory
state. The dyslipidemia, hyperglycemia, and
hypertension are all cardiac risk factors, while the
systemic hypercoagulable and proinflammatory state
may contribute to endothelial dysfunction and/or
thrombosis.
Lipoprotein a [Lp(a)] is an altered form of LDL that contains the apolipoprotein B-100 portion of LDL linked to apolipoprotein A (apo A); Lp(a) levels are associated with coronary and cerebrovascular disease risk, independent of total cholesterol or LDL levels.
Platelet-derived factors, as well as thrombin—through both its procoagulant and proinflammatory effects—are increasingly recognized as major contributors to vascular pathology.
Other factors. Factors associated with a less pronounced and/or difficult-to-quantitate risk include lack of exercise; competitive, stressful life style (“type A” personality); and obesity (the latter also being complicated by hypertension, diabetes, hypertriglyceridemia, and decreased HDL).
Figure 11-10 Evolution of arterial wall changes in the response to injury
hypothesis. 1, Normal. 2, Endothelial injury with monocyte and platelet adhesion.
3, Monocyte and smooth muscle cell migration into the intima, with
macrophage activation. 4, Macrophage and smooth muscle cell uptake of
modified lipids, with further activation and recruitment of T cells. 5, Intimal
smooth muscle cell proliferation with extracellular matrix production, forming
a well-developed plaque.
Hemodynamic Disturbances. The importance of hemodynamic
turbulence in atherogenesis is illustrated by the observation that plaques tend to occur at ostia of exiting
vessels, branch points, and along the posterior wall of the abdominal aorta, where there are disturbed flow patterns. In vitro studies have demonstrated that nonturbulent laminar flow leads to the induction of endothelial genes whose products (e.g., the antioxidant superoxide dismutase) actually protect against atherosclerosis. Such
“atheroprotective” genes could explain the nonrandom localization of early atherosclerotic lesions.
Lipids. Lipids are transported in the bloodstream bound
to specific apoproteins (forming lipoprotein complexes).
Dyslipoproteinemias are lipoprotein abnormalities that
may be present in the general population (and indeed, are
found in many myocardial infarction survivors) include
(1) increased LDL cholesterol levels, (2) decreased HDL
cholesterol levels, and (3) increased levels of the abnormal
lipoprotein (a). These may result from mutations that
lead to defects in apoproteins or lipoprotein receptors,
or arise from other underlying disorders that affect
circulating lipid levels, such as nephrotic syndrome, alcoholism,
hypothyroidism, or diabetes mellitus. All of these
abnormalities are associated with an increased risk of
Atherosclerosis.
1-The dominant lipids in atheromatous plaques are cholesterol and cholesterol esters.
2-Genetic defects in lipoprotein uptake and metabolism that cause hyperlipoproteinemia are associated with
accelerated atherosclerosis. For example, familial hypercholesterolemia, caused by defective LDL receptors
and inadequate hepatic LDL uptake (Chapter 5), can precipitate myocardial infarctions before age 20.
Similarly, accelerated atherosclerosis occurs in animal models with engineered deficiencies in apolipoproteins
or LDL receptors.
3-Other genetic or acquired disorders (e.g., diabetes mellitus, hypothyroidism) that cause hypercholesterolemia
lead to premature atherosclerosis.
4-Epidemiologic analyses demonstrate a significant correlation between the severity of atherosclerosis and the
levels of total plasma cholesterol or LDL.
5-Lowering serum cholesterol by diet or drugs slows the rate of progression of atherosclerosis, causes regression
of some plaques, and reduces the risk of cardiovascular events.
Figure 11-11 Sequence of cellular interactions in atherosclerosis. Hyperlipidemia, hyperglycemia, hypertension, and other influences cause endothelial dysfunction.
This results in platelet adhesion and recruitment of circulating monocytes and T cells, with subsequent cytokine and growth factor release from inflammatory cells leading to smooth muscle cell migration and proliferation as well as further macrophage activation. Foam cells in atheromatous plaques derive from macrophages and smooth muscle cells that have accumulated modified lipids (e.g., oxidized and aggregated low density lipoprotein [LDL]) via scavenger and LDL-receptor-related proteins. Extracellular lipid is derived from insudation from the vessel lumen, particularly in the presence of hypercholesterolemia, as well as from degenerating foam cells. Cholesterol accumulation in the plaque reflects an imbalance between influx and efflux; high-density lipoprotein (HDL)
likely helps clear cholesterol from these accumulations. In response to the elaborated cytokines and chemokines, smooth muscle cells migrate to the intima, proliferate, and produce extracellular matrix, including collagen and proteoglycans. IL-1, interleukin-1; MCP-1, monocyte chemoattractant protein-1.
