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Onemocnění cévní soustavy a krve

Ischemická choroba srdeční (ICHS)

Podkladem je patologický proces v koronárním řečišti, který může způsobit akutní nebo chronické omezení, případně úplné zastavení přítoku krve do určité oblasti srdečního svalu, čímž vzniká ischémie a následně až nekróza. K poškození srdečního svalu tedy dochází z důvodu nepoměru mezi dodávkou a potřebou kyslíku a živin v myokardu. V naprosté většině případů je hlavní příčinou ateroskleróza koronárních tepen, která je způsobena hlavně ukládáním tukových či krevních elementů do cévní stěny, což má za následek zúžení průsvitu cévy (vznik stenózy). Kromě aterosklerózy se na klinickém syndromu ICHS mohou podílet i další příčiny jako např. koronární spazmy, embolie do koronárního řečiště či trombóza v koronární tepně bez aterosklerózy.

 

 

  Akutní formy ICHS

·         Infarkt myokardu

·         nestabilní angina pectoris

·         náhlá srdeční smrt

 

Chronické formy ICHS

·         Stabilní angina pectoris

·         Němá ischémie myokardu

·         městnavá srdeční nedostatečnost

 

Infarkt myokardu

Jeho podkladem je uzavření koronární tepny krevní sraženinou – trombem, způsobující odumření (nekrózu) části myokardu, kterou tato koronární tepna zásobuje. Nekróza se hojí jizvou, která se již nestahuje a v různém rozsahu omezuje funkci. Uzavření tepny může být trvalé nebo přechodné a tedy co nejrychlejší zprůchodnění je hlavním cílem léčby AIM.

AIM je výrazně stresujícím stavem, kdy dochází ke značné stimulaci sympatiku s vyplavením katecholaminů (adrenalin a noradrenalin), které ještě zhoršují nepoměr mezi potřebou a dodávkou kyslíku. Tento mechanismus může způsobit i život ohrožující arytmie jako komorovou fibrilaci nebo tachykardii. 

 

Stabilní angina pectoris

Je charakterizována stenokardiemi vázanými na námahu, ty ustupují do 20 minut nebo po podání nitrátů, projevuje se jako bolest vyvolaná ischémií myokardu, vznikající při fyzické nebo psychické zátěži a mizící v klidu. Doba trvání obvykle velmi krátká 1-3 min, nepřesahuje 5 min, obvykle také intenzita bolesti menší než u AIM

- na rozdíl od infarktu myokardu nejsou přítomny přidružené příznaky (nauzea, zvracení, pocení, úzkost, neklid). Je způsobena zúžením koronárních tepen, které vzniká postupně a není provázeno trombózou. V klidu či při malé námaze je průtok dostatečný, ale při větší námaze nemůže dojít k dostatečnému zvýšení průtoku krve myokardem a dochází ke vzniku ischémie.

Terapie - lékem první volba jsou nitráty – příznivě ovlivňují průtok krve věnčitými tepnami,  - při anginózním záchvatu se užívá Nitroglycerin tbl., Nitromint spray pod jazyk nebo Isoket i.v.,  - dlouhodobě účinkující nitráty (Iso-Mack retard, Nitro-Mack retard, Monosan), - blokátory kalciových kanálů (Cordipin, Blocalcin, Diacordin)

- beta-blokátory – léky snižující aktivitu sympatiku při námaze (Tenormin, Vasocardin)

- antiagregancia (Anopyrin) 

Němá ischémie myokardu

Termín je vyhrazen pro objektivně prokazatelnou ischémii myokardu, která se u nemocného klinicky neprojeví anginou pectoris ani jejím ekvivalentem. Příčina chybění bolesti v době ischémie myokardu není dosud zcela objasněna. Bylo zjištěno, že nemocní s častými epizodami němé ischémie myokardu mají obecně zvýšený práh pro vnímání bolesti. Předpokládá se, že na zvýšený práh vnímání bolesti mohou mít vliv v těle vytvářené endorfiny (opoidy, působící analgeticky stejně jako opiáty). V současné době se přijímá názor, že nemocní s němou ischémií myokardu mají celkově porušený systém vnímání bolesti ze všech orgánů. Němá ischémie se definuje jako objektivně prokazatelná ischémie myokardu bez klinických projevů bolesti typu anginy pectoris. Němá ischémie se zjistí obvykle náhodně.

