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In addition kamagra gold 100mg otc erectile dysfunction at age of 20, he presents breathlessness discount kamagra gold 100 mg with mastercard erectile dysfunction vitamin d, tachycardia with a pulse rate of 140 beats per minute which requires immediate correction 100 mg kamagra gold free shipping erectile dysfunction virgin, and sweating discount kamagra gold 100mg without prescription erectile dysfunction medications side effects. In the long-term the goal is to improve exercise capacity and limit risk of onset of a myocardial infarction (heart attack). In ischaemic heart disease, as the number of coronary arteries with athero- sclerosis and the extent of occlusion increase, the risk of angina and myo- cardial infarction increases. By causing dilation of the coronary veins isosorbide dinitrate reduces venous return and results in a reduction of cardiac output. When patients with ischaemic heart disease feel chest pain they are usually advised to use sublingual glyceryl trinitrate or glyceryl trinitrate spray and to take aspirin preferably dispersed in water or chewed for a more immediate drug release compared with swallowing a tablet. Patient or carers should inform health professionals what medi- cation the patient has already taken when symptoms of attack started. A48 C Isosorbide dinitrate is a coronary vasodilator and side-effects of peripheral vasodilation may occur. A49 A When heparin is administered by intravenous or subcutaneous injection, it has a rapid onset of action and an average halflife of 1. There is variability in halflife ranging between 1 to 6 h depending on a number of factors such as renal impairment and liver disease. A50 D Isosorbide dinitrate is initially given intravenously to achieve a fast onset of action and response. Heparin is given to reduce thrombin generation and fibrin formation and unless there are further complications, treatment is continued for about 48 h. It is very important that diabetic patients have their blood pressure very well controlled as these patients have multiple risk factors towards the development of cardiovascular disease. During treatment metformin causes conversion of glucose to lactate in the intestinal mucosa; lactate is transported to the liver where it is normally metabolised. High plasma concentrations of metformin such as in renal impairment or high lactate concentrations in blood caused by liver disease and alcohol abuse lead to the inability by the liver to clear the lactate. Metformin should not be used in renal impairment, and diabetic patients receiving metformin should have their renal function monitored to exclude renal function deterioration, which may warrant withdrawal of metformin. To decrease gastrointestinal side-effects such as abdominal discomfort, nausea, diarrhoea and metallic taste, patients are advised to take tablets with meals. Gastrointestinal side-effects are quite common and in some patients lead to the patient not accepting treatment with metformin. Heparin may also induce hyperkalaemia because it inhibits aldosterone secretion from the adrenal glands. Risk of hyperkalaemia is increased in diabetic patients, in patients with chronic renal failure and in patients taking potassium-sparing diuretics. Furosemide is a loop diuretic that inhibits sodium, potassium and water retention in the kidney and its use may precipitate hypokalaemia. Use of statins is recommended in patients with ischaemic heart disease to decrease morbidity and mortality. Patient should be advised to follow a diet low in choles- terol in conjunction with long-term statin therapy. Before initiating statins, liver function tests should be carried out, as statins are contraindicated in active liver disease. Test 3: Answers 161 A56 A Glyceryl trinitrate patches should be applied on chest wall, upper arm or shoulder and replaced daily. The advantage of the spray over the sublingual tablets is that sublingual tablets have problems of stability which require the patient to discard any tablets remaining after 8 weeks from opening. He is admitted with a stroke, a cerebrovascular accident that is occlusion of a cerebral artery by an embolus in the brain or cerebrovascular haemorrhage. Other factors that increase risk of stroke include age, diabetes, transient ischaemic attacks and previous stroke. The use of antiplatelet agents in the management of a non-haemorrhagic stroke is the main line of treatment aimed at preventing formation of thrombi in the