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Heart Disease
Paul Morris, David Warriner, Allison Morton
CHAPTER 1:
First principles
1.1 Cardiovascular anatomy
HEART
Surface anatomy and relations
Chambers and valves
Left atrium
Mitral valve
Left ventricle
Aortic valve and aortic root
Right atrium
Tricuspid valve
Right ventricle
Pulmonary valve
Blood supply and drainage
Arterial supply
Left coronary artery
Right coronary artery
Arterial dominance
Venous return
The cardiac conduction pathway
The bundle of His
The pericardium
VESSELS
Structure
Tunica intima
Tunica media
Tunica externa
Types
Elastic arteries
Muscular arteries
Arterioles
Capillaries
The microcirculation
Venules and veins
Key regional vascular anatomy
Carotid arteries
The gut
1.2 Development of the cardiovascular system
Development of the heart
Endocardial tubes
Looping
Atrioventricular septation
Ventricular septation
Atrial septation
Outflow tract septation
The conduction tissue
Development of vessels
Arterial development
Coronary arteries
Venous development
1.3 Cardiovascular physiology
Electrophysiology
Cardiomyocytes
Resting membrane potential
Stage 1
Stage 2
Stage 3
Stage 4
Gated ion channels
Cardiomyocyte depolarization
Phase 4: resting
Phase 0: depolarization
Phase 1: transient partial repolarization
Phase 2: plateau
Phase 3: repolarization
Refractory periods
Pacemaker depolarization
Pacemaker potentials
Pacemaker hierarchy
Conduction pathway
Cardiomyocyte contraction
Myofibrils
Sarcolemma
Myofibril contraction
Inotropism
Autonomic control of the heart
The sympathetic nervous system
Effects
The parasympathetic nervous system
The cardiac cycle
Atrial systole
Ventricular systole
Ventricular pressure increases
Ventricular ejection
Ventricular diastole
Ventricular relaxation
Atrioventricular valves open
Blood flow
Global control – the cardiovascular center
Cardiac output
Stroke volume
Heart rate
Total peripheral resistance
Vascular smooth muscle
Vascular tone
Coronary blood flow
Left coronary artery flow
Right coronary artery flow
Coronary flow reserve
Hemodynamics
Pressure, flow and resistance
Poiseuille's equation
Flow velocity
Laminar and turbulent flow
Blood pressure
Determinants of blood pressure
Control of blood pressure
Short-term control
Long-term control
Hemostasis
Vasoconstriction
Platelet aggregation
Platelet activation
The coagulation cascade
The extrinsic pathway
The intrinsic pathway
Thrombolysis
Anti-coagulation systems
Lipid metabolism
Polarity
Lipolysis
Regulation of lipolysis
Fatty acid oxidation
Glycerol
Lipogenesis
Acetyl coenzyme A synthesis
Malonyl coenzyme A synthesis
Fatty acid synthase
Further elongation
Unsaturation of fatty acids
Regulation of fatty acid metabolism
Prostaglandins
Cholesterol metabolism
Cholesterol synthesis
Cholesterol absorption
Cholesterol esterification
Lipid absorption and transport: lipoproteins
Types
Pathways
The exogenous pathway
The endogenous pathway
Intracellular cholesterol transport
Reverse cholesterol transport
CHAPTER 2:
Clinical essentials
2.1 History taking
Symptoms
Chest pain
Dyspnea
Palpitations
Syncope
Ankle swelling
Types
Taking a history
Presenting complaint
History of presenting complaint
Past medical history
Drug history
Allergy history
Family medical history
Social history
Systems review
Summary
2.2 Cardiovascular examination
Starting the examination
General inspection
Hands
Finger clubbing
Signs of infective endocarditis
Palmar erythema
Peripheral cyanosis
Capillary refill time
Arterial pulse
Radial pulse
Carotid pulse
Respiration
Head and neck
Jugular venous pulse
Chest
Inspection
Palpation
Auscultation
Lungs
Lower limb
Inspection
Palpation
Abdomen
Blood pressure
Pulse pressure
Mean arterial pressure (MAP)
Blood pressure symmetry
Fundi
Diabetic retinopathy
Hypertensive retinopathy
2.3 Investigations
Blood tests
Cardiac biomarkers
Lipid profiles
Electrocardiography (ECG)
Leads
The 12-lead ECG
Chest leads
Limb leads
Virtual leads
The ECG shape
Cardiac axis
Analysis of the ECG
BP and ECG monitoring
Exercise testing
Imaging
Chest radiography
Ultrasound
Echocardiography
Nuclear medicine
Computed tomography
Magnetic resonance imaging
Cardiac catheterization
2.4 Cardiovascular risk assessment
Uses
Risk factors
Assessment tools
When not to use risk assessment tools
2.5 Conservative management
Smoking cessation
Exercise
Alcohol
Diet
2.6 Medication
Lipid-lowering drugs
Statins
Other lipid-lowering drugs
Anti-coagulants
Coumarins
Heparins
Novel oral anticoagulants
Anti-platelet drugs
Salicylic acid
Thienopyridines
Anti-arrhythmic drugs
Class I
Class II
Class III
Class IV
Class V
Diuretics
Loop diuretics
Thiazide diuretics
Potassium sparing diuretics
