THE MINISTRY OF PUBLIC HEALTH OF UKRAINE
VINNITSIA NATIONAL MEDICAL UNIVERSITY
named after M.I. PIROGOV
METHODICAL RECOMMENDATION
FROM PATHOPHYSIOLOGY
FOR 3RD COURSE STUDENTS OF MEDICAL FACULTY
Modul № 2 PATHOLOGY OF ORGANS AND SYSTEMS
Practical training №5 PATHOLOGY OF RESPIRATORY AND CARDIOVASCULAR SYSTEMS
VINNITSIA- 2012
The methodical recommendations from pathophysiology is approved and recommended for the introduction into the educational process at pathophysiology department meeting.
Protocol № 9 from 30.12.2011
Authors: Head of Department, Dr. of Med. Sc. Rikalo N.A.,
As. Grytsenko A.S.
The manual is recommended for the foreign students of the medical (3rd course) faculty.
Thematic plan of practical classes:
Lesson 1 «Pathophysiology of systemic blood circulation. Cardiac failure».
Lesson 2 «Pathophysiology of peripheral vassels. Arrhythmias».
Lesson 3 «Pathophysiology of external breathing. Respiratory insufficiency».
Lesson 4 «Pathological type of breathing».
Theme: «CARDIAC INSUFFICIENCY».
Actuality of the theme.
Cardiac insufficiency is one of the frequent reasons for loss of capacity, disability and death of patients, which suffer from diseases of the cardiovascular system. Study of their etiology and pathogenesis is necessary for practical activity of a doctor. Knowledge of reasons and mechanisms of development of the given pathology will assist to development of clinical thought, choice of rational approaches to medical treatment of every concrete patient.
The study in the experiment on the animals of cardiac insufficiency allows exposing the mechanisms of development of these pathological states.
General purpose of the lesson to characterize cardiac insufficiency, to explain reasons for origin and mechanisms of development of different forms of cardiac insufficiency; to explain the pathogenetical methods of its treatment.
For this it is necessary to know (the concrete purposes):
· To marked typical pathological states and violations at the blood circulation system: cardiac insufficiency, arrhythmias; arterial hypertension, arterial hypotension; arteriosclerosis, atherosclerosis.
· To analyze and use present classification of typical disorders of blood circulation system.
· To analyse changes of main indexes of hemodynamic and cardiodynemic at cardiac insufficiency (frequency and power of cardiac contractions, minute and systolic volume of heart; systolic, diastolic and puls pressure of heart, venous blood pressure).
· To analyse cause-effective relationships, separate changes pathological and compensative-adaptative, local and systemic changes at the pathogenesis of insufficiency of systemic blood circulation, cardiac insufficiency, myocardial infarction, shock states (cardiogenic shock).
· To analyse the mechanisms of clinical manifestations development at cardiac insufficiency and insufficiency of systemic blood circulation.
· To analyse the reasons and mechanisms of coronary insufficiency, explain its possible consequences.
· To analyse violations of main heart functions at acute coronary insufficiency.
For realization of purposes of lesson it is necessary to have the base knowledges-skills.
1. To explain the mechanism of heart contraction (Normal Physiology Department)
2. To explain the role of cardiac and extra cardiac mechanisms in regulation of hearts work (Normal Physiology Department)
3. To interpret the basic indexes of heart work (Normal Physiology Department)
4. To explain the influence of change of heartbeats frequency and volume of the stroke volume on efficiency of hearts work (department of normal physiology)
The checking of primary level of knowledges.
Give the answers to the following questions:
1. Definition of notion «cardiac insufficiency».
2. Basic indexes of cardiac insufficiency.
3. Definition of notion «insufficiency of blood circulation». To compare with notion "cardiac insufficiency".
4. Classification of insufficiency of blood circulation.
5. Reasons for insufficiency of blood circulation.
6. Classification of cardiac insufficiency according pathogenesis, clinical course, intensity of clinical symptoms.
7. Reasons for cardiac insufficiency, which arises up as a result of overload by a volume.
8. Reasons for cardiac insufficiency, which arises up as a result of overload by resistance.
9. Reasons for cardiac insufficiency, which arises up as a result of damage of myocardium.
10. Reasons for outcardiac insufficiency.
11. Mechanism of development of cardiac insufficiency as a result of overload by a volume.
12. Mechanism of development of cardiac insufficiency as a result of overload by resistance.
13. Mechanism of development of cardiac insufficiency as a result of damage of myocardium.
14. Mechanism of development of cardiac insufficiency as a result of damage of pericardium.
15. Hypertrophy of heart, definition. Notion about tonogenic and myogenic dilatation of heart.
16. Feature of structure, function and metabolism of myocardium during compensate hyperfunction ( basic stages by F.Z. Meerson).
17. Reasons and mechanisms of development of sharp cardiac insufficiency.
18. Reasons and mechanisms of development of chronic cardiac insufficiency.
19. Indexes of cardiac insufficiency (gemodinamichni, clinical), mechanisms of their development.
Standards of answers on the questions of the primary level of knowledges:
Insufficiency of systemic blood circulation – it is the state of inability of the cardiovascular system to provide organs and tissues of an organism by the necessary amount of blood.
