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Phase 1A Jono Wells Rizwan Malatagar The Peer Teaching Society is not liable for false or misleading information…

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Presentation on theme: "Phase 1A Jono Wells Rizwan Malatagar The Peer Teaching Society is not liable for false or misleading information…"— Presentation transcript:

1 Phase 1A Jono Wells Rizwan Malatagar The Peer Teaching Society is not liable for false or misleading information…

2 First half – 25mins on anatomy and physiology Second half – 25mins on pathology and clinical applications Last 5mins – questions and quiz sheets. The Peer Teaching Society is not liable for false or misleading information… introduction

3 Know what it is, how it works, how it goes wrong and how to recognise when it does. Not comprehensive! Emphasis on understanding principles then applying these to work out signs and symptoms of disease Know your definitions Generally doesn’t cover management Quiz sheet based on the kind of questions in Phase 1A exams. The Peer Teaching Society is not liable for false or misleading information… Learning aims: CV system

4 Basics: What is the function of the heart? – Distributing O2 and nutrients to all body tissues – Transportation of CO2 and metabolic waste products (eg. urea) away from the tissues – Distribution of water, electrolytes and hormones – Immune support – Thermoregulation The Peer Teaching Society is not liable for false or misleading information… Cardiovascular Anatomy

5 The Peer Teaching Society is not liable for false or misleading information… Cardiovascular Anatomy

6 Posterior to the sternum Medial to the lungs Anterior to vertebral column Base lies beneath 2 nd rib Apex at 5 th intercostal space Lies upon diaphragm The Peer Teaching Society is not liable for false or misleading information… Location of the Heart

7 The Peer Teaching Society is not liable for false or misleading information… Clinical Relevance

8 Pericardium – Loose fitting double layered sac – Fibrous + Serous Visceral Pericardium – membrane on the surface of the heart Parietal Pericardium – secretes pericardial fluid The Peer Teaching Society is not liable for false or misleading information… Heart coverings Serous Pericardium

9 2 main arteries R and L Both arteries originate directly above the aortic valve The Peer Teaching Society is not liable for false or misleading information… Coronary Circulation

10 Sympathetic: – Cervical and upper thoracic portions of sympathetic trunks – +ve chronotropic, +ve inotropic, dilatatory – Norepinephrine/Epinephrine Parasympathetic: – Branches of the vagus – -ve inotropic, -ve chronotropic, constrictory – Acetylcholine The Peer Teaching Society is not liable for false or misleading information… Nervous supply

11 Not going to cover embryology in this lecture; but worth looking over no matter how boring it may seem!! The Peer Teaching Society is not liable for false or misleading information… Embryology

12 Three main types – Arteries – Veins – Capillaries The Peer Teaching Society is not liable for false or misleading information… Blood Vessels

13 The Peer Teaching Society is not liable for false or misleading information… Blood Vessels Function relates to form

14 The Peer Teaching Society is not liable for false or misleading information… Histology of Blood Vessels

15 Controlled by the SA node Depolarisation spreads through adjacent atria causing atrial systole AV node limits the depolarisation Continues through bundle of His Purkinje fibres distribute impulse to cells in endocardium Impulse spread through the epicardium The Peer Teaching Society is not liable for false or misleading information… Cardiac conduction

16 The Peer Teaching Society is not liable for false or misleading information… Cardiac conduction

17 The Peer Teaching Society is not liable for false or misleading information…

18 Involuntary, striated muscle Cardiac contraction controlled by calcium concentration When Ca rises, the cardiac muscle contracts and when it falls the cardiac muscle relaxes The Peer Teaching Society is not liable for false or misleading information… Cardiovascular physiology

19 Energized cross-bridge binds to actin Cross-bridge moves ATP binds to myosin → cross bridge detaches Hydrolysis of ATP → cross-bridge becomes energized The Peer Teaching Society is not liable for false or misleading information… Cardiovascular physiology

20 Three types of Troponin:- C: Ca binds to C make a conformational change to Troponin I T: binds to tropomyosin to form troponin-tropomyosin complex I: binds to actin to hold the tropomyosin-troponin complexes in place The Peer Teaching Society is not liable for false or misleading information… Cardiac muscle contraction

