nLk1LNSICN

1. Def|ne hypertens|on and |earn the targets for b|ood pressure contro|

nypertens|on ls a chronlc medlcal condlLlon ln whlch Lhe blood pressure ls elevaLed > 140]90
lL ls classlfled as elLher:
LSSLN1IAL 9S
1hls ls prlmary hyperLenslon whlch ls when no medlcal cause ls found.
SLCCNDAk
1hls ls hyperLenslon LhaL ls caused as a resulL of anoLher condlLlon.

2. Descr|be symptoms and s|gns of hypertens|on
Symptoms
- usually asympLomaLlc
- headaches
- eplsLaxls
- sweaLlng

S|gns
- elevaLed 8

3. Learn secondary causes of hypertens|on

4. Learn about the assoc|ated card|ovascu|ar r|sk factors that shou|d be |ooked for |n pat|ents
w|th hypertens|on

PyperLenslon ls a rlsk facLor for developlng a cardlovascular dlsease such as Ml/SLroke and also
kldney damage. 1he more chronlc lL ls Lhe more damage Lhere ls Lo Lhe arLerles, Lhe more pressure
Lhere ls on Lhe hearL.

LIILS1LL kISk IAC1CkS:
Smoklng
CbeslLy
Alcohol
unhealLhy dleL
LlLLle exerclse

1kLA1A8LL kISk IAC1CkS:
8
CholesLerol
ulabeLes
kldney dlsease

IAMILIAL:
Male
SLrong famlly hlsLory
Age
LLhnlc group (Aslans)
Larly menopause

S. Descr|be the re|evant |nvest|gat|ons to |ook for causes and comp||cat|ons of hypertens|on


6. D|scuss the non pharmaco|og|ca| treatment

LCSL WLlCP1
uC LxL8ClSL
LA1 PLAL1P?
8LuuCL SAL1 ln1AkL
S1C u8lnklnC
S1C SMCklnC!!!!!

7. L|st 6 c|asses of drugs that can be used to contro| b|ood pressure
















lf paLlenL ls >33yrs C8 8lack lf paLlenL ls <33yrs
A C or D
S1L 1
S1L 2 A + C or C + D
A + C + D S1L 3
S1L 4 Add
lurLher DIUkL1IC
Cr
ALnA 8LCCkLk
Cr
8L1A 8LCCkLk

A = ACL]Ak8
C = Ca|c|um channe| b|ocker
D = D|uret|c
ACL INnI8I1CkS e.g. kam|pr||, Captopr||
8locks Lhe converslon of angloLensln 1 lnLo angloLensln 2 whlch ls a poLenL vasoconsLrlcLor.
S/L PypoLenslon
ury cough

ANGIC1LNSIN II kLCL1Ck AN1AGCNIS1 e.g. Losartan
8locks Lhe recepLor for angloLensln ll
S/L noL slgnlflcanL

CALCIUM CnANNLL 8LCCkLkS e.g. Am|od|p|ne, n|fed|p|ne
Causes arLerlole dllaLaLlon and reduces Lhe force of hearL conLracLlons
S/L Peadaches
SweaLlng
alplLaLlons
llushlng

DIUkL1ICS e.g. 1h|az|des
lncreases waLer secreLlon from Lhe body by noL absorblng na Lherefore na remalns lnL he
fllLraLe and waLer follows
S/L lncreases cholesLerol levels
lmpalred glucose Lolerance

8L1A 8LCCkLkS e.g. Ateno|o|
8locks Lhe sympaLheLlc nervous sysLem Lo Lhe hearL and rennln angloLensln sysLem
S/L 8radycardla
bronchospasm

ALnA 8LCCkLkS e.g. razos|n
Blocks u1 receptors leading to vasodilatation
S/L PypoLenslon

8. Learn the def|n|t|on of acce|erated hypertens|on
Ma||gnant hypertens|on ls a compllcaLlon of hyperLenslon characLerlzed by very elevaLed blood
pressure LhaL occurs rapldly, and organ damage ln Lhe eyes, braln, hearL and/or kldneys.
1he eyes may show papllloedema, reLlnal haemorrhage, or exudaLes
1he braln shows manlfesLaLlons of lncreased lnLracranlal pressure, such as headache,
vomlLlng, subarachnold, and cerebral haemorrhage
aLlenLs wlll usually suffer from lefL venLrlcular dysfuncLlon
1he kldneys wlll be affecLed, resulLlng ln haemaLurla, proLelnurla, and acuLe renal fallure.
SysLollc and dlasLollc blood pressures are usually greaLer Lhan 220mmPg and 120mmPg, respecLlvely.
9. D|scuss the pr|nc|p|e of emergency b|ood pressure contro| |n hypertens|on.
Should noL brlng down Lhe 8 Loo qulckly as Lhere ls a rlsk of cerebral, reLlnal, renal Ml
IV Sod|um n|tropruss|de
IV |abeta|o|




ANGINA

1. Descr|be symptoms and s|gns of ang|na
Ang|na: radlaLlng chesL paln caused by lnsufflclenL blood flow Lo an area of Lhe hearL.
1here are Lwo Lypes:
S1A8LL: occurs upon exerLlon and fades wlLh resL
unS1A8LL: occurs suddenly and sponLaneously wlLh no exerLlon
Symptoms
- 1|ght, du|| heavy chest d|scomfort
- 8eLrosLernal or radlaLlng Lo Lhe lefL arm, neck, back or [aw
- 8reaLhlessness
- nausea
- LplgasLrlc dlscomforL LhaL ls noL relleved wlLh anLaclds
S|gns
- usually none!
- PypercholesLerolaemla (xanLhalasma, corneal arcus)
- Anaemla (pallor, Lachy)
- 1hyroLoxlcosls (caroLld brulLs)
- PyperLenslon

2. Learn about d|fferent|a| d|agnos|s for retrosterna| chest pa|n
!"#$% '( - aln would lasL longer Lhan 3mln and would noL be relleved by resL
!"#$% )%*+",*-+$+. - Lends Lo be more consLanL paln LhaL ls aggravaLed wlLh lnsplraLlon, lyolng flaL
and movlng
/012 - ofLen a burnlng paln LhaL ls more common afLer eaLlng and lylng down plus relleved wlLh
anLaclds/l
34%#564+, - pleurlLlc chesL paln (sharp paln on lnsplraLlon) also purulenL spuLum
37 - haemopLysls
!6*$+" -+..%"$+64 - more consLanL paln
/,88.$64%. - may cause acuLe cholecysLlLls buL paln ls noL relaLed Lo exerclse
'#."#86.9%8%$,8 - worse on movemenL and may have ln[ury Lo Lhe chesL/splne.

