An abnormal or irregular rhythm, usually in reference to the heart.
Causes As a rule, a person is not conscious of the beating of the heart except when the nervous system is unduly excited. A disorder of the rhythm of the heart (ARRHYTHMIA) may cause palpitations. Sudden emotions, such as fright, or overuse of tobacco, tea, co?ee or alcohol may bring it on. Sometimes it may appear in people with organic heart disease.
Symptoms There may simply be a ?uttering of the heart and a feeling of faintness, or the heart may be felt pounding and the arteries throbbing, causing great distress. The subject may be conscious of the heart missing beats.
Treatment Although these symptoms can be unpleasant, they do not necessarily signify serious disease. Moderate exercise is a good thing. If the person is a smoker, he or she should stop. Tea, co?ee, alcohol or other stimulants should be taken sparingly. If symptoms persist or are severe, the individual should see a doctor and any underlying disorder should be investigated – including by exercise ECG – and treated. The BETA-ADRENOCEPTOR-BLOCKING DRUGS are the most useful drugs in controlling the palpitations of anxiety and those due to some cardiac arrhythmias.... palpitation
Men are more likely to have a heart attack than women, and smokers are at greater risk. Other risk factors include increased age, unhealthy diet, obesity, and disorders such as hypertension and
diabetes mellitus. Atherosclerosis of the coronary arteries is usually a factor.
Symptoms include sudden pain in the centre of the chest, breathlessness, feeling restless, clammy skin, nausea and/or vomiting, or loss of consciousness. Myocardial infarction may cause immediate heart failure or arrhythmias.
Diagnosis is made from the patient’s history and tests including ECG and measurement of enzymes released into the blood from damaged heart muscle.
A myocardial infarction is a medical emergency. Initial treatment may include aspirin, thrombolytic drugs, analgesic drugs, and oxygen therapy. Diuretic drugs, intravenous infusion of fluids, antiarrhythmic drugs, and beta-blocker drugs may also be given. Electrical defibrillation may be used to control severe arrhythmias.
After recovery, preventive measures such as taking more exercise, losing weight, stopping smoking, and dietary changes are recommended.
Statin drugs are usually given to lower blood cholesterol; aspirin or beta-blocker drugs are given to reduce the risk of further attacks.... myocardial infarction
Habitat: Kashmir and Himachal Pradesh up to 2,500 m.
English: Indian Belladonna, Indian Atropa.Ayurvedic: Suuchi.Unani: Luffaah, Luffaah-Barri, Yabaruj, Shaabiraj.Action: Highly poisonous; sedative, narcotic, anodyne, nervine, antispasmodic (used in paralysis); parkinsonism; encephalitis; carcinoma; spastic dysmenorrhoea; whooping cough, spasmodic asthma; colic of intestines, gall bladder or kidney, spasm of bladder and ureters; contraindicated in enlarged prostate.
Key application: In spasm and colic-like pain in the areas of the gastrointestinal tract and bile ducts. (German Commission E, The British Herbal Pharmacopoeia.) It is contraindicated in tachycardiac arrhythmias, prostate adenoma, glaucoma, acute oedema of lungs.A. belladonna L. (European sp. Belladonna, Deadly Nightshade) is cultivated in Kashmir and Himachal Pradesh.The herb contains tropane (tropine) or solanaceous alkaloids (up to 0.6%), including hyoscamine and atropine; flavonoids; coumarins; volatile bases (nicotine).Tropane alkaloids inhibit the para- sympathetic nervous system, which controls involuntary bodily activities; reduces saliva, gastric, intestinal and bronchial secretions, and also the activity of urinary tubules. Tropane alkaloids also increase the heart rate and dilate the pupils. These alkaloids are used as an additive to compound formulations for bronchitis, asthma, whooping cough, gastrointestinal hy- permotility, dysmenorrhoea, nocturnal enuresis and fatigue syndrome.Atropine provides relief in parkin- sonism and neurovegetative dystonia.The root is the most poisonous, the leaves and flowers less, and the berries the least. (Francis Brinker.)Dosage: Leaf, root—30-60 mg powder. (CCRAS.)... atropa acuminata royle exHabitat: Western temperate Himalayas from 2,500 to 4,000 m.
English: American cowslip, Marsh Marigold, Water Buttercup.Folk: Mamiri (Punjab).Family: Theaceae.Habitat: Cultivated in Assam, Darjeeling, Travancore, the Nilgiris, Malabar, Bengal, Dehra Dun and Kumaon.
English: Tea.Unani: Chaai, Shaahi, Shaayi.Siddha/Tamil: Thaeyilai.Action: Stimulant, diuretic, astringent. In China, used for diarrhoea and dysentery (causes gastrointestinal upsets and nervous irritability when consumed in excess). Green tea: anticancer effects have been observed in Chinese green tea, Camellia thea, extract; the extract of Japanese green tea showed antihepatotoxic effects.
Important constituents of leaf buds and very young leaves are: caffeine, with a much smaller amount of other xanthines (theophylline and theo- bromine); tannins (the main tannin in green tea is (-)-epigallocatechin); flavonoids, quercetin, kaempferol. The stimulant and diuretic are due to caffeine content, the astringency due to the tannins.Drinking tea lowers thiamine and thiamine diphosphate losses in urine and blood serum respectively but increases niacin losses. Hot water extract of black tea facilitates Ca absorption in the body experimentally. Tea may decrease zinc bioavailability.The tea, if added to the meal, significantly lower the availability of iron. Milk is as effective as ascorbic acid in countering the depressing effect of tea on iron availability (in vitro).The green tea catechin inhibited car- cinogenesis in small intestines when given during or after carcinogen treatment to experimental rats. (-)-epi- gallocatechin gallate and theaflavin di- gallate from green tea inhibited the in- fectivity of both influenza A and B virus (in vitro).Green tea, when added to a lard- cholesterol diet, decreased the cholesterol and triglyceride levels in fowls. Tea polyphenols exhibit hypocholes- terolaemic activity.Tea polyphenols—(-)-epicatechin gallate, (-)-epigallocatechine galate, theaflavin monogallate A or B, and or theaflavin digallate—are used for treating hyperglycaemia.Saponins from tea are used as an- tiulcer agents.Concurrent use of tea and beta- adrenergic agonists may increase the risk of cardiac arrhythmias. Caffeine, a component of tea, may increase insulin resistance. (Sharon M. Herr.)... camellia sinensisRarely, an enlarged gland may be the result of cancer in the thyroid.
