C reactive protein

C reactive protein (CRP) is a non-specific marker of inflammation and concentrations are raised in a wide variety of inflammatory disorders. High sensitivity assay methods allow accurate measurement of small increases in CRP and there is evidence that raised concentrations are an independent risk factor for myocardial infarction, peripheral vascular disease, and stroke. The reference range for CRP is 0-2.5 mg l Figure 3.2 Relative risks of myocardial infarction in apparently healthy men...

Problems With Targeting Absolute Risk

The principle of targeting treatment at high absolute CHD risk rather than high cholesterol is now accepted for statin treatment, but the similar policy for antihypertensive treatment is less widely known and practised. Antihypertensive treatment was targeted at defined blood pressure thresholds for decades, and the idea that treatment to lower blood pressure should not be targeted at blood pressure but at CHD risk is difficult for some to grasp. This difficulty is compounded by the intense...

Importance Of Absolute Risk In Hypertension

Hypertension is consistently associated with an increased risk of cardiovascular complications, including stroke, myocardial infarction, heart failure, and renal failure. Antihypertensive treatment decreases the risk of all cardiovascular complications by about 25 , largely through reducing stroke by 38 and coronary events by 16 .6 A key point is that the relative risk reduction, 25 , is approximately constant across all groups of patients,2 meaning that it is similar in men and women, young...

Other Major Risk Factors

Major risk factors other than LDL cholesterol and diabetes are listed in table 3.1. Age, blood pressure, and high density lipoprotein (HDL) cholesterol, as well as total cholesterol, are used as continuous variables to calculate CHD risk in the current Joint British Societies' guidelines, together with cigarette smoking and diabetes as categorical variables.5 Alternatively age, hypertension, low HDL cholesterol, and family history of premature CHD can all be used as categorical variables to...

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Figure 12.2 Cumulative incidence of progression to aortic valve replacement in initially asymptomatic patients with severe aortic regurgitation and normal left ventricular function randomised to treatment with digoxin 0.25 mg daily or nifedipine 20 mg twice daily. Reproduced from Scognamiglio etal2 with permission of the Massachusetts Medical Society. Figure 12.2 Cumulative incidence of progression to aortic valve replacement in initially asymptomatic patients with severe aortic regurgitation...

Congenital heart disease

Intrauterine pulmonary vascular disease is unusual, and the disease generally starts at birth.12 The rate of change depends on the type of intracardiac abnormality, but some exceptional children appear to be genetically predisposed to develop an accelerated form of the disease. Endothelial cell damage, medial smooth muscle cell hyperplasia, hypertrophy, and site specific changes in cell phenotype are well described in early infancy12 (fig 22.2). Respiratory unit arteries, about half of which...

Arrhythmia Management General Considerations

Antiarrhythmic treatment of AF can be divided in three strategies termination of the arrhythmia in paroxysmal and persistent AF, maintenance of sinus rhythm in paroxysmal and persistent AF, and finally control of ventricular rate during paroxysmal, persistent, and permanent AF (table 18.1). Removal of precipitating factors such as pericarditis, pulmonary embolism, thyrotoxicosis or excessive alcohol intake may result in disappearance of the arrhythmia. For this reason, a thorough diagnostic...

Control Points For Gene Expression

All of the stages of gene expression are points at which regulation can be exerted. However, the primary point of control is at the level of transcription. Many promoters and enhancers of myocardial genes have been cloned and transcription factors Table 28.1 Some examples of key transcription factors expressed in the heart MADS box family MADS box family SAP domain family CTA(A T)4TAG CC(A T)6GG (AcrG box) Does not bind directly to DNA, but binds to SRF as co-factor TNNAGTG (high affinity) C(a...

Obesity

Obesity commonly precedes the development of hypertension, glucose intolerance, and dyslipidaemia. Several studies have shown a strong positive correlation between the degree of adiposity and fasting triglycerides, even after correcting for other variables. Plasma cholesterol is also positively correlated with body mass index, although less strongly than triglyceride, whereas HDL cholesterol is inversely correlated. The pattern of obesity is also important in that the metabolic effects of...