After understanding genesis and basic morphology, It’s time to define atherosclerosis.
After understanding genesis and basic morphology, It’s time to define atheroma
These were the theories during my UG days.
Figure 11-12 Fatty streak, a collection of foamy macrophages (MØ) in the intima. A, Aorta with fatty streaks (arrows), associated largely with the ostia of branch vessels. B, Photomicrograph of fatty streak in an experimental hypercholesterolemic rabbit, demonstrating intimal, macrophage-derived foam cells (arrows).
(B, Courtesy Myron I. Cybulsky, MD, University of Toronto, Canada.)
Figure 11-12 Fatty streak, a collection of foamy macrophages in the intima. A, Aorta with fatty streaks (arrows), associated largely with the ostia of branch vessels. B, Photomicrograph of fatty streak in an experimental hypercholesterolemic rabbit, demonstrating intimal, macrophage-derived foam cells (arrows).
(B, Courtesy Myron I. Cybulsky, MD, University of Toronto, Canada.)
Atherosclerotic Plaque. The key processes in atherosclerosis are intimal thickening and lipid accumulation, which together form plaques (Figs. 11-7, 11-10, and 11-11). Atheromatous plaques are white-yellow and encroach on the lumen of the artery; superimposed thrombus over ulcerated plaques is red-brown. Plaques vary in size but can coalesce to form larger masses (Fig. 11-13).Atherosclerotic lesions are patchy, usually involving only a portion of any given arterial wall and are rarely circumferential; on cross-section, the lesions therefore appear “eccentric” (see Fig. 11-14A).
Figure 11-13 Gross views of atherosclerosis in the aorta. A, Mild atherosclerosis composed of fibrous plaques, one of which is denoted by the arrow. B, Severe disease with diffuse and complicated lesions including an ulcerated plaque (open arrow), and a lesion with overlying thrombus (closed arrow).
Atherosclerotic plaques have three principal components:
(1) smooth muscle cells, macrophages, and T cells; (2) extracellular matrix, including collagen, elastic
fibers, and proteoglycans; and (3) intracellular and extracellular lipid (Fig. 11-14). These components occur in varying
proportions and configurations in different lesions. Typically, there is a superficial fibrous cap composed of smooth muscle
cells and relatively dense collagen. Beneath and to the side of the cap (the “shoulder”) is a more cellular area containing macrophages, T cells, and smooth muscle cells. Deep to the fibrous cap is a necrotic core, containing lipid (primarily cholesterol and cholesterol esters), debris from dead cells, foam cells (lipidladen macrophages and smooth muscle cells), fibrin, variably organized thrombus, and other plasma proteins; the cholesterol content is frequently present as crystalline aggregates that are washed out during routine tissue processing and leave behind
only empty “clefts.” The periphery of the lesions demonstrate neovascularization (proliferating small blood vessels; Fig.
11-14C). Most atheromas contain abundant lipid, but some plaques (“fibrous plaques”) are composed almost exclusively of
smooth muscle cells and fibrous tissue. Plaques generally continue to change and progressively enlarge through cell death and degeneration, synthesis and degradation (remodeling) of extracellular matrice, and organization of any superimposed thrombus. Moreover, atheromas often undergo calcification (Fig. 11-14C). Patients with advanced coronary calcification have increased risk for coronary events.
Figure 11-14 Histologic features of atheromatous plaque in the coronary artery. A, Overall architecture demonstrating fibrous cap (F) and a central necrotic core (C) containing cholesterol and other lipids. The lumen (L) has been moderately compromised. Note that a segment of the wall is plaque free (arrow); the lesion is therefore “eccentric.” In this section, collagen has been stained blue (Masson trichrome stain). B, Higher-power photograph of a section of the plaque shown in A, stained for elastin (black), demonstrating that the internal and external elastic laminae are attenuated and the media of the artery is thinned under the most advanced plaque (arrow). C, Higher magnification photomicrograph at the junction of the fibrous cap and core, showing scattered inflammatory cells, calcification (arrowhead), and neovascularization (small arrows).