Treatment A symptomless goitre may gradually disappear or be so small as not to merit treatment. If the goitre is large or is causing the patient di?culty in swallowing or breathing, it may need surgical removal by partial or total thyroidectomy. If the patient is de?cient in iodine, ?sh and iodised salt should be included in the diet.
Hyperthyroidism is a common disorder affecting 2–5 per cent of all females at some time in their lives. The most common cause – around 75 per cent of cases – is thyrotoxicosis (see below). An ADENOMA (or multiple adenomas) or nodules in the thyroid also cause hyperthyroidism. There are several other rare causes, including in?ammation caused by a virus, autoimune reactions and cancer. The symptoms of hyperthyroidism affect many of the body’s systems as a consequence of the much-increased metabolic rate.
Thyrotoxicosis is a syndrome consisting of di?use goitre (enlarged thyroid gland), over-activity of the gland and EXOPHTHALMOS (protruding eyes). Patients lose weight and develop an increased appetite, heat intolerance and sweating. They are anxious, irritable, hyperactive, suffer from TACHYCARDIA, breathlessness and muscle weakness and are sometimes depressed. The hyperthyroidism is due to the production of ANTIBODIES to the TSH receptor (see THYROTROPHIN-STIMULATING HORMONE (TSH)) which stimulate the receptor with resultant production of excess thyroid hormones. The goitre is due to antibodies that stimulate the growth of the thyroid gland. The exoph-
thalmos is due to another immunoglobulin called the ophthalmopathic immunoglobulin, which is an antibody to a retro-orbital antigen on the surface of the retro-orbital EYE muscles. This provokes in?ammation in the retro-orbital tissues which is associated with the accumulation of water and mucopolysaccharide which ?lls the orbit and causes the eye to protrude forwards.
Although thyrotoxicosis may affect any age-group, the peak incidence is in the third decade. Females are affected ten times as often as males; the prevalence in females is one in 500. As with many other autoimmune diseases, there is an increased prevalence of autoimmune thyroid disease in the relatives of patients with thyrotoxicosis. Some of these patients may have hypothyroidism (see below) and others, thyrotoxicosis. Patients with thyrotoxicosis may present with a goitre or with the eye signs or, most commonly, with the symptoms of excess thyroid hormone production. Thyroid hormone controls the metabolic rate of the body so that the symptoms of hyperthyroidism are those of excess metabolism.
The diagnosis of thyrotoxicosis is con?rmed by the measurement of the circulating levels of the two thyroid hormones, thyroxine and TRIIODOTHYRONINE.
Treatment There are several e?ective treatments for thyrotoxicosis. ANTITHYROID DRUGS These drugs inhibit the iodination of tyrosine and hence the formation of the thyroid hormones. The most commonly used drugs are carbimazole and propylthiouricil: these will control the excess production of thyroid hormones in virtually all cases. Once the patient’s thyroid is functioning normally, the dose can be reduced to a maintenance level and is usually continued for two years. The disadvantage of antithyroid drugs is that after two years’ treatment nearly half the patients will relapse and will then require more de?nitive therapy. PARTIAL THYROIDECTOMY Removal of three-quarters of the thyroid gland is e?ective treatment of thyrotoxicosis. It is the treatment of choice in those patients with large goitres. The patient must however be treated with medication so that they are euthyroid (have a normally functioning thyroid) before surgery is undertaken, or thyroid crisis and cardiac arrhythmias may complicate the operation. RADIOACTIVE IODINE THERAPY This has been in use for many years, and is an e?ective means of controlling hyperthyroidism. One of the disadvantages of radioactive iodine is that the incidence of hypothyroidism is much greater than with other forms of treatment. However, the management of hypothyroidism is simple and requires thyroxine tablets and regular monitoring for hypothyroidism. There is no evidence of any increased incidence of cancer of the thyroid or LEUKAEMIA following radio-iodine therapy. It has been the pattern in Britain to reserve radio-iodine treatment to those over the age of 35, or those whose prognosis is unlikely to be more than 30 years as a result of cardiac or respiratory disease. Radioactive iodine treatment should not be given to a seriously thyrotoxic patient. BETA-ADRENOCEPTOR-BLOCKING DRUGS Usually PROPRANOLOL HYDROCHLORIDE: useful for symptomatic treatment during the ?rst 4–8 weeks until the longer-term drugs have reduced thyroid activity.
Hypothyroidism A condition resulting from underactivity of the thyroid gland. One form, in which the skin and subcutaneous tissues thicken and result in a coarse appearance, is called myxoedema. The thyroid gland secretes two hormones – thyroxine and triiodothyronine – and these hormones are responsible for the metabolic activity of the body. Hypothyroidism may result from developmental abnormalities of the gland, or from a de?ciency of the enzymes necessary for the synthesis of the hormones. It may be a feature of endemic goitre and retarded development, but the most common cause of hypothyroidism is the autoimmune destruction of the thyroid known as chronic thyroiditis. It may also occur as a result of radio-iodine treatment of thyroid overactivity (see above) and is occasionally secondary to pituitary disease in which inadequate TSH production occurs. It is a common disorder, occurring in 14 per 1,000 females and one per 1,000 males. Most patients present between the age of 30 and 60 years.
