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For Phase 1a Maria Digby & Rowena Speak Cardiology The Peer Teaching Society is not liable for false or misleading information…

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Presentation on theme: "For Phase 1a Maria Digby & Rowena Speak Cardiology The Peer Teaching Society is not liable for false or misleading information…"— Presentation transcript:

1 For Phase 1a Maria Digby & Rowena Speak Cardiology The Peer Teaching Society is not liable for false or misleading information…

2 1 st Half *Physiology *Pharmacology *Anatomy *ECG 2 nd Half *Pathophysiology + Clinical Scenarios *More Pharmacology! *Question time What we’re going to cover… The Peer Teaching Society is not liable for false or misleading information…

3 Ventricles The Peer Teaching Society is not liable for false or misleading information… * Phase 0: depolarisation – Na+ in *Phase 1: partial repolarisation – Na+ channels shut, K+ out *Phase 2: plateau – Ca2+ in through L- type channels *Phase 3: repolarisation – K+ out *Phase 4: resting potential – (-90mV) – Na+/K+ ATPase

4 SAN The Peer Teaching Society is not liable for false or misleading information… *Phase 4 = pacemaker potential – less K+ out, Na+ in through F-type channels, Ca2+ in through T-type channels *Phase 0 = slower depolarisation – Ca2+ in through L-channels NOT Na+ in like depolarisation ventricles!) *Phase 3 = repolarisation – K+ out

5 Antiarrhythmic drugs: Vaughan Williams classification The Peer Teaching Society is not liable for false or misleading information… *Class I: Na+ channel blockers 1a) Quinidine – moderate blocker 1b) Lignocaine – weak blocker 1c) Flecainide – strong blocker *Class II: Beta blockers: block sympathetic stimulation - atenolol *Class III: K+ channel blockers: prolong repolarisation - amiodarone *Class IV: Ca2+ channel blockers: verapramil I IV Phase 4 Phase 0 Phase 1 Phase 2 Phase 3 0 mV -80mV II III

6 Cardiac cycle The Peer Teaching Society is not liable for false or misleading information… -AP = aortic pressure -LVP = left ventricular pressure -LAP = left atrial pressure -LVEDV = left ventricular end diastolic volume -LVESV = left ventricular end systolic volume

7 Cardiac cycle: Systole The Peer Teaching Society is not liable for false or misleading information… Systole -After ventricular filling, pressure in ventricles > in atria = AV valves close (SOUND 1 = “lub”) 1.Isovolumetric contraction: ventricles contracts when all valves are shut (this increases pressure in ventricles) 2.Ventricular ejection: pressure in ventricles > in pulmonary artery/aorta = semilunar valves open and blood flows out of ventricle

8 Cardiac cycle: Diastole The Peer Teaching Society is not liable for false or misleading information… Diasystole -After ventricular ejection, pressure in pulmonary artery/aorta > than in ventricles = semilunar valves shut (SOUND 2 = “dub”) 1.Isovolumetric relaxation: ventricles relax when all valves are shut (this decreases the pressure in the ventricles) 2.Ventricular filling: pressure in ventricles < in atria = AV valves open

9 Cardiac cycle: “atrial kick” The Peer Teaching Society is not liable for false or misleading information… Ventricular filling is mostly a passive process But towards the end of diastole, the atria contract causing a small increase in pressure in the ventricles = “atrial kick”

10 Cardiac cycle: dicrotic notch The Peer Teaching Society is not liable for false or misleading information… When the aortic valve closes, blood rebounds against the valve causing a decrease then a rebound of aortic pressure = dicrotic notch

11 Equations: learn these!! The Peer Teaching Society is not liable for false or misleading information… *SV = EDV - ESV *CO = HR x SV *MAP = DP + 1/3(SP-DP) *BP = CO x TPR

12 Monitoring MAP: Baroreceptors The Peer Teaching Society is not liable for false or misleading information… Where are the arterial baroreceptors? a) Carotid sinus + b) Aortic arch  Baroreceptors detect changes in arterial pressure  Afferent nerve (Glossopharyngeal)  CNS (Medullary Cardiovascular Centre)  Efferent nerve i.Sympathetic outflow to heart and arterioles ii.Parasympathetic (Vagus) outflow to heart

13 Maintaining MAP (BP = CO x TPR) The Peer Teaching Society is not liable for false or misleading information… BP COTPR

14 Maintaining MAP: 1. Changing CO The Peer Teaching Society is not liable for false or misleading information…  CO = HR x SV Change Heart Rate *Sympathetic nervous stimulation of the heart *Parasympathetic nervous stimulation of the heart (Vagus) *Plasma adrenaline Change Stroke Volume *Sympathetic nervous stimulation of the heart *Plasma adrenaline *End-diastolic ventricular volume (preload) – FRANK- STARLING MECHANISM