3. Descr|be the pathogenes|s of atheroma and exp|a|n how th|s |eads to ang|na

4. Learn about r|sk factors for deve|opment atheroma and out||ne how each shou|d be
contro||ed |n a pat|ent w|th ang|na
MLn
SMCklnC - sLop smoklng
ALCCPCL - sLop drlnklng
PlCP CPCLLS1L8CL - reduced faLLy lnLake, sLaLlns
C8LSl1? - lose welghL and exerclse
ulA8L1LS - conLrol blood sugar
P?L81LnSlCn - reduce salL lnLake/ anLlhyperLenslve meds

S. Descr|be |nvest|gat|ons that can be used to conf|rm the d|agnos|s of ang|na
a) PlS1C8?
b) LCC
c) LxL8ClSL LCC
d) M?CCA8ulAL L8luSlCn SCAnS - wlll show areas of Lhe hearL LhaL ls noL geLLlng perfused
e) C1 CC8CnC8? AnClC8AM - excellenL ln dlagnoslsg coronary arLery dlsease

6. L|st 4 c|asses of drugs used to contro| ang|na

S?M1CMA1lC G1N spray (powerful vasodllaLor)
LCnC 1L8M
8L1A 8LCCkLkS e.g. Ateno|o|
8locks Lhe sympaLheLlc nervous sysLem Lo Lhe hearL Lhus reduclng exclLablllLy and hearL raLe
and force of conLracLlons
S/L 8radycardla
bronchospasm

LCNG AC1ING NI1kA1LS e.g. Isorsorb|de monon|trate
8elaxes coronary arLerles Lo lncrease blood flow Lo Lhe hearL
S/L Peadaches
1lredness
Sleep and guL dlsLurbances

CALCIUM CnANNLL 8LCCkLkS e.g. Am|od|p|ne, n|fed|p|ne
Causes arLerlole dllaLaLlon and reduces Lhe force of hearL conLracLlons
S/L Peadaches
SweaLlng
alplLaLlons
llushlng

k+ CnANNLL AC1IVA1CkS e.g. N|corand||
ArLerlole and venous vasodllaLor
S/L flushlng
ulcers
vomlLlng

7. Lxp|a|n to a pat|ent how to take a sub||ngua| G1N spray |n the event of chest pa|n

S1C whaL Lhey are dolng and resL

use G1N as lnsLrucLed spray 1-2 sprays under Lhe Longue and close

1ake a 2
nd
dose of G1N lf paln has noL eased afLer 3ml[

1ake a 3
rd
dose of G1N lf paln has noL eased afLer anoLher 3mln

Ca|| 999 for an ambulance lf paln has noL eased afLer anoLher 3mln (13mln) or lf you are feellng
unwell or Lhe paln ls worse.

8. G|ve |nd|cat|ons for referra| of a pat|ent w|th ang|na to a spec|a||st card|o|ogy serv|ce
All paLlenLs should be referred for an exerclse LCC wlLhouL delay. aLlenLs wlLh a severe coronary
arLery dlsease are aL a hlgh rlsk of Ml whlch could be faLal Lhus refer Lo a rapld access chesL paln
cllnlc sLralghLaway.

Immed|ate hosp|ta| referra| |f:
- aln aL resL
- aln on mlnlmal exerLlon
- Anglna LhaL ls geLLlng worse desplLe LreaLmenL

Lar|y referra| to a card|o|og|st:
- revlous Ml/CA8C/1CA presenLlng wlLh anglna
- LCC showlng abnormallLles/prevlous Ml
- new Al
- PearL fallure + anglna
- AorLlc sLenosls
- PyperLrophlc cardlomyopaLhy

9. Descr|be measures that shou|d be undertaken to prevent |nfarct|on and to |mprove
funct|on |n a pat|ent.

ASIkIN S1A1INS ACL INnI8I1CkS

10. Def|ne unstab|e ang|na and the r|sk of progress|on to MI

Acute coronary syndrome lncludes unsLable anglna, nS1LMl and S1LMl.
Unstab|e ang|na ls caused by an unsLable plaque LhaL can rupLure and leak lLs conLenLs Lo form cloLs
whlch may embollze ln Lhe hearL or braln = sLroke/Ml.

8lsk of Ml ln Lhe flrsL monLh ls 30

11. Descr|be s|gns and symptoms of unstab|e ang|na
Symptoms:
1) Cccurs aL resL
2) Severe and new onseL
3) Crescendo paLLern (more severe & prolonged)

S|gns:
1) PearL sound
2) 8asal crackles
3) PypoLenslon
4) Murmurs

12. L|st |nvest|gat|ons for unstab|e ang|na
LCC: May be normal or show S1 depresslon or 1
wave lnverslon
8lCCPLMlCAL MA8kL8S: 1o assess rlsk of Ml

13. Descr|be the management of unstab|e
ang|na
lf paln perslsLs Lhen refer Lo cardlology Leam for urgenL anglography +/- angloplasLy/CA8C
14. Descr|be the process of coronary ang|ography, ang|op|asty and stent|ng to a pat|ent

Coronary ang|ography: x-ray examlnaLlon
of Lhe coronary vessels Lo see narrowlng
uslng conLrasL dye.
a. Cral/lv sedaLlve glven Lo relax
paLlenL
b. Skln around femoral arLery numbed
and needle lnserLed
c. CaLheLer goes along femoral arLery
and gulded up Lo Lhe coronary
arLerles
d. uye ln[ecLed lnLo each of Lhe ma[or
arLerles Lo see blood flow and plcs
Laken
e. CaLheLer removed, pressure applled
on Lhe femoral arLery and paLlenL
dlscharged.


Coronary ang|op|asty (1CA): dllaLlng Lhe coronary arLerles wlLh a balloon and Lhen placlng a sLenL.
a. Cral/lv sedaLlve glven Lo relax paLlenL
b. Skln around femoral arLery numbed and needle lnserLed
c. CaLheLer goes along femoral arLery and gulded up Lo Lhe
coronary arLerles
d. uye ln[ecLed lnLo each of Lhe ma[or arLerles Lo see blood
flow and plcs Laken
e. A balloon Lype caLheLer ls Lhen lnserLed and
lnflaLed/deflaLed aL Lhe slLe of Lhe blockage (heparln ls
glven Lo reduce cloLs)
f. 1he balloon has a sLenL around lL so LhaL when Lhe balloon
ls lnflaLed, Lhe sLenL also lnflaLes and meshes lnLo place
g. CaLheLer removed, pressure applled on Lhe femoral arLery.


1S. L|st comp||cat|ons of these procedures and d|scuss the|r prevent|on and management

16. D|scuss |nd|cat|ons for CA8G
When Lhere are |onger, ca|c|f|ed leslons ln tortuous vesse|s or lnvolvlng ma[or b|furcat|ons and
chron|c occ|us|ons.

17. Descr|be some deta||s about the process of putt|ng a pat|ent onto card|opu|monary bypass
Card|opu|monary bypass: ls a Lechnlque LhaL Lemporarlly Lakes over Lhe funcLlon of Lhe hearL and
lungs durlng surgery malnLalnlng clrculaLlon of blood and Lhe oxygen conLenL of Lhe body.

1) Cannula ls lnserLed lnLo 8A Lo draln venous reLurn
2) venous blood passes lnLo venous reservolr under gravlLy
3) CxygenaLed and Lhen CC2 removed and heaL exchanger conLrols LemperaLure
4) ArLerlal pump reLurns blood lnLo aorLa. ArLerlal fllLer removes any bubbles
3) SucLlon used Lo remove blood from Lhe operaLlng fleld (paLlenL)
6) 8eLurned Lo paLlenL vla cardloLomy reservolr.