Léčí se shodně jako klinicky manifestní ischémie. Přetrvává-li ischémie při léčbě medikamentózní, je u nemocných indikováno koronarografické vyšetření a podle jeho výsledku se určuje další léčebný postup.  

 

Městnavá srdeční slabost – srdeční selhávání

Je způsobena dlouhodobě zhoršeným prokrvením myokardu s postupným rozšířením srdečních oddílů. Příčiny: - ICHS se zhoršeným funkce levé komory, kardiomyopatie, stenózy aorty, stenózy aortální chlopně, systémová hypertenze. Příčinou je chronické plicní onemocnění nebo přeneseně při nedostatečnosti levé komory

1. Pravostranné selhávání - dochází ke zpomalení odtoku krve z celého těla

- otoky dolních končetin, břicha, zvýšená náplň krčních žil, cyanóza sliznic, nevýkonnost, slabost, pocity pnutí v břiše, později i dušnost, - tachykardie, tachypnoe, hypertenze

2. Levostranné selhávání - dochází k překrvení plic a vzniku srdeční dušnosti – astma cardiale vrcholící až plicním edémem. Subjektivní příznaky-těžký dech, špatně spí, podkládá si více hlavu, zlepšení pociťuje více v sedě, nebo ve stoje

-objektivní příznaky-špatná výkonnost, zhoršující se dušnost, záchvaty dušnosti v noci nutící k posazení, při rozvinutém plicním edému vykašlávání zpěněného narůžovělého sputa, cyanóza, úzkost, na plicích slyšitelné vlhké chropy, někdy slyšitelné na dálku („bublání ode dveří“)

3. Globální – pravolevé – selhávání - kombinace pravostranného a levostranného selhávání („chrůpky i otoky dolních končetin“)

Terapie - poloha vsedě nebo v polosedě, oxygenoterapie, Nitroglycerin, diuretika – Furosemid 20-80 ml i.v., zklidnění – diazepam (Apaurin) i.v. nebo lépe malé množství Morphinu i.v.,  event. další léky – Digoxin, kortikoidy-Solu-Medrol, Hydrocortison,…

 

Embolie, trombóza

Trombóza – ucpání cév pouze trombem neboli sraženinou krve.

Embolie – ucpání cév embolem, což je cokoli, co brání průchodu krve cévou (epitelie, vzduchová bublina, krev, tuk, cizopasníci,…).

 

Tromboembolická nemoc

Hluboká žilní trombóza - trombóza v hlubokých žilách

Flebotrombóza - primární trombóza, převážně v hlubokém žilním systému

Tromboflebitida - trombóza se vyvíjí po prvotním poškození žilní stěny a onemocnění postihuje zejména povrchový systém.

Akutní komplikací hluboké žilní trombózy: plicní embolizace, chronická plicní hypertenze a chronický posttrombotický syndrom

Posttrombotický syndrom - tvoří 80% příčin chron. plicní nedostatečnosti

Diagnostika - anamnéza a klinické vyšetření je základ. Otok, teplá kůže, zarudlý tuhý pruh, palpační bolestivost ve středu plosky, bledá končetina, RTG kontrastní, CT

Léčba - HEPARIN, Antikoagulancia – 3 měs. až doživotně. Vhodná nenáročná chůze

 

