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Файл:Pathophysiology of breathing and cardiovascular pathology. Educational and methodological manual
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Topic 1. Cardiac pathophysiology
levels increase 6—8 hours after the onset of a pain attack, the peak is
18—24 hours, activity decreases to normal values on the 4—5 day.
The increase in enzyme activity in dynamics may indicate the expansion of the necrosis focus, the involvement of other organs and
tissues, for example, the liver, in the pathological process.
5. During infarction, the content of lactate dehydrogenase
(LDH) increases. LDH is a cytoplasmic zinc-containing enzyme
found in almost all human organs and tissues, its concentration inside cells is much higher than in blood serum. It catalyzes the reversible oxidation reaction of L-lactate to pyruvate. The greatest
activity is observed in the kidneys, liver, heart, skeletal muscles,
pancreas, blood cells (different tissues differ in the isoenzyme
composition of LDH).
An important property of cardiac troponins is a long period of
increase in blood concentration: up to 10 days for troponin I and up
to 14 days for troponin T. For the purpose of diagnosing repeated
myocardial necrosis, if they develop in the next 2 weeks, "short"
markers can be used: sensitivity to creatine phosphokinase, myoglobin, FABP2. The use of a common CK for the diagnosis of MN
is not recommended. The positive result of determining the biochemical marker of myocardial necrosis is a necessary component
of the complex diagnosis of MN.
When taking blood samples to determine biochemical markers
of myocardial necrosis, their changes in dynamics are necessarily
taken into account. For example, the normal activity of sensitivity
to creatine phosphokinase in a sample obtained 3 hours after the
onset of the attack is an expected fact, and it does not deny the diagnosis of developing MN. Therefore, during the first day, blood
tests for biochemical markers of myocardial necrosis should be
taken repeatedly, for example, with an interval of 4—6 hours (this
does not apply to the definition of troponins). Moreover, the determination of the concentration of troponin or sensitivity to creatine phosphokinase in a sample taken deliberately earlier than the
time when they can be expected to increase can be considered jus-
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Pathophysiology of breathing and cardiovascular pathology
tified: this gives the necessary reference point. When analyzing the
replicates, a curve can be obtained that reflects a typical pattern of
increasing and then decreasing the concentration (activity) of
markers. This is necessary not only to clarify the diagnosis of MN
itself, but also to detect the recurrence of MI.
The concentration of cardiac troponin in the blood can increase
not only with MI, but also with other heart lesions and even extracardiac diseases. More often, this is observed when using modern
highly sensitive test systems.
Therefore, the "golden rule" — the diagnosis of MN is established on the basis of a set of data and taking into account the clinical picture of the disease — retains its strength when using such
markers of myocardial necrosis as cardiac troponins.
SITUATIONAL TASKS
Clinical case №
1
In patient C. 52 years old, who is being treated in the cardiology department with a diagnosis of CHD: large-hour myocardial
infarction of the anterior wall of the left ventricle with pathological
tooth Q, a weakening of the I tone of the heart is detected with auscultation of the heart.
Questions:
1. In what phases of the heart cycle is the I tone of the heart
formed, what components of the I tone?
2. Which tone I component is weakened and why?
3. What are the signs of pathological Q wave, clinical interpre-
tation?
Answer:
1. The I tone of the heart is formed in the phase of isovolumetric ventricular contraction (muscle and valvular components) and
in the phase of expulsion (vascular component).
12
Topic 1. Cardiac pathophysiology
2. The muscular component of tone I is weakened due to the
fact that necrosis of a vast area of the myocardium has occurred
and the contractility of the myocardium is significantly reduced.
3. Pathological wave Q by amplitude > of its corresponding
wave R. This implies necrosis > 50
% of myocardial thickness, i. e.
large-frequency myocardial infarction.
Clinical case №
2
In patient M., 52 years old, complaints of bouts of sternal pain,
compressive and compressive nature, provoked by physical activity
(walking 500 m, climbing the stairs to the 2 floor), irradiating into
the left arm, stopped by taking 1 tablets of nitroglycerin for 1—3 minutes. At the time of the attack when walking, the patient "freezes."
From the history of the disease: the above complaints worry for a
year.
Questions:
1. At what stage of the diagnostic search can the diagnosis in
this patient be assumed?
2. What diagnosis can you make to this patient?
3. What is the mechanism of pain in this situation?
Answer:
1. It is possible to make a diagnosis already at the initial stage
of the diagnostic search, as a result of interviewing the patient,
clarifying complaints and justifying the primary diagnostic hypothesis.