18. Learn comp||cat|ons of card|opu|monary bypass
rolonged bypass lnduces cyLoklne acLlvaLlon and an lnflammaLory response whlch resulLs ln...
- 1hrombocyLopenla
- CloLLlng abnormallLles
- uecreased pulmonary gas exchange
- Cerebrovascular accldenLs
- Alr embollsm
-
19. uescrlbe Lhe process of CA8C and Lhe rlsk of compllcaLlons Lo a
paLlenL
a. aLlenL anaesLheLlsed
b. LndoLracheal Lube ls lnserLed and secured and mechanlcal
venLllaLlon sLarLed
2
6
3
4
3
1
c. 1he chesL ls opened vla a medlan sLernocoLomy and Lhe hearL ls examlned by Lhe surgeon
d. 1he bypass grafLs are harvesLed (lnLernal Lhoraclc, radlal, saphenous velns, lnLernal
mammary arLery). When harvesLlng ls done, Lhe paLlenL ls glven heparln Lo prevenL Lhe
blood from cloLLlng
e. 1he cardlopulmonary bypass pump ls Lurned on and Lhe surgeon Lhen suLures Lhe cannula
lnLo Lhe hearL and lnsLrucLs Lhe perfuslonlsL Lo sLarL Lhe bypass. Cnce Lhe bypass ls
esLabllshed Lhe surgeon places Lhe aorLlc cross clamp across Lhe aorLa and lnsLrucLs Lhe
asslsLanL Lo dellver cardloplegla Lo sLop Lhe hearL.
f. Cne end of each grafL ls sewn onLo Lhe coronary arLerles beyond Lhe blockages and Lhe
oLher end ls aLLached Lo Lhe aorLa
g. 1he hearL ls resLarLed
h. roLamlne ls glven Lo reverse Lhe effecLs of heparln
l. 1he sLernum ls wlred LogeLher and Lhe lnclslons are suLured closed
[. 1he paLlenL ls moved Lo lCu





































ACU1L CCkCNCk SNDkCML]MI

1. Descr|be the coronary c|rcu|at|on and exp|a|n wh|ch vesse|s supp|y wh|ch myocard|a|
reg|ons

2. Lxp|a|n how an LCG can be sue to determ|ne the s|te of MI and |nd|cate wh|ch vesse| |s
occ|uded
aLrlal depolarlsaLlon
kS venLrlcular depolarlsaLlon
1 venLrlcular repolarlsaLlon

k |nterva| Llme Laken for lmpulse Lo pass from SA
Lo Av node.








8lghL posLerlor
descendlng arLery
Marglnal arLery
3. Descr|be the evo|ut|on of LCG changes fo||ow|ng an MI



AfLer Lhe flrsL few mlnuLes, Lhe 1 waves become Lall, polnLed and uprlghL and Lhere ls S1 segmenL
elevaLlon. AfLer Lhe flrsL few hours, Lhe 1 waves lnverL, Lhe 8 wave volLage ls decreased and C waves
form. AfLer a few days, Lhe S1 segmenL reLurns Lo normal. AfLer weeks/monLhs, Lhe 1 wave may
reLurn uprlghL buL C waves remaln.

4. Descr|be the changes |n card|ac enzymes |nc|ud|ng 1rop 1 and creat|n|ne k|nase
Cardlac markers are LesLs used Lo evaluaLe hearL funcLlon. 1hey lnclude Lhe followlng ln order of
senslLlvlLy:

1kCCNINS: 1hese are proLelns LhaL lnvolved ln muscle conLracLlons ln boLh cardlac and skeleLal
muscle. 1here are Lhree forms, Lrop 1, l and C.
uurlng Ml, Lhe Lroponlns are released by Lhe myocyLes due Lo degradaLlon of acLln and myosln.
Wldely used as Lhey are more speclflc Lo heaL ln[ury and remaln elevaLed for a longer perlod of Llme.

Ck-M8: Lhls ls an enzyme LhaL ls found ln Lhe cyLosol and Lhere are dlfferenL proporLlons secreLed by
cardlac and skeleLal muscle.
Card|ac musc|e has CkM8: CkMM of 30:70
Ske|eta| musc|e has CkM8: CkMM 1:99
Pence CkM8 ls a good marker of Ml.

S. L|st comp||cat|ons of MI
neart fa||ure
Myocard|a| rupture
VSD - due Lo lnfarcL ln sepLum
M|tra| regurg|tat|on - Ml of lnferlor wall, due Lo lnfarcL of pappllary muscle
Card|ac arrhythm|as- Ml of anLerlor wall
Conduct|on d|sturbances - Ml of lnferlor wall presenLs as hearL block

6. Descr|be s|gns and symptoms of MI comp||cat|ons
A88P?1PMlAS:
V1 - lv beLablockers, lldocalne or amladerone...deflbrlllaLe
VI - deflbrlllaLe
AI - bblockers and dlgoxln
8radyarrythm|a - lv aLroplne

CA8ulAC lAlLu8L:
Crackles ln Lhe lungs, 3
rd
hearL sound, cardlogenlc shock
lv frusemlde +/- C1n
C2 Lherapy
ACL lnhlblLors lf 8 ls ok

7. Descr|be the ro|e of rehab|||tat|on |n recovery from MI
Clve paLlenLs adequate |nformat|on abouL Lhe condlLlon before Lhey leave Lhe hosplLal. Lncourage
Lhem Lo eaL a Med|terranean sty|e d|et. 1ell Lhem Lo stop smok|ng, start exerc|s|ng, |ose we|ght,
and contro| the|r 8 and b|ood sugar.

8. L|st drugs needed to |mprove prognos|s fo||ow|ng an MI

ASIkIN 8L1A 8LCCkLk ACL INnI8I1Ck S1A1IN
CLCIDCGkLL (1yr)

9. Descr|be s|gns and symptoms of an acute MI
Symptoms:
CnLS1 AIN!!!
CharacLerlsLlc cenLral, eplgasLrlc chesL paln radlaLlng Lo Lhe arms, shoulders, neck and [aw.
SweaLlng
nausea/vomlLlng
uyspnoea
laLlgue
alplLaLlons

S|gns:
Low grade fever
ale
Clammy skln
3
rd
/4
Lh
hearL sound
Slgns of hearL fallure

10. Descr|be the pathogenes|s of an acute MI
Whlch can Lhen embollze and block of blood supply compleLely (S1LMl) or parLlally occludlng Lhe
blood vessel Lo decrease Llssue perfuslon (nS1LMl)

11. Descr|be the emergency |nvest|gat|ons to d|agnose an MI
LCG
CAkDIAC MAkkLkS
I8C, U&L, GLUCCSL, LIIDS
Ckk

A normal LCC does noL exclude ACS

12. Descr|be the cr|ter|a for the d|agnos|s of an MI
Increase |n b|ochem|ca| markers + elLher......
lschaemlc sympLoms
LCC changes.

1here are Lwo baslc Lypes of acuLe Ml's
1) 1kANSMUkAL: lnvolves Lhe whole Lhlckness of Lhe hearL wall. 1he underlylng leslon ls an
arLheromaLous plaque LhaL has rupLured and produces a Lhrombus (occluslve). usually a
large coronary arLery ls blocked/reglonal lnfarcL.
2) SU8LNDCCAkDIAL: conflned Lo Lhe lnner Lhlrd or half of Lhe myocardlum. 8esulLs from
generallsed under perfuslon of Lhe myocardlum

Cllnlcally Ml ld furLher subclasslfled lnLo
S1 e|evat|on (occluslve)
S1 depress|on (suboccluslve)

As Lhe LreaLmenL dlffers for boLh.