Rupture, ulceration, or erosion of the surface of atheromatous plaques exposes highly thrombogenic substances and leads to thrombosis, which may partially or completely occlude the vessel lumen (Fig. 11-15). If the patient survives, the clot may become organized and incorporated into the growing plaque.Hemorrhage into a plaque. Rupture of the overlying fibrous cap, or of the thin-walled vessels in the areas of neovascularization, can cause intraplaque hemorrhage; a contained hematoma may expand the plaque or induce plaque rupture. Atheroembolism. Plaque rupture can discharge atherosclerotic debris into the bloodstream, producing microemboli. Aneurysm formation. Atherosclerosis-induced pressure or ischemic atrophy of the underlying media, with loss of elastic tissue, causes weakness and potential rupture.
Figure 11-16 The natural history, morphologic features, main pathogenic events, and clinical complications of atherosclerosis.
Figure 11-15 Atherosclerotic plaque rupture. A, Plaque rupture without superimposed thrombus, in a patient who died suddenly. B, Acute coronary thrombosis superimposed on an atherosclerotic plaque with focal disruption of the fibrous cap, triggering fatal myocardial infarction. In both A and B, an arrow points to the site of plaque rupture. (B, Reproduced from Schoen FJ: Interventional and Surgical Cardiovascular Patherosclerosisology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989, p 61.)
Large elastic arteries (e.g., aorta, carotid, and iliac arteries) and large and medium-sized muscular arteries (e.g., coronary and
Popliteal arteries) are the major targets of atherosclerosis. Symptomatic atherosclerotic disease most often involves the arteries supplying the heart, brain, kidneys, and lower extremities. Myocardial infarction (heart attack), cerebral infarction (stroke), aortic aneurysms, and
peripheral vascular disease (gangrene of the legs) are the major consequences of atherosclerosis.
Atherosclerotic Stenosis. In small arteries, atherosclerotic
plaques can gradually occlude vessel lumina, compromisingblood flow and causing ischemic injury. At early stages
of stenosis, outward remodeling of the vessel media tends to preserve the size of the lumen. However, there are limits on the extent of remodeling, and eventually the expanding atheroma impinges on the lumen to such a degree that blood flow is compromised. Critical stenosis is the stage at which the occlusion is sufficiently severe to produce tissue ischemia. In the coronary (and other) circulations, this typically occurs at when the occlusion produces a 70% decrease in luminal cross-sectional area; with this degree of stenosis, chest pain may develop with exertion (so-called stable angina; see Chapter 12). Although acute plaque rupture (see later) is the most dangerous consequence, atherosclerosis also takes a toll through chronically diminished arterial perfusion: mesenteric occlusion and bowel ischemia, sudden cardiac death, chronic ischemic heart disease, ischemic encephalopathy,
and intermittent claudication (diminished perfusion of the extremities) are all consequences of flow-limiting
stenoses. The effects of vascular occlusion ultimately depend on arterial supply and the metabolic demand of
the affected tissue.
Figure 11-17 Vulnerable and stable atherosclerotic plaque. Vulnerable plaques have thin fibrous caps, large lipid cores, and greater inflammation. Stable plaques have thickened and densely collagenous fibrous caps with minimal inflammation and underlying atheromatous core. (Adapted from Libby P: Circulation 91:2844, 1995.)
Plaque changes fall into three general categories:
Rupture/fissuring, exposing highly thrombogenic plaque constituents
Erosion/ulceration, exposing the thrombogenic subendothelial basement membrane to blood
Hemorrhage into the atheroma, expanding its volume
It is now recognized that plaques that are responsible for myocardial infarction and other acute coronary syndromes are often asymptomatic before the acute change.
Thus, pathologic
and clinical studies show that the majority of plaques that
undergo abrupt disruption and coronary occlusion previously
showed only mild to moderate noncritical luminal
stenosis. The worrisome conclusion is that a large number
of now asymptomatic adults may be at risk for a catastrophic
coronary event. Unfortunately, it is presently
impossible to identify such individuals.
Plaques rupture when they are unable to withstand
mechanical stresses generated by vascular shear forces.
The events that trigger abrupt changes in plaques and
subsequent thrombosis are complex and include both
intrinsic factors (e.g., plaque structure and composition)
and extrinsic elements (e.g., blood pressure, platelet reactivity,
vessel spasm).