2. Primary diagnostic hypothesis: Based on the patient's complaints about bouts of pain for the sternum of a pressing and compressive nature, with irradiation into the left arm, provoked by
physical activity — walking 500 m, climbing the stairs to the
2 floors, stopping with nitroglycerin for 1—3 minutes, "fading" at
the time of the attack; as well as a history of the disease — the
above complaints worry for a year, we can assume the diagnosis:
CHD: stable angina tension.
13
Pathophysiology of breathing and cardiovascular pathology
3. In this case, we are talking about anginous coronary pain due
to atherosclerotic damage to the coronary vessels: rigidity of the
walls of the vessels and narrowing of their lumen due to the formation of atherosclerotic plaques.
Clinical case №
3
Patient R., 18 years old, was admitted to the Department of
Cardiology with complaints of shortness of breath worsening with
physical exertion and in a horizontal position, aching constant pain
in the heart area, not relieved by nitroglycerin, palpitations, a feeling of heart failure, an increase in body temperature to subfebrile
numbers in the evening. From the history of the disease: a month
ago he suffered follicular sore throat. 2 weeks after the sore throat,
he began to note pain in the heart, progressive shortness of breath.
From the history of life: heredity is burdened: the mother has rheumatic heart disease.
Objective: general condition of moderate severity. The consciousness is clear, the position is preferably orthopneous. Acrocyanosis is noted. Dyspnea of inspiratory nature. From the cardiovascular system: the pulse is arrhythmic, rapid, frequency 95 per minute. Apical shock low, weak, low resistance. The extension of the
boundaries of the heart is predominantly to the left. Auscultatory:
HR 95 per minute. Heart tones are muted, arrhythmic (there are
extraordinary contractions with a subsequent compensatory pause),
a "gallop rhythm" is heard, systolic noise at the I point of auscultation of a functional nature. Emphasis of tone II on point III of auscultation.
Laboratory and instrumental data:
Complete blood count:
RBC — 3.7
× 1012, WBC — 10,8 × 10
Lymphocytes — 22
%, Monocytes — 6 %, ESR — 30 mm/h.
9
, Neutrophils — 68 %,
Blood chemistry: CRP (+ + +).
ECG: Sinus rhythm. HR 92 per minute, deviation of the elec-
trical axis of the heart to the left. Single right-ventricular extrasystoles. Reduction of teeth voltage. Signs of A-V blockade 1 st.
14
Topic 1. Cardiac pathophysiology
Questions:
1. What is your diagnosis and its rationale?
2. What diagnostic criteria are used for diagnosis to this pa-
tient?
3. Draw up a follow-up plan.
Answer:
1. Acute rheumatic fever. Myocarditis. Abnormal heart rhythm
by ventricular extrasystole type. Type I AV block conduction disturbance.
2. The main diagnostic criteria for myocarditis (tachycardia,
weakening of heart tones, gallop rhythm, functional systolic noise
at the top of the heart, emphasis of 2 tone on III t. Auscultation); ad-
ditional clinical ones — fever, laboratory and instrumental ones —
leukocytosis (10,8
9
× 10
), ESR acceleration (30 mm/h), ECG-sinus
rhythm, HR 92 in 1 minute, deviation of the electrical axis of the
heart to the left Single right-ventricular extrasystoles. Reduction of
teeth voltage. Signs of A-V blockade 1 st.
3. It is necessary to confirm the presence of A-streptococcal infection (swab from the throat — inoculation for the determination
of positive A-streptococcal culture, determination of anti-streptococcal antibodies). Ultrasound of the heart.
Clinical case №
4
The patient being treated in the cardiology department has the
following pathological symptoms:
• The pulse is full, solid.
• Apical shock spilled, resistant, strong, high.
• Percutory — displacement of the left border of the heart outward by 1.5 cm.
• With auscultation of the heart there is an emphasis of 2 tones
on the point of auscultation of the aortic valve.
Questions:
1. What diagnosis can be assumed based on the available objective data?
15
Pathophysiology of breathing and cardiovascular pathology
2. What syndromes can be assumed in this patient?
3. Draw up a follow-up plan.
Answer:
1. Hypertension.
2. Artherial hypertension syndrome, left ventricular hypertrophy syndrome.
3. ECG, cardiac ultrasound, lipidogram, blood glucose determination, daily BP monitoring, urinalysis, Zimnytskii urinalysis,
renal ultrasound, renal angiography, cranial X-ray, blood plasma
catecholamine level, thyroid hormone level.