Symptoms As thyroid hormones are responsible for the metabolic rate of the body, hypothyroidism usually presents with a general sluggishness: this affects both physical and mental activities. The intellectual functions become slow, the speech deliberate and the formation of ideas and the answers to questions take longer than in healthy people. Physical energy is reduced and patients frequently complain of lethargy and generalised muscle aches and pains. Patients become intolerant of the cold and the skin becomes dry and swollen. The LARYNX also becomes swollen and gives rise to a hoarseness of the voice. Most patients gain weight and develop constipation. The skin becomes dry and yellow due to the presence of increased carotene. Hair becomes thinned and brittle and even baldness may develop. Swelling of the soft tissues may give rise to a CARPAL TUNNEL SYNDROME and middle-ear deafness. The diagnosis is con?rmed by measuring the levels of thyroid hormones in the blood, which are low, and of the pituitary TSH which is raised in primary hypothyroidism.
Treatment consists of the administration of thyroxine. Although tri-iodothyronine is the metabolically active hormone, thyroxine is converted to tri-iodothyronine by the tissues of the body. Treatment should be started cautiously and slowly increased to 0·2 mg daily – the equivalent of the maximum output of the thyroid gland. If too large a dose is given initially, palpitations and tachycardia are likely to result; in the elderly, heart failure may be precipitated.
Congenital hypothyroidism Babies may be born hypothyroid as a result of having little or no functioning thyroid-gland tissue. In the developed world the condition is diagnosed by screening, all newborn babies having a blood test to analyse TSH levels. Those found positive have a repeat test and, if the diagnosis is con?rmed, start on thyroid replacement therapy within a few weeks of birth. As a result most of the ill-effects of cretinism can be avoided and the children lead normal lives.
Thyroiditis In?ammation of the thyroid gland. The acute form is usually caused by a bacterial infection elsewhere in the body: treatment with antibiotics is needed. Occasionally a virus may be the infectious agent. Hashimoto’s thyroiditis is an autoimmune disorder causing hypothyroidism (reduced activity of the gland). Subacute thyroiditis is in?ammation of unknown cause in which the gland becomes painful and the patient suffers fever, weight loss and malaise. It sometimes lasts for several months but is usually self-limiting.
Thyrotoxic adenoma A variety of thyrotoxicosis (see hyperthyroidism above) in which one of the nodules of a multinodular goitre becomes autonomous and secretes excess thyroid hormone. The symptoms that result are similar to those of thyrotoxicosis, but there are minor di?erences.
Treatment The ?rst line of treatment is to render the patient euthyroid by treatment with antithyroid drugs. Then the nodule should be removed surgically or destroyed using radioactive iodine.
Thyrotoxicosis A disorder of the thyroid gland in which excessive amounts of thyroid hormones are secreted into the bloodstream. Resultant symptoms are tachycardia, tremor, anxiety, sweating, increased appetite, weight loss and dislike of heat. (See hyperthyroidism above.)... goitre
Arrhythmias An abnormal rate or rhythm of the heartbeat. The reason is a disturbance in the electrical impulses within the heart. Sometimes a person may have an occasional irregular heartbeat: this is called an ECTOPIC beat (or an extrasystole) and does not necessarily mean that an abnormality exists. There are two main types of arrhythmia: bradycardias, where the rate is slow – fewer than 60 beats a minute and sometimes so slow and unpredictable (heartblock) as to cause blackouts or heart failure; and tachycardia, where the rate is fast – more than 100 beats a minute. A common cause of arrhythmia is coronary artery disease, when vessels carrying blood to the heart are narrowed by fatty deposits (ATHEROMA), thus reducing the blood supply and damaging the heart tissue. This condition often causes myocardial infarction after which arrhythmias are quite common and may need correcting by DEFIBRILLATION (application of a short electric shock to the heart). Some tachycardias result from a defect in the electrical conduction system of the heart that is commonly congenital. Various drugs can be used to treat arrhythmias (see ANTIARRHYTHMIC DRUGS). If attacks constantly recur, the arrhythmia may be corrected by electrical removal of dead or diseased tissue that is the cause of the disorder. Heartblock is most e?ectively treated with an arti?cial CARDIAC PACEMAKER, a battery-activated control unit implanted in the chest.
Cardiomyopathy Any disease of the heart muscle that results in weakening of its contractions. The consequence is a fall in the e?ciency of the circulation of blood through the lungs and remainder of the body structures. The myopathy may be due to infection, disordered metabolism, nutritional excess or de?ciency, toxic agents, autoimmune processes, degeneration, or inheritance. Often, however, the cause is not identi?ed. Cardiomyopathies are less common than other types of heart diseases, and the incidence of di?erent types of myopathy (see below) is not known because patients or doctors are sometimes unaware of the presence of the condition.
The three recognised groups of cardiomyopathies are hypertrophic, dilated and restrictive.
•Hypertrophic myopathy, a familial condition, is characterised by great enlargement of the muscle of the heart ventricles. This reduces the muscle’s e?ciency, the ventricles fail to relax properly and do not ?ll suf?ciently during DIASTOLE.
In the dilated type of cardiomyopathy, both ventricles overdilate, impairing the e?ciency of contraction and causing congestion of the lungs.
In the restrictive variety, proper ?lling of the ventricles does not occur because the muscle walls are less elastic than normal. The result is raised pressure in the two atria (upper cavities) of the heart: these dilate and develop FIBRILLATION. Diagnosis can be di?cult and treatment is symptomatic, with a poor prognosis. In suitable patients, heart TRANSPLANTATION may be considered. Disorders of the heart muscle may also be
caused by poisoning – for example, heavy consumption of alcohol. Symptoms include tiredness, palpitations (quicker and sometimes irregular heartbeat), chest pain, di?culty in breathing, and swelling of the legs and hands due to accumulation of ?uid (OEDEMA). The heart is enlarged (as shown on chest X-ray) and ECHOCARDIOGRAPHY shows thickening of the heart muscle. A BIOPSY of heart muscle will show abnormalities in the cells of the heart muscle.