arterial vessels. Aspirin has antiplatelet effects as it irreversibly inhibits cyclo-oxygenase, which in platelets is responsible for the conversion of arachidonic acid into 162 Test 3: Answers thromboxane A2 which is a vasoconstrictor and stimulates platelet aggrega- tion. A58 B Dipyridamole is an adenosine reuptake inhibitor and a phosphodiesterase inhibitor which has antiplatelet and vasodilating properties. It is incompletely absorbed from the gastrointestinal tract and therefore it should be administered before food. Dipyridamole should be used with caution in patients with hypotension, heart failure, rapidly worsening angina, aortic stenosis and myocardial infarction. It is essential to avoid hypotension, to maintain systemic circulation and to avoid orthostatic changes in patients with an acute stroke, as compromised blood supply to the brain may precipitate degeneration of the condition. A59 A The most common side-effects to be expected from dipyridamole are gastro- intestinal effects such as nausea, abdominal pain, constipation, dizziness, throbbing headache, hypotension, hot flushes and tachycardia. Risk of occur- rence of constipation is higher in hospitalised patients and in patients with limited mobility. As it has minimal effect on cardiac conduction and negative inotropic effect is very low at thera- peutic doses, it rarely precipitates heart failure. Test 3: Answers 163 A61 B Nifedipine is rapidly and efficiently absorbed from the gastrointestinal tract but undergoes an extensive first-pass effect. Use of normal-release tablets in the management of hypertension leads to large variations in blood pressure as a three-times-daily dosage regimen would still leave periods during which blood pressure is not controlled. A63 A Glibenclamide is a second-generation sulphonylurea that has a duration of effect of 20–29 h but which may be even longer in older people. Hypo- glycaemia may lead to confusion, unconsciousness and coma if no immediate intake of glucose is taken. Deterioration in renal function, which can be monitored by measuring blood urea and creatinine concentrations, may occur, especially in patients who have existing kidney disease and heart failure. Advan- tages over isosorbide dinitrate include a higher bioavailability after oral administration as it does not undergo first-pass hepatic metabolism and a longer halflife. This is a chronic, progress- ive inflammatory disease that leads to articular and extra-articular symptoms which present significant morbidity to the patient. She is also receiving folic acid, calcium and vitamin D supplements and disodium pamidronate, which is a biphosphonate. In rheumatoid arthritis, aims of treatment are to decrease disease progression, limit morbidity and decrease occurrence of flare-ups. A66 E Rheumatoid arthritis is associated with inflammation of the synovial membrane of different joints. It is not a localised condition and affects different joints commonly in the hands, wrists, knees, feet and shoulders. Onset is insidious and the disease usually presents initially with non-specific symptoms such as fatigue, malaise, diffuse musculoskeletal pain and stiffness. Charac- teristically, at onset the patient presents with symmetrical small-joint polyarthri- tis in the hands, wrists and feet. Diagnostic criteria for rheumatoid arthritis include presence of morning stiffness, presence of arthritis in three or more joints, symmetrical involvement, rheumatoid nodules, serum rheumatoid factor and radiographic changes. A68 A As rheumatoid arthritis progresses, morning stiffness becomes prolonged and more disabling, interfering with patient’s daily activities.

Chemistry & Pharmacokinetics Ezetimibe is readily absorbed and conjugated in the intestine to an active glucuronide order kamagra gold 100 mg with visa erectile dysfunction drugs recreational use, reaching peak blood levels in 12–14 hours kamagra gold 100mg cheap biking causes erectile dysfunction. Plasma concentrations are substantially increased when it is administered with fibrates and reduced when it is given with cholestyramine cheap kamagra gold 100 mg online erectile dysfunction drugs in philippines. Mechanism of Action Ezetimibe selectively inhibits intestinal absorption of cholesterol and phytosterols safe kamagra gold 100mg list all erectile dysfunction drugs. It is effective in the absence of dietary cholesterol because it also inhibits reabsorption of cholesterol excreted in the bile. Therapeutic Uses & Dosage The effect of ezetimibe