Systole abnormalities

Sepsis The systemic inflammatory response syndrome and documented infection (culture or Gram stain of blood, sputum, urine, or normally sterile body fluid positive for pathogenic microorganisms Severe sepsis Sepsis associated with organ dysfunction, hypoperfusion, or hypotension (systolic blood pressure less than 90 mm Hg). Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria, or acute alteration in mental status. 

Systolic dysfunction An abnormal contraction of the ventricles during... 

Septic shock Sepsis with hypotension (a systolic blood pressure of <90 mm Hg or a reduction of <40 mm Hg from baseline), despite adequate fluid resuscitation, along with the presence of perfusion abnormalities as seen by severe sepsis. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured. 

The echocardiogram is the single most useful evaluation procedure because it can identify abnormalities of the pericardium, myocardium, or heart values and quantify the left ventricular ejection fraction (LVEF) to determine if systolic or diastolic dysfunction is present. 

In adults, the signs and symptoms of hypothyroidism include somnolence, slow mentation, dryness and loss of hair, increased fluid in body cavities (e.g., the pericardial sac), low metabolic rate, tendency to gain weight, hyperlipidemia, subnormal temperature, cold intolerance, bradycardia, reduced systolic and increased diastolic pulse pressure, hoarseness, muscle weakness, slow return of muscle to the neutral position after a tendon jerk, constipation, menstrual abnormalities, infertility, and sometimes myxedema (hard edema of subcutaneous tissue with increased content of proteoglycans in the fluid). A goiter (i.e., enlargement of the thyroid gland) may be present. 

It is a synthetic compound with structural similarity to ephedrine and is available in racemic and dextro isomers. It increases the systolic and diastolic blood pressure. Amphetamine is a potent CNS stimulant and causes alertness, insomnia, increased concentration, euphoria or dysphoria and increased work capacity. Amphetamine produces wakefulness and improved physical performance. It contracts the sphincter of the bladder and relaxes the bronchial smooth muscle in large doses. Amphetamines are drugs of abuse and can produce behavioural abnormalities and can precipitate psychosis. It can produce psychological but no physical dependence. 

The pharmacokinetic properties of these drugs are set forth in Table 12-5. The choice of a particular calcium channel-blocking agent should be made with knowledge of its specific potential adverse effects as well as its pharmacologic properties. Nifedipine does not decrease atrioventricular conduction and therefore can be used more safely than verapamil or diltiazem in the presence of atrioventricular conduction abnormalities. A combination of verapamil or diltiazem with 3 blockers may produce atrioventricular block and depression of ventricular function. In the presence of overt heart failure, all calcium channel blockers can cause further worsening of heart failure as a result of their negative inotropic effect. Amlodipine, however, does not increase the mortality of patients with heart failure due to nonischemic left ventricular systolic dysfunction and can be used safely in these patients. 

Three studies carried out in Bangladesh (8), Pakistan (9), and China (10) showed similar adverse reactions patterns. In the Bangladeshi study, nine of 254 women had a rise in both systolic and diastolic blood pressures, but five had a reduction of the same magnitude. In the Chinese women there were no significant changes in blood pressure. However, five Chinese women developed abnormal liver function tests and three of these women had liver enlargement after treatment for more than 2 years. 

Sinus bradycardia. An abnormally low sinoatrial impulse rate (< 60/min) can be raised by parasympatholytics. The quaternary ipratropium is preferable to atropine, because it lacks CNS penetrability (p.108). Sympathomimetics also exert a positive chronotropic action they have the disadvantage of increasing myocardial excitability (and automaticity) and, thus, promoting ectopic impulse generation (tendency to extra-systolic beats). In cardiac arrest, epinephrine, given by intrabronchial instillation or intracardiac injection, can be used to reinitiate heart beat. 

In some types of rhythm disorders, antiar-rhythmics of the local anesthetic, Na+-channel blocking type are used for both prophylaxis and therapy. These substances block the Na+ channel responsible for the fast depolarization of nerve and muscle tissues. Therefore, the elicitation of action potentials is impeded and impulse conduction is delayed. This effect may exert a favorable influence in some forms of arrhythmia, but can itself act arrhythmogenically. Unfortunately, antiarrhythmics of the local anesthetic, Na+-channel blocking type lack suf -cient specificity in two respects (1) other ion channels of cardiomyocytes, such as K1 and Ca+ channels, are also affected (abnormal QT prolongation) and (2) their action is not restricted to cardiac muscle tissue but also impacts on neural tissues and brain cells. Adverse effects on the heart include production of arrhythmias and lowering of heart rate, AV conduction, and systolic force. CNS side effects are manifested by vertigo, giddiness, disorientation, confusion, motor disturbances, etc. 