Where the cause of cardiomyopathy is unknown, as is the case with most patients, treatment is symptomatic using DIURETICS to control heart failure and drugs such as DIGOXIN to return the heart rhythm to normal. Patients should stop drinking alcohol. If, as often happens, the patient’s condition slowly deteriorates, heart transplantation should be considered.
Congenital heart disease accounts for 1–2 per cent of all cases of organic heart disease. It may be genetically determined and so inherited; present at birth for no obvious reason; or, in rare cases, related to RUBELLA in the mother. The most common forms are holes in the heart (atrial septal defect, ventricular septal defect – see SEPTAL DEFECT), a patent DUCTUS ARTERIOSUS, and COARCTATION OF THE AORTA. Many complex forms also exist and can be diagnosed in the womb by fetal echocardiography which can lead to elective termination of pregnancy. Surgery to correct many of these abnormalities is feasible, even for the most severe abnormalities, but may only be palliative giving rise to major diffculties of management as the children become older. Heart transplantation is now increasingly employed for the uncorrectable lesions.
Coronary artery disease Also known as ischaemic heart disease, this is a common cause of symptoms and death in the adult population. It may present for the ?rst time as sudden death, but more usually causes ANGINA PECTORIS, myocardial infarction (heart attack) or heart failure. It can also lead to a disturbance of heart rhythm. Factors associated with an increased risk of developing coronary artery disease include diabetes, cigarette smoking, high blood pressure, obesity, and a raised concentration of cholesterol in the blood. Older males are most affected.
Coronary thrombosis or acute myocardial infarction is the acute, dramatic manifestation of coronary-artery ischaemic heart disease – one of the major killing diseases of western civilisation. In 1999, ischaemic heart disease was responsible for about 115,000 deaths in England and Wales, compared with 153,000 deaths in 1988. In 1999 more than 55,600 people died of coronary thrombosis. The underlying cause is disease of the coronary arteries which carry the blood supply to the heart muscle (or myocardium). This results in narrowing of the arteries until ?nally they are unable to transport su?cient blood for the myocardium to function e?ciently. One of three things may happen. If the narrowing of the coronary arteries occurs gradually, then the individual concerned will develop either angina pectoris or signs of a failing heart: irregular rhythm, breathlessness, CYANOSIS and oedema.
If the narrowing occurs suddenly or leads to complete blockage (occlusion) of a major branch of one of the coronary arteries, then the victim collapses with acute pain and distress. This is the condition commonly referred to as a coronary thrombosis because it is usually due to the affected artery suddenly becoming completely blocked by THROMBOSIS. More correctly, it should be described as coronary occlusion, because the ?nal occluding factor need not necessarily be thrombosis.
Causes The precise cause is not known, but a wide range of factors play a part in inducing coronary artery disease. Heredity is an important factor. The condition is more common in men than in women; it is also more common in those in sedentary occupations than in those who lead a more physically active life, and more likely to occur in those with high blood pressure than in those with normal blood pressure (see HYPERTENSION). Obesity is a contributory factor. The disease is more common among smokers than non-smokers; it is also often associated with a high level of CHOLESTEROL in the blood, which in turn has been linked with an excessive consumption of animal, as opposed to vegetable, fats. In this connection the important factors seem to be the saturated fatty acids (low-density and very low-density lipoproteins [LDLs and VLDLs] – see CHOLESTEROL) of animal fats which would appear to be more likely to lead to a high level of cholesterol in the blood than the unsaturated fatty acids of vegetable fats. As more research on the subject is carried out, the arguments continue about the relative in?uence of the di?erent factors. (For advice on prevention of the disease, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Symptoms The presenting symptom is the sudden onset, often at rest, of acute, agonising pain in the front of the chest. This rapidly radiates all over the front of the chest and often down over the abdomen. The pain is frequently accompanied by nausea and vomiting, so that suspicion may be aroused of some acute abdominal condition such as biliary colic (see GALLBLADDER, DISEASES OF) or a perforated PEPTIC ULCER. The victim soon goes into SHOCK, with a pale, cold, sweating skin, rapid pulse and dif?culty in breathing. There is usually some rise in temperature.
Treatment is immediate relief of the pain by injections of diamorphine. Thrombolytic drugs should be given as soon as possible (‘rapid door to needle time’) and ARRHYTHMIA corrected. OXYGEN is essential and oral ASPIRIN is valuable. Treatment within the ?rst hour makes a great di?erence to recovery. Subsequent treatment includes the continued administration of drugs to relieve the pain; the administration of ANTIARRHYTHMIC DRUGS that may be necessary to deal with the heart failure that commonly develops, and the irregular action of the heart that quite often develops; and the continued administration of oxygen. Patients are usually admitted to coronary care units, where they receive constant supervision. Such units maintain an emergency, skilled, round-the-clock sta? of doctors and nurses, as well as all the necessary resuscitation facilities that may be required.
The outcome varies considerably. The ?rst (golden) hour is when the patient is at greatest risk of death: if he or she is treated, then there is a 50 per cent reduction in mortality compared with waiting until hospital admission. As each day passes the prognosis improves with a ?rst coronary thrombosis, provided that the patient does not have a high blood pressure and is not overweight. Following recovery, there should be a gradual return to work, care being taken to avoid any increase in weight, unnecessary stress and strain, and to observe moderation in all things. Smoking must stop. In uncomplicated cases patients get up and about as soon as possible, most being in hospital for a week to ten days and back at work in three months or sooner.
Valvular heart disease primarily affects the mitral and aortic valves which can become narrowed (stenosis) or leaking (incompetence). Pulmonary valve problems are usually congenital (stenosis) and the tricuspid valve is sometimes involved when rheumatic heart disease primarily affects the mitral or aortic valves. RHEUMATIC FEVER, usually in childhood, remains a common cause of chronic valvular heart disease causing stenosis, incompetence or both of the aortic and mitral valves, but each valve has other separate causes for malfunction.