on cholesterol absorption is constant over the dosage range of 5–20 mg/d. Experience to date reveals a low incidence of reversible impaired hepatic function with a small increase in incidence when given with a reductase inhibitor. Patients must maintain a low fat diet to avoid steatorrhea but should take steps to minimize deficiency of fat- soluble nutrients. Lomitapide is given orally in gradually increasing doses of 5–60 mg capsules once daily 2 hours after the evening meal. It is important to note that the apo B-100 gene is also transcribed in the retina and in cardiomyocytes. However, it was withdrawn from clinical trials because it increased cardiovascular events and deaths in the treatment group. Therapeutic agents currently include antibodies (eg, evolocumab, alirocumab) and antisense oligonucleotides. The lowest effective doses should be used in combination therapy and the patient should be monitored more closely for evidence of toxicity. Effective doses of the individual drugs may be lower than when each is used alone; for example, as little as 1–2 g of niacin may substantially increase the effects of the other agents. Balwani M et al: Clinical effects and safety profile of recombinant human lysosomal acid lipase in patients with cholesteryl ester storage disease. Bruckert E, Labreuche J, Amarenco P: Meta-analysis of the effect of nicotinic acid alone or in combination on cardiovascular events and atherosclerosis. International Atherosclerosis Society Position Paper: Global Recommendations for the Management of Dyslipidemia. His laboratory findings are also negative except for slight anemia, elevated erythrocyte sedimentation rate, and positive rheumatoid factor. With the diagnosis of rheumatoid arthritis, he is started on a regimen of naproxen, 220 mg twice daily. His symptoms are reduced at this dosage, but he complains of significant heartburn that is not controlled by antacids. He is then switched to celecoxib, 200 mg twice daily, and on this regimen his joint symptoms and heartburn resolve. The outcome of the immune response for the host may be deleterious if it leads to chronic inflammation without resolution of the underlying injurious process (see Chapter 55). Chronic inflammation involves the release of multiple cytokines and chemokines plus a very complex interplay of immunoactive cells. The cell damage associated with inflammation acts on cell membranes to release leukocyte lysosomal enzymes; arachidonic acid is then liberated from precursor compounds, and various eicosanoids are synthesized (see Chapter 18). The lipoxygenase pathway of arachidonate metabolism yields leukotrienes, which have a powerful chemotactic effect on eosinophils, neutrophils, and macrophages and promote bronchoconstriction and alterations in vascular permeability. During inflammation, stimulation of the neutrophil membranes produces oxygen-derived free radicals and other reactive molecules such as hydrogen peroxide and hydroxyl radicals. The interaction of these substances with arachidonic acid results in the generation of chemotactic substances, thus perpetuating the inflammatory process. Furthermore, most of the nonopioid analgesics (aspirin, etc) have anti-inflammatory effects, so they are appropriate for the treatment of both acute and chronic inflammatory conditions. The glucocorticoids also have powerful anti-inflammatory effects and when first introduced were considered to be the ultimate answer to the treatment of inflammatory arthritis. Although there are data indicating that low-dose corticosteroids have disease-modifying properties, their toxicity makes them less favored than other medications, when it is possible to use the others. However, the glucocorticoids continue to have a significant role in the long-term treatment of arthritis. While renal excretion is the most important route for final elimination, nearly all undergo varying degrees of biliary excretion and reabsorption (enterohepatic circulation). Drugs with short half-lives remain in the joints longer than would be predicted from their half-lives, while drugs with longer half-lives disappear from the synovial fluid at a rate proportionate to their half-lives. Several large epidemiologic studies have shown a 50% reduction in relative risk for this neoplasm when the drugs are taken for 5 years or longer. Aspirin is now rarely used as an anti-inflammatory medication and will be reviewed only in terms of its antiplatelet effects (ie, doses of 81–325 mg once daily). Aspirin is absorbed