21 Approximately 0.9 seconds The Peer Teaching Society is not liable for false or misleading information… Cardiac Cycle Diastole: Passive filling of the ventricles AV valves open Semi lunar valves closed Isovolumic Contraction: Ventricular pressure>atrial pressure Causing AV valves close Systole: Ventricular pressure>atrial pressure Semilunar valves open Isovolumic Relaxation: Both valves closed When ventricular pressure { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/3721621/13/slides/slide_20.jpg", "name": "Approximately 0.9 seconds The Peer Teaching Society is not liable for false or misleading information… Cardiac Cycle Diastole: Passive filling of the ventricles AV valves open Semi lunar valves closed Isovolumic Contraction: Ventricular pressure>atrial pressure Causing AV valves close Systole: Ventricular pressure>atrial pressure Semilunar valves open Isovolumic Relaxation: Both valves closed When ventricular pressureatrial pressure Causing AV valves close Systole: Ventricular pressure>atrial pressure Semilunar valves open Isovolumic Relaxation: Both valves closed When ventricular pressure

22 The Peer Teaching Society is not liable for false or misleading information… Cardiac Cycle

23 The Peer Teaching Society is not liable for false or misleading information… ECG representation P wave = atrial contraction QRS complex = ventricular contraction T wave = ventricular relaxation

24 MAP = CO X TPR The Peer Teaching Society is not liable for false or misleading information… Regulation of MAP

25 CO = HR X SV The Peer Teaching Society is not liable for false or misleading information… Cardiac output mL/minBeats/minmL/beat

26 What are Baroreceptors? Located in the carotid sinus and aortic arch Respond to the stretch of the vessel wall Impulse carried to medulla Increases parasympathetic drive: decreases sympathetic drive Decreases HR and decreases BP The Peer Teaching Society is not liable for false or misleading information… Baroreceptors

27 Located in carotid and aortic bodies Hypercapnia/hypoxia/acidosis increases excitation Increased excitation = vasoconstriction + bradycardia The Peer Teaching Society is not liable for false or misleading information… Chemoreceptors

28 “stroke volume of the heart increases in response to the volume of blood filling the heart (end diastolic volume)” – Starling’s law Preload: force associated with the degree of initial stretch in the ventricle from initial volume load Contractility: Ability of the heart to contract independently of the afterload and preload The Peer Teaching Society is not liable for false or misleading information… Stroke volume

29 Increased TPR = decreased venous return + decreased stroke volume Control: – Sympathetic nervous system (vasoconstriction) – Hormonal control: The Peer Teaching Society is not liable for false or misleading information… Total peripheral resistance

30 Atherosclerosis Thromboembolism Shock Heart failure Arrhythmia The Peer Teaching Society is not liable for false or misleading information… Cardiovascular pathology

31 Arteriosclerosis - thickening and hardening of arteries. Atherosclerosis – the process leading to arteriosclerosis where atheroma forms. Arteriolosclerosis – arteriosclerosis of the small vessels. Mainly caused by HTN. The Peer Teaching Society is not liable for false or misleading information… Atherosclerosis - definitions

32 ObesityHyperlipidemia Hypercholester olaemia SmokingDiabetes Family HistoryOld ageMale genderSE AsianAlcohol Poor dietInsufficient exercise Low SESType A coronary-prone Stress The Peer Teaching Society is not liable for false or misleading information… Atherosclerosis – risk factors Constitutional Environmental Lifestyle

33 The Peer Teaching Society is not liable for false or misleading information… Atherosclerosis - process

34 The Peer Teaching Society is not liable for false or misleading information… 1. Endothelial injury

35 The Peer Teaching Society is not liable for false or misleading information… 2. Fatty streak

36 The Peer Teaching Society is not liable for false or misleading information… 3. Bulge

37 The Peer Teaching Society is not liable for false or misleading information… 4. Fibrous cap

38 Narrowed lumen Occlusion Emboli – fragmentation of plaque Aneurysm – due to loss of elasticity Learn examples of each. The Peer Teaching Society is not liable for false or misleading information… Atherosclerosis - outcomes

39 Virchow’s triad – stasis, hypercoagulability and endothelial injury The Peer Teaching Society is not liable for false or misleading information… Thromboembolism

40 Thrombosis = inappropriate coagulation of blood inside a vessel In veins it’s fibrin rich due to low pressure, in arteries they’re platelet rich e.g. atheroma. Main clinical problems are DVT and PE. The Peer Teaching Society is not liable for false or misleading information… Thromboembolism Virchow’s triad – stasis, hypercoagulability and endothelial injury

41 Where? – Affects deep veins e.g. femoral, popliteal Presentation? – Pain, swelling, redness and possibly distended superficial veins and distal proximal oedema Treat with anticoagulation May also present as pulmonary embolism The Peer Teaching Society is not liable for false or misleading information… DVT

42 Definition – an acute failure of the cardiovascular system to perfuse the tissues of the body. 4 main types: – Hypovolaemic – Distributive – Cardiogenic – Obstructive The Peer Teaching Society is not liable for false or misleading information… SHOCK!

