Graduate School #8 Natural Disease

I.          Introduction

A.        Natural Disease

B.         Sudden Death Unexpected Death

C.        No Physician

II.         No Physician

A.        Poverty

B.         Christian Scientists

1.         Pretty darn old

2.         Healthy lifestyle

3.         Cancer

C.        Fear

1.         Breast tumor

2.         Rodent ulcer

III.       Sudden Death

Death within ~12 hours of symptoms

Went to bed, woke up dead.

C.        Hypertensive and atherosclerotic cardiovascular disease

1.         50% Sudden and unexpected

2.         85% ACVD

3.         DM makes it worse

4.         Tamponade, ruptured infarct 100%

5.         AMI, 90%

6.         1-2-3 vessels > 75% stenosis 70%

7.         Angina

a.         Stable

b.         Unstable

c.         Prinzmetal’s

8.         Claudication

9.         Silent killer

a.         labile

b.         Not show up in Dr.’s Office

c.         If physical signs present, it existed.

d.         Weasel words

D.        Systematic examination of the heart

1.         Heart weight 0.05% TBW in kg

a.         350 g M, 300 g F; +/- 40 gm M 30 gm F

b.         2 SD 410, 360

c.         Over 500 g sudden death at any time

i.          Big hearts don’t beat right

d.         Over 750 g cor bovinum

e.         IHSS

i.          hypertrophic cardiomyopathy

ii.          Death in 40’s

iii.         Genetic

iv.         Wavy fibers

2.         Coronary arteries

a.         Anomalous origin, course, tunneling

b.         Cystic medial necrosis

c.         CA dissection women, peripartum

3.         Chambers

a.         Scarring

b.         Thinning

c.         Fatty replacement

4.         Valves

a.         Floppy valves–Marfan’s other collagen vascular diseases

b.         Artificial valves

i.          Anticoagulation

ii.          Mechanical breakage

5.         Conduction system

a.         Pain in the arse

b.         SA node anteriolateral junction of the SVC/RA artery

c.         Funny right ventricle

i.          Dysplasia of the fibers

ii.          Fatty infiltration

d          Long QT–molecular studies

i.          Mayo Clinic

ii.          Takes for bloody ever

6.         Commotio Cordis

Vasculature

a          Aorta

i.          atherosclerosis

ii.          CMN

Marfan’s

b.         Atherosclerotic aneurysms

i.          Smoking

ii.          Infrarenal distribution

iii.         >5 cm operate

iv.         90% mortality emergent disease

v.         1% elective procedure

vi          Gore-tex grafts

c.         What other things do you have to graft?

I. Aorta bi-fem, fem distal, fem-popleteal, amputation (fem-chop)

Carotid atherosclerosis

Plaque disruption

E.         Pulmonary Emboli Truly instantaneous

1.         90% come from popleteal veins

a.         Saddle emboli

2.         Hypercoagualable state

a.         Balance between clotting and anticoagulants

i.          Factor V Leiden

ii.          Activated protein C resistance

iii.         Lupus anticoagulant (anti cardiolipin antibodies)

iv.         OCP

v.         Smoking

vi.         Obesity

vii.        Immobilization

3.         History, best predictor is previous PE

a.         Hemoptysis, dyspnea, anxiety

b.         V/Q mismatch

c.         >60% of one lung fatal

d.         Little ones resolve

F.         CNS

1.         Berry Aneurysms

a.         Circle of Willis middle and anterior

b.         Congenital

c.         1 in 20 adults have one

d.         Worst headache of life

2.         AVM

a.         Blood vessels with arteries going directly to veins

b.         Spontaneously bleed

c.         Embolize

3.         Strokes

a.         60% atherosclerotic

b.         20% embolic

c.         Brain exquisitely sensitive to anoxia/ischemia

i.          Neurons, astrocytes, oligodendroglia, microglia, vascular endothelium

ii.          Sommer’s sector in the Hippocampus, Purkinje cells of cerebellum, watershed

iii.         Hemorrhagic vs. ischemic reperfusion injury

iv          Calpains, Ca++ channel blockers

v.         Lenticulostriate branches of middle cerebral artery a)     Anatomic reason Little arteries off big

Total head

4.         Epilepsy–SUDEP–SUdden DEath in EPelepsy

a.         Poorly controlled males

b.         Epileptics drown

c.         Driving and epilepsy

i.          Some states required report

ii.          Kinds of seizures

F.         Infectious Diseases

1.         Not usually sudden or unexpected

a.         These things take time

b.         Setting of immunosuppression

i.          Lots of immunosuppressed people running around out there

ii.          Clostridium perfringens and rectal

2.         Nisseria meningiditdis

a.         Respiratory route

b.         Dorms and barracks

c.         Young adults

d.         People freak out news media etc.

3.         Legonella pneumophilia

a.         Water organism

b.         Chevy plant

4.         Lemierre’s syndrome

a.         Supperative jugular thrombophelbitis

b.         Fusobacterium necrophorum

c.         Toxic shock