as such and is rapidly hydrolyzed (serum half-life 15 minutes) to acetic acid and salicylate by esterases in tissue and blood (Figure 36–3). Alkalinization of the urine increases the rate of excretion of free salicylate and its water-soluble conjugates. Clinical Uses: Aspirin decreases the incidence of transient ischemic attacks, unstable angina, coronary artery thrombosis with myocardial infarction, and thrombosis after coronary artery bypass grafting (see Chapter 34). Adverse Effects: In addition to the common side effects listed above, aspirin’s main adverse effects at antithrombotic doses are gastric upset (intolerance) and gastric and duodenal ulcers. Although previously not recommended during pregnancy, aspirin may be valuable in treating preeclampsia-eclampsia. All nonacetylated salicylates are effective anti-inflammatory drugs, although they may be less effective analgesics than aspirin. The nonacetylated salicylates are administered in doses up to 3–4 g of salicylate a day and can be monitored using serum salicylate measurements. It is not as selective as celecoxib and may be considered “preferentially” selective rather than “highly” selective. Similarly, while meloxicam is known to inhibit synthesis of thromboxane A , even at2 supratherapeutic doses, its blockade of thromboxane A does not reach levels that result in decreased in vivo platelet2 function (see common adverse effects above). A preparation combining diclofenac and misoprostol decreases upper gastrointestinal ulceration but may result in diarrhea. Another combination of diclofenac and omeprazole was also effective with respect to the prevention of recurrent bleeding, but renal adverse effects were common in high-risk patients. Diclofenac in rectal suppository form can be considered for preemptive analgesia and postoperative nausea. Diflunisal Although diflunisal is derived from salicylic acid, it is not metabolized to salicylic acid or salicylate. It undergoes an enterohepatic cycle with reabsorption of its glucuronide metabolite followed by cleavage of the glucuronide to again release the active moiety. Diflunisal is subject to capacity-limited metabolism, with serum half-lives at various dosages approximating that of salicylates (Table 36–1). It is claimed to be particularly effective for cancer pain with bone metastases and for pain control in dental (third molar) surgery. Because its clearance depends on renal function as well as hepatic metabolism, diflunisal’s dosage should be limited in patients with significant renal impairment. Hepatic metabolism is extensive; its (R)(+) and (S)(−) enantiomers are metabolized differently, and it does not undergo chiral conversion.

The potassium-sparing diuretics reduce Na+ reabsorption by for the electroneutral cotransport of Na+/Cl− order kamagra gold 100mg without a prescription impotence 25 years old. Excretion of Cl− proven 100mg kamagra gold impotence ka ilaj, Na+ and either antagonizing aldosterone (spironolactone) or blocking Na+ accompanying H O is increased 100 mg kamagra gold fast delivery erectile dysfunction pumps side effects. This causes the electrical potential 2 tubule stimulates Na+ exchange with K+ and H+ cheap kamagra gold 100mg with mastercard erectile dysfunction protocol hoax, increasing their excre- across the tubular epithelium to fall, reducing the driving force for K+ tion and causing hypokalaemia and a metabolic alkalosis. Hyperkalaemia is also likely to occur Adverse effects if patients are also taking inhibitors of angiotensin-converting enzyme Adverse effects include weakness, impotence and occasionally skin (e. More common are the following metabolic effects: Spironolactone competitively blocks the binding of aldosterone to 1 Hypokalaemia may precipitate cardiac arrhythmias, especially in its cytoplasmic receptor and so increases the excretion of Na+ (Cl− and patients on digitalis. This can be prevented by giving potassium sup- H O) and decreases the ‘electrically coupled’ K+ secretion. It is a weak 2 plements if necessary, or by combined therapy with a potassium- diuretic, because only 2% of the total Na+ reabsorption is under aldos- sparing diuretic. Uric acid levels in the blood are often increased ascites, Conn’s syndrome (primary hyperaldosteronism) and severe because thiazides are secreted by the organic acid secretory system in heart failure. Drugs acting on the kidney: diuretics 35 15 Drugs used in hypertension Centrally acting Medulla Initial effect Diuretics α2? They are no longer