Treatment for Sleep Apnea

Treatment and management
The goals of treating obstructive sleep apnea are to:
• Restore regular breathing during sleep
• Relieve symptoms such as loud snoring and daytime sleepiness
- Lifestyle changes is only for mild OSA
Lifestyle Changes
If you have mild sleep apnea, some changes in daily activities or habits may be all that you need.
• Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep. (alcohol causes URT muscle to relax)
• Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
• Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
• Keep your nasal passages open at night with nose sprays or allergy medicines, if needed. Talk to your doctor about whether these treatments might help you.
• Stop smoking.
• Gargle with salt water (without swallowing) to shrink your tonsils.
• Develop regular sleep habits, and make sure you get enough sleep at night.
• Use an air humidifier at night.
Mouthpiece/oral appliance
- Help with mild OSA or snoring
- Customize to fit different patients, plastic made.
- It adjust your lower jaw and your tongue to help keep your airways open while asleep.
- Make sure it is comfortable, adjustable.
-
Breathing Devices
CPAP – continuous positive airway pressure for moderate to severe sleep apnea in adults.
- It’s a mask that fits over mouth and nose and blows air into the throat.
- Air pressure adjusted to avoid airway being narrowed or blocked during sleep
- Sleep apnea returns if CPAP stops or not used correctly
- Machine set up by a technician with doctor’s orders
- May cause side effects, dry or stuffy nose, irritated skin on face, sore eyes, and headaches, stomach bloating and discomfort.
- Nasal spray and adding moisture to air is helped to relieve SE.
There is no drug that completely treats sleep apnea. Some of the drugs used in combination with CPAP include:
• Medroxyprogesterone -- side effects may include nausea, depression, excess hair growth, breast tenderness, and fluid retention.
• Protriptyline -- this medication is used rarely. Side effects may include dry mouth, constipation, frequent urination, impotence, and confusion (in the elderly).
• Modafinil -- sometimes prescribed in combination with CPAP to treat excessive daytime sleepiness.

Surgery
- To widen breathing passage, involves removing, shrinking or stiffening excess tissue in the mouth and throat or resetting the lower jaw.
- Shots to shrink tissue or plastic pieces inserted to stiffen loose tissue.
- Surgery to remove tonsils maybe helpful for children. Or wait for tissues to shrink by itself.
Uvulopalatopharyngoplasty (UPPP) -- The operation involves the removal of the uvula and back of the soft palate, often accompanied by tonsillectomy.
In UPPP, soft tissue on the back of the throat and soft palate (the uvula) is removed.
UPPP does not address apnea or snoring caused by obstructions at the base of tongue.
• First patient undergoes soft tissues surgeries, UPPP together with genioglossus advancement or hyoid suspension and usually fails
• Then a maxillomandibular advancement surgery to move the top jaw and bottom jaw forward. (pulling tongue forward)
• High rates of complication
Surgeons usually use either conventional scalpel techniques or newer laser methods (LAUP, or Laser-Assisted Uvulopalatoplasty). LAUP may have a higher rate of success than UPPP, but it also requires the expertise of a surgeon highly skilled in laser procedures.
LAUP Treatment Procedure
A laser beam to remove and tighten floppy soft palate tissue in the back of the mouth, thereby reducing the amount that these tissues contribute to snoring.
LAUP causes mild discomfort after surgery. Local anesthestic.
LAUP needs up to five treatments spaced four to eight weeks apart (although one to three are usual).

Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are anatomical problems (rarely done)
General anesthesia, exposure of the tracheal cartilage rings. The surgeon then creates an opening into the trachea and inserts a tracheostomy tube.
Complementary and Alternative Therapies
Useful in treating sleep apnea caused by allergies.
Homeopathy and nutrition are most likely to have a positive effect.
Nutrition and Supplements
• Diet: Try eliminating mucus-producing foods (such as bananas) for 2 weeks, then reintroducing them to see if you notice any difference in sleepiness or other symptoms.
• Essential fatty acids (EFAs) moderate inflammatory response and decrease allergic response. EFAs are low in obese people. Fish oil, evening primrose oil, flaxseed oil, and borage oil all contains essential fatty acids.
Acupuncture
Some evidence suggests that a type of acupuncture called auriculotherapy acupoint pressure may help treat sleep apnea.


http://www.umm.edu/altmed/articles/sleep-apnea-000156.htm
http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html
http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm
http://www.sleepdisordersguide.com/topics/laup.html
http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm

Complications & Prognosis Of OSA

Common Problems
¢CVS Problems
¢Daytime Fatigue
¢Complications with Medicine & Surgery
¢Sleep-deprived partners
¢Nocturia
¢Impotence =P
¢GERD
¢ADHD

Daytime Fatigue
¢OSA make normal, restorative sleep impossible.
¢experience severe daytime drowsiness, fatigue and irritability.

Nocturia
¢Increased pressure=increased preload=increased CO
¢Heart works harder
¢Release of ‘atrial natriuretic peptide’(ANP) from atrial myocytes.
¢Function of ANP?

Impotence
¢Many hypothesis….still not confirmed
1.Many men have erections during REM sleep. I don’t okay… Since patients have less sleep..therefore less REM erections.
2.Levels of testosterone drops in patients with sleep OSA. Less testosterone=less manhood=ED

GERD
¢phrenoesophageal ligament (PEL) connects the diaphragm to the lower esophageal sphincter (LES).
¢During OSA ,increased respiratory effort by the diaphragm.
¢PEL will open the LES due to increased activity of diaphragm when threshold is reached.
¢Gastric fluid enter esophagus.

CVS Problems
¢Blood oxygen levels drop.Furthermore, levels of NO drops. Increase in blood pressure leading to hypertension.
¢Severe hypoxia/hypoxemia leads to sudden death…

Attention Deficit Hyperactivity Disorder(ADHD)
¢Definition=co-existence of attentional problems and hyperactivity, with each behavior occurring frequently together.empirical evidence that there is overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.

Prognosis
¢Untreated:
1.life-threatening.
2.Fall asleep at inappriopriate times.
Impt: no cure for sleep apnea!!

Are children predisposed to snoring if their parents are ‘snorers’?
¢Chest(April 2006)
¢Researchers from Cincinnati Children's Hospital studied 681 children, 45% girls, 80% white.
¢parents filled in questionnaires-to determine if there was a link.
¢20% of the mothers and 46% of the fathers were habitual snorers .

Result
¢Incidence of snoring among infants who had at least one parent who was a habitual snorer was 3 X>than infants whose parents did not snore.