Plicní embolie

je ucpání části plicního cévního řečiště krevní sraženinou, méně často tukovými částečkami, cizími tělesy, vzduchem nebo plodovou vodou. Může probíhat velmi nenápadně – postupně narůstající dušností, ale může být i příčinou náhlého úmrtí. K plicní embolii může dojít po náročných chirurgických operacích, ale i po zlomeninách dolních končetin, po dlouhém cestování. Zdrojem krevní sraženiny bývá nejčastěji trombóza (ucpání cévy krevní sraženinou) pánevních žil nebo hlubokých žil dolních končetin. Rizikovými faktory vzniku žilní trombózy jsou poškození cévní stěny úrazem nebo zánětem v okolí, poruchy krevní srážlivosti a snížení rychlosti toku krve v končetinách. K tomu dochází při těhotenství, srdečním selhání, při znehybnění končetiny sádrou, po operacích.

Daleko méně často dochází k embolii tukových částeček (po závažných zlomeninách nebo při ortopedických operacích), vzduchu nebo cizích těles (části kanyl při složitých vyšetřeních cév apod.). Při embolizaci nádorových hmot vznikají plicní metastázy.

Závažnost a klinický obraz plicní embolie závisí na jejím rozsahu. Při masivní PE, která vzniká při ucpání více než poloviny plicního řečiště, dochází k okamžitému srdečnímu selhání. Projevuje se náhle vzniklou těžkou klidovou dušností a silnou bolestí na hrudníku. Středně velká embolie (submasivní PE) uzavírá menší plicní tepnu a vede k rozvoji dušnosti a bolestem na hrudníku v okolí embolie, může být vykašlávána krev. Plicní tkáň, která je špatně prokrvena, se může infikovat a vzniká zápal plic. Pokud dochází opakovaně k emboliím drobných krevních sraženin, tak se dušnost, únavnost a otoky dolních končetin rozvíjejí postupně a nenápadně.

 

Anémie

Anémie není vlastním onemocněním, ale pouze klinickým příznakem či komplikací jiného onemocnění. Jedná se o snížení kapacity nosičů kyslíku v krvi jako důsledek poklesu hematokritu (poměr objemu krvinek k tekuté části krve plazmě), hemoglobinu nebo celkového počtu červených krvinek pod normální hodnoty.

Přenos kyslíku v těle se uskutečňuje z plic do všech buněk a tkání lidského těla. Kyslík je transportován pomocí červených krvinek, v nichž se váže na červené krevní barvivo - hemoglobin. Pokud v tomto procesu dojde k poruše, pak se do svalů a dalších orgánů dostává méně kyslíku. Zároveň se v nich hromadí velké množství oxidu uhličitého. Na nedostatek kyslíku lidské tělo začne odpovídat. Srdce pracuje s rychlejší frekvencí a zrychlí se i dýchání. Výsledkem je, že se po čase začnete cítit unavení a vyčerpaní.

K chudokrevnosti dochází:

·         při poruchách tvorby červených krvinek nebo při jejich rozpadu. K tomu může dojít, nemá-li vyvíjející se krvinka dostatek železa, vitamínu B12 či kyseliny listové. Červené krvinky vznikají v kostní dřeni. Proto může být jejich vývoj narušen útlakem kostní dřeně nádorovými buňkami – leukémie.

·         při krvácení (vnitřním nebo vnějším) po poranění, při krvácení z močových nebo pohlavních cest a z trávicího traktu. Menší ztráty krve se vyrovnávají přesunem z krevních zásobáren (játra, slezina) a převedením tkáňového moku do krve. Tím se však krev naředí a výsledkem je opět anémie.

·         častou příčinou chudokrevnosti jsou u psů otravy způsobené jedy na hubení hlodavců.

·         jestliže je více červených krvinek zničeno než vytvořeno. Sem také patří nemoci krevního barviva - hemoglobinu. Krvinka, která v sobě nese špatné krevní barvivo, bývá zničena dříve než krvinka zdravá. Tímto způsobem se tělo zbavuje buněk, které mu nepřináší žádný užitek.

