Rapitful Shqip

What is diastolic dysfunction ?  It is excessive stiffness of the heart resulting in an inability of the heart to fill properly (Eur Heart J 1998; 19: 990-1003).  This is in contrast to systolic dys-function, where contractility is impaired.  Patients have clinical features of left heart failure but normal systolic function by echocardiography or radionuclide ven-triculography.  It is a feature of hypertrophic cardiomyopathy, severe left ventricular hypertrophy (e.g. aortic stenosis or hypertension) and restrictive cardiomyopathy (e.g. amyloidosis).  Treatment is directed towards the underlying cause.

What is the pharmacological treatment of left ventricular systolic dysfunction ?   • Diuretics for symptomatic patients to maintain appropriate fluid balance.   • For patients with systolic dysfunction (EF <40%) who have no contraindications: -ACE inhibitors for all patients.   - Beta-blockers for all patients except those who are haemodynamically unstable or who are intolerant.   - Spironolactone for patients with rest dyspnoea or with a history of rest dypnoea. -Digoxin both for patients who remain symptomatic despite diuretics, ACE inhibitors and beta-blockers and patients with rest dyspnoea or who have a history of rest dyspnoea.

What is Kussmaul's sign ?  Normally there is an inspiratory decrease in JVP. In constrictive pericarditis there is an inspiratory increase in JVP. Kussmaul's sign is also seen in severe right heart failure regardless of aetiology.  It is caused by the inability of the heart to accept the increase in right ventricular volume without a marked increase in the filling pressure.  Adolf Kussmaul (1822-1902) was Professor of Medicine successively at Heidelberg, Enlargen, Freiburg and Strasbourg, and coined the term 'polyarteritis nodosa' (Ber/ Klin Wochnschr 1873; 10: 433).  Kussmaul breathing is deep sighing respiration seen when the arterial pH is Iow.

What do you know about the waveforms in the jugular pulse ?   There are two outward-moving waves (the a and v wave) and two inward-moving waves (the x and y descent).   • The 'a' wave is caused by atrial contraction and is presystolic. It can be identified by simultaneous auscultation of the heart and the examination of the jugular venous pulse. The 'a' wave occurs at about the first heart sound.   • The 'c' wave is due to closure of the tricuspid valve and is not readily visible.   • The 'v' wave results from venous return to the right heart (not due to ventricular contraction) and occurs nearer to the second heart sound.   • The 'x' descent is due to atrial relaxation (sometimes referred to as systolic collapse). • The 'y' descent is produced by opening of the tricuspid valve and rapid inflow of blood into the right ventricle.

What do you know about the hepatojugular reflux ? A positive hepatojugular (abdominojugular) reflux is a feature of left ventricular systolic failure with secondary pulmonary hypertension. [t is elicited by upper abdominal compression for -10 seconds. An abnormal response is one wher there is an increase followed by an abrupt fall. The hepatojugular manoeuvre is often useful in eliciting venous pulsations when they are not readily visible.

How do you differentiate jugular venous pulsations from carotid artery pulsations ?  Unlike the arterial pulse, the venous pulse has a definite upper level which falls during inspiration and changes with posture.  The venous pulse is seen to have a dominant inward motion, towards the midline (the 'y' descent), whereas l~he arterial pulse exhibits a dominant outward wave.  The venous pulse is better seen than felt, whereas the arterial pulse is readily felt by very slight pressure of the clinician's finger.

What are the causes of a raised jugular venous pulsations ? • Congestive cardiac failure. • CDr pulmonale. • Tricuspid regurgitation (prominent 'v' waves). • Tricuspid stenosis (prominent 'a' waves). • Complete heart block (cannon waves). • Non-pulsatile neck veins seen in superior venal caval obstruction.