Definition, Apopnea-Hypopnoea Index (AHI) , anatomy

Definition of OSA
- a sleep disorder
- Pauses in breathing during sleep due to airway obstruction
- 1 or more breaths are missed during each episode, occurring repetitively throughout sleep
- Breathing is interrupted by obstruction in airway despite the effort to breathe, preventing an adequate flow of air

Apopnoea-Hypopnoea Index
• To assess the severity of sleep apnoea
• Total number of complete cessation (apnoea) and partial obstructions (apopnoea) of breathing occurring per hour of sleep
• Pauses in breathing must last for 10s

Classification :
•Mild = 5-15
•Moderate = 15-30
•Severe = >30

Anatomy (the ones i think are relevant to Karim's case)
- Mouth
- tongue
- palate
- tonsils
- trachea

Diabetic Screening Test

TESTS
The best screening test for diabetes, the fasting plasma glucose (FPG), is also a component of diagnostic testing. The FPG test and the 75-g oral glucose tolerance test (OGTT) are both suitable tests for diabetes; however, the FPG test is preferred in clinical settings because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive. An FPG ≥126 mg/dl (7.0 mmol/l) is an indication for retesting, which should be repeated on a different day to confirm a diagnosis. If the FPG is <126 mg/dl (7.0 mmol/l) and there is a high suspicion for diabetes, an OGTT should be performed. A 2-h postload value in the OGTT ≥200 mg/dl (11.1 mmol/l) is a positive test for diabetes and should be confirmed on an alternate day. Table 2 presents the diagnostic criteria for diabetes. Fasting is defined as no consumption of food or beverage other than water for at least 8 h before testing.
Nondiabetic individuals with an FPG ≥110 mg/dl (6.1 mmol/l) but <126 mg/dl (7.0 mmol/l) are considered to have IFG, and those with 2-h values in the OGTT ≥140 mg/dl (7.8 mmol/l) but <200 mg/dl (11.1 mmol/l) are defined as having IGT. Both IFG and IGT are risk factors for future diabetes. Normoglycemia is defined as plasma glucose levels <110 mg/dl (6.1 mmol/l) in the FPG test and a 2-h postload value <140 mg/dl (7.8 mmol/l) in the OGTT.

If necessary, plasma glucose testing may be performed on individuals who have taken food or drink shortly before testing. Such tests are referred to as casual plasma glucose measurements and are given without regard to time of last meal. A casual plasma glucose level ≥200 mg/dl (11.1 mmol/l) with symptoms of diabetes is considered diagnostic of diabetes. A confirmatory FPG test or OGTT should be completed on a different day if the clinical condition of the patient permits.
Laboratory measurement of plasma glucose concentration is performed on venous samples with enzymatic assay techniques, and the above-mentioned values are based on the use of such methods. The A1C test values remain a valuable tool for monitoring glycemia, but it is not currently recommended for the screening or diagnosis of diabetes. Pencil and paper tests, such as the American Diabetes Association’s risk test, may be useful for educational purposes but do not perform well as stand-alone tests. Capillary blood glucose testing using a reflectance blood glucose meter has also been used but because of the imprecision of this method, it is better used for self-monitoring rather than as a screening tool.

role of GP+fitness for driving+insurance

a health assessment is done before a driving permit is given

sleep problems
vision
dibetis
heart problems
epilepsy
blackouts and fainting
psychiatric disorders
age related decline


The Driver Licensing Authority always makes the final decision


Generally, only longer-term conditions will impact on your
licence status and will need to be reported to the
Driver Licensing Authority.
The relationship between you and your doctor is confidential,
therefore your doctor will not normally communicate directly
with the Driver Licensing Authority. He or she will provide
you with advice about your ability to drive as well as with
a letter or report to take to the authority.

In South Australia and the Northern Territory,
however, doctors are required by law to report
drivers who they believe to be medically unfit
to drive to the Driver Licensing Authority.

http://www.austroads.com.au/aftd/cvd.html



Apnea Index of:
0-10 - typically no additional life insurance cost
11-20 - 50% table rating increase over standard life insurance rates
21-30 - 100% table rating increase over standard life insurance rates
31-40 - 150% table rating increase over standard life insurance rates
Above 40 - decline.

http://www.lifeinsuranceadvisors.com/life-insurance-for-sleep-apnea.html

6 steps to management of asthma and yoga breathing exercises

To get back the natural and automatic diaphragmatic breathing, and not the thoracic type of breathing
To concentrate on exhalation especially at the commencement of an attack
Increasing the flexibility of the chest wall and to relax the accompanying muscles of the respiratory system and
To correct other problems commonly associated with chronic asthma


Since few of us are immune to the constant stresses and strains of modern life, most of us tend to take short shallow breaths, using only a half to two thirds of our lung capacity.
And asthmatics chronically over-breathe, often at a rate two to three times faster than normal which robs the cells of essential fuel versus providing more oxygen.

The more stress, pressure and emotion we experience, the more restricted the breath becomes, as the alarm bells of the sympathetic nervous system are constantly being rung.
This perpetuates the cycle of stress, anxiety and shallow breathing. This in turn deprives the body of oxygen

Benefits
Increased efficiency of each breath
Increased lung capacity
Increased flow of oxygen to all parts of the body
Increase concentration, creativity and cognitive brain functions
Increase relaxation and calmness by releasing tension
Improved mind and body control, helping control emotions and relieve tension.
Improved abdominal and diaphragm control and strength.

Step 1
If you recognise any of the following symptoms then you probably have moderate to severe
asthma:
• If you need asthma medication most weeks of the year.
• If you have needed urgent medical attention for asthma in the past year or so.
• If your peak flow measurement is consistently below expected, despite optimal
treatment.
Assess the severity of your asthma and have it checked by your doctor.

Step 2
When you are at your best you should ideally have:
• No symptoms.
• Best possible peak flow measurements and
• Your chest should sound normal when your doctor examines you. It may take a few
weeks of medication to achieve your best. Monitoring peak flow measurements at
home can help you to check your progress.
When you have reached your best you will probably feel much better.

Step 3
Find out what sets off your asthma and try to stay away from it. These triggers could be:
• House dust, pollens, pets, moulds.
• Tobacco smoke.
• Things around your workplace or school, like wood dust, flour dust, chemical fumes,
animals and many other things.
• Food preservatives, colourings and monosodium glutamate (MSG).
Air pollution and respiratory infections, such as colds or bronchitis, commonly trigger asthma
but are difficult to avoid.
Exercise is good for everyone including people with asthma. Although it can trigger asthma it is important not to avoid exercise. Exercise induced asthma (EIA) can usually be easily controlled through medication and an appropriate exercise regime. Talk to your doctor or local
Asthma Educator to learn how to control asthma during exercise.

Step 4
If you need medications these should be as simple, safe and effective as possible.
This is why inhaled medications are most often used for asthma.
There are four types of inhaled medication that your doctor might advise you to use.
• “Relievers” (such as Bricanyl, Ventolin, Asmol, Airomir and Epaq) are called
bronchodilators. These provide relief of asthma symptoms and are used in asthma first
aid.
• “Preventers” (such as Flixotide, Qvar, Pulmicort, Intal, Tilade, and Singulair) help to
keep your asthma under good control preventing asthma attacks. These will only work
if you use them regularly.
• “Symptom Controllers” (such as Oxis, Foradile, and Serevent)
• “Combination Medications” (such as Seretide and Symbicort) these combine a
Symptom Controller and a Preventer in one device.
Your doctor will prescribe the medications which are best for you.