Mineralocorticoid receptor antagonists
Anti-hypertensives
Alpha-blockers
Angiotensin converting enzyme inhibitors
Angiotensin II receptor blockers
Hydralazine
Calcium channel blockers (dihydropyridines)
Anti-anginal drugs
Nitrates
Nicorandil
Ivabradine
Ranolazine
2.7 Surgical management
Percutaneous coronary intervention
Arterial bypass
Arterial repair
Heart transplantation
Valve repair/replacement
Myocardial repair and support
CHAPTER 3:
Atherosclerosis
3.1 Clinical scenario
Painful, cold right foot
Presentation
Diagnostic approach
Further history
Examination
Diagnostic approach
Investigations
Diagnosis
3.2 Atherosclerosis
Epidemiology
Etiology
Location
Prevention
Pathogenesis
Clinical features
Diagnostic approach
Investigations
Management
Prognosis
CHAPTER 4:
Hypertension
4.1 Clinical scenario
Opportunistic blood pressure measurement
Presentation
Diagnostic approach
Further history
Examination
Diagnostic approach
Investigations
Diagnosis
4.2 Essential hypertension
Types
Epidemiology
Etiology
Clinical features
Investigations
Management
Medication (Figure 4.3)
4.3 Secondary hypertension
Clinical features
Investigations
Management
4.4 Hypertensive emergencies
CHAPTER 5:
Hyperlipidemia
5.1 Clinical scenario
Skin lesions and chest pain
Presentation
Diagnostic approach
Further history
Diagnostic approach
Examination
Diagnostic approach
Investigations
Diagnosis
5.2 Hyperlipidemia
Types
Epidemiology
Etiology
Primary
Secondary causes
Clinical features
Diagnostic approach
Investigations
Management
Diet and exercise
Medication
5.3 Familial hypercholesterolemia
Epidemiology and etiology
Homozygous FH
Heterozygous FH
Clinical features
Homozygous FH
Heterozygous FH
Diagnostic approach
Management
CHAPTER 6:
Coronary heart disease
6.1 Clinical scenario
Pain radiating across chest and down left arm
Presentation
Diagnostic approach
Further history
Diagnostic approach
Examination
Diagnostic approach
Investigations
Diagnosis
6.2 Angina
Epidemiology
Risk factors
Pathogenesis
Clinical features
Clinical signs
Investigations
Management
Medication
Surgery
Prognosis
6.3 Acute coronary syndromes
Types
Epidemiology
Etiology
Pathogenesis
Clinical features
Angina
Dyspnea
Signs
Investigations
Chest X-ray
Electrocardiography
Blood tests
Coronary angiography
Management
Unstable angina
NSTEMI
STEMI
Prognosis
6.4 Complications of myocardial infarction
Arrhythmia
Clinical features
Management
Cardiac arrest
Clinical features
Management
Rupture of myocardial structures
Clinical features
Management
Ongoing ischemia or recurrent myocardial infarction
Clinical features
Management
Left ventricular thrombus
Clinical features
Management
Pericarditis
Clinical features
Management
CHAPTER 7:
Arrhythmias
7.1 Clinical scenario
Lethargy and fainting
Presentation
Diagnostic approach
Further history
Examination
Diagnostic approach
Investigations
Diagnosis
7.2 Mechanisms of arrhythmia
Conduction block
Ectopic beats
Re-entry
Triggered activity and after-depolarizations
CHD arrhythmogenesis
Ischemia
Electrochemistry
Sympathetic activation
Infarction
7.3 Bradyarrhythmias
Cardiac pauses
Clinical features
Investigations
7.4 Tachyarrhythmias
Supraventricular/narrow complex tachyarrhythmias
Epidemiology
Etiology
Atrioventricular nodal re-entry tachycardia
Atrioventricular reciprocating tachycardia
Atrial flutter
Atrial tachycardia
Atrial fibrillation
Clinical features
Investigations
Management
Vagal manoeuvers
Medication
Catheter ablation
Prognosis
Ventricular tachycardia
Types
Etiology
Clinical features
Investigations
Underlying cause
Electrophysiology
Quantifying risk
Management
Medication
Surgery
Cardioverter defibrillators
Prognosis
Ventricular fibrillation
7.5 Atrial fibrillation
CHAPTER 8:
Heart failure
8.1 Clinical scenario
Breathlessness at night, ankle swelling and cough
Presentation
Diagnostic approach
History
Diagnostic approach
Examination
Diagnostic approach
Investigations
Diagnosis
8.2 Chronic heart failure
Physiology – systolic versus diastolic
Epidemiology
Etiology
Prevention
Pathogenesis
Clinical features
Investigations
Management
Lifestyle modification
Medication
Devices
Surgical management
Prognosis
8.3 Acute heart failure
Epidemiology
Etiology
Prevention
Clinical features
Investigations
Management
CHAPTER 9:
Prevention of cardiovascular disease
9.1 Preventive measures
Calculating cardiovascular risk
Risk factor reduction
Behavioral change
Smoking
Physical activity
Diet
Weight
Blood pressure
Lipids
Diabetes
Stress
Aspirin
9.2 Secondary prevention/cardiac rehabilitation
Management of stable angina
INDEX
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Index
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