Aortic valve disease is more common with increasing age. When the valve is narrowed, the heart hypertrophies and may later fail. Symptoms of angina or breathlessness are common and dizziness or blackouts (syncope) also occur. Replacing the valve is a very e?ective treatment, even with advancing age. Aortic stenosis may be caused by degeneration (senile calci?c), by the inheritance of two valvular leaflets instead of the usual three (bicuspid valve), or by rheumatic fever. Aortic incompetence again leads to hypertrophy, but dilatation is more common as blood leaks back into the ventricle. Breathlessness is the more common complaint. The causes are the same as stenosis but also include in?ammatory conditions such as SYPHILIS or ANKYLOSING SPONDYLITIS and other disorders of connective tissue. The valve may also leak if the aorta dilates, stretching the valve ring as with HYPERTENSION, aortic ANEURYSM and MARFAN’S SYNDROME – an inherited disorder of connective tissue that causes heart defects. Infection (endocarditis) can worsen acutely or chronically destroy the valve and sometimes lead to abnormal outgrowths on the valve (vegetations) which may break free and cause devastating damage such as a stroke or blocked circulation to the bowel or leg.
Mitral valve disease leading to stenosis is rheumatic in origin. Mitral incompetence may be rheumatic but in the absence of stenosis can be due to ISCHAEMIA, INFARCTION, in?ammation, infection and a congenital weakness (prolapse). The valve may also leak if stretched by a dilating ventricle (functional incompetence). Infection (endocarditis) may affect the valve in a similar way to aortic disease. Mitral symptoms are predominantly breathlessness which may lead to wheezing or waking at night breathless and needing to sit up or stand for relief. They are made worse when the heart rhythm changes (atrial ?brillation) which is frequent as the disease becomes more severe. This leads to a loss of e?ciency of up to 25 per cent and a predisposition to clot formation as blood stagnates rather than leaves the heart e?ciently. Mitral incompetence may remain mild and be of no trouble for many years, but infection must be guarded against (endocarditis prophylaxis).
Endocarditis is an infection of the heart which may acutely destroy a valve or may lead to chronic destruction. Bacteria settle usually on a mild lesion. Antibiotics taken at vulnerable times can prevent this (antibiotic prophylaxis) – for example, before tooth extraction. If established, lengthy intravenous antibiotic therapy is needed and surgery is often necessary. The mortality is 30 per cent but may be higher if the infection settles on a replaced valve (prosthetic endocarditis). Complications include heart failure, shock, embolisation (generation of small clots in the blood), and cerebral (mental) confusion.
PERICARDITIS is an in?ammation of the sac covering the outside of the heart. The sac becomes roughened and pain occurs as the heart and sac rub together. This is heard by stethoscope as a scratching noise (pericardial rub). Fever is often present and a virus the main cause. It may also occur with rheumatic fever, kidney failure, TUBERCULOSIS or from an adjacent lung problem such as PNEUMONIA or cancer. The in?ammation may cause ?uid to accumulate between the sac and the heart (e?usion) which may compress the heart causing a fall in blood pressure, a weak pulse and circulatory failure (tamponade). This can be relieved by aspirating the ?uid. The treatment is then directed at the underlying cause.... heart, diseases of
Each year around 50 people in the United Kingdom are reported as dying from carbon monoxide poisoning, and experts have suggested that as many as 25,000 people a year are exposed to its effects within the home, but most cases are unrecognised, unreported and untreated, even though victims may suffer from long-term effects. This is regrettable, given that Napoleon’s surgeon, Larrey, recognised in the 18th century that soldiers were being poisoned by carbon monoxide when billeted in huts heated by woodburning stoves. In the USA it is estimated that 40,000 people a year attend emergency departments suffering from carbon monoxide poisoning. So prevention is clearly an important element in dealing with what is sometimes termed the ‘silent killer’. Safer designs of houses and heating systems, as well as wider public education on the dangers of carbon monoxide and its sources, are important.
Clinical effects of acute exposure resemble those of atmospheric HYPOXIA. Tissues and organs with high oxygen consumption are affected to a great extent. Common effects include headaches, weakness, fatigue, ?ushing, nausea, vomiting, irritability, dizziness, drowsiness, disorientation, incoordination, visual disturbances, TACHYCARDIA and HYPERVENTILATION. In severe cases drowsiness may progress rapidly to COMA. There may also be metabolic ACIDOSIS, HYPOKALAEMIA, CONVULSIONS, HYPOTENSION, respiratory depression, ECG changes and cardiovascular collapse. Cerebral OEDEMA is common and will lead to severe brain damage and focal neurological signs. Signi?cant abnormalities on physical examination include impaired short-term memory, abnormal Rhomberg’s test (standing unsupported with eyes closed) and unsteadiness of gait including heel-toe walking. Any one of these signs would classify the episode as severe. Victims’ skin may be coloured pink, though this is very rarely seen even in severe incidents. The venous blood may look ‘arterial’. Patients recovering from acute CO poisoning may suffer neurological sequelae including TREMOR, personality changes, memory impairment, visual loss, inability to concentrate and PARKINSONISM. Chronic low-level exposures may result in nausea, fatigue, headache, confusion, VOMITING, DIARRHOEA, abdominal pain and general malaise. They are often misdiagnosed as in?uenza or food poisoning.