Step 5
Together with your doctor you can work out a plan so that you can:
ﾕ Recognise when your asthma is getting worse.
ﾕ Know how to treat it quickly.
ﾕ Know how and where to get the right medical assistance.
Early attention to worsening asthma may prevent you from having a serious attack. Ask your
doctor for an Asthma Action Plan.

Step 6
Asthma can usually be kept under control. Follow your 6 point management plan and see
your doctor for regular check-ups, not just in emergencies. You should have your asthma
reviewed by your GP every 6 months.

Causes/Triggers of Asthma

The exact cause of asthma isn't known. Researchers think a combination of factors (family genes and certain environmental exposures) interact to cause asthma to develop, most often early in life. These factors include:

An inherited tendency to develop allergies, called atopy.
Parents who have asthma.
Certain respiratory infections during childhood.
Contact with some airborne allergens or exposure to some viral infections in infancy or in early childhood when the immune system is developing.

The factors(triggers) that can set off an asthma attack include:

inhaled allergens (such as dust mites, pollen, and cat and dog allergens).
tobacco smoke.
air pollution.
exercise.
strong emotional expressions (such as crying or laughing hard).
chemical irritants.
certain drugs (aspirin and beta-blockers).

pathophysiology

pathophysiology:

-airway inflammation
-intermittent airflow obstruction
-bronchial hyperresponsivness


http://emedicine.medscape.com/article/296301-overview


In allergic (extrinsic) asthma, the most common form, the respiratory
crisis is triggered by allergies in pollen, mold, animal dander, food,
dust mites, or cockroaches. Exposure causes release of histamine,
interleukins, and several other inflamatory chemicals, which
triggers intense airway inflammation.

Nonallergic
(intrinsic) asthma is not caused by allergens but can be triggered by
infections, drugs, air pollutants, cold dry air, exercise, or emotions.

Within minutes, bronchospasm occurs,along with wheezing, coughing and
possible fatal suffocation.

6-8 hours later, interleukins attract eosinophils to the bronachial
tissue. The eosinophils secrete protiens that paralyze the cilia,
damage the epithelium, and scar and cause long term damage to the
lungs. The bronchioles also oedematize and get plugged with thick
stucky mucus.

Saladin, unity of form

Definition, Types, Incidence and Prevalence of Asthma

Definition



Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The result is difficulty breathing. The bronchial narrowing is usually either totally or at least partially reversible with treatments.

Types of Asthma

1. Allergies and Asthma

Allergies and asthma often go hand-in-hand. Allergic rhinitis (also called hay fever) is inflammation of the inside lining of the nose and is the single most common chronic allergic disease. In those with allergic rhinitis, increased sensitivity (allergy) to a substance causes your body’s immune cells to release histamines in response to contact with the allergens. Histamines along with other chemicals lead to allergy symptoms. The most common allergens enter the body through the airway.

With allergic rhinitis, you may feel a constant runny nose, ongoing sneezing, swollen nasal passages, excess mucus, weepy eyes, and a scratchy throat. A cough may result from the constant postnasal drip. Many times asthma symptoms are triggered by allergic rhinitis. Your doctor may prescribe medications to control the allergies and, in doing so, the cough and other asthma symptoms may subside.

2. Exercise-Induced Asthma

Exercise-induced asthma is a type of asthma triggered by exercise or physical exertion. Many people with asthma experience some degree of symptoms with exercise. However, there are many people without asthma, including Olympic athletes, who develop symptoms only during exercise.

With exercise-induced asthma, airway narrowing peaks five to 20 minutes after exercise begins, making it difficult to catch your breath. You may have symptoms of an asthma attack with wheezing and coughing. Your doctor can tell you if you need use an asthma inhaler (bronchodilator) before exercise to prevent these uncomfortable asthma symptoms.

Cough-Variant Asthma

In the type of asthma called cough-variant asthma, severe coughing with asthma is the predominant symptom. There can be other causes of cough such as postnasal drip, chronic rhinitis, sinusitis, or gastroesophageal reflux disease (GERD or heartburn). Coughing because of sinusitis with asthma is common.

Asthma is a serious cause of cough that is common today. Cough-variant asthma is vastly underdiagnosed and undertreated. Asthma triggers for cough-variant asthma are usually respiratory infections and exercise.

For any persistent cough, contact your doctor. Your doctor may order specific asthma tests, such as lung function tests, to show how well your lungs work. You might need to see a lung specialist for further tests before an asthma diagnosis is made.

Incidence and Prevalence

The prevalence of asthma in Australia is among the highest in the world: between 10% and 15% of children and between 10% and 12% of adults have asthma. Although it is not a major cause of death, asthma is one of the most common problems managed by doctors and is a frequent reason for the hospitalisation of children, especially boys.

In Malaysia, asthma is among the commonest conditions treated in the health
clinics. More than 73 % of outpatient attendances in the health clinics have been
managed for respiratory symptoms and asthma is one of the cases note to be
treated in health clinics.

Chan (1994) reported that 5 % of all outpatients in Ipoh General Hospital were
treated for asthma. Report was also shown that the hospital discharge due to
asthma was on the rise in the past five years (1990 - 1995). The mortality
statistics was also showed the similar trend.

http://www.healthinsite.gov.au/topics/Asthma

http://www.aihw.gov.au/publications/acm/aia08/aia08.pdf

http://www.medicinenet.com/asthma/page2.htm

http://www.webmd.com/asthma/guide/types-asthma

CAM

Acupuncture
This is the ancient Chinese treatment of inserting very fine needles into specific parts of the body to influence the flow of energy. Some studies show that:
· Acupuncture can give short-term relief from asthma symptoms
· No long-term benefits have been documented yet
· People whose asthma is triggered by allergens benefit more than those who experience exercise induced asthma

Chiropractic
This is expert manipulation of the spine. Some research has shown that chiropractic has a beneficial effect on airway circulation and lung capacity.

Herbal therapy
- Rhizomes : treat asthma by removing phlegm, pungent, warming, anti-spasmodic sedative herb with a terrible smell, which increases perspiration and acts as an expectorant and diuretic
- Great mullein (Verbascum Thapsus) : bitter, cooling herb which soothes and lubricates tissues, has expectorant and analgesic effects and helps healing.
- Asafoetida, bayberry, cardamom, cayenne, colt’s foot, comfrey, echinacea, eucalyptus, fennel, garlic, gingko, lobelia, parsley, roman chamomile, saffron and thyme.

Homeopathy
This includes preparing a special medicine containing tiny amounts of the allergic substance. The patient then takes the medicine and ‘trains’ their immune system to recognise the allergen as safe. Research has shown that homeopathy may be helpful for some people with asthma. One drawback is trying to pinpoint the exact allergen since most people with asthma have more than one.

Hypnosis
This is a deep state of relaxation that allows the patient to focus their complete attention on one thing or idea. Hypnosis is helpful in some cases, particularly for reducing stress, but not all people can be hypnotised. Relaxation techniques such as meditation or visualisation could be worthwhile if stress is a trigger.