smoking, obesity, hyperlipidaemia, diabetes and left ventricular hyper- preferred for uncomplicated hypertension but may be used if there are trophy. Centrally acting drugs (top left) are little used because of their reduction, if appropriate, reduced alcohol consumption and moderate adverse effects. The effectivness of antihyper- pressure by decreasing vasoconstrictor tone and hence peripheral tensive therapy is clear, but many, if not most, patients do not have resistance. Diuretics Calcium-channel blockers have no direct effect on vascular smooth muscle and the vasodilatation (see also Chapters 16 and 17) they cause seems to be associated with a small but persistent reduction The tone of vascular smooth muscle is determined by the cytosolic + Ca2+ concentration. One possible mechanism is that a fall in smooth muscle 1 + 2+ (resulting from sympathetic tone), which triggers Ca2+ release from Na causes a secondary reduction in intracellular Ca , so that the muscle becomes less responsive to endogenous vasoconstrictors. There are also receptor-operated cation gout (see also Chapter 14), but it is now appreciated that they have a channels that are important because the entry of cations through them depolarizes the cell, opening voltage-dependent (L-type) Ca2+ chan- fat dose–response curve and the low doses of thiazides currently used nels and causing additional Ca2+ to enter the cell. This reduces the peripheral resistance and β-Adrenoceptor antagonists results in a fall in blood pressure. With continued treatment, the cardiac output returns to common side-effects are caused by excessive vasodilatation and normal, but the blood pressure remains low because, by an unknown include dizziness, hypotension, fushing and ankle oedema. A central mecha- α1-Adrenoceptor antagonists nism has been suggested, but this seems unlikely as some drugs Doxazosin causes vasodilatation by selectively blocking vascular α1- do not readily pass the blood–brain barrier. Unlike non-selective α-blockers, α1-selective drugs are in renal juxtaglomerular granule cells that secrete renin may be not likely to cause tachycardia, but they may cause postural hypoten- involved and such a mechanism could explain why β-blockers are sion. They are used with other antihypertensives in cases of resistant less effective in older patients who may have low renin levels. Disadvantages of β-blockade are the common adverse effects, such as cold hands and fatigue, and the less common, but serious, adverse Other vasodilators effects, such as the provocation of asthma. All of the β-blockers lower blood pressure, but at least headaches and fuid retention (as a result of secondary hyperaldos- some of the side-effects can be reduced by using cardioselective teronism). However, intravenous drugs are rarely necessary, and the trend not seriously impair, aldosterone secretion, and excessive K+ retention is to use oral agents whenever possible (e. With increasing age, oxygen demand, β-blockers may also increase the perfusion of the atheromatous plaques progressively narrow the arteries, and the ischaemic area, because the decrease in heart rate increases the dura- obstruction to blood fow may eventually become so severe that, when tion of diastole and hence the time available for coronary blood fow. The ischaemic muscle β-Blockers are the standard drugs used in angina, but they have then produces the characteristic symptoms of angina pectoris (epi- many side-effects and contraindications (Chapter 15). If β-blockers sodic chest pain that may radiate to the jaw, neck, or arms; shortness cannot be used, e. Calcium- The basic aim of drug treatment of angina is to reduce the work of channel blockers relieve angina mainly by causing peripheral arteri- the heart and hence its oxygen demand. Their main effect is to cause peripheral vasodilata- there is some degree of coronary artery spasm (variant angina). Reduction in the distension of the heart wall decreases should take low-dose aspirin to reduce the probability of platelet oxygen demand and the pain is quickly relieved. Glyceryl trinitrate aggregation, and statins should be considered to lower low-density given sublingually to avoid frst-pass metabolism is used to treat acute lipoprotein cholesterol. This causes platelet aggregation bined therapy is required in which β-adrenoceptor blockers (top left) and the formation of an intracoronary thrombus, which results in a or calcium-channel blockers (middle top) are taken in addition to sudden decrease in blood fow through the