Insufficiency of heart - it is the pathological state conditioned by inability of heart to furnish circulation of organs and tissues in accordance with their necessities.
Classification of cardiac insufficiency according pathogenesis:
1. Cardiac insufficiency as a result of the cardiac overload:
1.1 cardiac overload of heart by volume (reasons: heart disease with valvular insufficiency, hypervolemia);
1.2. cardiac overload of heart by resistance (reasons: heart disease with valvular stenosis, arterial hypertension);
2. Cardiac insufficiency as a result of the damage of myocardium (reasons: arrhythmias, myocarditis, myocardiopathys);
3. Cardiac insufficiency as a result of the violation of the coronary blood circulation (reasons: atherosclerosis, tromboembolism or spasm of coronal vessels);
4. Cardiac insufficiency as a result of the injury of pericardium (acute and chronic pericarditis, cardiac [pericardial] tamponade);
5. Mixed.
Intracardiac mechanisms of cardiac insufficiency compensation as a result of cardiac overload:
The heterometric mechanism provides compensation at the cardiac overload by a volume (reasons: heart disease with valvular insufficiency, hypervolemia). Its essence consists in the increase of force of the heartbeats in the case of entrance to the heart of bigger blood volume. A law of Frank-Starling's lies in the basis of this compensatory mechanism: according to which the longer initial length of muscular fibre (to 25% from initial), the more force of it contraction. At this mechanism the length of cardiac hystiocyte increases, so it is named heterometric.
The homeometric mechanism provides compensation at the cardiac overload by resistance (reasons: heart disease with valvular stenosis, arterial hypertension). Its essence consists in the increase of force of the heartbeats in case of the increase of resistance to blood flow. At this mechanism the tension of cardiac hystiocyte increases, but length of it does not changes, so it is named homeometric.
Hypertrophy of heart - it is the structural changes in a heart, which arise up at the protracted increase of loading on a heart and provide long-term adaptation.
By F. Meerson two variants of hypertrophy are selected:
Hypertrophy of heart at sportsmen - develops at the gradually growing loadings; thus all components of heart (balanced hypertrophy) are evenly multiplied and its functional backlogs are substantially multiplied.
Compensatory hypertrophy of heart:
- hypertrophy due to overloads (develops at the cardiac insufficiency, arterial hypertension);
- hypertrophy from the myocardium damage (develops at atherosclerosis, myocardiopathys).
At compensatory hypertrophy a pathogenic factor acts constantly; it is unbalanced (are increased amount only cardiomyocytes, the amount of vessels and nerves is not multiplied); quickly results in insufficiency of heart.
Stages of development of compensatory hypertrophy of heart according F. Meerson:
1. Emergency stage;
2. Stage of completed hypertrophy and relatively proof hyperfunction;
3. Stage of gradual exhaustion and progressive cardiosclerosis.
Tonogenic dilatation - this expansion of heart cavities, that is accompanied by the increase of shock volume of blood. It develops as a result of activating of heterometric mechanism of compensation.
Myogenic dilatation arises up at the dystrophic changes of myocardium. It is characterized by expansion of cavities of heart and decline of force of cardiac contractions. Arises up during decompensation of cardiac insufficiency.
Acute cardiac insufficiency develops quickly, at the surplus loading on a heart, when the compensatory mechanisms are not corrected with it, e.g., at the myocardium infarction and its complications (cardiogenic shock, tamponade of hearts), at arrhythmias (fibrillation of heart, paroxismal tachycardia, complete atrioventricular blockade), acute pericarditis, myocarditis, embolism of pulmonary artery.
Chronic (stagnant) cardiac insufficiency develops gradually, mainly as a result of metabolic violations in myocardium at protracted hyperfunction of heart or different types of myocardium damage (e.g., arterial hypertension, cardiomyopathies, and others).
Indexes of hemodinamics:
· speed of blood stream;
· volume of blood circulation
· stroke volume of heart
· minute volume of heart
· frequency of heartbeats
· arterial pressure
· vein pressure
· common peripheral resistance in vessels
· coefficient of oxygen utilization
Clinical manifestations of cardiovascular insufficiency:
· tachycardia;
· circulatory hypoxia;
· shortness of breathing;
· cyanosis;
· edema;
· cardiac cirrhosis of liver;
· violation of ABB;
· secondary hyperaldosteronism;
Тheoretical questions for the FMC №2.
1. Insufficiency of systemic blood circulation, definition, principles of classification, characteristics of cardio- and hemodynamic violations.
2. Concept about acute and chronic insufficiency of systemic blood circulation.
3. Etiology, pathogenesis, stages of chronic insufficiency of systemic blood circulation.
4. Mechanisms of main clinical signs of chronic cardiac insufficiency development (dyspnea, cyanosis, edema).
5. Cardiac failure, definition, principles of classification.
6. Cardiac failure resulted by cardiac overload.
7. Reasons of heart overload by volume and resistance.
8. Mechanisms of immediate and long-term adaptation of heart to the overload: tachycardia, hyperfunction (hetero- and homeometric), hypertrophy of myocardium.
