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Pain
Bismillah.
Learning Objective 1
Differential Diagnosis
Potentially life-threatening causes of chest pain are as follows:
Heart attack/ MI and Angina are coronary syndrome involve coronary artery
Heart attack (acute myocardial infarction): A heart attack occurs when blood flow
to the arteries that supply the heart (coronary arteries) becomes blocked. With
decreased blood flow, the muscle of the heart does not receive enough oxygen.
This can cause damage, deterioration, and death of the heart muscle.
Angina/ JUST ISCHEMIC: Angina is chest pain related to an imbalance between the
oxygen demand of the heart and the amount of oxygen delivered via the blood.
It is caused by blockage or narrowing of the blood vessels that supply blood to the
heart. Angina is different from a heart attack in that the arteries are not
completely blocked, and it causes little or no permanent damage to the heart.
"Stable" angina occurs repetitively and predictably while exercising and goes away
with rest. "Unstable" angina results in unusual and unpredictable pain not relieved
totally by rest, or pain that actually occurs at rest. (STABLE and UNSTABLE ANGINA)
Learning Objective 2
The Heart
Learning Objective 3
Branches
branches of the ascending aorta, above the aortic valve
Right coronary
Left coronary
1. Anterior interventricular
artery*
2. Circumflex artery*
3. Conus branch artery
4. Left marginal artery
5. Diagonal artery
Distribution
Right Cor onar y
Both atria & inter-atrial
septum
SA node (60%) & AV node
(90%) and bundle of His
Right ventricle except for a
narrow strip along the anterior
inter-ventricular groove
Posterior 1/2 of interventricular septum
A narrow strip of left ventricle
along the posterior interventricular groove
*Clinical application
Right Coronary
Disorders of right coronary
artery may cause
-
Sinus bradycardia
AV nodal block
Left Coronary
Anterior interventricular
branch/Left Anterior
Descending (LAD) artery is
the most often blocked
coronary artery
Stenosis of left coronary
artery is serious because it
supplies majority of the left
ventricle
Anastomoses
1. Between termination of
right coronary artery &
circumflex artery
2. Between posterior &
anterior interventricular
arteries
3. Between right & left conal
branches
Clinical applications
Progressive blockage anastomoses collateral
circulation may form to
make the cardiac muscle
viable
Sudden blockage of one
large branch usually lead to
myocardial infarction
(death of myocardial tissue
Coronary sinus
Continuation of great cardiac
vein
Empty into the right atrium
Parasympathetic
Vagus nerve
Synapse at cardiac plexuses
Postganglionic fibres
- SA + AV nodes & coronary
arteries
Learning Objective 4
Pace Maker
Depolarizing current
primarily by relatively fast
Na2+ Produce rapid
depolarisation
Referred as
fast response
action potentials
Referred as
slow response
action potentials
Cardiac Cycle
Definition: The sequence of events that occurs when
the heart beats
2 phases: Diastole phase The heart ventricles are relaxed
and the heart fills with blood
Systole phase The ventricles contract and pump
blood to the arteries
*1 cardiac cycle is completed when the heart fills
with blood and the blood is pumped out of the heart
Period of Ejection
When the ventricular pressure rises slightly
above 80 mmHg, the ventricular pressure
push the semilunar valves open.
Immediately, blood begins to pour out of the
ventricles.
Learning Objective 5
HR and SV
Heart rate- number of heartbeats per unit of
time. (bpm)
Stroke volume - volume of blood pumped
from one ventricle of the heart with each beat.
SV calculation - SV = EDV - ESV
EDV : Volume of blood just prior to the beat
ESV : Volume of blood in ventricle at end of
beat
Factors affecting Q
ANS
Cause bp changes.
Age
Infant HR 115 bpm, decrease to 100 bpm.
Epinephrine and norepinephrine
HR and SV, Q.
Gender
Female higher resting HR.
Physical fitness
Active person around 50 bpm resting HR.
Body temperature
temperature, Q.
Learning Objective 6
Lung conditions
If you have sharp chest pain that gets worse when you
breathe in and out, and is accompanied by other symptoms
such as a cough and breathlessness, it may be caused by a
condition affecting the lungs or surrounding tissue, such as:
- pneumonia inflammation of the lungs, usually caused
by an infection
- pleurisy inflammation of the membrane surrounding
the lungs, also usually caused by an infection
Mild cases of pneumonia can usually be treated with
antibiotics, rest and fluids. For people with other health
conditions, the condition can be severe and they may need to
be treated in hospital.
Treatment for pleurisy will depend on the underlying cause.
Pleurisy caused by a viral infection will often resolve without
needing treatment, whereas pleurisy caused by a bacterial
infection will usually need to be treated with antibiotics.
Learning Objective 7
Biomaker
What is biomarker?
In medicine, a biomarker is a term often used to refer
to a protein measured in blood whose concentration
reflects the severity or presence of some disease state.
More generally a biomarker is anything that can be
used as an indicator of a particular disease state
Biomarker that is being used in diagnose MI is called
cardiac marker. Example of cardiac marker is:
Chest X-ray
A doctor may be looking for specific features on a
chest x-ray. A posterior-anterior (PA) and lateral x-rays
will be conducted. Some of the common features that
may be noted include :
Tracheal alignment, lung segments and any signs of
effusions (fluid in the lungs).
Widening of the mediastinum, cardiothoracic ratio,
cardiac size and shape and major blood vessels shape,
size and position
Sternal, clavicle, scapula or rib fracture.