artery. Patches containing glycerol ducting tissues of the heart are also affected by calcium-channel block- trinitrate (transdermal administration) have a long duration of action ers, which produce a negative inotropic effect by reducing calcium (up to 24 h). However, the Long-acting nitratesare more stable and may be effective for several dihydropyridines (e. The use of isosorbide mononitrate, vascular muscle because it is relatively more depolarized than cardiac which is the main active metabolite of the dinitrate, avoids the variable muscle (membrane potential 50 mV cf. The arterial dilatation produced by the nitrates tone that causes a mild tachycardia and counteracts the mild negative causes headaches, which frequently limit the dose. Prolonged extent, diltiazem depress the sinus node, causing a mild resting high dosage may cause methaemoglobinaemia as a result of oxidation bradycardia. Smoking is prothrombotic and atherogenic; it of K-channels, causing membrane hyperpolarization that inhibits Ca reduces coronary blood fow, and the nicotine-induced rise in heart infux by switching off voltage-dependent Ca-channels. Generally in bypass operations, the distal end of the internal does not produce tolerance, presumably because the overnight rest mammary artery is inserted at a point beyond the stenosis of the allows tissue sensitivity to return by the next day. Angina is relieved or improved in 90% of is poorly understood, but depletion of sulphydryl group donors may be patients, but returns within 7 years in 50%. Mortality is decreased in involved, because tolerance to nitratesin vitrocan sometimes be reversed some pathological conditions (e. Unfortunately, β-Adrenoceptor antagonists this damages the vessel, often leading to proliferative growth of β-Blockers are used for the prophylaxis of angina. Intrinsic activity might be a disadvantage in angina, signifcantly reduced by the use of stents that elute sirolimus or pacli- and the cardioselective β-blockers such as atenolol and metoprolol taxel from a polymer–drug matrix bound to the stent (less than 10% are probably the drugs of choice. The adverse effects essential with drug-eluting stents because the endothelialization of the and contraindications of β-blockers should be reviewed (Chapters 9 stent (which prevents thrombosis) is delayed by the antiproliferative and 15). Unfortunately the ideal duration of antiplatelet therapy (aspirin Calcium-channel blockers with clopidogrel) with drug eluting stents is unkown but is probably These drugs are widely used in the treatment of angina and have fewer at least 12 months. Calcium-channel blockers inhibit Drugs used in angina 39 17 Antiarrhythmic drugs Sinus Vagal fibres Sympathetic fibres Supraventricular bradycardia adenosine I. Arrhythmias can occur in the An arrhythmia common after acute myocardial infarction is sinus apparently healthy heart, but serious ones (e. The effects of antiarrhythmic agents on the parasympathetic and sympathetic nerves, respectively (upper fgure). Arrhythmias may be caused by an ectopic focus, mias, especially in patients with ischaemic heart disease. Because of the limitations and dangers of antiarrhythmic drugs, muscle fbres which, being no longer refractory, again depolarize, invasive procedures and devices are increasingly being used in serious establishing a loop of depolarization (circus movement). Cardiac action potential These actions decrease the automaticity of pacemaker cells and increase Most cardiac cells have two depolarizing currents, a fast Na+ current the effective refractory period of atrial, ventricular and Purkinje fbres. The 2 those effective in ventricular arrhythmias (bottom left); and long refractory period of cardiac fbres normally protects them from 3 those effective in both types (middle left).

Subclavius Lateral pectoral nerve Pectoralis major Thoraco-acromial artery Pectoralis minor Medial pectoral nerve Lateral thoracic artery Fig generic 100mg kamagra gold visa popular erectile dysfunction drugs. The muscle fbers The thoracic wall is segmental indesign and composed of converge to form a flat tendon generic 100 mg kamagra gold amex erectile dysfunction surgical treatment options, which inserts into the skeletal elements and muscles buy 100mg kamagra gold with mastercard erectile dysfunction treatment in kuwait. Thoracic vertebrae Both the subclavius and pectoralis minor pull the tip of There are twelve thoracic vertebrae 100mg kamagra gold free shipping erectile dysfunction treatment