First-aid treatment is to remove the victim from the source of exposure, ensure an e?ective airway and give 100-per-cent oxygen by tight-?tting mask. In hospital, management is largely suppportive, with oxygen administration. A blood sample for COHb level determination should be taken as soon as practicable and, if possible, before oxygen is given. Ideally, oxygen therapy should continue until the COHb level falls below 5 per cent. Patients with any history of unconsciousness, a COHb level greater than 20 per cent on arrival, any neurological signs, any cardiac arrhythmias or anyone who is pregnant should be referred for an expert opinion about possible treatment with hyperbaric oxygen, though this remains a controversial therapy. Hyperbaric oxygen therapy shortens the half-life of COHb, increases plasma oxygen transport and reverses the clinical effects resulting from acute exposures. Carbon monoxide is also an environmental poison and a component of cigarette smoke. Normal body COHb levels due to ENDOGENOUS CO production are 0.4 to
0.7 per cent. Non-smokers in urban areas may have level of 1–2 per cent as a result of environmental exposure. Smokers may have a COHb level of 5 to 6 per cent.... carbon monoxide (co)
(electrocardiography), a wearable device called a Holter monitor is used to record the electrical activity of the heart by means of electrodes attached to the chest. The monitor is usually worn for 24 hours or longer and detects intermittent arrhythmias (abnormal heart rates and rhythms). The wearer can press a button on the monitor to mark the recording whenever symptoms occur. The recording can later be analysed to see if the periods of arrhythmia coincide with the symptoms.... ambulatory ecg
It is given, as tablets or injection, to people resistant to or intolerant of other treatment; and treatment is always initiated in hospital.
Side effects may include dizziness, visual disturbances, and worsening, or a new type of, arrhythmia.
Rarely, nausea, vomiting, urticaria, vertigo, and jaundice occur.... flecainide
Aerosols Asthmatic patients (see ASTHMA) ?nd aerosol devices to be of value in controlling their attacks. They provide an e?ective and convenient way of applying drugs directly to the bronchi, thus reducing the risks of unwanted effects accompanying SYSTEMIC therapy. BRONCHODILATOR aerosols contain either a beta-sympathomimetic agent or ipratropium bromide, which is an ANTICHOLINERGIC drug.
ISOPRENALINE was the ?rst compound to be widely used as an aerosol. It did however stimulate beta1 receptors in the heart as well as beta2 receptors in the bronchi, and so produced palpitations and even dangerous cardiac arrhythmias. Newer beta-adrenoceptor agonists are speci?c for the beta2 receptors and thus have a greater safety margin. They include SALBUTAMOL, TERBUTALINE, rimiterol, fenoterol and reproterol. Unwanted effects such as palpitations, tremor and restlessness are uncommon with these, more speci?c preparations. In patients who get insu?cient relief from the beta-adrenoreceptor agonist, the drug ipratropium bromide is worth adding. Salmeterol is a longer-acting choice for twice-daily administration: it is not intended for the relief of acute attacks, for which shorter-acting beta2 stimulants such as salbutamol should be used. Salmeterol should be added to existing corticosteroid therapy (see CORTICOSTEROIDS), rather than replacing it.
Patients must be taught carefully and observed while using their inhalers. It is important for them to realise that if the aerosol no longer gives more than slight transient relief, they should not increase the dose but seek medical help.... inhalants
continuously for 24 hours or longer.
The monitor records by means of electrodes attached to the chest and allows the detection of intermittent arrhythmias.... holter monitor
It may also be used to reduce the risk of further heart damage after myocardial infarction.
It relieves symptoms of hyperthyroidism and anxiety, and can prevent migraine attacks.
Possible adverse effects are typical of other beta-blocker drugs.... propranolol
Habitat: Native to Europe and Central Asia; also found in Kashmir
English: Horehound.Unani: Faraasiyun (wrongly equated with Valerian in National Formulary of Unani Medicine).Action: Expectorant, cholagogue; bitter tonic for stomach and liver, antispasmodic. Used for bronchitis, asthma, whooping cough, hard cough with little phlegm; also for cardiac extrasystols.
Key application: In loss of appetite, dyspepsia; bloating and flatulence. (German Commission E.) The British Herbal Pharmacopoeia and The British Herbal Compendium (additionally) indicate its use for acute bronchitis, non-productive cough and catarrh and the respiratory tracts.The herb yields a diterpenoid, pre- marrubiin, which generates marrubiin as an artefact; caffeic acid derivatives; and flavonoids—apigenin, apigenin-7- glucoside, luteolin, luteolin-7-gluco- side, quercetin-3-glucoside and -3- rhamnoglucoside. The extracts of the herb exhibit anti-inflammatory and antiserotonin activity experimentally. Marrubiin is considered to be responsible for expectorant activity. It has also shown to normalize extrasystolic arrhythmias. High doses may cause cardiac irregularities.The oil exhibits antimicrobial properties and is reported to be vasodilatory and hypotensive.... marrubium vulgareHabitat: Alpine Himalayas, Kumaon, Sikkim and Bhutan.
English: Spikenard, Musk-root.Ayurvedic: Maansi, Jataamaansi, Bhuutajataa, Tapaswini, Sulo- mashaa, Jatilaa, Naladaa.Unani: Sumbul-e-Hindi, Sambul-ut- Teeb, Naardeen-e-Hindi, Baalchhar.Siddha/Tamil: Sadamanchil.Action: Used as a substitute for Valerian. Tranquilizer, sedative, hypotensive. Used for the treatment of epilepsy, hysteria, convulsive affections, palpitation of heart and in intestinal colic. A decoction of powdered roots is prescribed as a home remedy for high blood pressure. It is used in dysmenorrhoea for pain relief and smooth menstrual flow. It is used in hair oil for arresting hair loss and greying of hair.