Vertebral body height and disc spaces.
Any foreign objects or abnormal, opaque mass.
Basically, doctor look for cardiac size and
cardiothoracic ratio if any heart disease is suspected.
Lipid profile
Lipid profile is the collective term given to the estimation of, typically,
Total cholesterol
High density lipoprotein cholesterol (HDL-C) often called good
cholesterol
Low density lipoprotein cholesterol (LDL-C) often called bad cholesterol
Triglycerides
An extended profile may also include:
Very low density lipoprotein cholesterol (VLDL-C), IDL, chylomicron
The lipid profile is used to help determine your risk of heart disease and to help guide
you and your health care provider in deciding what treatment may be best for you if
you have borderline or high risk
Learning Objective 8
Cholesterol &
Lipoprotein Metabolism
The
OH group at carbon 3 makes cholesterol
amphipathic (both hydrophilic & hydrophobic);
allowing cholesterol to insert itself into
membranes.
Cholesterol has several functions, one of
which being an essential component of
eukaryotic membranes and that it modulates
the fluidity of these membranes.
HDL Metabolism
HDL is the smallest lipoprotein, containing the
least amount of lipid. It contains of a lipid core
of CE and TG, surrounded by PLs and apo A-I.
Its particles are formed in blood by the
addition of lipid to apo A-I, an apolipoprotein
made by the liver and intestine and secreted
into the blood. Apo A-I accounts for 70% of
the apoproteins in HDL.
Learning Objective 9
Prevention :
Lifestyle modification
Anti-hyperlipidemic
drugs (atherosclerosis
prevention)
Anti-coagulants/anti-thrombotic
Binding to antithrombin 3, with the subsequent rapid
inactivation of coagulant factors. Also include inhibition of
serine proteases, thrombin clotting factor (factor 2a & factor
5a)
Thus limit the expansion of thrombi by preventing fibrin
formation
Example : Heparin, low-molecular weight heparins LMWHs
For acute phase of MI
Balloon angioplasty
Surgery
Anti-hyperlipidemic
Treatment goals :
reduction of LDL level
Reducing total serum cholesterol and
triglycerides
Increasing HDL level
Drugs used :
Statins (HMG-CoA reductase inhibitors)
Atorvastatin,rosuvastatin, simvastatin, Lovastatin, Pravastatin,
fluvastatin
Bile Acid BindingResins:
Cholestyramine, Colestipol, colesevelam
Nicotinic acid
Niacin
FibricAcid Derivatives
Gemfibrozil, clofibrate, Fenofibrate, bezafibrate& ciprofibrate
Ezetimibe
Lifestyle modification
Learning Objective 10
Epidemiology of MI
Myocardial infarction is a common presentation of
coronary artery disease.
The World Health Organization estimated in 2004, that
12.2% of worldwide deaths were from ischemic heart
disease.
Rates of death from ischemic heart disease (IHD) have
slowed or declined in most high-income countries.
In contrast, IHD is becoming a more common cause of
death in the developing world. For example in India,
IHD had become the leading cause of death by 2004.
Risk Factors of MI
High blood pressure
- Alone or in association with obesity, smoking, high blood
cholesterol levels or diabetes, high blood pressure increases
the risk of myocardial infarction and stroke.
Smoking
- Smoking appears to be the cause of 20% of coronary artery
disease.
- Tobacco smoking (including secondhand smoke) and shortterm exposure to air pollution such as carbon monoxide,
nitrogen dioxide, and sulfur dioxide have been associated
with MI.
- Smokers also have a two to four time higher risk of sudden
cardiac death (within an hour of a heart attack).
Diabetes
- Approximately two-thirds of patients with
diabetes die from heart or blood vessel
disease. Adults with diabetes are three to
seven times more likely to develop heart
disease.
- A recent recommendation from the U.S.
government advocates aggressive treatment
of high cholesterol in people with diabetes.
Management of MI
Ways to reduce the risk of MI:
Quit smoking
- Smokers have more than twice the risk for heart attack as
nonsmokers.
- If you smoke, quit. Better yet, never start smoking at all.
- Nonsmokers who are exposed to constant smoke (such as living
with a spouse who smokes) also have an increased risk.
Control diabetes
- If not properly controlled, diabetes can contribute to significant
heart damage, including heart attacks and death.
- Control diabetes through a healthy diet, exercise, maintaining a
healthy weight, and taking medications as prescribed by your
doctor.
Get active
- Many of us lead sedentary lives, exercising infrequently or
not at all.
- People who don't exercise have higher rates of death and
heart disease compared to people who perform even mild to
moderate amounts of physical activity.
- Even leisure-time activities like gardening or walking can
lower your risk of heart disease. Most people should exercise
30 minutes a day, at moderate intensity, on most days.
Control high blood pressure
- Nearly one in three adults has systolic blood pressure (the
upper number) over 140, and/or diastolic blood pressure (the
lower number) over 90, which is the definition of
hypertension.
- Control blood pressure through diet, exercise, weight
management, and if needed, medications.
Manage stress
- Poorly controlled stress and anger can lead to
heart attacks and strokes.
- Use stress and anger management techniques to
lower your risk.
- Learn to manage stress by practicing relaxation
techniques, learning how to manage your time,
setting realistic goals, and trying some new
techniques such as guided imagery, massage, Tai
Chi, or yoga.