13. Descr|be the |mmed|ate management of a pat|ent w|th MI
Morph|ne - oplaLe relleves paln (S]L consLlpaLlon, addlcLlon)
Cxygen - nasal Cannula
N|trate - vasodllaLor (S]L hypoLenLlon, headaches)
Asp|r|n - lnhlblLs producLlon of Lhromboxane whlch ls needed for plaLeleL aggregaLlon (S]L ulcers)

14. Learn about the pros and cons on the use of CI versus thrombo|ys|s
rlmary percuLaneous coronary lnLervenLlon ls Lhe reperfuslon Lherapy of cholce lf lL can be
dellvered wlLhln 90mln of Lhe paLlenL presenLlng Lo hosplLal.

lf Lhese condlLlons can noL be meL, LhrombolyLlc Lherapy eg tenectap|ase should be admlnlsLered lf
Lhere are no conLralndlcaLlons.

S1kL1CkINASL - acLlvaLes plasmln Lo plasmlnogen whlch breaks down cloLs
S]L do noL repeaL dose as body forms anLlbodles agalnsL lL.

1S. Def|ne "arr|va| to LCG" and "door to need|e" t|mes

"Arr|va| to LCG": havlng an LCC done wlLhln 10mln on arrlval Lo emergency deparLmenL whlch
reduces Lhe Llme Lo ldenLlfy S1LMl Lherefore 'Llme ls muscle'

"Door to need|e": paLlenLs havlng an Ml should recelve LhrombolyLlc drugs wlLhln 30mln of reachlng
hosplLal.




















Akkn1nMIAS AND CCNDUC1ICN DLILC1S

1. Descr|be norma| card|ac conduct|on and how |t re|ates to LCG waveform
1he SAn and Avn are made from auLo arrhyLhmlc flbres LhaL
are small elongaLed self exclLable flbres. 1hey are able Lo
sponLaneously depolarlse by Lhemselves Lherefore seLLlng
Lhelr own pacemaker poLenLlal.

a. 1he SAn ls locaLed lnferlor Lo Lhe superlor vena cava.
lL seLs off Lhe maln hearL rhyLhm - slnus rhyLhm aL
around 73 lmpulses per mlnuLe. 1he lmpulse Lhen
Lravels Lhrough Lhe walls of boLh aLrlums, maklng
Lhem conLracL and reach Lhe Avn. 1hls Lakes
approxlmaLely 60ms.
b. AL Lhe Avn Lhe lmpulse ls delayed by 60ms Lo allow
Lhe aLrla Lo fully conLracL. 8oLh aLrla's are able Lo
conLracL synchronously as Lhey are connecLed by
lnLercalaLed dlscs mechanlcally and gap [uncLlons
elecLrlcally, Lo allow lons Lo pass Lhrough so LhaL
depolarlsaLlon of all cells can happen aL Lhe same Llme...funcLlonal syncyLlum.
c. 1he Avn Lhen seLs off lLs own lmpulse LhaL Lravels Lo Lhe bundle of Pls locaLed ln Lhe
aLrlovenLrlcular sepLum and Lhen follows Lhrough Lo Lhe rlghL and lefL bundle branches ln
Lhe lnLervenLrlcular sepLum causlng Lhe venLrlcles Lo conLracL
d. 1he lmpulses Lhen reach Lhe purken[e flbres aL Lhe apex of Lhe hearL and runs along Lhe
ouLer wall of Lhe hearL Lo compleLe Lhe conLracLlon of Lhe venLrlcles.

2. 8e ab|e to d|agnose and d|st|ngu|sh between the fo||ow|ng:

88Au?CA8ulA.......

A88P?1PMlA LCC cause S&S

PearL block
1
sL
degree






rolonged -8 lnLerval >0.22s

AcuLe lnfecLlon
MyocardlLls
Ca blocker/b
blocker/dlgoxln

asympLomaLlc
2
nd
degree
Lype 1
MoblLz/Wank'







rogresslve -8 lnLerval elongaLlon unLll a wave
falls Lo conducL aL all.
1hls would show LhaL Lhere ls a problem wlLh Lhe A-
v node

LlghL
headedness
ulzzlness
syncope
2
nd
degree
Lype 2








no -8 wave elongaLlon buL wave falls Lo conducL
Lo C8S someLlmes aL a raLe of 3:1
3
rd
degree
1here ls no relaLlon beLween Lhe C8S and wave
l.e. Lhere ls no conducLlon Lo Lhe venLrlcles from Lhe
aLrla.
lf C8S ls narrow = 8undle of Pls Lakes over
lf C8S ls wlde = purkln[e Lakes over

Coronary
lschaemla
SLL
urug lnduced
endocardlLls


8undle
branch block

(when Lhe
lmpulses are
blocked ln
elLher r/l
bundle
branches)
8888



8lghL venLrlcular depolarlzaLlon ls delayed due Lo
8888 Lhus Lhe lefL branch acLlvaLes Lv and Lhen 8v.
So Lhls comes up as Lwo separaLe waves slnce Lhe
venLrlcles are belng depolarlsed separaLely - 2 C8S
complexes!
M wave ln v1 as Lhe Lv depolarlses flrsL and Lhen
8v.
W wave ln v6, lead 1 as venLrlcular repolarlsaLlon ls
delayed, Lhere ls a wlde and deep S wave

ASu
L
Cor pulmonale

L888
LefL venLrlcular depolarlsaLlon ls delayed due Lo
L888 Lhus Lhe rlghL branch acLlve 8v and Lhe Lv.
W wave ln v1
M wave ln v6

AorLlc sLenosls
lschaemlc
dlsease


lnvLS1lCA1lCnS:
1) AmbulaLory holLer monlLorlng
2) Lcho
3) Lxerclse LCC

MAnACLMLn1:
lf asympLomaLlc and raLe > 40bpm = nC 18LA1MLn1
lf raLe <40bpm or paLlenL sympLomaLlc:
1) A18ClnL
2) 1LMC8A8? AClnC Wl8L



1ACP?CA8ulA

A88P?1PMlA LCC cause S&S
Supraventr|u|ar
1achycard|a
ALrlal
lluLLer




8hyLhm ls sLlll regular (lnLerval beLween C8S
complexes) buL Lhere are waves aL a raLe of
>230/mln. 1here ls no flaL basellne beLween
waves
8e enLranL
rhyLhm
CAu
PyperLenslon
cardlomyopaLhy

palplLaLlons
ALrlal
flbrlllaLlon




AbsenL waves and lncreased and lrregular hearL
raLe
PyperLhyroldlsm
lschaemlc hearL
dlsease
valvular
problems

alplLaLlons
ChesL paln
ulzzy
SC8

Ventr|cu|ar 1achycard|a




> 3 consecuLlve venLrlcular beaLs ln all leads and
C8S complexes are broad.

lschaemla
CardlomyopaLhy
hyperLenslon
Severe
hypoLenslon

Ventr|cu|ar f|br|||at|on




1here ls no C8S complex and LCC ls dlsorganlsed
Cardlac arresL
Loss of
consclousness

lnvLS1lCA1lCnS & MAnACLMLn1 of ALrlal lluLLer and ALrlal llbrlllaLlon

1) 8loods Lo check renal and Lhyrold funcLlon
2) ChesL x-ray Lo check for ay hearL or lung abnormallLles
3) MalnLaln slnus rhyLhm:
a. uC Cardloverslon
b. AnLl arrhyLhmlc drugs e.g. AMluA8CnL
4) 8educe hearL raLe:
a. ullLlazam
b. verapll
c. MeLoprolol
3) revenL SLroke
a. Peparln
b. Warfarln
c. Asplrln

MAnACLMLn1 lC8 v1/vl

ueflbrlllaLe!!!
Amladarone/lldocalne Lo prevenL relapse.