9. Hypertrophy of myocardium: kind, reasons, mechanisms of development, stages (according to F. Meerson).
10. Features of hypertrophic myocardium, reasons and mechanisms of it decompensation.
11. Myocardial cardiac failure.
12. Coronarogenic injury of myocardium.
13. Coronary insufficiency (absolute and relative), mechanisms of development.
14. Role of psychical factor at the development of ischemic heart disease and its complications.
15. Concept about “critical stenosis”.
16. Consequences about ischemic heart disease: depression of contractive ability, electric dystability, injury/ necrosis of cardiomyocytes, additional injury at reperfusion.
17. Ischemic heart disease as a sign of coronary insufficiency, its kind.
18. Clinlcal-laboratory criterias, manifestations and complications of myocardial infarction.
19. Pathogenesis of cardiogenic shock.
20. Principles of prophylaxis and treatment of ischemic heart disease.
21. Etiology and pathogenesis of noncoronarogenic injury of myocardium.
22. Cardiomyopathy. Classification. Characteristic of reasons and mechanisms of development, main clinical manifestations.
Themes of abstracts:
· Cardiac insufficiency, that develops at the myocardium infarction.
· Cardiac insufficiency, that develops as a result of inborn cardiomyopathy.
· Cardiac insufficiency, that develops at arrhythmias.
· Cardiac insufficiency, that develops at tamponade of hearts.
Literature is necessary for studying of the theoretical questions.
1. Pathophysiology/ Edited by prof. Zaporozan, OSMU, 2005. – Р. 207-216.
2. Handbook of general and Clinical Pathophysiology/ Edited by prof. A.V.Kubyshkin, CSMU, 2005. – P.221-232
3. General and clinical pathophysiology/ Edited by Anatoliy V/ Kubyshkin – Vinnytsia: Nova Knuha Publishers – 2011. p.460-478
Question for checking final level of knowledges.
Testing according system "Krok-I"
Tests of an open database (2010)
1. A patient suffering from stenocardia was taking nitroglycerine which caused restoration of blood supply of myocardium and relieved pain in the cardiac area. What intracellular mechanism provides restoration of energy supply of insulted cells?
A Intensification of ATP resynthesis
B Reduction of ATP resynthesis
C Increased permeability of membranes
D Intensification of oxygen transporting into the cell
E Intensification of RNA generation
2. In course of a preventive examination of a miner a doctor revealed changes of cardiovascular fitness which was indicative of cardiac insufficiency at the compensation stage. What is the main proof of cardiac compensation?
A Myocardium hypertrophy
B Tachycardia
C Rise of arterial pressure
D Dyspnea
E Cyanosis
3. A patient ill with essential arterial hypertension had a hypertensic crisis that resulted in an attack of cardiac asthma. What is the leading mechanism of cardiac insufficiency in this case?
A Heart overload caused by high pressure
B Heart overload caused by increased blood volume
C Absolute coronary insufficiency
D Myocardium damage
E Blood supply disturbance
4. ECG of a 44-year-old patient shows signs of hypertrophy of both ventricles and the right atrium. The patient was diagnosed with the tricuspid valve insufficiency. What pathogenetic variant of cardiac dysfunction is usually observed in case of such insufficiency?
A Heart overload by volume
B Heart overload by resistance
C Primary myocardial insufficiency
D Coronary insufficiency
E Cardiac tamponade
5. Dystrophic changes of the heart muscle are accompanied with cardiac cavity enlargement, decrease of the strength of heart contraction, increased amount of blood, which remains in the heart during systolic phase, overfilled veins. For what state of heart is it characteristic?
A Myogenic dilatation
B Tonogenic dilatation
C Emergency stage of hyperfunction and hypertrophy
D Cardiosclerosis
E Tamponage of the heart
6. Transmural myocardial infarction in the patient was complicated with progressive acute left ventricle insufficiency. What is the most typical for this state?
A Edema of the lungs
B Edema of the extremities
C Cyanosis
D Ascites
E Arterial hypertension
7. Processes of repolarisation are disturbed in ventricular myocardium in examined person. It will cause amplitude abnormalities of configuration and duration of the wave:
A T
B Q
C R
D S
E P
8. After a serious psycho-emotional stress a 45-year-old patient suddenly felt constricting heart pain irradiating to the left arm, neck and left scapula. His face turned pale, the cold sweat stood out on it. The pain attack was stopped with nitroglycerine. What process has developed in this patient?
A Stenocardia
B Myocardial infarction
C Stroke
D Psychogenic shock
E Stomach ulcer perforation
9. A patient who suffers from severe disorder of water-salt metabolism experienced cardiac arrest in diastole. What is the most probable mechanism of cardiac arrest in diastole?
A Hyperkaliemia