The Ayurvedic Pharmacopoeia of India recommends dry rhizomes in obstinate skin diseases, erysipelas, disturbed mental state and insomnia.The rhizome is rich in sesquiter- penoids. The crude drug gave an oil (yield 2.5% v/w), which contains d- nardostachone, valeranone and jata- mansone as the major ketonic sesqui- terpenes. The oil potentiated phenobarbital narcosis in rats, reduced brain serotonin content and decreased the conditioned avoidance performance in cats.Jatamansone was shown to exert tranquilizing effect in mice and monkeys. In rabbits, jatamansone was found to impair biosynthesis of serotonin in the brain leading to a reduction in brain level of 5-hydroxytrypta- mine. The degradation of serotonin was unaffected. The mode of action of jatamansone was thus in variance with that of reserpine which has direct action on the cell to liberate serotonin.On the other hand, the alcoholic extract of the roots of Indian Nard caused an overall increase in the levels of central monamines, 5-hydroxy indole acetic acid and the inhibitory amino acids, gamma-aminobutyric acid, norepinephrine, dopamine and serotonin in rat brain.In a clinical trial on hyperkinetic children, jatamansone showed significant reduction in hyperactivity and improvement in restlessness and aggressiveness, almost at par with D- amphetamine.The volatile oil was found to be less active than quinidine in several tests. It did not counteract digitalis induced ventricular arrhythmias.Jatamansone semicarbazone, a sesquiterpene ketone, was found to possess antiestrogenic activity.N. jatamansi is also used in place of Muraa (Selinum tenuifolium Wall. ex DC.)Dosage: Root—2-3 g powder; 5-10 g for infusion; 50-100 ml infusion. (API, Vol. I; CCRAS.)... nardostachys jatamansiThe diagnosis is confirmed by ECG. Emergency treatment is with defibrillation and antiarrhythmic drugs.... ventricular fibrillation
Possible side effects include headache, flushing, dizziness, and ankle swelling.... verapamil
A chronic condition, endomyocardial fibrosis, is seen in Black Africans: the cause is unknown.... endomyocarditis
Constituents: alkaloids, coumarins, tannins, iridoids.
Action: powerful relaxant to the central nervous system, vasodilator, analgesic; to calm down physical violence in hysteria and reduce a dangerously high pulse rate. Antispasmodic, hypotensive (transient). Tranquilliser. Combines well with Hawthorn for cardiac arrhythmias. No evidence of dependence in clinical use.
Use s. Pressive nervous headache (constrictive migraine). Facial neuralgia, cramp, intermittent claudication, pain in womb and ovaries, temporal arteritis. Pain in tail bone at base of the spine (coccydynia). Spasm of the osteopathic lesion. Great restlessness, convulsions, contracted pupils and circulatory excitement.
Avoid in heart disease and low blood pressure. Practitioner use. Tincture Gelsemium, 2-5 drops, 2-3 times daily. Pharmacy only sales.
A weaker tincture may frequently be used with good effect: 5 drops to 100ml water – 1 teaspoon hourly. (Dr Finlay Ellingwood) ... gelsemium
Inadequate blood supply to the heart is usually due to coronary artery disease. Other causes include coronary artery spasm, in which the blood vessels narrow suddenly for a short time, aortic stenosis, in which the aortic valve in the heart is narrowed, and arrhythmias. If the pain of angina pectoris continues, it may be due to myocardial infarction. Rare causes include severe anaemia and polycythaemia, which thickens the blood, causing its flow through the heart muscle to slow.
The pain usually starts in the centre of the chest but can spread to the throat, upper jaw, back, and arms (usually the left one) or between the shoulderblades. The pain usually comes on when the heart is working harder and requires more oxygen, for example during exercise. Angina developing during sleep or without provocation is known as unstable angina. Other symptoms may include nausea, sweating, dizziness, and breathing difficulty.
Diagnostic tests usually include an ECG, which may register normal between attacks, and a cardiac stress test. Blood tests and coronary angiography may also be performed.
To help control the symptoms, it is important to stop smoking and to lose weight if necessary. Attacks of angina pectoris may be prevented and treated by nitrate drugs. However, if nitrates are not effective or are causing side effects, beta-blocker drugs or calcium channel blockers may be used.
Drug treatment can control the symptoms for many years.
If attacks become more severe or more frequent, despite treatment, coronary artery bypass surgery or angioplasty may be necessary.... angina pectoris
The causes of anorexia are unclear, but the condition may be linked to a lack of self-worth that leads to excessive concern over physical appearance. Normal dieting may develop into starvation.
In the early stages, sufferers may be overactive and exercise excessively. They are obsessed with food, and often make complicated meals for their families, but are reluctant to eat socially and manage to avoid eating the meals themselves. As weight loss continues, they become tired and weak, the skin becomes dry, lanugo hair (fine, downy hair) grows on the body, and normal hair becomes thinner. Starvation leads to amenorrhoea in many women. Some anorexics sometimes make themselves vomit or take laxative drugs or diuretic drugs to promote weight loss (see bulimia). Chemical imbalances as a result of starvation with or without vomiting can cause potentially fatal cardiac arrhythmias.
Hospital treatment is often necessary and is usually based on a closely controlled feeding programme, combined with psychotherapy or family therapy. For some people, antidepressant drugs may be helpful. Many sufferers relapse after treatment, and long-term psychotherapy is required.... anorexia nervosa
In sinus tachycardia, the rate is raised, the rhythm is regular, and the beat originates in the sinoatrial node (see pacemaker). Supraventricular tachycardia is faster and the rhythm is regular. It may be caused by an abnormal electrical pathway that allows an impulse to
circulate continuously in the heart and take over from the sinoatrial node. Rapid, irregular beats that originate in the ventricles are called ventricular tachycardia. In atrial flutter, the atria (see atrium) beat regularly and very rapidly, but not every impulse reaches the ventricles, which beat at a slower rate. Uncoordinated, fast beating of the atria is called atrial fibrillation and produces totally irregular ventricular beats. Ventricular fibrillation is a form of cardiac arrest in which the ventricles twitch very rapidly in a disorganized manner.
Sinus bradycardia is a slow, regular beat. In heart block, the conduction of electrical impulses through the heart muscle is partially or completely blocked, leading to a slow, irregular heartbeat. Periods of bradycardia may alternate with periods of tachycardia due to a fault in impulse generation (see sick sinus syndrome).