Clinical case №
5
Patient K., 32 years old, presents complaints of shortness of
breath with minor physical activity, feeling of heaviness in the
right hypochondrium, enlargement of the abdomen, swelling of the
legs. From the history of the disease: two years ago, atrial fibrillation appeared. Occasionally, hemoptysis is noted. From the history
of life: in childhood she often had sore throats, suffered polyarthritis.
Objective: acrocyanosis, "mitral butterfly," positive vein pulse
on the neck, epigastric pulsation. Breathing is tough, in the posterior parts of the lungs, silent fine-wheezed wheezing is heard. RR
(respiratory rate) — 22 per min. Pulse of weak filling and tension,
arrhythmic, 85 per min. Pulse deficit 15 per 1 min. Heart shock is
determined along the left edge of the sternum. The right border of
the heart is 2 cm outward from the right edge of the sternum, the
upper in the 2nd intercostal region, the left is located along the left
midclavicular line. HR 100 per minute. 1 tone at the top of the
heart is strengthened, the "quail" rhythm and diastolic noise are
heard there, 2 tone on the pulmonary artery is accented. BP —
110/90 mmHg. The abdomen is moderately enlarged due to ascites
and an enlarged liver, which protrudes 6 cm from under the costal
arch, dense, painful, the edge is pointed, there is a transfer pulsa-
16
Topic 1. Cardiac pathophysiology
tion of the liver. The size of the liver according to Kurlov 15—
14—13 see. Swelling of the lower extremities to the upper third of
the lower legs.
Results of additional examination:
Complete blood count: WBC — 4,3
RBC — 4,7
× 10
12
/l.
9
× 10
/l, ESR — 16 mm/h,
Blood chemistry: CRP — (–), fibrinogen — 250 mg%, albumins — 56
beta-globulins — 12
%, alpha-1-globulins — 4 %, alpha-2-globulins — 7 %,
%, gamma-globulins — 19 %, Antistreptoly-
sin-O (ASO) — 220 units.
ECG: HR 100 per minute. Deviation of the electrical axis of
the heart to the right. Atrial shimmer.
FKG: change in the amplitude of 1 and 2 tones, the presence of
an additional tone, diastolic noise at the top.
ECHO-CG: decrease in the area of the left atrioventricular orifice. Doors mitral valve (MV) — U-shaped; posterior tightened.
Enlargement of the cavity of the left atrium and right ventricle is
noted. In "E" mode, increase of MV speed (stenotic flow);
Questions:
1. Justify the clinical diagnosis of this patient.
Answer:
Based on the patient's complaints of shortness of breath, swelling of the lower extremities, abdominal enlargement, feeling of
heaviness in the right hypochondrium, occasionally hemoptysis,
history of the disease: she suffered polyarthritis in childhood, atrial
fibrillation appeared two years ago; based on objective data: acrocyanosis, "mitral butterfly," positive vein pulse on the neck, epigastric pulsation; in the posterior-lower parts of the lungs, silent
fine wheezing is heard, RR (respiratory rate) — 22 per minute;
pulse of weak filling and tension, arrhythmic, 85 per minute, pulse
deficit 15 per minute; mitral heart configuration; Heart rate is 100
per minute, the quail rhythm is listened to at the top of the heart,
diastolic noise is determined there, 2 tones on the pulmonary artery
are accented; the abdomen is moderately enlarged in size due to
17
Pathophysiology of breathing and cardiovascular pathology
ascites and enlargement of the liver, which protrudes 6 cm from
under the costal arch, dense, painful, transmission pulsation of the
liver, swelling of the legs is noted;
as well as based on the survey data: ECG — HR 100 per minute. Deviation of the electrical axis of the heart to the right. Atrial
shimmer. Electrocardiograms (EKG): change in amplitude of 1 and
2 tones, presence of additional tone, diastolic noise at the top.
Echocardiography: reduced area of the left atrioventricular
orifice. Doors mitral valve (MV) — U-shaped; posterior tightened.
Enlargement of the cavity of the left atrium and right ventricle is
noted. In "E" mode, increase of MV speed (stenotic flow); a clinical diagnosis can be made:
Main diagnosis: Chronic rheumatic heart disease. Mitral valve
stenosis.
Complications: Heart rhythm disturbance by atrial fibrillation
type. Ascites.