hypnosis, each of which is the shoulder inferiorly. A continuous layer of deep fascia, the clavipectoral Tyical thoracic vertebra fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the floor of the axilla A typical thoracic vertebra has a heart-shaped vertebral below. Nerves, and the laminae are broad and overlap with those of the vessels, and lymphatics that pass between the pectoral vertebra below. The superior articular processes are region and the axilla pass through the clavipectoral fascia flat, with their articular surfaces facing almost directly pos­ between the subclavius and pectoralis minor or pass under teriorly, while the inferior articular processes project the inferior margins of the pectoralis major and minor. Anterior Superior articular process Facet for articulation Superior with tubercle of rib Superior demifacet Posterior Inferior Spinous process Facet for ariculation Inferior articular process Demifacets for ariculation with tubercle of rib with head of ribs Posterior Superior view Superolateral view 143 Fig. Articulation with ribs A typical thoracic vertebra has three sites on each side for articulation with ribs. The superior costal facet articulates with part of the head of its own rib, and the inferior costal facet artic­ ulates with part of the head of the rib below. Superior costal facet for head of rib I • An oval facet (transverse costal facet) at the end of the transverse process articulates with the tubercle of its own rib. Although all ribs articulate with the vertebral column, only the costal cartilages of the upper seven ribs, known as true ribs, articulate directly with the sternum. The posterior end articulates with the vertebral column and is characterized by a head, neck, and tubercle. The smaller superior surface articulates with the inferior costal facet on the body of the vertebra above, whereas the larger inferior facet articulates with the superior costal facet of its own vertebra. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: Grooves • The articular part is medial and has an oval facet for articulation with a corresponding facet on the trans­ verse process of the associated vertebra. Rib X Like other ribs, the tubercle has a facet for articulation with The head of rib X has a single facet for articulation with the transverse process. The adult sternum consists of three major elements: the Body of the sternum broad and superiorly positioned manubrium of the sternum, the narrow and longitudinally oriented body of The body of the sternum is flat. The manubrium of the sternum forms part of the bony The lateral margins of the body of the sternum have framework of the neck and the thorax. Superiorly, each lateral The superior surface of the manubrium is expanded margin has a demifacet for articulation with the inferior laterally and bears a distinct and palpable notch, the aspect of the second costal cartilage. Immediately inferior to this fossa, on At the inferior end of the body of the sternum is a demi­ each lateral surface of the manubrium, is a facet for the facet for articulation with the upper demifacet on the attachment of the frst costal cartilage. The inferior end of the body of the the lateral border is a demifacet for articulation with the sternum is attached to the xiphoid process. On each side of movements of all of the ribs on the vertebral column are its upperlateralmargin is a demifacet for articulation with essential for altering the volume of the thoracic cavity the inferior end of the seventh costal cartilage. Joint with head of rib Joints The two facets on the head of the rib articulate with the Costovertebral joints superior facet on the body of its own vertebra and with the A typical rib articulates with: inferior facet on the body of the vertebra above. This joint is divided into two synovial compartments by an intra­ • the bodies of adjacent vertebrae, forming a joint with articular ligament, which attaches the crest to the adjacent the head of the rib; and intervertebral disc and separates the two articular surfaces • the transverse process of its related vertebra, forming a on the head of the rib. Costotransverse joints Costotransverse joints are synovial joints between A third ligament, the superior costotransverse liga­ the tubercle of a rib and the transverse process of the ment, attaches the superior surface of the neck of the rib related vertebra (Fig. The joint is stabilized by two strong extra­ Slight gliding movements occur at the costotransverse capsular ligaments that span