--- module: 009-01 language: en chapter: 9 title: "Ischaemia, Heart Failure, Valve Disease, and Arrhythmia" module_title: "Foundations" source_sha256: d4df267932d791c0f53ff11af5a3c10885b86d1c7071c164a44779e95def65ac --- # Ischaemia, heart failure, valve disease and arrhythmia ## Orientation ### Supply, pump, valve, rhythm, vascular control ### The categories overlap and feed each other ### No single finding makes the diagnosis ## Atherosclerosis ### A disease of the arterial intima ### Endothelial dysfunction admits apolipoprotein B lipoproteins ### Monocytes, macrophages, foam cells ### Smooth muscle, matrix, inflammation, calcification ### Fibrous cap over a lipid-rich core ## Coronary syndromes ### Plaque burden limits flow on exertion ### Disruption or erosion, platelets, thrombus ### The culprit need not be the tightest lesion ### Other routes to ischaemia #### Spasm, embolism, dissection #### Microvascular disease #### Severe supply-demand imbalance ### Stable angina: exertion, relief with rest ### Acute symptoms at rest, longer, with autonomic features ## Infarction and troponin ### Injury with evidence of acute ischaemia ### Troponin shows injury, not its cause #### Myocarditis, tachyarrhythmia, heart failure #### Pulmonary embolism, critical illness, kidney disease ### Rise and fall read with symptoms and context ### Fifth Universal Definition #### Primary: acute coronary pathology #### Secondary: another acute illness driving imbalance #### Procedure-related: within thirty days ### Separate injury, ischaemia and cause ## Early management ### Recognition, electrocardiography, monitoring ### Antiplatelet and antithrombotic decisions ### Timely reperfusion for suspected occlusion ### Oxygen for hypoxaemia, not routinely ### Bleeding risk, kidneys, alternative diagnoses ## Heart failure ### Low output, high filling pressure, or both ### Reduced, mildly reduced, preserved fraction ### Preserved fraction is not normal function ### Low forward output: fatigue, cool limbs, kidney dysfunction ### Left-sided congestion #### Orthopnoea and paroxysmal nocturnal dyspnoea #### Pulmonary oedema ### Right-sided congestion #### Raised jugular venous pressure and hepatic congestion #### Ascites and peripheral oedema ### Compensation that helps then harms #### Sympathetic and renin-angiotensin-aldosterone activation #### Afterload, demand, fibrosis and arrhythmia rise ### Natriuretic peptides vary with age, kidneys, obesity, rhythm ### Acute diuresis against chronic disease modification ## Valve disease ### Stenosis: obstruction and pressure load ### Regurgitation: backward flow and volume load ### Aortic stenosis: pressure overload, concentric hypertrophy ### Murmur intensity misleads when output is low ### Chronic aortic regurgitation widens pulse pressure ### Acute regurgitation gives no time to adapt ### Mitral stenosis: atrial enlargement, atrial fibrillation ## Arrhythmia ### Atrial fibrillation may be silent or disabling ### Rate, rhythm, precipitants, thromboembolic risk ### Regular narrow tachycardia suggests supraventricular re-entry ### Treat broad-complex tachycardia as ventricular ### Unstable rhythm: synchronised cardioversion ### Pulseless rhythm: defibrillation and resuscitation ### Bradycardia: drugs, nodal disease, block, ischaemia ## Pericardium and myocardium ### Pleuritic pain eased by sitting forward ### A rub is specific but transient ### Tamponade: obstructive physiology, pulsus paradoxus ### Rapid fluid tamponades at a smaller volume ### Myocarditis from silent injury to shock ### Avoid strenuous exercise during active inflammation ## Prevention and follow-up ### Absolute risk guides intensity ### Secondary prevention after atherosclerotic disease ### Track weight, volume, rhythm, kidneys, electrolytes ### Rehabilitation: activity, education, recovery