Download Circulatory System Teaching Syllabus

Disease of cardiovascular system
Valvular heart disease
Purpose and requirement
1 Grasp the pathophysiologic charactors clinical manifestations and diagnostic methods
of common sorts of valvular heart disease.
2 Be familial to the relationship between rheumatic fever and rheumatic heart disease,in
addition,the knowledge of common differential diagnosis complications therapeutical
principles and implications to surgery are also important.
3 Know about some knowledge about the epidemiology and some advances in such
disease.
Content
1 Introduction
The incidence of rheumatic fever has declined, and as the result the rheumatic heart
disease is not the most important cause of valvular disease in developed countries; but
valvular disease caused by rheumatic heart disease is still very common in the china
and other developing countries.
2 Mitral stenosis and mitral regurgitation
A. Pathophysiology: the effects of abnormal homodynamic caused by mitral lesions to
left atrium pulmonary circulation and right heart.
B. Clinical features:
1) Major symptoms and signs of mitral stenosis and mitral regurgitation
2) Investigations: ECG, chest radiography, echocardiography and cardiac
catheterization
C. Diagnosis and differential diagnosis
1) Diagnosis is based on the major symptoms, signs and combined with the results of
investigations.
2) Differential diagnosis: its necessary to distinguish other disease that can cause the
similar apical diastolic murmur (eg, Austin Flint murmur) with mitral stenosis
3 aortic stenosis and aortic regurgitation
A. Pathophysiology: wether stenosis or regurgitation will increase the burden of left
ventricle, as the result left ventricle undergoes hypertrophy and eventually become
dilated. These changes accompany series changes of homodynamic in left heart.
B. Clinical features:
1) Major symptoms and signs of mitral stenosis and mitral regurgitation
2) Investigations: ECG, chest radiography, echocardiography and cardiac
catheterization
C. Diagnosis and differential diagnosis:
1) Diagnosis is based on the major symptoms, signs and combined with the results of
investigations.
2) Differential diagnosis:
a) Differention between aortic regurgitation and pulmonary regurgitation secondary to
pulmonary artery dilation;
b) Distinguish different causes of aortic regurgitation (e.g.: rheumatic, degenerative,
congenital et al.);
c) Aortic stenosis should be differented from obstructive hypertrophic cardiomyopathy
or congenital aortic stenosis
4-Mutivavular diseases
5 Complications with valvular disease
A. Cardiac insufficiency
B. Acute pulmonary edema
C. Arrhythmia: especially atrial fibrillation
D. Infective endocarditis
E. Respiratory tracts infection
F. Systemic emboli
6 Management
A. Therapeutical principles to patients without complications: maintain and improve
cardiac function, prevent the occurrence of complications
B. Management of complications: treat cardiac insufficiency; releive acute pulmonary
edema; treatments of atrial fibrillation (restore sinus rhythm; control heart rate;
anticoagulation)
C. Surgery: indications and contraindications
7. Prevention of rheumatic fever and prognosis
Cardiomyopathy and myocarditis
Purpose and requirement
1 Understand the principles of diagnosis and treatment for cardiomyopathy
2 Be familial to etiology, diagnosis and treatment for myocarditis
Content
1. cardiomyopathy
A. General introduction
Defenition, clinical classification, pathologic classification and epidemiology
B. Dilated cardiomyopathy
1) Definition
2) Characters of pathophysiology
3) Clinical features: symptoms and signs
4) Investigetions: ECG, X-ray, UCG, catheterization and endomyocadial biopsy
5) Essentials of diagnosis and treatment
6) Prognosis
2. Hypertrophy cardiomyopathy
A. Definition
B. Characters of pathophysiology
C. Clinical features: symptoms and signs
D. Investigetions: ECG, X-ray, UCG, catheterization and endomyocadial biopsy
E. Essentials of diagnosis and treatment
F. Prognosis
3. Miscellaneous cardiomyopathy
Alcoholic cardiomyopathy; peripartum cardiomyopathy; restrictive
cardiomyopathy;other special types of cardiomyopathy such as KESHAN disease
4. Viral myocarditis
A.Etiology: commonly initiated by coxsackievirus B
B. Pathology: focal patchy or diffuse inflammatory infiltrate with adjacent myocyte injury
C.Symptoms: asmptomatic/chest discomfort/classic symptoms of congestive heart
failure/syncope
D. Signs: vary widely
E. Investigations: ECG, X-ray, measurement of serum antibody and isolation of virus et
al.