Epidemiology And Classification Of Dm1

The incidence of DM1 is estimated to be 1 in 8000 births and its worldwide prevalence ranges from 2.1 to 14.3 100 000 inhabitants.1 Based on the age of onset and on its clinical features, DM1 can be divided into three forms congenital, classical, and minimal, which may occur in the same kindred. Congenital DM1 presents at birth or during the first year of life in a severe form. It is characterised by neonatal hypotonia, facial diplegia, joint contractures, frequent and often fatal respiratory...

Fishing with chips the rise of microarrays

Increased use of robotics in molecular biology has led to ways of planting far more genetic information in the form of cDNA or oligonucleotide sequences onto solid matrices than achievable before. Indeed, a complete cDNA library can now be grid-ded onto a single filter (called a gene array), rather than the dozen or so we might have expected to use five years ago. The move to miniaturisation is exemplified by the development of DNA microarrays, where DNAs or oligonucleotides are printed onto...

Impaired glucose tolerance

Impaired glucose tolerance predicts cardiovascular events whether or not this is manifested as overt diabetes. Hyperinsulinaemia is a common accompaniment of impaired glucose tolerance and, as mentioned earlier, the two are frequently associated with other risk factors such as hypertension, obesity, and dyslipidaemia in the metabolic syndrome. Table 3.1 Major risk factors for CHD, other than LDL cholesterol and diabetes.4 Hypertension (> '40 90 mm Hg or on antihypertensive medication) Low HDL...

Aortic Stenosis

Calcific aortic stenosis may be caused by progressive calcification of a congenitally bicuspid valve, when it typically presents in the fourth and fifth decades of life, or senile calcification of a morphologically normal tricuspid valve when it tends to present later in life (fig 12.1). The disease appears to be an active process that has much in common with atherosclerosis and is probably mediated by mechanical stress (wear and tear), lipid deposition, and inflammation significant coronary...

Timing Of Surgical Correction Of Mitral Regurgitation

Mitral Jet

The timing of mitral surgery translates into a simple categorical answer when the patient is seen that is, should we advise the patient to have mitral surgery promptly or should we advise follow up with conservative management This process can be stratified according to aetiology and severity of mitral regurgitation. Severe mitral regurgitation patient has overt symptoms or left ventricular dysfunction These patients with severe mitral regurgitation with overt severe consequences should be...

References

The implantable cardioverter defibrillator. Lancet 2001 357 1107-17. C This article provides a thorough review of the details of device functioning and clinical trial data for health care professionals. 2 Engel GE. The need for a new medical model a challenge for biomedicine. Science 1977 196 129-36. 3 Sears SF, Todaro JF, Saia TL, et al. Examining the psychosocial impact of implantable cardioverter defibrillators a literature review. Clin Cardiol 1999 22 481-9. C All...

Clinical And Research Implications Related To

Psychosocial and QOL interventions for ICD patients Table 16.2 details each of the studies available that used psychosocial intervention for ICD patients. General methodological problems are consistent across studies. Firstly, the studies report on very limited sample sizes and incur a resulting low statistical power. Secondly, most of the studies were conducted using a support group format, which typically involves a participant led, unstructured approach rather than a professional led,...

Practical Issues In Exercise Testing

Exercise testing with concurrent measurement of gas exchange parameters can be undertaken using either treadmill or bicycle exercise protocols (table 9.1). Peak Vo2 has been found to be 10-20 higher on treadmill exercise compared to bicycle exercise. Patient familiarity is important and subjects who are unaccustomed to riding bicycles may be unable to sustain bicycle exercise for as long because of leg fatigue. It is important that patients are given time to become accustomed to the...