3. L|st card|o|og|ca| causes of co||apse
Syncope ls a LranslenL loss of consclousness due Lo lnadequaLe cerebral flow. 1he causes can elLher
be:
VASCULAk
l. Vasovaga| (neurocard|ogen|c) : slmple falnL due Lo lncrease vagus nerve acLlvlLy
whlch causes a decrease ln hearL raLe and conLracLlons and lncreased perlpheral
dllaLaLlon Lherefore an lncrease ln parasympaLheLlc acLlvlLy buL decrease ln
sympaLheLlc acLlvlLy.
ll. ostura| hypotens|on: drop of 8 by 20mgP when movlng from a slLLlng/lylng Lo
a sLandlng poslLlon. Can be due Lo dlureLlcs or dehydraLlon
lll. Carot|d s|nus syncope: occurs when Lhere ls an exaggeraLed vagal response Lo
caroLld slnus sLlmulaLlon provoked by wearlng a LlghL collar, looklng upwards or
Lurnlng Lhe head

C8S1kUC1IVL
I. Aort|c stenos|s
II. u|monary stenos|s
III. L
All cause syncope due Lo decreased blood flow from Lhe hearL Lo Lhe resL of Lhe
clrculaLlon

Akkn1nMIAS
l. Stokes Adams attack: Lhe aLLacks are caused by a loss of cardlac ouLpuL due Lo
cadlac aysLole, hearL block or vl resulLlng ln lack of blood flow Lo Lhe braln -
falnL. ale....falnLs.....wakes up.....flushed.

4. Cut||ne treatment and management

CpLlons for Lhe long Lerm managemenL of cardlac LachyarrhyLhmlas lnclude:
AnLlarrhyLmlc drugs
AblaLlon Lherapy
uevlce Lherapy

Catheter ab|at|on: ls an lnvaslve procedure used Lo remove a faulLy elecLrlcal paLhway from Lhe
hearLs of Lhose who are prone Lo developlng cardlac arrhyLhmlas such as AI, atr|a| f|utter, SV1.
lL lnvolves advanclng several flexlble caLheLers lnLo Lhe paLlenLs blood vessels LhaL are Lhen
advanced Lowards Lhe hearL and hlgh frequency elecLrlcal lmpulses are used Lo lnduce Lhe
arrhyLhmla and Lhen ablaLe (desLroy) Lhe abnormal Llssue LhaL ls causlng Lhe arrhyLhmla.
CompllcaLlons lnclude b|ood c|ots, stroke and per|card|a| haemorrhage.

Imp|antab|e Card|overter def|br|||ator (ICD): ls a small baLLery powered elecLrlcal lmpulse generaLor
whlch ls lmplanLed ln paLlenLs who are aL rlsk of sudden cardlac deaLh due Lo VI]V1. 1he devlce ls
programmed Lo deLecL cardlac arrhyLhmlas and correcL lL by dellverlng a [olL of elecLrlclLy.








CAkDIAC IAILUkL]ULMCNAk CLDLMA

1. Descr|be the s|gns and symptoms of |eft, r|ght and b| ventr|cu|ar card|ac fa||ure
SympLoms:
- DSNCLA
- Ck1nCNCLA
- IA1IGUL

Slgns:
- CAkDICMLGAL
- 3
kD
, 4
1n
nLAk1 SCUNDS
- IV
- 1ACn]nC1LNSICN
- 8I 8ASAL CkACkLLS
- ASCI1LS
- LLUkAL LIIUSICN
- ANkLL CLDLMA
- nLA1CMLGAL

1here are 4 classes of cardlac fallure:
l. no sympLom
ll. SympLoms on exerLlon
lll. SympLoms on mlnlmal exerLlon
lv. SympLoms aL resL

2. Learn about the d|fferent|a| d|agnos|s for breath|essness

LUNGS AsLhma, CCu, lung cancer, sarcoldosls
nLAk1 aorLlc dlssecLlon, cardlomyopaLhy, hearL fallure, L
nALMA1CLCG Anaemla, hypoLhyroldlsm, sepsls, anxleLy blah blah blah

3. L|st causes of |eft, r|ght and b|ventr|cu|ar heart fa||ure

LLI1 Commonly InD buL can also occur wlLh va|vu|ar heart d|sease & hypertens|on.
kIGn1 LefL slded hearL fallure may lead Lo rlghL slded hearL fallure. Causes lnclude r|ght
ventr|cu|ar card|omyopathy, r|ght ventr|cu|ar |nfarct|on, and pu|monary hypertens|on.
8C1n elderly hyperLenslve paLlenLs

Ma|n causes:
InD
CAkDICMCA1n
nLk1LNSICN

4. Descr|be the |nvest|gat|ons that can be used o conf|rm d|agnos|s

8LCCD 1LS1S - lull blood counL
CnLS1 k-kA - Cardlomegaly (cardloLhoraclc raLlo>30), pulmonary congesLlon, pulmonary
oedema, kurley 8 llnes
LCG - for lschaemla, hyperLenslon or arrhyLhmla/hyperLrophy
LCnC - sysLollc and dlasLollc funcLlon and cardlac chamber dlmenslon.

S. Def|ne card|ac output and how th|s |s measured

Cardlac ouLpuL = sLroke volume x hearL raLe
3l = 70ml x 70bpm

Cardlac ouLpuL ls Lhe amounL of blood pumped from Lhe hearL Lo Lhe resL of Lhe body ln one mlnuLe
and ls approxlmaLely 3 llLres. lL ls calculaLed by measurlng Lhe sLroke volume (volume of blood
pumped ouL per conLracLlon) and hearL raLe (number of hearL conLracLlons per mlnuLe)

6. Draw and exp|a|n the star||ng curve descr|b|ng the re|at|on between card|ac f||||ng and
card|ac output
lrank SLarllng low sLaLes LhaL Lhe greaLer Lhe Lnd dlasLollc volume (Luv), Lhe greaLer Lhe Sv.



CC



Luv

7. Lxp|a|n pre|oad, after |oad and card|ac contract|b|||ty
kLLCAD: 1hls ls Lhe amounL of sLreLch Lhe venLrlcles experlence durlng dlasLole preparlng for
sysLole. reload ls always proporLlonal Lo Luv, so lf Luv lncreases, so does preload Lo make
conLracLlons as sLrong as posslble Lo expel Lhe remalnlng fluld. 1hus lf preload lncreases, sLroke
volume lncreases and cardlac ouLpuL lncreases.

AI1LkLCAD: Lhls ls Lhe pressure LhaL Lhe venLrlcles need Lo overcome ln order Lo conLracL. Meanlng
Lhe pressure ln Lhe venLrlcles has Lo be hlgher Lhan Lhe pressure ln Lhe aorLa ln order for Lhe blood
Lo be e[ecLed and for Lhe valves Lo open. lf Lhe afLer load lncreases, Lhe sLroke volume decreases as
Lhere ls a shorLer duraLlon of conLracLlon whlch reduces cardlac ouLpuL. 1hls happens when Lhe
elasLlclLy/compllance of Lhe aorLa decreases such as ln hyperLenslon and aLherosclerosls.