Supplements
Vitamin C, the mineral magnesium and fish oils have found to be helpful in some studies, but not in others.

Don't take echinacea or royal jelly
People with asthma should never take echinacea or royal jelly. They can have serious side effects for people with asthma and other allergies. Severe reactions may include:
· Asthma attacks
· Breathing difficulties
· Severe allergic reaction
· Death.

Things to remember
· Complementary therapies should never replace your asthma medication and usual treatment.
· The limited research on complementary therapies means that no one is sure of their exact effect or worth.
· Always discuss complementary therapies first with your doctor.
· Never abandon your medication and mainstream management techniques.

Drugs for Management of Hypertension

Diuretics

Types:

Thiazides – Inhibits ion transporter, thus causing water retention in urine. Works at different location (distal convoluted tubule) from loop.

Loop Diuretics – generally location of action is at the loop of Henle by inhibiting reabsorption of sodium. Hence, water which usually follows sodium into ECF now follows sodium into urine.

Potassium-sparing – these kinds of diuretics are more oriented towards function than location. Hence, potassium sparing means potassium is spared from being secreted into urine.

Adverse effects are uncommon, unless high doses are used. These include increased serum cholesterol, glucose and uric acid; decreased potassium, sodium and magnesium levels and erectile dysfunction.

Beta-blockers

Work by slowing heart rate down, hence decreasing blood pressure.

They are particularly useful in hypertensive patients with effort angina, tachyarrhythmias or previous myocardial infarction where they have been shown to reduce cardiovascular morbidity and mortality.

Adverse effects reported include masking of hypoglycaemia (since you inhibit sympathetic system activity which shows symptoms), increased incidence of new onset diabetes mellitus, erectile dysfunction, nightmares and cold extremities.

Contraindications of beta-blockers are related to their cardiac mechanisms and include bradycardia, reduced exercise capacity, heart failure, hypotension, and atrioventicular (AV) nodal conduction block. Beta-blockers are therefore contraindicated in patients with sinus bradycardia and partial AV block. The side effects listed above result from excessive blockade of normal sympathetic influences on the heart.

Bronchoconstriction can occur, especially when non-selective beta-blockers are administered to asthmatic patients. Therefore, non-selective beta-blockers are contraindicated in patients with asthma or chronic obstructive pulmonary disease. Bronchoconstriction occurs because sympathetic nerves innervating the bronchioles normally activate β₂-receptors that promote bronchodilation. Blockade of these receptors can lead to bronchoconstriction.

Calcium Channel Blockers

Dihydropyridine calcium channel blockers are often used to reduce systemic vascular resistance and arterial pressure. However, the vasodilation and hypotension can lead to reflex tachycardia.

Phenylalkylamine calcium channel blockers are relatively selective for myocardium, reduce myocardial oxygen demand and reverse coronary vasospasm, and are often used to treat angina. They have minimal vasodilatory effects compared with dihydropyridines and therefore cause less reflex tachycardia, making it appealing for treatment of angina.

Benzothiazepine calcium channel blockers (Diltiazem) are an intermediate class between phenylalkylamine and dihydropyridines in their selectivity for vascular calcium channels. By having both cardiac depressant and vasodilator actions, benzothiazepines are able to reduce arterial pressure without producing the same degree of reflex cardiac stimulation caused by dihydropyridines.

Adverse effects include initial tachycardia, headache, flushing, constipation and ankle oedema. Unlike other CCBs, Verapamil may reduce heart rate and care should be exercised when used with beta- blockers.

ACE Inhibitors

They lower arteriolar resistance and increase venous capacity; increase cardiac output, stroke volume, lower renovascular resistance, and lead to increased excretion of sodium in the urine.

Normally, angiotensin II will have the following effects:

▪ vasoconstriction (narrowing of blood vessels), which may lead to increased blood pressure

▪ stimulation of the adrenal cortex to release aldosterone, a hormone that acts on kidney tubules to retain sodium and chloride ions and excrete potassium. Sodium is a "water-holding" molecule, so water is also retained, which leads to increased blood volume, hence an increase in blood pressure.

ACE Inhibitors inhibits the production of angiotensin II from angiotensin I, thus, assisting in increasing blood pressure.

In pregnant women, ACE inhibitors taken during the first trimester have been reported to cause major congenital malformations, stillbirths, and neonatal deaths. Commonly reported fetal abnormalities include hypotension, renal dysplasia, anuria/oliguria, patent ductus arteriosus and incomplete ossification of the skull.

Adverse effects include cough (bradykinin increase but disputed) and renal failure.

Angiotensin Receptor Blockers

Angiotensin II receptor antagonists are primarily used for the treatment of HT where the patient is intolerant of ACE Inhibitor therapy. They do not inhibit the breakdown of bradykinin or other kinins, thus rarely associated with the persistent dry cough. However, may present dizziness or headache.

Hypertensive retinopathy

Hypertensive retinopathy is a retinal vascular damage due to hypertension.

How it happens?
- Acute BP elevation
- Prolonged / severe hypertension

Due to hypertension, the small blood vessels in the retina are damaged. This results in a thickened blood vessels' wall, decreasing their blood flow to the retina. Some parts of the retina which did not receive enough blood becomes damaged. Eventually, there is blood leakage, resulting in blindness if the macula is affected.

Hypertensive patients who have diabetes as well are at an increased risk of vision loss.
Smoking aggravates the adverse effect of hypertension on retina

Symptoms - headache, vision problems

Signs (through fundoscopy)
- vasocontriction of retinal blood vessels
- fluid oozing from blood vessels
- cotton wool spots & hard exudates
- swelling of optic nerve and macula
- bleeding in the back of the eye

THE ONE AND ONLY TREATMENT - treat the underlying cause, ie, hypertension

Definition of Hypertension

A condition that occurs when the pressure in the arteries is consistently above the normal range for that specific age group
If the Blood Pressure reading is consistently equal to or higher than 140 systolic and 90 diastolic or both in adults older than 18 years, then the doctor will give a diagnosis of high blood pressure or hypertension

Classification of Hypertension in Malaysia

Classification of blood pressure for adults aged 18 and older and the prevalence


Category..........Systolic(mmHg).......Diastolic(mmHg).......Prevalence in Malaysia


Optimal..............<120...................<80......................32%

Prehypertension......120-139................80-89....................37%

Hypertension

Stage 1...............140-159...............90-99....................20%

Stage 2...............160-179..............100-109....................8%
Stage 3.................180...................110.....................4%


When SBP and DBP fall into different categories, the higher category should be selected to classify the individual’s BP.