the space between the trans­ joints. The Intercostal nerves and associated major arteries and second to seventh joints are synovial and have thin cap­ veins lie in the costal groove along the inferior margin of sules reinforced by surrounding sternocostal ligaments. The artery costal cartilage to the junction of the manubrium and the is inferior to the vein, and the nerve is inferior to the body of the sternum. Therefore, the nerve is the structure most at risk when objects Interchondral joints perforate the upper aspect of an intercostal space. Interchondral joints occur between the costal cartilages of Small collateral branches of the major intercostal nerves adjacent ribs (Fig. Deep to the intercostal spaces and ribs, and separating Interchondral joints provide indirect anchorage to the these structures from the underlying pleura, is a layer of sternum and contribute to the formation of a smooth infe­ loose connective tissue, called endothoracic fascia, rior costal margin. Muscles associated with the upper limbs Manubriosternal and xiphisternal joints and back overlie the spaces. The joints between the manubrium and the body of the sternum and between the body of the sternum and the xiphoid process are usually symphyses (Fig. Only slight angular movements occur between the manubrium and the body of the sternum during respiration. The joint between the body of the sternum and the xiphoid process In the clinic often becomes ossifed with age. A clinically useful feature of the manubriosternal joint Cervical ribs is that it can be palpated easily. This is because the manu­ Cervical ribs are present in approximately 1 o of the brium normally angles posteriorly on the body of the population. Rib I is not palpable, because it lies infe­ Plain radiographs may demonstrate cervical ribs as rior to the clavicle and is embedded in tissues at the base small horn-like structures (see Fig. The plane Clinically, "thoracic outlet syndrome" is used to also passes through the end of the ascending aorta and the describe symptoms resulting from abnormal beginning of the arch of the aorta, the end of the arch of compression of the brachial plexus of nerves as it passes over the frst rib and through the axillary inlet into the the aorta and the beginning of the thoracic aorta, and the upper limb. The anterior ramus of T1 passes superiorly bifurcation of the trachea, and just superior to the pulmo­ out of the superior thoracic aperture to join and nary trunk (see Fig. The cervical band from a cervical rib is one cause of thoracic outlet syndrome by putting upward stresses on the lower Intercostal spaces parts of the brachial plexus as they pass over the Intercostal spaceslie between adjacent ribs andare flled frst rib. Regional anatomy • Thoracic Wal Posterior ramus of spinal nerve Posterior intercostal artery and vein Lateral branches of - intercostal nerve and vessels Internal thoracic artery and vein Costal groove Anterior cutaneous branch of intercostal nerve Collateral branches of intercostal nerve and vessels Anterior perforating branches of Anterior intercostal artery and vein intercostal vessels A Lung Pleural cavity Visceral pleura Parietal pleura Intercostal vein Intercostal artery Intercostal nerve Collateral branches B Fig. Muscles In the clinic Muscles of the thoracic wall include those that fll and Collection of sternal bone marrow support the intercostal spaces, those that pass between the The subcutaneous position of the sternum makes it possible to place a needle through the hard outer sternum and the ribs, and those that cross several ribs cortex into the internal (or medullary) cavity containing between costal attachments (Table 3. Oncethe needle is in this position, bone The muscles of the thoracic wall, together with marrow can be aspirated. In the clinic Rib fractures Intercostal muscles Single rib fractures are of little consequence, though extremely painful. The intercostal muscles are three flat muscles found Afer severe trauma, ribsmaybe broken in two or in each intercostal space that pass between adjacent ribs more places. As a group, the intercostal muscles provide structural support for the intercostal spaces during breathing. External intercostal muscles Theeleven pairs of external intercostal muscles extend from the inferior margins (lateral edges of costal grooves) of the ribs above to the superior margins of the ribs below. When the thoracic wall is viewed from a lateral position, the muscle fbers pass obliquely anteroinferiorly (Fig.