CAkDIAC CCN1kAC1I8ILI1: SubsLances LhaL lncrease conLracLlblllLy are called poslLlve lonoLropes
such as adrenallne, noradrenallne. SubsLances LhaL decrease conLracLlblllLy are called negaLlve
lonoLropes such as calclum channel blockers and poLasslum channel acLlvaLors.

8. LlsL drugs whlch alLer Lhe followlng



9. D|scuss non pharmo|og|ca| treatments
ke vascu|ar|sat|on - angloplasLy +/- sLenLlng slnce ma[orlLy of hearL fallure ls cause by CAu
8|ventr|cu|ar pacemaker - advlsable for Lhose noL respondlng Lo Lherapy Lo lmprove symLoms
Card|ac transp|antat|on - LreaLmenL of cholce for young people

10. rognos|s
rognosls ls poor ln Lhose wlLh severe hearL fallure (breaLhless aL resL or on mlnlmal exerLlon) wlLh a
1 year survlval raLe of 30

11. atho|og|ca| process of heart fa||ure
When Lhe hearL falls, compensaLory mechanlsms aLLempL Lo malnLaln cardlac ouLpuL and perlpheral
perfuslon. Powever as Lhe hearL fallure progresses, Lhe mechanlsms are overwhelmed and become
paLhophyslologlcal

- Sympathet|c nervous system: hearL raLe and conLracLlllLy maklng Le hearL work more
and lncreaslng afLer load
- ken|n ang|otens|n system: Lhe falllng cardlac ouLpuL causes a decrease ln renal
perfuslon whlch acLlvaLes Lhe rennln angloLensln sysLem and lncreases salL and waLer
reLenLlon.
- Natr|uret|c pept|des: released from Lhe aLrla has dlureLlc and hypoLenslve properLles
whlch reduces pre/afLer load
- Ventr|cu|ar d||atat|on





























ACU1L CIkCULA1Ck IAILUkL

1. Descr|be how the fo||ow|ng can cause shock

SnCCk when Lhere ls |nsuff|c|ent blood flow Lo Llssues resulLlng ln hypox|a


2. Descr|be how c||n|ca| exam|nat|on can be used to d|st|ngu|sh between the causes of shock

8, a|e, C|ammy hands, 1achycard|a, 1achypnoea, Confus|on, Ur|ne output, Cap|||ary ref|||

3. Descr|be how centra| venous pressure |s measured and can be used to g|ve an |nd|cat|on of
shock

Centra| venous pressure: pressure of Lhe blood ln Lhe vena cava whlch ls = Lo rlghL aLrlum pressure
Can be measured uslng a centra| venous catheter whlch ls lnserLed lnLo a large veln
([ugular/subclavlan) whlch helps Lo calculaLe how much fluld Lhe person needs.

4. Learn to d|st|ngu|sh between bronch|a| and card|ac asthma
"Card|ac asthma" ls a Lerm used Lo descrlbe SC8 due Lo pulmonary oedema. 1he dlfference ls LhaL
people wlLh asLhma have SC8 due Lo narrowlng of Lhe alrways whereas cardlac asLhmaLlc paLlenLs
wake up ln Lhe nlghL wlLh SC8 (orLhopnoea) and have oLher sympLoms llke ankle oedema.

S. Descr|be how pat|ents |n shock shou|d be mon|tored
A vomlL/Lalklng/choklng
8 100 C
2
, 88, A8C's, chesL x-ray, saLs
C hearL raLe, LCC, 8, urlne ouLpuL

6. Lxp|a|n the pathophys|o|og|ca| consequences of shock

7. Descr|be the mechan|sm of act|on, p|ace |n therapy and ma[or S]L of the fo||ow|ng drugs.

ADkLNALINL: SLlmulaLe alpha & beLa adrenerglc recepLors. A low dose CC and vasoconsLrlcLlon.
S/L - Lxcesslve use = CC, ollgurla, perlpheral gangrene

NCkADkLNALINL: SLlmulaLes alpha adrenerglc recepLors causlng lncreased conLracLlllLy and
vasoconsLrlcLlon.
S/L - 8lsk of excesslve vasoconsLrlcLlon wlLh lmpalred organ perfuslon

DCAMINL (precursor of adrenallne): SLlmulaLes alpha and beLa and dopamlne recepLors Loo
lncrease CC by lncreaslng hearL raLe and conLracLlllLy and vasodllaLaLlon ln coronary clrculaLlon
S/L - vasoconsLrlcLlon ln hlgh doses

DC8U1AMINL: SLlmulaLes beLa 1 adrenerglc recepLors and decreases vascular reslsLance Lherefore
lncreases CC

















INILC1IVL LNDCCAkDI1IS

1. Descr|be how a pat|ent w|th |nfect|ve endocard|t|s may present

SympLoms of sysLemlc lnfecLlon ma|a|se, fever, n|ght sweats, we|ght |oss

2. Descr|be c||n|ca| s|gns that may present |n a pat|ent w|th |nfect|ve endocard|t|s

Va|ve destruct|on: leadlng Lo heart fa||ure and or new heart murmurs
Vascu|ar phenomena: due Lo embo||sat|on of vegetat|on and metastat|c abscess
formaLlon ln Lhe bra|n, sp|een and k|dney
Immune comp|ex: deposlLlon ln b|ood vesse|s produclng vasu||t|s and petech|a|
haemorrhage ln Lhe skln, under Lhe nalls (sp||nter haemorrhages) and ln Lhe reLlna (roth
spots), cuLaneous are called os|ers nodes and [aneway |es|ons and are uncommon
Immune comp|ex depos|t|on: ln Lhe [o|nts can cause arthra|g|a and ln Lhe klneys lL can
lead Lo g|omeru|onephr|t|s

3. G|ve a d|fferent|a| d|agnos|s for unexp|a|ned fever
lnlLC1lCnS
nLCLASMS e.g. lymphomas, leukaemla's
CCnnLC1lvL 1lSSuL ulSC8uL8S

4. L|st organ|sms that cause |nfect|ve endocard|t|s and exp|a|n how |nfect|on w|th each may
be acqu|red


Cn normal valves wlLh vlrulenL organlsms such as sLrep pneumonla or sLaph aureas

S. Descr|be the pathogenes|s of |nfect|ve endocard|t|s
LndocardlLls ls usually Lhe consequence of Lwo facLors:
1he presence of organlsm ln Lhe blood sLream
Abnormal cardlac endoLhellum faclllLaLlng Lhere adherence and growLh
8acLeraemla (presence of bacLerla ln Lhe blood) may occur due Lo paLlenL speclflc reasons such as
poor denLal hyglene, lv drug users eLc.

uamaged endocardlum promoLes plaLeleL and flbrln deposlLlon whlch allows organlsms Lo adhere
and grow leadlng Lo an lnfecLed vegeLaLlon.

valvular leslons may creaLe non lamlnar flow and [eL leslons from sepLal defecLs or paLenL ducLus
arLerlosus
AorLlc and mlLral valves are usually affecLed excepL lv drug users - Lrlcuspld!