Consequences Of Erratic Compliance

Stopping and restarting an antihypertensive medication can be dangerous. Studies have demonstrated that omission of dose of a short acting calcium channel blocker or P blocker resulted in significantly increased systolic and diastolic pressure and heart rate during the following two days, with three patients developing rebound hypertension.14 Abrupt discontinuation of non-intrinsic sympathomimetic activity blockers can also result in rebound hypertension.15 Doxazosin, a peripheral vasodilator,...

Determinants of perioperative morbidity

C Extent of coronary artery disease c Ventricular function c Comorbid conditions c Extent of the surgical trauma c Use of cardiopulmonary bypass c Global ischaemic cardiac arrest c Manipulation and instrumentation of the ascending aorta return by utilising the Trendelenburg position with or without additional fluid load and inotropic support.w25 Conventional bypass surgery via full sternotomy and CPB with a decompressed and arrested heart provides sufficient visibility and space to construct...

Echocardiography

LVH on ECG, defined as increased voltage plus T wave abnormality, doubles CHD risk. However, LVH with T wave abnormality is uncommon in hypertensive patients. Echocardiography is more sensitive for detecting LVH in patients with hypertension. Many doctors equate higher sensitivity with more powerful risk prediction and believe that echo-cardiography is superior to the ECG for CHD risk estimation. This is incorrect. Because echocardiographic LVH is more prevalent it is a much less powerful...

Pulmonary hypertension and portal hypertension

An increased pulmonary arterial pressure can sometimes complicate the question of liver transplantation and necessitate careful haemodynamic assessment. The pathological features can resemble those found in hypertensive congenital heart disease, possibly caused by vasoconstriction because the damaged liver cannot degrade circulating vasoconstrictor mediator(s). But generalised pulmonary arterial dilatation can also occur. Pulmonary hypertension is not usually a contraindication to liver...

Aneurysm formation and left ventricular thrombus

True aneurysms complicate transmural infarction and are caused by dilatation of an area of scar (fig 24.5). An aneurysm is defined as deformation of both the diastolic and systolic LV contours with dyskinesis in systole. TTE is a sensitive tool for the diagnosis but occasional false negatives occur, usually when the aneurysm involves a small part of the apex or the Figure 24.3 (A) Subcostal long axis transthoracic image showing a large post-infarction rupture (arrow) in the mid inferior...

Development Of The Atrial Septum

During early development, the initially tubular heart is suspended along its length by a dorsal mesocardium. It is at this stage that the so-called straight tube can be recognised, albeit that it has been shown that, with time, this part of the tube gives rise only to the ventricular component of the definitive heart.1011 At the stage when the developing heart tube is straight, the outflow tract, the atrioventricular canal, and the primary atrium have all still to form. With continued growth,...

Paul Schoenhagen Steven Nissen

N 1856 the pathologist Vircho published his no classic observations on atherothrombosis based on the examination of postmortem tomographic artery sections. The Vircho triad describes three components contributing to the atherothrombotic disease process the vessel all, the blood constituents, and blood flo. In vivo coronary imaging techniques became available more than 100 years later ith the introduction of selective coronary angiography in 1958 by Mason Sones. Selective coronary angiography...

External and internal DC cardioversion

Since the description of direct current electrical cardioversion of AF by Lown in 1962, this procedure has been widely used for restoration of sinus rhythm.5 External cardioversion may be applied in the anterolateral or anteroposterior position and is successful in up to 90 of cases. Outcome depends on a carefully performed procedure using firm pressure on appropriately placed paddles and a sufficient amount of energy. Biphasic shocks are more effective than conventional monophasic shocks.w24...

Reactive oxygen species

The production of oxygen-free radicals peaks during the first 2-10 minutes of reperfusion after coronary artery occlusion. Sources of oxygen free radicals include the xanthine oxidase reaction, mitochondria, and polymorphonuclear cells. The superoxide dismutase pathway, normally responsible for the clearance of superoxide anions, may be altered after an ischaemic insult. Administration of superoxide dismutase in combination with catalase led to a notable reduction of no-reflow, and...