8VM80 Pathophysiology of the
cardiovascular system
Inhoud
Vascular system – professor Sambeek .................................................................................................... 2
Lecture 2 - Organisation of Health care .............................................................................................. 2
Lecture 3 - Health care costs ............................................................................................................... 3
Lecture 4 - Peripheral circulation ........................................................................................................ 4
Lecture 5 – Evidence Based Medicine in Peripheral Vascular Disease................................................ 5
Lecture 6 – Imaging for peripheral vascular disease ........................................................................... 6
Lecture 7 - Imaging II Ultrasound ........................................................................................................ 7
Lecture 8 – Imaging II Ultrasound II .................................................................................................... 9
Lecture 9 – Peripheral Arterial Obstructive Disease ......................................................................... 10
Lecture 10 – Peripheral Arterial Obstructive Disease II .................................................................... 11
Lecture 11 – Abdominal Aortic Aneurysm ........................................................................................ 13
Lecture 12 – Abdominal Aortic Aneurysm II...................................................................................... 15
Lecture 13 – Cerebrovascular disease ............................................................................................... 16
Lecture 14 – Cerebrovascular disease II ............................................................................................ 18
Lecture 15 – New developments....................................................................................................... 19
Cardiovascular – professor Pijls............................................................................................................. 21
Lecture 1 – Introduction .................................................................................................................... 21
Lecture 2 – PV loops and variations in preload, afterload and contractility ..................................... 23
Lecture 3 – Heart failure.................................................................................................................... 25
Lecture 4 – Investigation methods for the heart .............................................................................. 27
Lecture 5 – Catheterization and Shock.............................................................................................. 29
Lecture 6 – ECG and ischemic heart disease ..................................................................................... 32
Lecture 7 – Ischemic heart disease and catheterizations ................................................................. 35
Lecture 8 – Angiography and FFR. ..................................................................................................... 36
,Vascular system – professor Sambeek
Lecture 2 - Organisation of Health care
Classification of health care purposes
1. Positive: realization of healhy behavior, focused on the lifestyle. The idea here is that a
person is less likely to become ill when he or she is healthy. Done by the food industry,
fitness, general practitioner, and people themselves.
a. Don’t smoke
b. Be active
c. Don’t drink much
2. Preventive: prevention of diseases and disabilities. Done by doctors, government (IVM)
a. Vaccinations
b. Isolation of diseased
c. Preventive operations on obese patients
3. Curative: restoring a person’s health, an ill patient needs to be cured. Done by the general
practitioner, physiotherapist, doctors in the hospital etc.
a. Give drugs against certain diseases
b. Help with bruises etc.
c. Operate on cancer/inflammations
4. Palliative: limit the suffering.
a. Mortality counseling
b. Learning to live with disabilities
Classification based on functional characteristics
1. Basic echelon: there is no request for help; the offering and initiative lies with the care
provider. Focuses on risk groups. The activities are preventive. (e.g. screening on breast
cancer)
2. First echelon: you enter health care. It is organized around patient’s houses and there is
limited medical specialization. Focuses on individuals. Action after request of patient. (e.g.
general preactioner)
3. Second echelon: only accessible after referral by the general practitioner. There is
(extensive) specialization.
Classification based on care-place
1. Extramural care: given outside the walls of the health care institutions: not in a hospital, so a
general practitioner is extramural care.
2. Semimural care: admission is not necessary by providing outpatient care or day treatment.
So it can be in a hospital, but only an appointment and no overnight stay.
3. Intramural care: admission to a care institution is required.
General practitioner (GP): plays a crucial role in providing personal care to those who appeal to the
GP for this purpose. This means a 24-hour care, focused on the physical, psychological and social
aspects of the patient’s illness.
Hospitals:
1. General: aims at the curative treatment of physical disorders.
2. Academic: is attached to a university and has a different fincancial system. Same aim as a
general hospital, but also has a task in education and scientific research.