CompllcaLlons:
Card|ac fa||ure (destruct|on of heart va|ve)
Lmbo||sm
G|omeru|onephr|t|s

6. Invest|gat|ons

1) 8LCCD CUL1UkLS - MuS1 beLaken before anLlbloLlcs are commenced, 3 dlfferenL slLes ln 24
hours and 3 seLs of LesLs (6 boLLles ln LoLal)
2) LCnC - 1o ldenLlfy vegeLaLlon and any valvular dysfuncLlon. Small vegeLaLlons may be
mlssed Lhus a Lransoesophageal echocardlogram ls essenLlal
3) SLkCLCGICAL 1LS1S - lf blood culLures are negaLlve and lf unusual organlsms are suspecLed
4) CnLS1 k-kA - Slgns of hearL fallure or emboll
3) LCG - may show Ml or conducLlon defecL
6) 8LCCD CCUN1 - W8C wlll be ralsed

7. now |s the d|agnos|s made
uukLS C8l1L8lA...........
Ma[or crlLerla
Mlnor crlLerla
- ulrecL evldence from hlsLology or culLure of vegeLaLlon
- 1wo ma[or crlLerla
- 1 ma[or, 3 mlnor
- 3 mlnor

8. D|scuss appropr|ate ant|b|ot|cs to treat organ|sm
Staph vancomyc|n
Strep gentamyc|n benzy|pen

Surgery Lo replace valve lf
Severe hearL fallure
lnfecLlon of prosLheLlc maLerlal
Worsenlng renal fallure
LxLenslve damage Lo valve







LkICAkDIAL DISLASL

1. Descr|be the character|st|cs of pa|n caused by per|card|a|
|nf|ammat|on
Sharp cenLral chest pa|n whlch ls exacerbaLed by movemenL,
resplraLlon and lylng down and ls characLerlsLlcally relleved by
|ean|ng forward

2. Descr|be the c||n|ca| s|gns of per|card|t|s, per|card|a| effus|on
and constr|ct|ve per|card|t|s and |ts causes, |nvest|gat|ons and management

LkICAkDI1IS LkICAkDIAL LIIUSICN CCNS1kIC1IVL LkICAkDI1IS
ueflnlLlon ...lnflammaLlon of Lhe
perlcardlum
...collecLlon of fluld wlLhln Lhe
perlcardlal sac
...perlcardlum becomes Lhlck and
flbrous and calclfled and loslng lLs
elasLlclLy
Causes MosL commonly due Lo
v|ra| |nfect|on & MI
-vl8AL : Cox sackle 8
-CS1 Ml
-8AC1L8lAL: SLaph aureus
ln Plv
-MALlCnAn1: carclnoma of
Lhe bronchus, breasLs and
hodgklns lymphoma
MosL commonly due Lo
per|card|t|s
-vl8AL : Cox sackle 8
-CS1 Ml
-MALlCnAn1:
-lnlLC1lCn - 18
-lnlLAMMA1lCn - Chronlc
perlcardlLls
Usua||y - IDICA1nIC
Cllnlcal
feaLures
Sharp chesL
paln
erlcardlal
frlcLlon rub
+\- fever
PearL sounds sofL
and dlsLanL
Apex beaL obscured
Cardlac Lamponade:
!v, 8, P8
!v
AsclLes
PepaLomegaly
uyspnoea
Cough
CrLhopnoea
8
faLlgue
LCC changes Concave upwards, (saddle
shaped) S1 segmenL
elevaLlon whlch Lhen
changes Lo 1 wave
flaLLenlng or lnverslon -
Lhen normallzes



Low volLage C8S complexes.
LCPC- shows echo free space
around Lhe hearL whlch ls Lhe
effuslon

Low volLage C8S complexes and 1
wave flaLLenlng/lnverslon
LCPC - 1hlckenlng of Lhe
perlcardlum

1reaLmenL 1reaL under|y|ng cause
Clve nSAlu's, lf no
lmprovemenL Lhen
corLlcosLerolds
1reaL under|y|ng cause
LkICAkDICCLN1LSIS - When
fluld ls asplraLed from Lhe
perlcardlum wlLh uS guldance
CompleLe resect|on of the
per|card|um
MCCAkDIAL DISLASL]CAkDICMCA1n

1. descr|be s|gns and symptoms of myocard|t|s
CnLS1 AIN ALI1A1ICNS IA1IGUL DSNCLA CCNGLS1IVL nLAk1 IAILUkL

SofL hearL sounds
3
rd
hearL sound
1achycardla
erlcardlal frlcLlon rub

2. ||st ma[or causes of myocard|t|s
CCx SACkLL 8
18?AnCSCMA C8uZl
S18L1CCCCCuS - 8heumaLlc fever

3. exp|a|n how the d|agnos|s of myocard|t|s can be conf|rmed by |nvest|gat|on
Chest x-ray: may show cardlac enlargemenL
LCG: S1 and 1 wave abnormallLles and arrhyLhmlas
Card|ac enzymes: are elevaLed

4. def|ne card|omyopathy and ||st the d|fferent types
Card|omyopathy: ls a group of dlseases of Lhe myocardlum LhaL affecL Lhe mechanlcal or elecLrlcal
funcLlon of Lhe hearL. 1hey are noL secondary Lo anyLhlng and frequenLly geneLlc

DILA1LD nLk1kCnIC kLS1kIC1IVL
Causes PyperLenslon
lschaemla
CongenlLal hearL dlsease
lnfecLlons
...geneLlc dlsorder caused by
muLaLlons ln genes codlng for
proLelns LhaL regulaLe
conLracLlons
....amyloldosls and sarcoldosls. 8uL
can be ldlopaLhlc lf famllal
Slgns and
sympLoms
SC8
Lmbollsm
ArrhyLhmla
PearL fallure
sympLoms (dyspnoea,
orLhopnoea, faLlgue)
usually asympLomaLlc
SC8, chesL paln,
syncope
!erky caroLld pulse
L[ecLlon sysLollc
murmur
ansysLollc murmur
uyspnoea
laLlgue and embollLlc
sympLoms
!v
PepaLomegaly
AsclLes
3
rd
and 4
Lh
hearL sounds
lnvesLlgaLlons CPLS1 x-8A?: Cardlac
enlargemenL
LCC: S1 segmenL and 1 wave
changes
LCPC: dllaLed venLrlcles

dllaLed lefL venLrlcle whlch
conLracLs poorly"
LCC: LeL venLrlcular
hyperLrophy
LCPC: venLrlcular hyperLrophy
wlLh lnvolvemenL of Lhe sepLum
CA8ulAC CA1PL1L8lSA1lCn:
CharacLerlsLlc pressure changes

rlgld myocardlum"
ManagemenL -1reaL hearL fallure and
arrhyLhmlas
-ulsease progresslon ls sloed
down wlLh ACL, A88's,
splronolacLone and 8-blckers.
-lCu's glven lf rlsk of v1
-lf lncreased rlsk of sudden
deaLh Lhen lmplanL lCu
-lf ok Lhe glve amladarone
-1reaL sympLoms wlLh b-
blockers and verapamll
-no LreaLmenL, poor prognosls
-PearL LransplanL ln some paLlenLs