A common cause of arrhythmia is coronary artery disease, particularly after myocardial infarction. Some tachycardias are due to a congenital defect in the heart’s conducting system. Caffeine can cause tachycardia in some people. Amitriptyline and some other antidepressant drugs can cause serious arrhythmias if they are taken in high doses.
An arrhythmia may be felt as palpitations, but in some cases arrhythmias can cause fainting, dizziness, chest pain, and breathlessness, which may be the 1st symptoms.
Arrhythmias are diagnosed by an ECG. If they are intermittent, a continuous recording may need to be made using an ambulatory ECG.
Treatments for arrhythmias include antiarrhythmic drugs, which prevent or slow tachycardias.
With an arrhythmia that has developed suddenly, it may be possible to restore normal heart rhythm by using electric shock to the heart (see defibrillation).
Abnormal conduction pathways in the heart can be treated using radio frequency ablation during cardiac catheterization (see catheterization, cardiac).
In some cases, a pacemaker can be fitted to restore normal heartbeat by overriding the heart’s abnormal rhythm.... arrhythmia, cardiac
Broken bones (see fracture) are a common complication of falls, especially in women. Not only do women have more falls, they are also more likely to suffer fractures because their bone strength may be reduced due to osteoporosis. A fall, or the fear of falling, can also have adverse psychological effects on an elderly person, who may become reluctant to leave the home.
Falls may be prevented by taking common-sense measures such as ensuring that handrails are secure, good lighting is available, suitable footwear is worn, and floor coverings and wiring are safe.... falls in the elderly
Left-sided heart failure may be caused by hypertension, anaemia, hyperthyroidism, a heart valve defect (such as aortic stenosis, aortic incompetence, or mitral incompetence), or a congenital heart defect (see heart disease, congenital). Other causes of left-sided heart failure include coronary artery disease, myocardial infarction, cardiac arrhythmias, and cardiomyopathy.
The left side of the heart fails to empty completely with each contraction, or has difficulty in accepting blood that has been returned from the lungs. The retained blood creates a back pressure that causes the lungs to become congested with blood. This condition leads to pulmonary oedema.
Right-sided heart failure most often results from pulmonary hypertension, which is itself caused by left-sided failure or by lung disease (such as chronic obstructive pulmonary disease (see pulmonary disease, chronic obstructive). Right-sided failure can also be due to a valve defect, such as tricuspid incompetence, or a congenital heart defect.
There is back pressure in the circulation from the heart into the venous system, causing swollen neck veins, enlargement of the liver, and oedema, especially of the legs and ankles. The intestines may become congested, causing discomfort.
Immediate treatment consists of bed rest, with the patient sitting up. Diuretic drugs are given, and digitalis drugs and vasodilators, especially ACE inhibitors, may also be administered. Morphine and oxygen may be given as emergency treatment in acute left-sided failure.... heart failure
Any of the 4 heart valves may be affected by stenosis (narrowing), which causes the heart to work harder to force blood through the valve, or by incompetence or insufficiency (leakiness), which makes the valve unable to prevent backwash of blood. These defects cause characteristic heart murmurs.
Heart-valve defects may be present at birth (see heart disease, congenital), or they may be acquired later in life. The most common congenital valve defects are aortic stenosis and pulmonary stenosis. Acquired heart-valve disease is usually the result of degenerative changes or ischaemia affecting part of the heart and leading to aortic stenosis or mitral incompetence. Rheumatic fever can cause mitral stenosis, mitral incompetence, aortic valve defects, tricuspid stenosis and tricuspid incompetence. The heart valves may also be damaged by bacterial endocarditis.
Heart-valve disorders commonly lead to heart failure, arrhythmias, or symptoms resulting from reduced blood supply to body tissues.
Heart-valve defects may be diagnosed by auscultation, chest X-ray, ECG, or echocardiography and may be corrected by heart-valve surgery.... heart valve
Hypercalcaemia causes nausea, vomiting, lethargy, depression, thirst, and passing urine excessively.
Higher blood levels of calcium produce confusion, extreme fatigue, and muscle weakness.
Without treatment, the condition can result in cardiac arrhythmias, kidney failure, coma, and even death.
Long-standing hypercalcaemia may cause nephrocalcinosis or kidney stones (see calculus, urinary tract).
Diagnosis is by blood tests.
Treatment is of the underlying cause.... hypercalcaemia
rabies An acute viral infection of the nervous system, once known as hydrophobia, that primarily affects dogs but can be transmitted to humans by a bite or a lick over broken skin. The virus travels to the brain; once symptoms develop, rabies is usually fatal.
The average incubation period is 1–3 months, depending on the site of the bite. The symptoms are slight fever and headache, leading to restlessness, hyperactivity, and, in some cases, strange behaviour, hallucinations, and paralysis. The victim develops convulsions, arrhythmias, and paralysis of the respiratory muscles and is often intensely thirsty, but drinking induces painful spasms of the throat. Death follows 10–14 days after the onset of symptoms.
Following an animal bite, immunization with human rabies immunoglobulin and a course of rabies vaccine is necessary; this may prevent rabies if given within 2 days. If symptoms appear, they are treated with sedative drugs and analgesic drugs. The main emphasis is on preventing the disease through quarantine regulations and human and animal immunization. (See also bites, animal.)... quinsy
radiofrequency ablation (RFA) the selective destruction of abnormal conducting tissue in the heart by the targeted delivery of radiofrequency energy via a catheter under X-ray and electrocardiographic guidance. It is usually curative in patients with supraventricular re-entrant tachycardia and is the treatment of choice for this condition (see supraventricular tachycardia; Wolff–Parkinson–White syndrome). It can be used for a variety of other arrhythmias with varying degrees of success. *Cryoablation is an alternative approach that uses freezing to destroy the abnormal tissue.... radioembolization
Health Encyclopedia