Clinical case №
6
Patient P., 15 years old, was admitted to the hospital with complaints of chills and a feeling of heat in the evening, accompanied
by an increase in temperature to subfebrile numbers (maximum up
to 37.4
°C), gait change, impaired handwriting, the appearance of
involuntary movements of the face and hands, mood lability.
Medical history: 1 month ago suffered a sore throat. She was
treated at home. After the resumption of education at school,
teachers noted a deterioration in handwriting, an increased lability
of mood. In the future, gait disturbance, twitching with the hands
and head, sometimes — involuntary protrusion of the tongue. In
the evening, an increase in body temperature to subfebrile numbers
was noted.
History of life: it is known that in childhood it grew and developed normally. Parents and younger brother are healthy. He
studies in the 9th grade of the school. As a child, she suffered chickenpox, mumps.
18
Topic 1. Cardiac pathophysiology
Objectively: on examination, the condition is relatively satisfactory. Attention is drawn to the increased emotional lability, involuntary movements of the fingers, protrusion of the tongue.
Handwriting and finger-nose tests are difficult to perform. In posture, Romberg is erratic. The skin is unchanged. There are no edema. The joints are not visually changed, when palpating and performing movements are painless. There are no wheezing in the
lungs. HH 16/min. Percutorally left border of the heart along the
midclavicular line. Heart tones muted, heart rate 100/min, noises
not listened to. The abdomen during palpation is soft, painless.
Liver and spleen are not enlarged.
Results of additional examination:
Complete blood count: leukocytes — 11
phils — 4
120 g/L, RBC — 4.5
%, segmented neutrophils — 78 %, hemoglobin —
12
× 10
/L, ESR — 18 mm/h.
9
× 10
/L, band neutro-
Questions:
1. What is the main diagnostic criterion for the patient? What
are its signs in this case?
2. Justify and formulate a preliminary diagnosis.
3. A follow-up plan?
Answer:
1. Increased emotional lability, involuntary movements of the
fingers, protrusion of the tongue, handwriting and finger-nose tests
are difficult, in Romberg's pose unstable: Sidengam's small chorea.
2. Based on the patient's complaints of chills and a feeling of
heat in the evening, accompanied by an increase in temperature to
subfebrile numbers (maximum up to 37.4
°C), a change in gait,
impaired handwriting, the appearance of involuntary movements of
the face and hands, mood lability, based on the history of the disease — 1 month ago suffered a sore throat, after the resumption of
training at school, teachers noted a deterioration in handwriting,
increased mood lability; subsequently, gait disturbance, twitching
with the hands and head, sometimes — involuntary protrusion of
the tongue; based on the examination data — increased emotional
19
Pathophysiology of breathing and cardiovascular pathology
lability, involuntary movements of the fingers, protrusion of the
tongue, handwriting and palcenos tests are difficult, in Romberg's
pose unstable, percutorally left border of the heart along the midclavicle line, heart tones are somewhat muted, heart rate is 100/min,
you can diagnose: Acute rheumatic fever. Chorea Sidengama. Myocarditis.
3. Biochemical blood count: sialic acids, fibrinogen; proteinogram. Swab from the throat — sowing to determine the positive
A-streptococcal culture. Determination of anti-streptococcal antibodies. Ultrasound of the heart. ECG.
Clinical case №
7
Patient I., 39 years old, a painter, complained of shortness of
breath of a mixed nature, with minor physical exertion, increasing
in a horizontal position, heart palpitations, heart outages, swelling
of the lower legs and feet, dry cough.
Medical history: he fell ill acutely, when the temperature rose
to 37.8
°C, a dry cough appeared, in connection with which he
turned to the local doctor. A diagnosis was made: ARVI. He received antibiotic and anti-starker therapy with no clinical effect.
Over the next 12 days, the patient's condition progressively worsened — shortness of breath appeared, of a mixed nature, which
progressed, swelling on the lower extremities.
History of life: smokes 10 cigarettes a day for 10 years. He
underwent surgery: removal of part of the left lung in 1993 for tuberculosis.
Objective data: moderate condition. Skin with jaundice tint,
sclera icteric, cyanotic lips. Wet wheezing is heard in the lungs
against the background of hard breathing in the lower parts. RR
(respiratory rate) 26 per minute. The boundaries of relative dullness of the heart are increased to the left by 2 cm. The tones of the
heart are muted, rhythmic, weakening of 1 tone at the top of the
heart and at the Botkin-Erb point, the accent is 2 tones above the
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