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