F. Essentials of diagnosis and treatment:
1) Diagnosis based on comprehensive analysis for clinical features, ECG, X-ray and lab
tests;
2) Treatment: bed rest; management of heart failure, arrythmia and other symptoms if
existed; other uncertain treatments (steroid, immunosuppressive therapy)
G. Prognosis
Heart failure
Purpose and requirement
1 understand causes and pathophysiological characters of heart failure
2 understand clinical manefestations, diagnosis and differential diagnosis of heart
failure
3 understand principles of treatment for heart failure, especially the use method of
digtalis,diuretics,ACEI and β-blocker. Learn the management of acute left heart failure
Content
Ⅰ.Chronic cardiac insufficiency
1 causes
A. Fundamental causes: myocardial damagement; cardiac overload
B. Precipitating factors: lack of compliance (diet, drug); uncontrolled hypertension;
myocardial infarction and ischemia; cardiac arrythmia; fluid overload; infection;
pregnancy et al.
2 pathophysiology
A. Compensatory homodynamic changes: distribution of blood, increase of blood
volume (retention of sodium);
B. Ventricular hypertrophy and dilation;
C. Most important: cardiac remolding and activation of neurohumoral system (RAAS,
sympathytic nerve system)
3 clinical manifestations
A. Left heart failure: most symptoms related to pulmonary congestion, including
dyspnea, cough, rals and gallop, et al.
B. Right heart failure: most symptoms related to system congeston, including upper
abdominal discomfort, hepatomergaly, jugular vein distention, thoraxic effusion, et al.
4 complications: thrombosis and embolsm, cirrhosis secondary to heart failure,
disbalance of electrolyte
5 investigations: ECG, X-ray, UCG and noninvasive or invasive measurement of
cardiac function
6 diagnoses
A. Diagnosis: based on clinical features and measurement of cardiac function
B. Differential diagnosis: distinguish pulmonary disease from left heart failure, exclude
chronic pericardial temponade, cirrhosis and nephritis before making diagnosis of right
heart failure.
7 Prevention and treatment
A. Prevention: avoid potential precipitating factors and manage combined disease
positively. Pay attention to daily activities and diet.
B. Digitalis: indication and prohibition, methoda and dosage, toxic effect and
management
C. Diuretics: principles for use of diuretics, side effects and management
D. ACEI: principles for use of ACEI, dosage, side effects
E. β-blocker:Indicatins and prohibition
F. Vasodilators and other drugs
8 management of refractory heart failure
Ⅱ.Acute left heart failure
1 cause: mitral stenosis, AMI, volume overload
2 pathogenesis: cardiac output declines rapiddly, with the increase of pulmonary
pressure, as the result acute pulmonary edema develops.
3 Clinical features: breathless and distressed, cough up pink frothy sputum,
hypotension and carcinogenic shock, many rales in bilateral lungs
4 diagnoses: diagnosis based on analysis of clinical manefestations, and excluding
attack of bronchial asthma.
5 management
A. Sit the patient up
B. Administer oxygen
C. Morphine
D. Frusemide
E. Vasodilators: sodium nitroprusside
6.Digitalis: pay attention to indication
7.Other drugs and methods
Common Arrhythmias
General Introduction
Purpose and Requirement
1. Grasp the etiology, clinical manifestations, diagnoses and treating principles of
common arrhythmias.
2. Be familiar with electrocardiographic features and diagnosis of common arrhythmias.
3. Understand nosogenesis of arrhythmias.
Content
1. Concept
A. The physiology of the heart, including myocardial automaticity, excitability,
conductibility and reentry. Elucidation of the close relationship between
arrhythmogenesis and the transformation of myocardial electrophysiology.
B. The etiology, pathology, mechanism and pathophysiology of cardiac arrhythmias and
conduction disturbances. Both disordered automaticity and impulse conduction
disturbances can cause arrhythmias. Cardiac output is influenced by altered heart rates,
atrioventricular dyssynchrony or loss of contractile function.
C. The clinical manifestations, diagnoses and approach to analyzing
electrocardiograms. Auscultative features. Analysis of P waves, QRS complexes, the
relationship between P waves and QRS complexes, P—P intervals.
2. Sinus Arrhythmias
A. Etiology. Physiological causes include exercises, drugs, etc. Pathological causes
consist of myocardial and noncardiac ones.
B. Clinical manifestation. The onset and ending of sinus arrhythmias of is a gradual
process, and is susceptible to vegetative nervous activities.
C. Electrocardiogram. Electrocardiographic features of sinus rhythm.
D. Treatment. Aim at causes mainly, also at symptoms.
3. Sick Sinus Syndrome
Introduction
A. Etiology
B. Clinical features
C. Electrocardiogram
D. The clinical indications for pacemaker therapy.
4. Supraventricular Arrhythmias
A. Premature beats
1) Etiology. Tension, cigarette, alcohol, tea, coffee, excited vagal nerve, structural heart
diseases, drugs, cardiac mechanic stimulation, cardiac surgery.