43 The Peer Teaching Society is not liable for false or misleading information… Shock – symptoms and signs Faintness, light headedness, dizziness Reduced level of consciousness Skin: Sweating + pallor. Cold Rapid, weak pulse Rapid, shallow breathing Oliguria Muscle weakness Intravascular compartment potential volume Low end organ perfusion

44 External fluid loss Internal fluid loss What causes these? The Peer Teaching Society is not liable for false or misleading information… Hypovolaemic shock

45 Total fluid volume is the same, it’s just maldistributed. Origin: septic or anaphylactic. Septic – exotoxins released from bacteria or endotoxins released when they die Anaphylactic – Inflammatory mediators – Peripheral vasodilatation, increased vascular permeability and bronchoconstriction The Peer Teaching Society is not liable for false or misleading information… Distributive shock

46 Pump failure – the heart isn’t pumping adequately to maintain the circulation e.g. arrhythmia, MI or myocarditis. Usually an acute presentation but can occur due to worsening heart failure. The Peer Teaching Society is not liable for false or misleading information… Cardiogenic shock

47 Direct outflow obstruction -> pressure on the heart or vessels leading to inadequate end organ perfusion. – Extrinsic compression – cardiac tamponade or tension pneumothorax – Intrinsic obstruction– Pulmonary embolism The Peer Teaching Society is not liable for false or misleading information… Obstructive shock

48 ‘A Syndrome of heart insufficiency’. It is failure of the heart to deliver oxygenated blood at the rate needed by metabolising tissues. Commonest cause is myocardial ischaemia. Other causes include – Pressure overload – Volume overload – Primary myocardial disease The Peer Teaching Society is not liable for false or misleading information… Heart failure

49 The myocardial failure leads to decreased CO and Starling’s law is impaired. Laplace’s law means that as heart muscle dilates, the myocytes require more energy to increase tension. Compensation due to sympathetic and renal system. Both relate to angiotensin II. The Peer Teaching Society is not liable for false or misleading information… Changes in circulation

50 Commonest symptoms – SOB, fatigue, ankle oedema Specific signs – raised JVP, displaced apex beat Heart failure can be right sided, left sided or mixed. Clinical features of either right or left relate to what’s behind that side in the vascular system. Also get a functional regurgitation murmur. The Peer Teaching Society is not liable for false or misleading information… Heart failure

51 Rate Rhythm Cardiac axis The Peer Teaching Society is not liable for false or misleading information… ECGs!

52 The Peer Teaching Society is not liable for false or misleading information… ECGs!

53 Rate – normal. Rhythm – look at all the waves and intervals. Cardiac axis – down in II and up in III. The Peer Teaching Society is not liable for false or misleading information… ECGs

54 Main types: – Supraventricular – Ventricular Or: – Bradycardias – Tachycardias The Peer Teaching Society is not liable for false or misleading information… Arrhythmias

55 Atrial fibrillation – irregularly, irregular. – Absent P waves, random contractions – Aetiology – Types – PPP! – Consequences – clots and death Atrial flutter – REALLY FAST. Sinus rhythm. – Sawtooth trace The Peer Teaching Society is not liable for false or misleading information… Atrial arrhythmias

56 1 st degree – prolonged PR interval 2 nd degree: – Mobitz type 1 (Wenkebach) – PR lengthens then miss QRS – Mobitz type 2 – PR constant lengths then loss of QRS complex – 2:1 block – every second P wave followed by QRS 3 rd degree - discoordination The Peer Teaching Society is not liable for false or misleading information… Heart Block

57 Bundle branch block – william marrow V1-6 ST elevation – Shows broken bits. Learn where leads represent After MI -> ST elevation within hours, T wave inversion within 24hrs and pathological Q waves after days. Potassium changes – Hyperkalaemia – absent P, wide QRS, tall T and VF – Hypokalaemia – small P, few T-waves, long QT The Peer Teaching Society is not liable for false or misleading information… Other points

58 Chest pain Leg pain Murmurs The Peer Teaching Society is not liable for false or misleading information… Clinical problems!