15 FRANK-STARLING MECHANISM – learn this! The Peer Teaching Society is not liable for false or misleading information… At any given heart rate…. Any ↑ Venous Return…. Causes ↑ End-Diastolic Volume… Causes ↑ stretch in the cardiac muscle (Preload)… Causes ↑ forceful contraction… Which ↑ Stroke Volume and thereby the Cardiac Output

16 Maintaining MAP: 2. Changing TPR The Peer Teaching Society is not liable for false or misleading information…  The arterioles are the principle site of resistance to blood flow Vasoconstriction *Local: Endothelin-1, internal blood pressure (myogenic response) *Neural: Sympathetic nerves *Hormonal: Adrenaline (on alpha receptors), Angiotensin II, Vasopressin (aka Antidiuretic hormone) Vasodilation *Local: decrease in Oxygen, increase in CO2/H+, Nitric Oxide, Eicosanoids, Prostacyclin *Neural: Neurons that release Nitric oxide *Hormonal: Adrenaline (on beta 2 receptors), Atrial Natriuretic Peptide

17 Important point… The Peer Teaching Society is not liable for false or misleading information… *There is sympathetic stimulation to both the heart and arterioles *But there is no parasympathetic stimulation to the arterioles, only to the heart

18 Terms to understand… The Peer Teaching Society is not liable for false or misleading information…  Active hyperaemia – vasodilation in response to an increase in metabolic activity  Flow autoregulation – vasodilation in response to decreased pressure  Reactive hyperaemia – when a tissue’s blood supply has been completely occluded, on removal of the occlusion there is a profound, transient increase in blood flow

19 GO LOOK AT… The Peer Teaching Society is not liable for false or misleading information…  VANDERS - especially page 399 (12 th edition)

20 Long term regulation of MAP The Peer Teaching Society is not liable for false or misleading information…  The Baroreceptor reflex is a short term regulator. They end up adapting to a maintained change in pressure.  The most important long-term regulator of arterial pressure is blood volume – this is regulated by the Renin-Angiotensin-Aldosterone System (RAAS)  ACE inhibitors inhibit RAAS to reduce blood volume (have a quick look at RAAS – try to understand it but don’t worry about memorising it until Phase 1b!)

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

22 Haemostasis The Peer Teaching Society is not liable for false or misleading information… 1.Platelet plug 2.Clotting cascade *Clotting factors dependent upon Vitamin K: II, VII, IX, X *Haven’t got time to talk about this now – make sure you understand the principles of it *Important for understanding pharmacology of Aspirin, Clopidogrel, Warfarin, Heparin and Fibrinolytics

23 Anatomy - valves The Peer Teaching Society is not liable for false or misleading information… ValveSurface markingAuscultation area Tricuspid4 th intercostal space -midline 5 th intercostal space -right and left sternal edge Pulmonary3 rd costal cartilage- sternal junction -left 2 nd intercostal space -left sternal edge Mitral4 th intercostal cartilage -midline 5 th intercostal space -left, midclavicular line Aortic3 rd intercostal space -left half of sternum 2 nd intercostal space -right sternal edge

24 Anatomy - valves The Peer Teaching Society is not liable for false or misleading information…

25 Valve pathology The Peer Teaching Society is not liable for false or misleading information… PathologyCauseMurmur Mitral stenosisRheumatic feverMid-diastolic Mitral regurgitationIschaemic heart disease, MI, Rheumatic fever Pan-systolic Aortic stenosisCalcific valve disease, Rheumatic fever Ejection-systolic Aortic regurgitationRheumatic fever, bicuspid aortic valve Diastolic

26 Rheumatic fever The Peer Teaching Society is not liable for false or misleading information… Endocarditis Post-Streptococcus pyogenes infection (Scarlet fever, Strep throat) Damages heart valves

27 Anatomy – heart borders The Peer Teaching Society is not liable for false or misleading information… Right: formed by right atrium, runs between 3 rd and 6 th right costal cartilages approximately 2-3cm from the midline in the adult Left: formed by left atrial appendage + left ventricle, apex  2 nd left intercostal space 2-3cm from midline Inferior: formed by right atrium and right ventricle + tiny bit of left ventricle

28 Anatomy – aorta The Peer Teaching Society is not liable for false or misleading information… Thoracic *Right + left coronary arteries *Brachiocephalic (aka innominate) artery *Left common carotid artery *Left subclavian artery Passes through diaphragm at T12 Abdominal *Abdominal aortic aneurysm – expansile, pulsatile mass, midline, above umbilicus Bifurcates at L4