2) Clinical features. Correlated to the number of premature beats and sensitivity of
patients. Auscultative features.
3) Electrocardiogram. Premature ectopic P waves, P—R intervals, compensatory
pauses.
4) Treatment. Elimination of causes. Indications and sorts of medical treatment.
5) Clinical significance. Rest with influence on cardiac function.
B. Paroxysmal Supraventricular Tachycardia
1) Etiology. Most of causes are unclear. A few PSVT are accompanied with structural
heart diseases or other diseases.
2) Clinical manifestations. Acute onset and ending. Auscultation. Jugular venous pulse.
3) Diagnosis. Based on clinical manifestations and electrocardiograms.
4) Electrocardiographic features and differential diagnosis. Classified as atrial, nodal
and supraventricular paroxysmal tachycardia.
5) Treatment. Drugs, stimulation of vagal nerve, electrical cardioversion, overspeed
suppression, interventional therapy, ie, radiofrequency catheter ablation.
6) Clinical significance. Rest with influence on cardiac function.
C. Atrial Fibrillation and Atrial Flutter
Classified as paroxysmal (acute) and persistent (chronic).
1) Etiology. Most are accompanied with structural heart diseases.
2) Clinical features. Result in cardiac dysfunction, pulse deficit and distinctive
auscultative features.
3) Diagnosis. Based on clinical manifestations and electrocardiograms.
4) Electrocardiogram. No P waves, presence of f waves or F waves.
5) Treatment. Drugs, electrical cardioversion.
5. Ventricular Arrhythmias
A. The premature beats are the commonest arrhythmia.
1) Etiology. As is displayed in Supraventricular Arrhythmias.
2) Clinical manifestations. Auscultative findings.
3) Diagnosis. Based on clinical manifestations and electrocardiograms.
4) Electrocardiogram. Premature QRS complexes and compensatory pauses.
5) Treatment. The indications of medical treatment comprise: ventricular premature
beats that occurs over 5 times per minute, polymorphic ventricular premature beats or
that presenting in the susceptible period. Presence of transient ventricular tachycardia.
Accompanied with coronary heart disease and severe symptoms produced by
ventricular premature beats.
6) Prognosis. Correlated with the causes of diseases.
7) Precaution. Based on the elimination of the causes of diseases.
8) Clinical significance. Rest with the influence on cardiac function.
B. Paroxysmal Ventricular Tachycardia
1) Etiology
2) Clinical manifestations and signs.
3) Diagnosis. Based on clinical manifestations and electrocardiograms.
4) Electrocardiographic features and differential diagnosis. Recapture and fusion beats
are the clues to differentiation between ventricular tachycardia and supraventricular
tachycardia with aberrant ventricular conduction.
5) Treatment. Drugs, electrical cardioversion, precaution of recurrence, seeking for
factors that producing stress (ventricular aneurysm, ischemic sites).
C. There is a strong linkage between sudden cardiac death and ventricular fibrillation.
1) Etiology. Usually observed in cardiac infarction, electric shock, drowning, asphyxia
and anesthesia.
2) Signs. Adams-Strokes’ syndrome.
3) Diagnosis. Based on clinical manifestations and electrocardiograms.
4) Electrocardiogram. No QRS complexes, nor T waves.
5) Treatment. Emergent resuscitation, electrical cardioversion, precaution of recurrence
with the help of drugs, control of risk factors.
Atrioventricular Block
D. Etiology. Drugs, rheumatic fever, acute cardiac infarction, acute infection, anesthesia,
coronary heart disease, rheumatic heart disease, congenital heart diseases.
E. Electrocardiographic features of first-degree, second-degree and third-degree
atrioventricular block.
F. Clinical manifestations. Adams-Strokes’ outbreak.
G. Diagnosis.
H. Treatment. Drugs, pacemakers.
6. Intraventricular Block
A. Etiology. Rheumatic heart disease, coronary heart disease, cor pulmonale and
congenital heart diseases.
B. Electrocardiographic features. Left and right bundle branch blocks, left anterior and
posterior fascicular blocks.
C. Treatment. Aim at etiology. Double bundle branch blocks can produce complete
atrioventricular block, and pacemaker therapy should be considered when necessary.
7. Preexcitation Syndrome
A. Mechanism.
B. Electrocardiographic features of different kinds of preexcitation syndromes.
C. Clinical features.
D. Treatment. Drugs, precaution of atrial arrhythmias and surgery.
E. Clinical significance.
Teaching Methods
1. Teach by demonstration of all sorts of arrhythmias, with the help of that has been
learned during clinical novitiate before class.