59  Differential diagnosis?  CVS, RS, GI and MSK conditions  Key questions?  Worse on breathing?  Related to food intake, positional?  Presence of CVS risk factors, radiation? The Peer Teaching Society is not liable for false or misleading information… Chest pain

60  Necrosis of an area of heart muscle due to compromised blood supply.  Atherosclerotic plaque ruptures -> occlusion  Necrosis -> scar tissue The Peer Teaching Society is not liable for false or misleading information… Myocardial infarction

61  Cardiac arrest  Unstable angina  Pericarditis  Cardiac tamponade  Mitral regurgitation – due to pap muscles  Arrhythmia  Thromboembolisms The Peer Teaching Society is not liable for false or misleading information… Consequences of MI

62  ABC  12-lead ECG  MONA  Consider thrombolytics, clopidogrel and PCI. The Peer Teaching Society is not liable for false or misleading information… Management

63  Lifestyle modification  Secondary prevention drugs (AC ABS)  Surgical treatments – PCI or CABG The Peer Teaching Society is not liable for false or misleading information… Treatment post-MI

64 Differential diagnosis? Vascular, musculoskeletal or neurological Key questions? – SOCRATES – Trauma – Risk factors for DVT or atherosclerosis The Peer Teaching Society is not liable for false or misleading information… Leg pain

65 Ischaemia -> low oxygen Lactic acid in muscles Can’t be got rid of until at rest Remember Pouiselle’s law! Also acute limb ischaemia: – 6 P’s: Pallor, paraesthesia, perishing cold, pain, pulselessness, paralysis The Peer Teaching Society is not liable for false or misleading information… Science of IC

66 DVT – Pain and clinical effects due partially to oedema and inflammation of tissues. Rheumatological conditions Cellulitis The Peer Teaching Society is not liable for false or misleading information… Differentials

67  Due to turbulent flow through valves  Timed with phases of heart contraction. Usually 1 of:  Systolic (ejection, mid or pan)  Diastolic (mid or early)  Continuous (machinery, venous hum or pericardial rub)  Also comment on site, character and radiation. The Peer Teaching Society is not liable for false or misleading information… Murmurs

68  S1 due to mitral/tricuspid closure, S2 due to aortic/pulmonary closure.  Added sounds:  Stenosis = whistle before  Insufficiency = swish after  Systolic -> aortic should be open, mitral should be closed.  Diastolic -> mitral should be open, aortic should be closed. The Peer Teaching Society is not liable for false or misleading information… Sounds

69  Damage due to:  Age – mechanical stresses and impact damage  Rheumatic fever  Infective endocarditis  Aortic root dissection  Papillary muscle damage  Congenital e.g. bicuspid aortic valve The Peer Teaching Society is not liable for false or misleading information… Valves – acellular flaps

70  Aortic stenosis  Mitral regurgitation  Aortic regurgitation  Mitral stenosis The Peer Teaching Society is not liable for false or misleading information… The big 4:

71  Outflow obstruction  Back-pressure effect on myocardium  Reduced CO  Ejection systolic, aortic area, radiates to neck The Peer Teaching Society is not liable for false or misleading information… Aortic stenosis

72  Leaks -> volume overload in LV  Back pressure on LA  Pansystolic, ‘blowing’, heard at apex, radiates to axilla. The Peer Teaching Society is not liable for false or misleading information… Mitral regurgitation

73  Leaks blood causing back pressure on LV  Early diastolic, ‘blowing, high-pitched’ at left sternal edge. Get patient to lean forward and breathe out. The Peer Teaching Society is not liable for false or misleading information… Aortic regurgitation

74  Back-pressure causes dilatation of LA and pulmonary vasculature causing…  Mid-diastolic, ‘low rumbling’ at apex which is louder with exercise. Listen with the bell and roll onto left side. The Peer Teaching Society is not liable for false or misleading information… Mitral stenosis

75  Heart failure  CVS  Respiratory  Fluid congestion The Peer Teaching Society is not liable for false or misleading information… Other signs and symptoms?

76  Surgery  Starr-Edwards valve – turbulent, ‘clicks’  Tissue valve – no rejection The Peer Teaching Society is not liable for false or misleading information… Treatments

77  Incidence 6-7/100,000 in UK  Affects endothelium and heart valves.  Febrile illness + murmur  Consider method of infection and prosthetic valves  50% death rate for acute infection! The Peer Teaching Society is not liable for false or misleading information… Infective endocarditis

78  Any questions? The Peer Teaching Society is not liable for false or misleading information… Thanks for listening!


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