29 Electrocardiography (ECG) – heart rate The Peer Teaching Society is not liable for false or misleading information…  Heart Rate – Quick estimation = 10 x no. of QRS complexes on one rhythm strip (check speed of ECG is 25mm/s) Sinus bradycardia < 60bpm Sinus tachycardia >100bpm Normal PR interval = s Normal QRS complex = s

30 ECG – AV block The Peer Teaching Society is not liable for false or misleading information…  1 st degree – PR interval prolonged, >0.20sec  2 nd degree:- 1.Mobitz type I - progressive lengthening of PR interval with each successive complex until a P wave is not conducted 2.Mobitz type II – PR interval constant, QRS complexes dropped intermittently or in fixed ratio to P wave rate  3 rd degree - Complete dissociation of P Waves and QRS complexes

31 ECG The Peer Teaching Society is not liable for false or misleading information…  Atrial flutter = saw tooth pattern  Atrial fibrillation = irregularly irregular rhythm

32 ECG – Ventricular fibrillation: fine and coarse The Peer Teaching Society is not liable for false or misleading information…  Ventricular fibrillation

33 Useful websites The Peer Teaching Society is not liable for false or misleading information…

34 Pathology/Pathophysiology Normal arterial structure The Peer Teaching Society is not liable for false or misleading information…

35 Getting old ain’t pleasant Progressive fibrous thickening of intima Fibrosis + scarring of muscular or elastic media Accumulation of mucopolysaccharide- rich ground substance Fragmentation of elastic laminae ATHEROSCLEROSIS The Peer Teaching Society is not liable for false or misleading information…

36 Atherosclerosis  Some predisposing factors?  Prevented? The Peer Teaching Society is not liable for false or misleading information…

37 Atherosclerosis Effects medium and large arteries Risk factors: Aging Male Hypertension Smoking Diabetes mellitus Hyperlipidemia Increase LDL Decreased HDL Having a factor 7 genetics Lifestyle -Exercise -Obesity -Diet -Stress and personality The Peer Teaching Society is not liable for false or misleading information…

38 Drugs – ‘all’s well that ends well’ ;) Drugs Calcium channel blockers “ipine”s eg: amlodipine ACE Inhibitors “il”s eg: ramipril Angiotensin Receptor Blockers “sartans” eg: candesartan Diuretics “ide”s eg: loop – furosemide, thiazide – bendoflumethiazide and K sparing - Amiloride Beta blockers “olol”s eg: atenolol Statins “statin”eg: simvastatin The Peer Teaching Society is not liable for false or misleading information…

39 Clopidogrel - is an oral, thienopyridine class antiplatelet agent Anticoagulants “rin” eg: warfarin and heparin NSAIDS “profen” eg: ibuprofen, aspirin *so doesn’t work for everything The Peer Teaching Society is not liable for false or misleading information…

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41 Angina Pectoralis Caused by chronic heart disease Atherosclerosis in the coronary artery Means less O2 to heart muscle Crushing chest pain No troponin No new changes on ECG Stable or unstable? Stable - Caused by activity / stress (watching Barnsley) - relieved by GTN/rest Unstable - NOT relieved by GTN /rest - Can occur at rest The Peer Teaching Society is not liable for false or misleading information…

42 MI What is an MI? How does it occur? How does it present? How is it prevented? ST elevation myocardial infarction Non-ST elevation myocardial infarction The Peer Teaching Society is not liable for false or misleading information…

43 MI - STEMI Crushing chest pain Feeling of “impending doom” in Barnsley – “gonna miss Barnsley play at weekend” ;) Nausea Sweating SOB Clammy skin Raised Troponin level ST elevation on ECG The Peer Teaching Society is not liable for false or misleading information…

44 MI - STEMI STEMI Ambulance MONA A and E β blocker (atenolol) Thrombolytics (tPA or streptokinase) ACE inhibitor (lisinopril) Clopidogrel Back at home Warfarin Aspirin β Blocker (metoprolol) ACE inhibitor Statin (simvastatin) The Peer Teaching Society is not liable for false or misleading information…

45 MI - NSTEMI Infarct Feeling again same “impending doom” - Barnsley be relegated? Nausea Sweating SOB Clammy skin Raised Troponin No new ECG changes The Peer Teaching Society is not liable for false or misleading information…

46 MI - NSTEMI NSTEMI Ambulance MONA M= Morphine O = Oxygen N = Nitrates A = Aspirin A and E β blocker (atenolol) LMW heparin GPIIb/IIIa antagonist (tirofiban) Nitrates Clopidogrel Back at home Warfarin Aspirin β Blocker (metoprolol) ACE inhibitor Statin The Peer Teaching Society is not liable for false or misleading information…