Divided into primary/essential hypertension (90%) where there is no identifiable cause and secondary hypertension (10%) where a cause can be determined (e.g. renal disease, endocrine illness, coarctation of the aorta, renovascular disease and drugs)

Prevalence and incidence

Malaysia:-

The prevalence of hypertension amongst those aged 30 years has increased from 32.9% in 1996 to 40.5% in 2004
Estimated that there are 4.8 million individuals with hypertension
Close to two thirds of individuals with hypertension were unaware that they have hypertension (Third National Health and Morbidity Survey of 2006)

The estimated figure worldwide is 1 billion individuals

America:-

High blood pressure was a primary or contributing cause of death for 326,000 Americans in 2006
About one out of three U.S. adults—31.3%—has high blood pressure
High blood pressure was listed as a primary or contributing cause of death for 326,000 Americans in 2006

Sign and Symptoms

Sign and Symptoms

1. Blood Pressure –

120/80 to 139/89 Pre Hypertension

140/90 to 159/99 Stage 1

160/100 above Stage 2

Isolated systolic hypertension >140 systolic and diastolic <90

2. Most frequent – headaches

3. Blurry or double vision

4. Drowsiness

5. Nausea

6. Dyspnea (Dangerous by then) Exertional and Paroxysmal Nocturnal Dyspnea

7. Heart palpitations

8. Fatigue

9. A flushed face

10. Nosebleeds

11. Strong need to urinate often (Especially at night)

12. Tinnitus

Severe hypertension that targets organ’s present with

- Nausea

- Vomiting

- Visual disturbance

- Chest pain

- Confusion

- Retinas are affected with narrowing of arterial diameter to less than 50% of venous diameter, copper or silver wire appearance, exudates, hemorrhages or papilledema

Hypertension could be due to other secondary endocrine diseases.

Hypertension is usually idiopathic.

End Organ Damage

End organ damage or target organ damage refers to damage happening in major organs that are circulated by the circulatory system due to hypertension, hypotension or hypovolemia.

The organs normally affected are:

The eyes- Acute BP elevation typically causes reversible vasoconstriction in retinal blood vessels, and hypertensive crisis may cause papilledema. More prolonged or severe hypertension leads to exudative vascular changes, a consequence of endothelial damage and necrosis. Other changes (eg, arteriole wall thickening) typically require years of elevated BP to develop. Smoking compounds the adverse effects of hypertension on the retina.

Hypertension is a major risk factor for other retinal disorders (eg, retinal artery or vein occlusion, diabetic retinopathy). Also, hypertension combined with diabetes greatly increases risk of vision loss. Patients with hypertensive retinopathy are at high risk of hypertensive damage to other end organs.

Kidney- High blood pressure makes the heart work harder and, over time, can damage blood vessels throughout the body. If the blood vessels in the kidneys are damaged, they may stop removing wastes and extra fluid from the body. The extra fluid in the blood vessels may then raise blood pressure even more. It’s a dangerous cycle.

High blood pressure is one of the leading causes of kidney failure, also called end-stage renal disease (ESRD). People with kidney failure must either receive a kidney transplant or have regular blood-cleansing treatments called dialysis. Every year, high blood pressure causes more than 25,000 new cases of kidney failure in the United States.

Heart- As vessel diameters grow smaller and smaller, the result is not unlike what occurs to water flow out of a hose when a small kink is placed in it. In order for it to bypass this increased resistance to flow, it must be pushed with a greater pressure or force. In much the same way, an increase in the body's blood vessel resistance to flow places a new burden upon the heart to push blood through the smaller opening. It is largely unknown why the body chooses to raise resistance to flow even after it becomes a chronic burden on the heart.

Reference:

http://kidney.niddk.nih.gov/kudiseases/pubs/highblood/
http://www.merck.com/mmpe/sec09/ch106/ch106f.html
http://www.heartfailure.org/eng_site/hf_causes_hypertension.asp#

Risk factors and Investigations

Risk factors:
• Age (male > 45) (female > 55)
• Obesity
• Gender (male>female)
• Unhealthy lifestyle. smoking, alcohol, sedentary life, a lot Na from salt, less K, stress
• Race. (in US afro Americans more affected)
• Family history
• Chronic conditions like diabetes, kidney disease, cholesterol, sleep apnea
• Pregnancy also could cause pregnancy (gestational hypertension)

http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_Causes.html
http://www.mayoclinic.com/health/high-blood-pressure/DS00100/DSECTION=risk-factors

Investigations:
To ensure that a person is a chronic hypertensive, more than just 1 BP test is required, unless the BP is exceptionally high or if end-organ damage is present.
Normally it is measured 3 times, each time a week apart. The patient must not be under the influence of caffeine or any other drugs that could alter the BP.
Another way to make a diagnosis would be home BP monitoring. A device that measures the BP every 30 minutes throughout the day and night is worn by the patient. This rules out white coat syndrome.
Source: Dr. Nik Asma

(Exclude or rule out secondary causes)

Effects of hypertension

Effects of hypertension

1. Arteriosclerosis and atherosclerosis
- Hypertension causes damage to the endothelial lining of the blood vessel. This leads to the hardening of the arteries which is called arteriosclerosis. Fats from the diet will enter the damaged cells and collect to form plaque (lipid accumulation), which is called atherosclerosis. Formation of plaque can obstruct the blood flow to various organs in the body, such as heart, brain and kidneys. The damage can cause many problems including angina, heart attack, heart failure and stroke.
- Atherosclerosis increases the risk of transient ischemic attack (TIA), or ministroke. TIA is a brief, temporary disruption of blood supply to the brain. A transient ischemic attack is often a warning that you're at risk of a full-blown stroke.
- Another potential effect is dementia. Vascular dementia, results from narrowing and blockage of the arteries that supply blood to the brain. It can also result from strokes caused by an interruption of blood flow to the brain.
2. Aneurysm
- Over time, the constant high pressure weakens the vessel wall and causes a section of the wall to enlarge and form a balloon –like bulge ( aneurysm). They can form in any arteries in the body, but most commonly in the body. An aneurysm can potentially rupture and cause internal bleeding (haemorrhage).
3. Enlarged left heart
- High blood pressure causes the heart to work harder because the heart has to pump harder against resistance. This causes the left ventricle to enlarge (left ventricular hypertrophy). This enlargement or stiffening limits the ventricle's ability to pump blood to your body. This increases the risk of heart attack, heart failure and sudden cardiac death.

Primary Causes of Hypertension

Primary Hypertension (Essential Hypertension)
1. High intake of salt (> 5.8g daily)
- The recommended daily salt intake for a healthy 19 to 50-year-old adult is only 3.8g, to replace the average amount lost daily through perspiration and to achieve a balanced diet.
Institute of Medicine of the National Academies
2. Genetic factors
- Genes for hypertension have not yet been identified.
- Current research focuses on the genetic factors affecting the
renin–angiotensin-aldosterone system (RAAS)
- RAAS is a system which regulates the Salt/Water balance and hence, blood pressure of the body.
- Approximately 30% of cases are attributed to genetic factors.
Example 1 : In the United States, the incidence of high blood pressure is greater among African Americans than among Caucasians or Asians.
Example 2 : In individuals who have one or two parents with hypertension, high blood pressure is double that of the general population.
3. Abnormality of arteries
- Reduced distensibility in peripheral arteries which leads to increased resistance of the arteries. Arteries will not be able to increase the diameter of their lumen during ventricular systole and hence, increased pressure. Vascular endothelium produces less nitric oxide (vasodilator agent) and its smooth muscle is also less sensitive to it.
- There is also an increase in the production of endothelin 1, which is a vasoconstrictor agent.
4. Age
- The older u get, the higher the likelihood that you will develop hypertension , especially the systolic pressure, because the vessel wall becomes less elastic.
5. Race
- African Americans have high blood pressure more often than whites. They develop high blood pressure at a younger age and develop more severe complications sooner.
6. Gender
- Men have a greater probability of developing high blood pressure than women.
7. Alcohol
- Drinking more than one to two drinks of alcohol per day tends to raise blood pressure in those who are sensitive to alcohol.
8. Oral Contraceptive Use
- Some women who take birth control pills tend to develop high blood pressure.
9. Drugs
- Certain drugs such as amphetamines, diet pills and medications used for cold and allergy, tend to increase blood pressure.