2. Give lessons with slides projection and wall maps.
3. Case discussion on the etiology, pathogenesis, clinical manifestations, diagnoses,
differential diagnoses and treatments of common arrhythmias during clinical novitiate
after class.
Hypertension
General Introduction
Purpose and Requirement
1. Be familiar with the pathogenesis of hypertension.
2. Grasp the classification and staging of hypertension, and the diagnostic and treating
principles of hypertensive crisis and hypertensive encephalopathy.
3. Understand the developing of the disease.
Teaching duration: 2 instructional classes
Content
1.Concept.
Definition and criteria of hypertension [according to WHO and ISH]. Difference between
primary hypertension and secondary hypertension.
Incidence(China), related factors eg. age, gender, genetic factor, career, body weight,
regional discrepancy.
2. Pathogenesis
Brief introduction to the major theories: neurogenic theory, renal theory, endocrine
theory,. Demonstrate the interaction between neural factors and humoral factors that
lead to hypertension by changing arterial tone and blood volume.
3. Pathology. Fundamental pathologic change is that arterial spasm develops into
arteriosclerosis, which presses its importance on subsequent pathologic changes of
heart, brain, kidneys and retinaes.
4. Clinical manifestation
Clinical types: benign and accelerated hypertension.
Clinical identity of benign hypertension: explain common symptoms, characteristics of
blood pressure, end organs’(retina, heart, brain and kidney) change and laboratory
tests’ results through related pathophysiological changes. Explain hypertensive
cardiopathy and hypertensive encephalopathy. Clinical identity of accelerated
hypertension: rapidly progressive, abound with end organs’ complications.
Brief introduction to hypertensive crisis, hypertensive encephalopathy and senile
hypertension.
Introduce classification and staging according to blood pressure degree, risk factors of
cardiovascular disease and involved end organs.
5. Diagnosis and differential diagnosis
Emphasize the importance of early diagnosis. Initial diagnosis should be made
discreetly. Classification and staging of hypertension should be decided by clinical
manifestation. Primary and secondary hypertension should be clarified. Briefly explain
clinical manifestation and diagnosis of common secondary hypertensions, which may
include renal hypertension(glomerulonephritis, chronic pyelonephritis, renal artery
stenosis), endocrine hypertension(pheochromocytoma, Cushing’s disease, primary
aldosteronism), conduction artery disease(aorta stenosis, takayasu arteritis), gestation
hypertension. Emphasize the impact of deciding etiology on therapy.
6. Therapy
Point out importance of early, long-term and active therapy.
A. General therapy: proper balance between work and rest, avoidance of overstrain,
salt restriction, physical exercise(eg. qigong, the shadowboxing), avoidance of tobacco,
weight-reduction, proper use of sedative, etc..
B. Antihypertensive drug therapy
1) Brief introduction to the six types of antihypertensive drugs
a) Diuretics: thiazides, related sulfonamide compounds, loop diuretics,
potassium-sparing diuretics.
b) Adrenergic blocking agent: propanolol and other β-blockers.
c) Calcium channel blocker(CCB)
d) ACE inhibitor(ACEI)
e) ARB
f) α-blocker
2) Choice of drugs
a) Individualized therapy: decide agents and dosage form according grading of the
patient.
b) Goal of antihypertensive drug therapy.
c) Applying plan.
3) Treatment with Chinese Medicine
a) Determination of treatment based on differentiation of symptoms and signs-to treat
the patient as the following principles: hyperactivity of liver-yang, deficiency of the
liver-yin and kidney-yin; deficiency of both yin and yang.
b) A single Chinese herbal medicine: Clerodendri Trichotomi(chou wutong), Herba
Apocyni Veneti(luobuma), etc..
c) Acupuncture
4) Treatment of hypertensive crisis and hypertensive encephalopathy
a) Gain adequate control of blood pressure immediately: sodium nitroprusside,
nitroglycerin, short-acting dihydroprtidines, urapidil.
b) Apply dehydrator or rapid diuretics on patients with hypertensive encephalopathy.
c) Keep the patient quiet.
7. Prognosis
Good prognosis is expected in patients with benign hypertension when properly treated,
whereas the contrary and excessive complications might be expected when not treated.
Accelerated type is supposed to be bad prognostic.`
8. Prevention
Find out patients early by screening. Eliminate and avoid related risk factors.
Teaching Method
1. Patients with primary and secondary hypertension might be demonstrated to the
students.
2. Wall maps, X-rays, ECG and funduscopic examination pictures would be presented.