47 Heart Failure Heart failure = pathophysiological state in which the heart is unable to pump sufficient blood to meet the needs of the metabolising tissues or can only do so with elevated filling pressures R, L or Congestive Systolic / diastolic /Both Excessive salt and water retention Low cardiac output and raised peripheral resistance The Peer Teaching Society is not liable for false or misleading information…

48 Causes:- 1.Ischaemic heart disease – 34% 2.Dilated cardiomyopathy – 32% 3.Primary valvular disease and congenital heart disease – 12% 4.Hypertensive heart disease – 11% 5.Other -5% The Peer Teaching Society is not liable for false or misleading information…

49 Physiological – A state where the heart is unable to pump enough blood to satisfy the needs of the metabolising tissues Clinical – A symptomatic condition where breathlessness, tiredness and fatigue are associated with a cardiac abnormality that reduces cardiac output The Peer Teaching Society is not liable for false or misleading information…

50 Key concepts - Pathophysiology 1.Initial insult 2.Fall in cardiac output 3. ↑ Preload to maintain ventricular performance 4. ↑ Afterload limits ventricular performance 5.Maladaptive hormonal responses 6.Progressive left ventricular remodelling 7.Progressive decline in cardiac performance The Peer Teaching Society is not liable for false or misleading information…

51 Left heart failure Symptoms: fatigue, exertional breathlessness, orthopnoea paroxysmal nocturnal dyspnoea Signs: (occur late) cardiomegaly, added heart sounds, tachycardia, crackles in lung bases The Peer Teaching Society is not liable for false or misleading information…

52 Right heart failure Symptoms: -swollen ankles, fatigue, anorexia Signs: (occur early) -raised jugular venous pressure -hepatomegaly -pitting oedema -ascites The Peer Teaching Society is not liable for false or misleading information…

53 Congestive A mixture of both left and right heart failure! Almost always right heart failure secondary to severe left heart failure… The Peer Teaching Society is not liable for false or misleading information…

54 Tetralogy of Fallot Congenital defect – most common form of cyanotic congenital heart disease Causes:- Low O2 levels in the blood leading to cyanosis The Peer Teaching Society is not liable for false or misleading information…

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56 Classic form includes 4 defects of the heart and its major blood vessels 1.Ventricular septal defect 2.Narrowing of the pulmonary outflow tract 3.Overriding aorta - shifted over to the RV and ventricular septal defect (usually just from LV) 4.Right ventricular hypertrophy The Peer Teaching Society is not liable for false or misleading information…

57 Factors that increase risk Alcoholism in mother Diabetes Mother who is over 40 years old Poor nutrition during pregnancy Rubella or other viral illnesses during pregnancy Children more likely to have Downs syndrome The Peer Teaching Society is not liable for false or misleading information…

58 Symptoms Cyanosed (blue skin) Clubbing of fingers Difficulty feeding Failure to gain wt Passing out Poor development Squatting during episodes of cyanosis The Peer Teaching Society is not liable for false or misleading information…

59 Signs and tests Chest Xray Complete blood count ECHO MRI (usually after surgery) Treatment Surgery to repair tetralogy of Fallot is done when the infant is very young Outcome – 90% survive to adulthood and live an active, healthy and productive life Do have to have regular cardiology appointments The Peer Teaching Society is not liable for false or misleading information…

60 Problem solving time 50 year old man presents with “crushing chest pain”, he was rushed in to AandE from the local Barnsley vs Owls, smoker for 35 years, the chest pain radiates to his jaw. He feels sweaty, nauseous and vomited. The Peer Teaching Society is not liable for false or misleading information…

61 a)MI b)Angina c)Tetralogy of Fallot d)Right heart failure e)Football fever The Peer Teaching Society is not liable for false or misleading information…

62 80 year old retired postman complains of severe onset central chest pain which comes on when he is walking his cat Jess. He sometimes gets it when sitting reading the sports section of the Barnsley Chronicle. Any ideas? The Peer Teaching Society is not liable for false or misleading information…

63 a)MI b)Unstable Angina pectoralis c)Palpitations d)Intermittent claudication e)Stable angina pectoralis The Peer Teaching Society is not liable for false or misleading information…

64 A 50 year old lady diabetic (type 2) complains of pain when walking in her calves and is relieved by rest. She used to smoke until 2 years ago and is a telesales rep The Peer Teaching Society is not liable for false or misleading information…

65 a)Cramp b)Intermittent Claudication c)DVT (deep vein thrombosis) d)Pulled a muscle e)Been stabbed in the leg in the past The Peer Teaching Society is not liable for false or misleading information…

66 Thank you for your attention


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