10. Body weight
- Obese people are 2 to 6 times more likely to develop hypertension compared to people whose weight are within the healthy range.
- Apple shaped people are at greater health risk compared to pear shaped people.

Complications

arteries

• Arteriosclerosis and atherosclerosis. High blood pressure can damage the cells of your arteries' inner lining. That launches a cascade of events that make artery walls thick and stiff, a disease called arteriosclerosis (ahr-teer-e-o-skluh-RO-sis), or hardening of the arteries. Fats from your diet enter your bloodstream, pass through the damaged cells and collect to start atherosclerosis (ath-ur-o-skluh-RO-sis). These changes can affect arteries throughout your body, blocking blood flow to your heart, kidneys, brain, arms and legs. The damage can cause many problems including chest pain (angina), heart attack, heart failure, kidney failure, stroke, peripheral arterial disease and aneurysms.
• Aneurysm. Over time, the constant pressure of blood coursing through a weakened artery can cause a section of its wall to enlarge and form a bulge (aneurysm). An aneurysm (AN-u-rizm) can potentially rupture and cause life-threatening internal bleeding. Aneurysms can form in any artery throughout your body, but they're most common in the aorta, your body's largest artery.

Heart

• Coronary artery disease. Coronary artery disease affects the arteries that supply blood to your heart muscle. Arteries narrowed by coronary artery disease don't allow blood to flow freely through your arteries, which can cause chest pain (angina). The condition also occurs when blood flow through your arteries becomes blocked, usually because of atherosclerosis. When blood can't flow freely to your heart, you can experience chest pain, a heart attack or irregular heart rhythms (arrhythmias). People with high blood pressure who have a heart attack are more likely to die of that heart attack than are people who don't have high blood pressure.
• Enlarged left heart. High blood pressure forces your heart to work harder than necessary in order to pump blood to the rest of your body. This causes the left ventricle to enlarge or stiffen (left ventricular hypertrophy) — just as your biceps get bigger when you lift weights. This enlargement or stiffening limits the ventricle's ability to pump blood to your body. This condition increases your risk of heart attack, heart failure and sudden cardiac death.
• Heart failure. Over time, the strain on your heart caused by high blood pressure can cause your heart muscle to weaken and work less efficiently. Eventually, your overwhelmed heart simply begins to wear out and fail. Damage from heart attacks adds to this problem.

Brain

• Transient ischemic attack (TIA). Sometimes called a ministroke, a transient ischemic (is-KEM-ik) attack is a brief, temporary disruption of blood supply to your brain. It's often caused by atherosclerosis or a blood clot - both of which can arise from high blood pressure. A transient ischemic attack is often a warning that you're at risk of a full-blown stroke.
• Stroke. A stroke occurs when part of your brain is deprived of oxygen and nutrients, causing brain cells to die. Uncontrolled high blood pressure can lead to stroke by damaging and weakening your brain's blood vessels, causing them to narrow, rupture or leak. High blood pressure can also cause blood clots to form in the arteries leading to your brain, blocking blood flow and potentially causing a stroke. High blood pressure can also cause an aneurysm — a bulge in the blood vessel wall that can burst, causing life-threatening bleeding in the brain.
• Dementia. Dementia is a brain disease resulting in impaired thinking, speaking, reasoning, memory, vision and movement. There are a number of causes of dementia. One cause, vascular dementia, can result from narrowing and blockage of the arteries that supply blood to the brain. It can also result from strokes caused by an interruption of blood flow to the brain. In either case, high blood pressure may be the culprit. High blood pressure that occurs even as early as middle age can increase the risk of dementia in later years.
• Mild cognitive impairment. Mild cognitive impairment is a transition stage between the changes in understanding and memory that come with aging and the more serious problems caused by Alzheimer's disease. Like dementia, it can result from blocked blood flow to the brain when high blood pressure damages arteries. This condition can affect language, attention, critical thinking, reading, writing, reaction time and memory.

Kidneys

· Kidney failure. High blood pressure is one of the most common causes of kidney failure. That's because it can damage both the large arteries leading to your kidneys and the tiny blood vessels (glomeruli) within the kidneys. Damage to either makes it so your kidneys can't effectively filter waste from your blood. As a result, dangerous levels of fluid and waste can accumulate. You might ultimately require dialysis or kidney transplantation.

· Kidney scarring (glomerulosclerosis). Glomerulosclerosis (glo-mer-u-lo-skluh-RO-sis) is a type of kidney damage caused by scarring of the glomeruli (glo-MER-u-li). The glomeruli are tiny clusters of blood vessels within your kidneys that filter fluid and waste from your blood. Glomerulosclerosis can leave your kidneys unable to filter waste effectively, leading to kidney failure.

· Kidney artery aneurysm. An aneurysm is a bulge in the wall of a blood vessel. When it occurs in an artery leading to the kidney, it's known as a kidney (renal) artery aneurysm. One potential cause is atherosclerosis, which weakens and damages the artery wall. Over time, high blood pressure in a weakened artery can cause a section to enlarge and form a bulge - the aneurysm. Aneurysms can rupture and cause life-threatening internal bleeding

Eyes

• Eye blood vessel damage (retinopathy). High blood pressure can damage the vessels supplying blood to your retina. Damaged enough, the blood vessels can leak or become blocked, resulting in retinopathy. This condition can lead to bleeding in the eye, microaneurysms, swelling of the optic nerve, blurred vision and complete loss of vision. If you also have both diabetes and high blood pressure, you're at an even greater risk.
• Fluid buildup under the retina (choroidopathy). In this condition, fluid builds up under your retina because of a leaky blood vessel in the choroid, a layer of blood vessels located under the retina. Choroidopathy (kor-oid-OP-uh-thee) can result in distorted vision or in some cases scarring that impairs vision.
• Nerve damage (optic neuropathy). This is a condition in which blocked blood flow damages the optic nerve. It can lead to the death of nerve cells in your eyes, which may cause bleeding within your eye or vision loss.

