Question
Angiotensin converting enzyme (ACE) inhibitors are one of the more common medications used in the management of primary hypertension.
What are some potential adverse reactions from and contraindications to using ACE inhibitors?
Korotkoff Sounds
Other known aliases – none
Definition – sounds heard during auscultation of the brachial artery during blood pressure measurements
Clinical Significance – these sounds are generated as the sphygmomanometer cuff is slowly being deflated to the point that the maximal impulse of the pressure wave is more than cuff, but the cuff still occluded the artery at the nadir of the impulse. This pressure difference produces turbulence in the blood flow and the characteristic sound on auscultation. There are five phases to the Korotkov sounds with the initiation of Phase 1 as the systolic pressure and the end of Phase 4 as the diastolic pressure.
History – named after Nicholai Korotkov (1874-1920), who was a Russian surgeon and earned his medical degree from Moscow University in 1895. He had a prestigious career as a military physician and surgeon earning him an appointment as professor of surgery at the Military Medical Academy at St. Petersberg in 1903. He was preparing his doctoral thesis on vascular surgery when he described his now famous technique for measuring blood pressure in only a 281 word excerpt from a presentation to the Imperial Military Medical Academy entitled “Izvestie Imp. Voiennomedicinskoi Akademii” in 1905.
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Definition of Heart Failure
Epidemiology
Causes and Pathophysiology
Any condition that leads to alteration in left ventricular structure or function can cause heart failure and the specific causes depends on the preservation of ejection fraction. There is considerable overlap between these with coronary artery disease and hypertension causes the majority of cases.
The problem is that the rest of the body feel the effects of the decreased cardiac output and activate the neurohormonal systems to compensate. The issue is that this makes the heart failure worse and it is a vicious cycle until it can be broken.
Signs and Symptoms
Framingham Clinical Criteria for Heart Failure
Clinical Decision Rule for Heart Failure
Diagnostic Studies
Classification and Grading
Current Nomenclature
Heart failure with reduced ejection fraction (HFrEF)
Heart failure with preserved ejection fraction (HFpEF)
Management
References
Question
Hypercholesterolemia is most commonly a laboratory diagnosis, but there are some class physical examination findings that can be seen. What are they?
Answer
There are five (5) classic physical exam findings associated with hypercholesterolemia and are more common in familial, genetic hyperlipoprotenemias.
Bundle of Kent
Other known aliases – atrioventricular bypass tract
Definition – As discussed in the WPW eponym, the Bundle of Kent is an accessory conduction pathway between the atrium and ventricle on either the right or left side of the heart.
Clinical Significance – this pathway occurs in up to 0.3% of patients and the cause of Wolff-Parkinson-White syndrome. It bypasses the traditional conduction system and allows for pre-excitation tachydysrthymias.
History – Named after Albert Frank Stanley Kent (1863-1958), an English physiologist who received his degree in 1886 from the Magdalen College of Oxford. He first described lateral atrioventricular connections in a monkey heart in 1893 and erroneously believed these were part of the normal specialized conduction system. These findings generated a lot of controversy at the time and were actually rejected by several notable anatomists and physiologists. In fact, in 1955, Lev and Learner dissected 33 neonatal hearts and found no evidence of “normal” lateral conduction systems.
References
Question
Hypercholesterolemia is most commonly a laboratory diagnosis, but there are some class physical examination findings that can be seen. What are they?
Wolff-Parkinson-White Syndrome
Other known aliases – ventricular pre-excitation with arrhythmia, auriculoventricular accessory pathway syndrome
Definition – paroxysmal supraventricular tachycardia caused by conduction through an abnormal accessory bypass tract between the atria and ventricles known as the Bundle of Kent. There are two types depending on the side of the heart it effects; Type A is between the right atrium and ventricle and Type B is between the left atrium and ventricle.
Clinical Significance – Patients with WPW can numerous cardiac dysfunction symptoms including tachydysrhythmias, palpitations, dyspnea, presyncope, syncope, and sudden cardiac arrest. It is characterized by the triad of abnormalities on EKG of widened QRS, shortened PR interval, and slurring of the initial part of the QRS (called a delta wave).
History – Named after Louis Wolff (1898-1972), Sir John Parkinson (1885-1976), and Paul Dudley White (1886-1973). Dr. Wolff was an American cardiologist who received his medical doctorate from Harvard Medical School in 1922. Dr. Parkinson was an English cardiologist who received his medical doctorate from University of Freiburg in 1910 and was also knighted by King George in 1948. Dr. White was an American cardiologist who received his medical doctorate from Harvard Medical School in 1911 and one of the founding presidents for the American Heart Association. He was a prominent advocate for preventive medicine receiving many national and international awards for his efforts to advance the importance of diet, exercise, and weight control in the prevention of cardiovascular disease. They collaborated to publish a series of 11 cases entitled “Bundle‐Branch Block with Short P‐R Interval in Healthy Young People Prone to Paroxysmal Tachycardia” in the American Heart Journal in 1930. It should be noted that Dr. Frank Norman Wilson and Dr. Alfred Wedd both described and published these findings in 1915 and 1921.
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