A series of trials in elderly hypertensive subjects has shown a very pronounced reduction in cardiac events as a result of treatment based on thiazide diuretics. In the European Working Party on Hypertension in the Elderly (EWPHE) trial (13), total cardiovascular deaths were reduced by 38%, all cardiac deaths by 43%, and deaths due to myocardial infarction by 60%. Benefits in the Systolic Hypertension in the Elderly Program (SHEP) included a reduction in fatal and non-fatal myocardial infarction of 25% and major cardiovascular events of 32% (14) and were seen in those with and without electrocardiographic abnormalities at entry. The risk of heart failure was also reduced in patients taking chlortalidone-based therapy (15). Relative risk was similar in patients with and without non-insulin dependent diabetes meUitus absolute risk reduction was twice as great in the diabetic subjects (16). The Swedish Trial of Old Patients with Hypertension (STOP-Hypertension) reported a significant reduction in myocardial infarction and all-cause mortahty (17). In the MRC Trial in elderly adults (18), diuretic treatment reduced coronary events by 44% and fatal cardiovascular events by 35%. 

Heart failure can result from any disorder that affects the ability of the heart to contract (systolic function) and/or relax (diastolic dysfunction) common causes of heart failure are shown in Table 14—1 Systolic heart failure is the classic, more familiar form of the disorder, but current estimates suggest that 20% to 50% of patients with heart failure have preserved left ventricular systolic function and suffer from diastolic dysfunction. In contrast to systolic heart failure that is usually caused by previous myocardial infarction (Ml), patients with diastolic heart failure typically are elderly, female, and have hypertension and diabetes. However, systolic and diastolic dysfunction frequently coexist. The common cardiovascular diseases such as MI and hypertension can cause both systolic and diastolic dysfunction thus many patients have heart failure as a result of reduced myocardial contractility and abnormal ventricular filling. 

Systolic contractile dysfunction is a cardinal feature of dilated cardiomyopathies. Although the cause of reduced contractility frequently is unknown, abnormalities such as interstitial fibrosis, cellular infiltrates, cellular hypertrophy, and myocardial cell degeneration are seen commonly on histologic examination. ... 

Although the history, physical examination, and laboratory tests can provide important clues to the underlying cause of heart failure, imaging is required to identify any structural abnormality of the heart. In most patients, an echocardiogram is used to detect any valvular, pericardial, or myocardial abnormalities. The echocardiogram also can determine the presence of systolic and/or diastolic dysfunction and the left ventricular ejection fraction (LVEE). 

Recent studies demonstrate that cardiac resynchronization therapy (CRT) offers a promising approach to selected patients with chronic heart failure. Delayed electrical activation of the left ventricle, characterized on the ECG by a QRS duration that exceeds 120 ms, occurs in approximately one-third of patients with moderate to severe systolic heart failure. Since the left and right ventricles normally activate simultaneously, this delay results in asynchronous contraction of the left and right ventricles, which contributes to the hemodynamic abnormalities of this disorder. Implantation of a speciahzed biventricular pacemaker to restore synchronous activation of the ventricles can improve ventricular contraction and hemodynamics. Recent trials show improvements in exercise capacity, NYHA classification, quality of life, hemodynamic function, and hospitalizations. A device that combined CRT with an implantable cardioverter-defibrillator (ICD) improved survival in addition to functional status. CRT is currently indicated only in NYHA class ni-IV patients receiving optimal medical therapy (ACE inhibitors, diuretics, -blockers, and digoxin) and... 

Abnormal precordial (over the heart) systolic bulge... 

Heart failure (HP) may becausedbya primary abnormality in systolic function, diastolic function, or both. Making the distinction is important because the prevalence, prognosis, and treatment of HP may be quite different depending on whether the predominant mechanism causing the symptoms is systolic or diastolic dysfunction. Some clinical studies have reported that as many as 30% to 50% of patients with congestive heart failure have preserved left ventricular (LV) function, making diastolic heart failure (DHP) very common. In addition, abnormalities in diastolic function also can play an important role in the development of symptoms in patients with cardiomyopathy and systolic heart failure (SHP). 

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