Others

• Sexual dysfunction. Although the inability to have and maintain an erection (erectile dysfunction) becomes increasingly common in men as they reach age 50, it's even more likely to occur if they have high blood pressure, too. Evidence linking high blood pressure to sexual dysfunction in women isn't conclusive.
• Bone loss. High blood pressure can increase the amount of calcium that's in your urine. That excessive elimination of calcium may lead to loss of bone density (osteoporosis), which in turn can lead to broken bones. The risk is especially increased in older women.
• Trouble sleeping. Obstructive sleep apnea — a condition where your throat muscles relax causing you to snore loudly — occurs in more than half of those with high blood pressure. It's now thought that high blood pressure itself may help trigger sleep apnea. Also, sleep deprivation resulting from sleep apnea can raise your blood pressure.

Malignant hypertension
it's a sudden rapid development of EXTREMELY high blood pressure.
Can cause:
Changes in mental status, reflexes
Strokes
Coma
Seizures
Angina
Heart attack
Kidney failure
permanent blindness

Definition, Incidence and Prevalence of Aortic Stenosis

Definition of aortic stenosis

• Aortic stenosis (AS) is also called as aortic valve stenosis
• AS happens when has become narrow or constricted (stenotic) and does not open fully thus restricting blood flow
• Aortic valve is located between the left ventricle and aorta
• The left ventricle pumps oxygen rich blood out of the heart to the aorta through aortic valve
• When aortic valce becomes stenotic, the ability of left ventricle to pump out from heart to aorta is impaired
• As a result, organs receive an insufficient supply of oxygen rich blood (heart failure), and blood may back up into the lungs causing SOB

Incidence and Prevalence

1. in US…
• Aortic sclerosis increases in incidence with age and is present in:
• 29% of individuals older than 65 years and in
• 37% of individuals older than 75 years

• Patients with severe AS may be asymptomatic for many years despite the presence of severe LV outflow tract obstruction
• Such patients have a survival similar to those without aortic stenosis
• With the appearance of symptoms, however, their survival is reduced:

Symptoms ....................Survival Rate
Angina .......................4.5 years
Syncope/dizziness............2.6 years
Congestive heart failure.....1 year

2. Mortality/Morbidity Rate

Symptomatic Patients (moderate AS)

Mortality rates are around 25% at 1 yr & 50% at 2 years
More than 50% of deaths are sudden

Asymptomatic Patients(critical AS)

Excellent prognosis regarding survival with death rate less than 1% in a year
Only 4% of sudden cardiac death in severe aortic stenosis

3. In Western populations,

Aortic sclerosis................Aortic stenosis
25% over 65.....................3 % over 75

Around 16% of patients progress to stenosis in 7 yrs

4. Incidence of MI,

DISORDER............................................INCIDENCE OF MI
Septuagenarians with normal aortic valve.........6% over 5 years
Aortic scelerosis....................................8.6%
Aortic stenosis......................................11.3%

5. As our population ages, the prevalence of aortic stenosis inevitably rises.
• By 2020, about 3.5 million of a total population of 54 million in England can be expected to have aortic sclerosis and
• 150 000 to have severe aortic stenosis

Causes of AS

Divided into two:-

Congenital

Bicuspid aortic valve (1 – 2%)
A misshapen tricuspid aortic valve
Unicuspid aortic valve (rare)

Acquired

Heart conditions and other disorders
Age-related changes (scarring and calcification)
Rheumatic fever – damages the valve
Endocarditis – damages the valve

Complications & Prognosis

AORTIC STENOSIS

Prognosis

Adults without symptoms
- excellent prognosis
- normal life expectancy but should receive
- advised to receive antibiotic prevention – aortic valve infection

Adults with symptoms
a) Mild – usually leads a normal life, but some may progress to severe disease
b) Moderate – most end up with coronary artery disease within 10 years
c) Severe – once symptoms occur, death within 2-4 years if untreated, mortality rates of 75%

- Disease curable with surgery
- Moderate & severe stenosis eventually treated with surgery (progressive disease)
- eg : valve replacement (10 year survival rate = 75%)

- Post-surgical risks
a) Arrhythmias - sudden death
b) Blood clots – stroke
c) New valve not working & need to be replaced.

Complications

—Arrhythmias
—Endocarditis
—Left ventricular hypertrophy
—Sudden death
—Congestive heart failure
—Exacerbation of coronary artery disease
—Pulmonary oedema

a) Left ventricular hypertrophy
- Aortic valve narrowed
- Left ventricle has to work harder to pump sufficient blood to aorta and rest of the body - HYPERTROPHY
- Eventually weakens, leading to
i) Heart failure
ii) Arrythmias
iii) Cardiac arrest
iv) Angina

b) Endocarditis
- Narrowed aortic valve more prone to infection
- Turbulence damages endothelium
- Bacteria & inflammatory cells adhere & grow, forming an infected vegetation
- Increased risk of bacteria entering bloodstream

c) Cardiac failure
- Lack of sufficient blood flow to meet body’s needs.
- Causes : MI, IHD, hypertension
- Leads to : Pulmonary oedema (L), peripheral oedema (R)


ANGINA

Prognosis

- Stable angina is a marker of underlying CHD
- People with angina are 2–5 times more likely to develop other manifestations of CHD than people who do not have angina.
- People with angina had higher mortality than people with no history of coronary artery disease at baseline


Features that indicate a poorer prognosis :
Ø more-severe symptoms
Ø Male
Ø abnormal resting ECG
Ø previous MI
Ø left ventricular dysfunction
Ø easily provoked or widespread coronary ischaemia on stress testing
Ø significant stenosis of all three major coronary arteries or the left main coronary artery.


Complications
- If untreated, chronic stable angina --> unstable angina (untreated)
a) Severe arrythmias
b) Sudden cardiac death

Pathophysiology

Video
http://coursewareobjects.elsevier.com/objects/hao/anim/13-010ap.htm
http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_stenosis_senile.html
3rd heart sound due to possible explanations include impact of the ventricle against the inner chest wall or a sound originating within the ventricular apex due to sudden limitation of longitudinal expansion.
4th heart sound due to forceful atrial ejection.
Pathophysiology of causes:
Calcium buildup on the valve. Calcium deposits result in stiffening of the leaflets of the valve.
Rheumatic fever. Rheumatic fever may result in scar tissue forming on the aortic valve. Scar tissue alone can narrow the aortic valve and lead to aortic valve stenosis.
Congenital heart defect.
Aortic valve narrows due to the causes above.
The blood flow of ejection is disturbed, causing a loud ejection systolic murmur.
The ventricles then have to hyperthrophy to compensate for the decrease in output. However, in the long run, the ventricles dilate and this decreases the compliance of the ventricles. The atria has to pump harder to fill the ventricles, thus the 4th heart sound.
Edema in lungs is due to backflow of blood.
Explanation in detail in PCL 

wiggers diagram

shows the blood pressure in the aorta, ventricles and atria, and the
ventricular blood volume, and ECG and heart sounds and valve opening
and closing in relation to eachother on a Y-axis agant an X-axis
denoting time. The purpose of this diagram is to make it easier to
see the relationship between these values.

http://library.med.utah.edu/kw/pharm/hyper_heart1.html

Medical Management for Aortic Stenosis

Surgical repairs increases survival rate greater than fourfold compared to medical treatment.