V určitém rozsahu probíhá neustálá obnova krevních buněk tím, že krvinky i plazma se jednak plynule nově vytvářejí, jednak zanikají.

Projevy vzniklé chudokrevnosti závisí na rychlosti jejího vzniku. Vzniká-li totiž anémie pomalu, nemocní se na ni postupně adaptují. Chudokrevní trpí na opakované infekce a špatné hojení ran. Celkově je pacient s anémií buď podrážděnější, anebo naopak propadá lhostejnosti až apatii. Při pokračující chudokrevnosti se stále snižuje tělesná výkonnost a mohou se přidat i známky srdečního selhávání. V extrémních případech může dojít až ke vzniku bezvědomí.

Pro historiky uvádím bizardnější příznaky, například tzv. piku a pagofagii. V prvním případě se jedná o nutkavé pojídání hlíny, škrobu či papíru, ve druhém o polykání ledu. Oba tyto projevy jsou velmi typické pro chudokrevnost z nedostatku železa.

 

Oběhový kolaps

Příčiny: velká ztráta krve (i v jedné části těla), prudké snížení tlaku krve, velké nárazové přejedení psa (krev jde do žaludku a trávicího ústrojí), leknutí, stres, úraz elektrickým proudem, dilatace cév (krev se ztrácí mimo oběh a tak nedochází k řádnému prokrvování mozku).

Příznaky: klesá tlak krve, stoupá pulz. ztráta vědomí, nekoordinované pohyby, pěna u úst, chroptění, stavy obdobné epileptickému záchvatu.

Prevence, léčba: vyplývá z příčin, předcházet přehřátí a přehnaným výkonům na slunci, úprava krmné dávky, chlad, studené obklady, medikamenty pro povzbuzení srdeční činnosti.

 

Leukémie

(řecky leukos  "bílý" a aima "krev"), představují nádorová onemocnění, která vycházejí z krvetvorné tkáně a z lymfatických uzlin. Hlavní rozdíl, oproti lymfomům (Lymfomy jsou zhoubné nádory mízních uzlin a lymfatické tkáně v okolí sleziny, játry, střev a velkých krevních cév) je ten, že leukémie postihují celý organizmus a nádorovými buňkami jsou větší či menší měrou prostoupeny všechny orgány. Leukémie je onemocnění krvetvorných orgánů, postihující bílou krevní řadu.

Leukémie jako onemocnění krvetvorných orgánů se projevuje zmnožením určitého typu bílých krvinek. U některých forem však počet bílých krvinek nemusí být zvýšen. Mohou být virového původu.

Klinický obraz - Zvětšení mízních uzlin v podkoží i jinde v těle, zvětšení sleziny a jater. Příznaky se liší podle postiženého orgánu.

Rozdělení leukémií - Podle průběhu můžeme leukémie rozdělit na akutní (rychle probíhající) a chronické (pomalu probíhající). Podle krvetvorných buněk, ve kterých došlo ke zvratu v nádor, rozlišujeme leukémie z lymfocytů a leukémie z myelocytů a jejich podtypů.

 ·         Lymfatická leukémie – množení lymfocytů v mízních uzlinách

·         Myeloidní – bujení leukocytů v kostní dřeni, slezině a játrech

·         Monocytární – bujení monocytů ve slezině, játrech, kostní dřeni. Monocyty mají ledvinovitý tvar jádra, téměř homogenní cytoplazmu, jsou součástí imunitního systému –RES- těla. Fagocytózou se mění na makrofágy, ty pohlcují větší částice – např. odloupané epitele

 Příznaky: NEbolestivé stavy, zvětšení mízních uzlin, snížení výkonu, únava, bledé sliznice a spojivky – anémie z důsledku nepoměru mezi erytrocyty a leukocyty

Léčba: zdlouhavá, nejistá

Formy ICHS mohou být: akutní (AIM, nestabilní AP, náhlá srdeční smrt), chronické (stabilní AP, němá ischémie myokardu, městnavá srdeční nedostatečnost)

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