3. Categorical: for a specific target group. (children, cancer institues, burns centers etc.)
,Integrated health care is characterized by the following aspects:
- Man is seen as a whole. Attention is paid to the backgrounds and the way in which the
complaints develop, both physically, mentally and psychosocial.
- The relationship between patient and care provider is central. The therapist is more in role of
a coach.
- Apply all suitable therapeutic approaches, healthcare professionals and disciplines, taking
science into account.
- Achieve optimal health and optimal recovery.
Chain care (=ketenzorg): Various care providers from different disciplines are involved in the
treatment of a chronic illness. In chain care, all those caregivers join forces, with one common goal:
to improve the quality of life of patients.
Caregivers look over the walls of their practice or institution and tailor the care to the needs of the
patient. They work together in the organization and implementation of care and bring cohesion to
this.
Three specialists:
Surgical specialists (=snijders), Considering (=beschouwend) and Supportive (=ondersteunend, they
don’t have patients themselves).
Vascular surgeon: operates. E.g. bypasses or removes a plaque or implants a stent to decrease the
aorta diameter.
Lecture 3 - Health care costs
The Netherlands has one of the most expensive health care systems of Europe, but also one of the
best. The total healthcare costs account for 13.3% of the gross domestic product (includes child day-
care and farmaceutical industry).
Curative care is paid by insurance, most other care is paid by government through taxes. Due to the
increase of life expectancy: higher health care costs. How to decrease these costs? → budget cuts in
medicine and hospitals. Insurance companies and hospitals negotiate. The insurance companies are a
big income of the hospitals. Cheaper healthcare is needed.
, Diagnosis-treatment combination (DBC): provides info about the treatment process. How much
insurance has to pay depends on average treatment costs, severity of the treatment, how many visits
to specialists and whether surgery is needed. There are thus ‘care-packages’, that are calculated
based on the average patient.
Lecture 4 - Peripheral circulation
Blood vessels have intima, media and adventitia.
Tunica intima consists of endothelium. Arteries have
internal elastic lamina, are better regulated and can
better constrict. Arteries also have more muscle
cells and are stronger. The vein is larger but with a
thinner wall. Arteries and veins are usually close to a
nerve and to each other.
Oxygenated blood is in the arteries, except for the
pulmonary artery: this goes from the right ventricle
to the lungs. Veins go to the heart, arteries go to
other organs.
Pulse pressure is affected by stroke volume and
compliance (=stijfheid). When the stroke volume
increases, the pulse pressure increases. When the
arterial compliance decrease, the pulse pressure
increases. The pulse pressure depends on the place of the
artery. In the aorta it is better measurable than in for example a
capillary. To measure the pulse pressure however, you can’t
easily measure the aorta, so you do it in the arms with a cuff. In
the legs it is less easy because there are more muscles and
arthroses.
Dicrotic notch in the heart cycle is the closing of the aortic
valve. The systolic phase is the ejecting phase, then the dicrotic
notch is visible and the diastole starts.
The end-diastolic volume is the preload and is highly influenced
by the venous return. The venous return is affected by the
blood volume (venoconstriction/kidneys) and negative
intrathoracic pressure (affected by breathing). The valves in the veins are very important: when
valves don’t work anymore, edema happens.
All living cells require metabolic substrates (glucose, O2, amino acids) and a mechanism to remove
byproducts of the metabolism (CO2, lactic acid). To accomplish the necessary exchange, organisms
have a system of blood vessels that facilitate this. The exchange only happens in the capillaries,
which have a mean diameter of 8 micrometers. These are in close proximity to all cells in the body,
and thereby permit exchange to occur. Different exchange happens in different cells, depending on
the need. Some waste products of the cells are taken up by the blood and transported to other
organs for metabolic processing and elimination into the outside environment through either gastro-
intestinal tract and kidneys.
- Lungs: exchange of O2 and CO2.
- Intestines: blood picks up glucose, amino acids, fatty acids.
