CARDIOVASCULAR SYSTEM

 

ISCHEMIC HEART DISEASE

 

A)      ACUTE MYOCARDIAL INFARCTION -

 

Very little can be done other than supportive measures. Complete Artery occlusion may not necessarily cause Myocardial Infarction owing to numerous collaterals which develop to maintain perfusion.

 

Depending on the size if the infarction , 50 % die and 50% survive 10 years. Of those who die, half die in the first 3 hours, 1/4th die within the first year, all despite the modern intensive care treatment.

 

The so- called life saving reperfusion mode of action via dissolving the clot is questionable. Complete Ischaemia takes only 30 mins to initiate irreversible Myocardial damage . So repurfusion after that should be logically useless. Reperfusion arrythmias and injuries by themselves are very harmful.

 

The injured infarcated myocardial and endothelial cells release tissue Plasminogen activated by a day which converts Plasminogen in Plasma to Plasma to Plasmin which lyses the clots.

 

B)      Cardiogenic Shock carries poor prognosis despite adequate treatment.

 

C)      Most arrythmias are harmless other than V- tach or V- fibrillation. The excitatory automaticity in excitatory tissues of the heart are multiple - atrium (SAN), AV node RBBB, LBBB and also the lower the tissue, the loweris the rate of impulse generation. If a high pacemaker fails, a lower cetopic pacemaker overtakes.

 

D)      Studies have shown patients treated at home do much better than patients treated in ICCU.

 

E)      Aspirin prevented only 2.5 % death / AMI in 1000 treated cases & Betablockers only 4.2 % in 1000 treated. Aspirin decreases the incidences of AMI and increases incidence of peptic ulcer. Lipid lowering agents prevented only 3.7% events (Secondary prevention after one AMI )

 

PTCA has failure rate of 36 % of 6 months and CABG has more than 50 % failure rate at 10 years with 5 % neurological  complications.PTCA controls symptoms better but with more frequent cardiac events. & has little effect on overall mortality.

 

 

HYPERTENSION

 

A)      Normal Blood Pressure has not yet been defined. Any definition of Hypertension is    therefore arbitrary.According to the Framingham study , one half of the white population have BPs more than 140 /90 & one fifth more than 160 /95.

 

B)      1423 young patients have to be treated with Beta- Blockers to prevent one stroke and 286 old patients have to be treated to prevent 1 stroke.

 

C)      The figures are even less correlative for heart attacks (MRC trails ).

 

D)      Hypertensive Encephalopathy is simply an association of Encephalopathy with coincidental high BP with a questionable cause effect relationship.

 

E)      In malignant Hypertension it is unwise to lower BP too quickly as this may compromise tissue perfusion and cause brain damage like occipital blindness or precipitate coronary or Renal insufficiency.

 

F)      Hypertension can never cause increased bleeding , cerebral Oedema , Haemorrhage as the precapillary sphincter contracts by autoregulatory mechanisms and even if BP systolic rises by 150 % the capillary pressure rises by less than 30% only.

 

 

VALVULAR HEART DISEASE

              

A)      Mitral Regurgitation / Aortic Regurgitation are usually asymptomatic and Aortic  Stenosis is very slowly progressive or asymptomatic.

 

B)      Mitral Stenosis presents gradually over years . Hypertrophy of various relevant chambers of the heart make- up for the deficit by maintaining cardiac output.

 

C)      Atrial Fibrillation is usually associated with an AV block which is protective.

 

D)      Gradual occurrence if Left Heart Failure tends to increase Pulmonary arteriolar resistance ( PH ) which protects against pulmonary oedema.

 

E)      Right Heart Failure is well compensated by fluid loss into the peritoneal cavity (Ascites), interstitium (oedema) . Hepatomegaly and hepatic and Splenic congestion actually decongest the venous return by holding a large portion of Blood volume. This compensates the failure since the liver can accomodate large amount of Blood volume.

 

Acute exacerbations are caused by factors like Anaemia , Infections, Excess salt, stress and rise in BP,which settles down with removal of the precipitating factor.. 

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