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  <head>
    <title>009-02 Coronary flow, congestion phenotypes, and structural decision-making</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Coronary flow, congestion phenotypes, structural decisions">
      <outline text="Coronary flow and perfusion">
        <outline text="Epicardial arteries and resistance vessels"/>
        <outline text="Collateral channels"/>
        <outline text="Perfusion pressure and diastolic time"/>
        <outline text="An open artery with microvascular limitation"/>
        <outline text="Collaterals beyond a chronic severe stenosis"/>
        <outline text="Anatomy, flow and injury are not identical"/>
      </outline>
      <outline text="Plaque and thrombus">
        <outline text="Lipid retention and inflammation"/>
        <outline text="Smooth-muscle response and matrix turnover"/>
        <outline text="Vulnerability beyond percentage narrowing">
          <outline text="Cap integrity and inflammatory activity"/>
          <outline text="Core composition and mechanical stress"/>
        </outline>
        <outline text="Disruption exposes thrombogenic material"/>
        <outline text="Platelets adhere, thrombin forms fibrin"/>
      </outline>
      <outline text="Ischaemia and injury">
        <outline text="Metabolism and relaxation change first"/>
        <outline text="Then contraction and electrical properties"/>
        <outline text="Membrane integrity fails if severe and prolonged"/>
        <outline text="Wall-motion change precedes necrosis markers"/>
        <outline text="Electrical instability from altered ion gradients"/>
        <outline text="Imbalance without acute plaque thrombosis">
          <outline text="Tachyarrhythmia, hypertension, hypoxaemia, anaemia"/>
          <outline text="The wrong label adds bleeding risk"/>
        </outline>
      </outline>
      <outline text="Troponin and ischaemic evidence">
        <outline text="A rise or fall shows dynamic injury"/>
        <outline text="Infarction needs ischaemic causation">
          <outline text="Symptoms and electrocardiographic evolution"/>
          <outline text="New regional imaging change or coronary thrombus"/>
        </outline>
        <outline text="Sampling interval and assay precision"/>
        <outline text="Chronic elevation with structural or kidney disease"/>
        <outline text="Compare with previous values and trajectory"/>
        <outline text="One non-diagnostic tracing does not dismiss risk"/>
      </outline>
      <outline text="Congestion, perfusion, diuresis">
        <outline text="Wet or dry by filling pressure"/>
        <outline text="Warm or cold by peripheral perfusion"/>
        <outline text="Cold congestion means limited reserve"/>
        <outline text="Warm limbs do not exclude high pressures"/>
        <outline text="Left-sided: interstitial oedema, poor compliance"/>
        <outline text="Right-sided: raised systemic venous pressure"/>
        <outline text="Renal venous hypertension cuts filtration"/>
        <outline text="Natriuretic peptides need context">
          <outline text="Obesity suppresses concentration"/>
          <outline text="Age, kidneys, atrial fibrillation raise it"/>
        </outline>
        <outline text="Diuretic delivery, tubular secretion, sodium load"/>
        <outline text="Apparent resistance: adherence, absorption, dose"/>
      </outline>
      <outline text="Disease-modifying therapy">
        <outline text="Renin-angiotensin-aldosterone blockade"/>
        <outline text="Evidence-based beta blockade"/>
        <outline text="Mineralocorticoid receptor antagonism"/>
        <outline text="Sodium-glucose cotransporter two inhibition"/>
        <outline text="Titrate against pressure, potassium, kidneys"/>
        <outline text="An early filtration change is not always injury"/>
        <outline text="Preserved ejection fraction is heterogeneous">
          <outline text="A normal resting study can miss exertional pressure"/>
        </outline>
      </outline>
      <outline text="Valve lesions as loads">
        <outline text="The gradient rises with flow"/>
        <outline text="Low gradient despite severe narrowing"/>
        <outline text="Integrate area, gradients, function, symptoms"/>
        <outline text="Chronic regurgitation allows chamber adaptation"/>
        <outline text="Acute regurgitation has no time to adapt"/>
        <outline text="Loudness follows flow and pressure difference"/>
        <outline text="Intervene before irreversible damage"/>
      </outline>
      <outline text="Atrial fibrillation and embolism">
        <outline text="Electrical and structural disease together"/>
        <outline text="Stretch, fibrosis, inflammation, autonomic triggers"/>
        <outline text="Rapid activation drives further remodelling"/>
        <outline text="Rate control limits the ventricular response"/>
        <outline text="Rhythm control by cardioversion, drugs, ablation"/>
        <outline text="Neither strategy removes stroke-risk assessment"/>
        <outline text="Stasis, endothelial change, prothrombotic state"/>
        <outline text="Bleeding review finds modifiable hazards"/>
        <outline text="Mechanical recovery lags electrical restoration"/>
      </outline>
      <outline text="Integrating mechanisms">
        <outline text="One deterioration, several mechanisms"/>
        <outline text="Ischaemia weakens contraction and provokes regurgitation"/>
        <outline text="Rapid atrial fibrillation unmasks valve disease"/>
        <outline text="Name the dominant mechanism, not every abnormality"/>
        <outline text="Trajectory after treatment tests the causal model"/>
      </outline>
      <outline text="Discharge and follow-up after intervention">
        <outline text="Rest-time improvement is not long-term stability"/>
        <outline text="Residual congestion, standing pressure, walking tolerance"/>
        <outline text="Name the symptoms that warrant early contact"/>
        <outline text="Fix the up-titration plan, test timing and who reviews"/>
        <outline text="Residual microvascular disease after revascularisation"/>
        <outline text="Recovery after valve treatment, recurrence after ablation"/>
      </outline>
    </outline>
  </body>
</opml>