However there is no proven medical treatments that delay the progression of AS

Also most AS patients have cardiac conditions that are controlled using medication which is hypertension, AF, CAD

Hypertension –

Uses Angiotensin converting enzyme inhibitors for severe AS

Use second generation dihydropyridine calcium channel blockers for asymptomatic AS patients

Diuretics

AF –

Use beta blockers and rate slowing calcium channel blockers

CAD –

No smoking

Regular exercise

Aspirin prophylaxis

Antimicrobial prophylaxis

Statins

Antiplatelet therapy

Anticoagulant therapy

Signs & Symptoms

Symptoms

There are usually no symptoms until aortic stenosis is moderately severe (when the aortic orifice is reduced to one-third of its normal size). At this stage, exercise-induced syncope, angina, and dyspnoea develop. When symptoms occur, prognosis is poor- on average, death occurs within 2-3 years if there has been no surgical intervention.


Signs


Pulse

The carotid pulse is of small volume and is slow-rising or plateau in nature.

Precordial Palpation

The apex beat is not usually displaced because hypertrophy (as opposed to dilatation) does not produce noticeable cardiomegaly. However, the pulsation is sustained and obvious. A double impulse is sometimes felt because the fourth heart s

Publish Post

ound or atrial contraction (kick) may be palpable. A systolic thrill may be felt in the aortic area.

Auscultation

The most obvious auscultatory finding in aortic stenosis is an ejection systolic murmur that is usually 'diamond-shaped' (crescendo-descendo)
the murmue is usually rough in quality and best head in the aortic area. it radiates into the carotid arteries and also the pericardium. the intensity of the murmur is not a good guide to the severity of the condition because it lessened by reduced carotid output. in severe cases, the murmur may be inaudible.
other findings include:
systolic ejection click unless the valve has become immobile and calcified
soft or inaudible artic second heart sound when the aortic valve becomes inaudible
reversed splitting of the second heart sound (splitting on expiration)
prominent fourth heart sound unless coexisitng mitral stenosis prevents this.

Pathophysiology of atrial fibrillation (AF)

A healthy heart's electrical system

Controls the rate and rhythm of the heartbeat

With each heartbeat, an electrical signal spreads from the top of the heart to the bottom. As the signal travels, it causes the heart to contract and pump blood. The process repeats with each new heartbeat.

The Electrical Problem in Atrial Fibrillation

The heart's electrical signals don't begin in the SA node.

Commonly begin in the left atria or in the nearby pulmonary veins.

The signals don't travel normally and spread throughout the atria in a rapid, disorganized way causing the atria to fibrillate (quivering)

The firing of these impulses results in a very rapid and disorganized heartbeat.

The rate of impulses through the atria can range from 300 to 600 beats per minute

As the AV node limits the number of impulses it allows to travel to the ventricles, the pulse rate is often less than 150 beats per minute, but this is fast enough to cause symptoms.

So, even though the ventricles may be beating faster than normal, they aren't beating as fast as the atria.

Thus, the atria and ventricles no longer beat in a coordinated way.

This creates a fast and irregular heart rhythm. In AF, the ventricles may beat 100 to 175 times a minute.

As only a small amount of blood enters the ventricles, the normal force created by the cardiac muscles decreases and only a small amount of blood is ejected from the heart. (frank-starling law of the heart)

The body gets rapid, small amounts of blood and occasional larger amounts of blood.

Most of the symptoms of AF are related to how fast the heart is beating. If medicines or age slow the heart rate, the symptoms are minimized.

AF may be brief, with symptoms that come and go and end on their own. Or, the condition may be persistent and require treatment.

Sometimes AF is permanent, and medicines or other treatments can't restore a normal heart rhythm.

Tends to become a chronic disease as molecular and structural changes occur and makes it hard to achieve sinus rhythm

Video at http://www.nhlbi.nih.gov/health/dci/Diseases/af/af_what.html

References : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC546076/ , http://www.webmd.com/heart-disease/atrial-fibrillation/heart-disease-atrial-fibrillation-basics , http://www.mayoclinic.com/health/atrial-fibrillation/DS00291 , http://www.medscape.com/infosite/atrial-fibrillation/article-2

Differential Diagnosis by Shakir and JB

Atrial Fibrillation

- Occuring in 5-10% of patients over 65 years

- Deterioration of exercise capacity

- Irregular pulse

- ECG shows fine oscillations of the baseline

- No clear P waves

- QRS rhythm is rapid and irregular

- Ventricular rate around 120-180 per minute

- Palpitations

- Decreased blood pressure

- Weakness

- Dizziness

- Confusion

- Shortness of breath

- Chest pain

Sick Sinus Syndrome

-Fatigue

-Dizziness

-Syncope

-Chest pains

-Insomnia

-Confusion

-Palpitations

Endocarditis

- Fever

- Chills

- Heart murmurs

- Fatigue

- Aching joints and muscles

- Night sweats

- Shortness of breath

- Paleness

- Persistent cough

- Swelling in lower limbs or abdomens

- Weight loss

- Haematuria

- Spleen tenderness

- Osler's nodes (red tender spots under skin of finger)

- Petechiae (tiny purple red spots on skin, sclera, or inside mouth)

Holiday Heart Syndrome

- Acute cardiac rhythm and/or conduction disturbance

- Supraventricular tachyarrythmia

- Associated with heavy ethanol consumption with no other clinical evidence of heart disease

- Resolve rapidly during subsequent abstinence from alcohol use

- ECG shows prolongation of the PR, QRS, and QT intervals compared with patient's who experienced arrhythmias in the abscence of alcohol consumption

- Palpitations

- Chest discomfort

- Shortness of breath

- Feeling of faintness

Wolff-Parkinson-White Syndrome

- Electrical Syndrome arrive at the ventrical too soon

- A category of electrical abnormality known as "pre-excitation syndromes"

- ECG will show that an extra pathway or shortcut exists from the atria to the ventricles

- May have dizziness, chest palpitations, fainting or rarely, cardiac arrest

Supraventricular Tachycardias (SVTs)

-Unlike atrial fibrillation, SVTs arise from atrium or atrioventricular joint

- Has P wave as SA node will be working

Paroxysmal Atrial Fibrillation

- Irregular in rhythm

- Start abruptly

- Terminate as suddenly

- Lead to symptoms such as syncope, presyncope, dyspnoea or chest pain

- May have episodes only a few times a year or every day

Atrial Flutter

- Shares clinical presentation with atrial fibrillation

- Organized atrial rhythm with an atrial rate between 250 & 350 beats per minute

- ECG shows regular sawtooth- like atrial flutter waves (F waves) between QRS complexes

- Ventricular rate of 150 b.p.m.

- Occasionally heart rate of 300 b.pm.

Reference : Clinical Medicine by Kumar & Clark, http://heart.emedtv.com, www.emedicine.medscape.com, www.mayoclinic.com