The composition of plaques is dynamic and can contribute
to risk of rupture. Thus, plaques that contain large
areas of foam cells and extracellular lipid, and those in
which the fibrous caps are thin or contain few smooth
muscle cells or have clusters of inflammatory cells, are
more likely to rupture; these are referred to as “vulnerable
plaques” (Fig. 11-17).
The fibrous cap undergoes continuous remodeling that can
stabilize the plaque, or conversely, render it more susceptible to
rupture. Collagen is the major structural component of the
fibrous cap, and accounts for its mechanical strength and stability. Thus, the balance of collagen synthesis versus
degradation affects cap integrity. Collagen in atherosclerotic
plaque is produced primarily by smooth muscle cells
so that loss of these cells results in a less sturdy cap.
Moreover, collagen turnover is controlled by metalloproteinases
(MMPs), enzymes elaborated largely by macrophages
and smooth muscle cells within the atheromatous
plaque; conversely, tissue inhibitors of metalloproteinases
(TIMPs) produced by endothelial cells, smooth muscle
cells, and macrophages modulate MMP activity. In general,
plaque inflammation results in a net increase in collagen
degradation and reduced collagen synthesis, thereby
destabilizing the mechanical integrity of the fibrous cap
(see later). The inflammatiion induced by cholesterol
deposits themselves may contribute to plaque destabilization.
Conversely, statins may have a beneficial therapeutic
effect not only by reducing circulating cholesterol levels,
but also by stabilizing plaques through a reduction in
plaque inflammation. Influences extrinsic to plaques also contribute to acute plaque
changes. Thus, adrenergic stimulation can increase systemic
blood pressure or induce local vasoconstriction, thereby
increasing the physical stresses on a given plaque. Indeed,
the adrenergic stimulation associated with wakening and
rising can cause blood pressure spikes (followed by heightened
platelet reactivity) that have been causally linked to
the pronounced circadian periodicity for onset of acute MI
(peaking between 6 AM and noon). Intense emotional stress
can also contribute to plaque disruption; this is most dramatically
illustrated by the uptick in the incidence of
sudden death associated with natural or other disasters,
such as earthquakes and the September 11, 2001, attack on
the World Trade Center.
It is also important to note that not all plaque ruptures
result in occlusive thromboses with catastrophic consequences.
Indeed, plaque disruption and an ensuing superficial
platelet aggregation and thrombosis are probably
common, repetitive, and often clinically silent complications
of atheroma. Healing of these subclinical plaque
disruptions—and resorption of their overlying thrombi—
is an important mechanism in the growth of atherosclerotic
lesions.
Thrombosis. As mentioned earlier, partial or total thrombosis
superimposed on a disrupted plaque is a central factor in acute coronary syndromes. In its most serious
form, thrombosis leads to total occlusion of the affected vessel. In contrast, in other coronary syndromes (Chapter
12), luminal obstruction by the thrombus is incomplete,and may even wax and wane with time.
Mural thrombi in a coronary artery can also embolize.Indeed, small embolic fragments of thrombus can often be
found in the distal intramyocardial circulation or in association with microinfarcts in patients with atherosclerosis
who die suddenly. Finally, thrombin and other factors associated with thrombosis are potent activators of smooth
muscle cells and can thereby contribute to the growth of atherosclerotic lesions.
Vasoconstriction compromises lumen size, and, by increasing the local mechanical forces, can potentiate plaque disruption. Vasoconstriction at sites of atheroma may be stimulated by (1) circulating adrenergic agonists, (2) locally released platelet contents, (3) endothelial cell dysfunction with impaired secretion of endothelialderived relaxing factors (nitric oxide) relative to contracting factors (endothelin), and (4) mediators released from perivascular inflammatory cells.
In descending order, the most extensively involved vessels are the lower abdominal aorta, the coronary arteries, the popliteal arteries, the internal carotid arteries, and the vessels of the circle of Willis. In humans, the abdominal aorta is typically involved to a much greater degree than the thoracic aorta. Vessels of the upper extremities are
usually spared, as are the mesenteric and renal arteries, except their ostia. Although most individuals tend to have a consistent degree of atherosclerotic burden in the affected vasculature, severity of disease in one arterial distribution does not always predict its severity in another.