S. d|scuss the advantages]d|sadvantages of screen|ng |n fam|||es w|th card|omyopathy
1he number of posslble muLaLlons means LhaL geneLlc LesLlng ls noL generally pracLlcal. Careful
pedlgree analysls of famlly members can be useful ln ldenLlfylng Lhose aL mosL rlsk. lL has been
recommended LhaL adulL relaLlves are screened by cllnlcal evaluaLlon, LCC and LCPC every 3 years














































CAkDIC kLSIkA1Ck AkkLS1

1. kecogn|se card|o resp|ratory arrest
1hls ls when Lhere ls cessaLlon of normal clrculaLlon due Lo lneffecLlve conLracLlons of Lhe hearL.
ArresLed blood clrculaLlon prevenLs C
2
dellvery Lo Lhe body and also Lhe braln, causlng loss of
consclousness whlch leads Lo abnormal or absenL breaLhlng

- Absent pa|pab|e pu|se
- Unconsc|ous
- Stopped breath|ng

Cardlo resplraLory arresL ls classlfled lnLo:
SPCCkA8LL e.g. vl and pulseless v1
nCn SPCCkA8LL e.g. asysLole and pulseless elecLrlcal acLlvlLy

2. erform bas|c ||fe support

Call for help

1hump Lhe chesL flrmly over Lhe sLernum (v1/vl reverLs Lo slnus rhyLhm)

lace paLlenL on Lhelr back on a flrm surface

8emove any obsLrucLlng maLerlal e.g. vomlL, blood

Cpen Lhe alrway by flexlng Lhe neck and exLendlng Lhe head

Clve 4 breaLhs ln qulck successlon. WaLch for rlse and fall of paLlenL's chesL lndlcaLlng adequaLe
venLllaLlon

ChesL compresslons

Compresslon: resplraLlon ln a raLlo of 30:2 wlLh 100 compresslons per mlnuLe

3. Lxp|a|n the ro|e and deta||s about the card|ac arrest team and descr|be how to contact
them
Members of Lhe crash Leam lnclude duty anaesthet|st (breaLhlng/alrways), med|ca| SnC (Leam
leader/deflbrlllaLor), med|ca| nC (drug Lherapy), paed|atr|c SnC and nurses x2. ln Lhe evenL of a
cardlac arresL, dlal a cerLaln bleep and sLaLe locaLlon, swlLchboard Lhe Lells Lhe resL of Lhe Leam.

4. kecogn|se VI and V1 on an LCG trace

Ventr|cu|ar I|br|||at|on
....un co-ordlnaLe conLracLlon of cardlac
muscle of Lhe venLrlcles maklng Lhem qulver
raLher Lhan conLracL

Ventr|cu|ar 1achycard|a
....Lachycardla orlglnaLlng from Lhe venLrlcles,
llfe LhreaLenlng as lL can lead Lo vl, asysLole
and sudden deaLh
S. Lxp|a|n the |mportance of rap|d
def|br|||at|on |n a pat|ent w|th VI or pu|se|ess V1
lrreverslble braln damage occurs wlLhln Lhe flrsL Lhree mlnuLes lf an adequaLe clrculaLlon ls noL
esLabllshed
lf Lhe deflbrlllaLlon ls delayed, Lhe rhyLhm ls llkely Lo degeneraLe lnLo asysLole
- Larly recognlLlon
- Larly C8
- Larly deflbrlllaLlon
- Larly advanced care
lf one or more llnks are delayed Lhen Lhe chances of survlval drop slgnlflcanLly

6. Demonstrate how to use a def|br|||ator

Assess wheLher lL ls shockable or non shockable: vl/pulseless v1

LlecLrode [elly or pads should be used Lo ensure good conLacL

Al personnel sLand clear of Lhe paLlenL

ueflbrlllaLor dlscharged Lo 200!

lmmedlaLely resume C8 30:2 for 2 mlnuLes

Assess rhyLhm



7. Descr|be the mechan|sm of act|on and ro|e of adrena||ne, ||gnoca|ne, am|odarone and
magnes|um |n the management of card|ac arrest

vl/pulseless v1

C8

ueflbrlllaLe

lv amldarone ln refracLory perlod



AsysLole

C8

ALroplne, adrenallne

Ant| arrhythm|c drugs
Am|adarone: mops up all cardlac arrhyLhmlas!
L|doca|ne: blocks na volLage gaLed channels ln neuronal cell membrane (anaesLheLlc &
anLlarrhyLhmaLlc)
Magnes|um: lndlcaLed wlLh Lorsades de ponLes, sLablllses abnormal nerve exclLaLlon
Adrena||ne: lmproves myocardlal oxygenaLlon by lncreaslng coronary perfuslon

8. L|st the revers|b|e causes of a card|ac arrest
uurlng C8 conslder and correcL reverslble causes based on Lhe hlsLory of Lhe evenL and any clues
found durlng resusclLaLlon

nCkIA
nCVCLLIMIA
nLkkALALMIA
nC1nLkMIA

1LNSICN NLUMC1nCkAk
1AMCNADL
1CkINS
1nkCM8CSIS

9. Descr|be the prognos|s
Cverall survlval = 6.8

lf paLlenL has un8 form, Lhen do noL call Lhe crash Leam
































VALVULAk nLAk1 DISLASL

1. Descr|be the anatomy of the heart and the structure of the va|ves


2. Lxp|a|n the card|ac cyc|e and descr|be how each va|ve opens and shuts dur|ng th|s cyc|e

















S1 = MlLral/Lrlcuspld closure
S2 = ulmonary/aorLlc closure

3. 8e ab|e to descr|be the haemodynam|c consequences of atr|a| and ventr|cu|ar septa|
defects
VSD - LefL venLrlcular pressure ls hlgher Lhan rlghL venLrlcular pressure Lherefore blood moves from
lefL Lo rlghL and pulmonary blood flow lncreases. Cradually, pulmonary pressure lncreases unLll lL ls
greaLer Lhan Lhe rlghL aLrlum. 1hls Lhen lncreases pressure on Lhe rlghL aLrlum and Lhen you have a
rlghL Lo lefL shunL and cenLral cyanosls develops
ASD - LefL aLrlal pressure ls greaLer Lhan rlghL aLrlal pressure Lherefore bloods moves from lefL Lo
rlghL. 1hls lncreases volume of blood ln Lhe rlghL aLrlum and rlghL venLrlcle causlng volume overload
and lefL unLreaLed resulLlng ln hearL fallure.
AorLlc valve closes
AorLlc valve opens
A-v valve opens
A-v valve closes
SS1CLIC MUkMUkS

1. Descr|be symptoms and s|gns of aort|c stenos|s, aort|c sc|eros|s, m|tra| regurg|tat|on,
tr|cusp|d regurg|tat|on and pu|monary stenos|s, the|r causes and character|st|cs of the|r
murmurs.

1he followlng valve condlLlons have sysLollc murmurs as Lhey are elLher open/close durlng sysLole. lf
open = sLenosls, lf closed = regurglLaLlon

ACk1IC S1LNCSIS ULMCNAk S1LNCSIS MI1kAL kLGUkG 1kICUSID kLGUkG
ueflnlLlon CuLflow of blood from
Lhe Lv ls obsLrucLed
whlch lncreases Lhe
pressure wlLhln Lhe Lv
causlng LV hypertrophy
CuLflow of blood from
Lhe 8v ls obsLrucLed by
Lhe pulmonary valve
whlch reduces blood flow
Lo Lhe lungs, Lhls leads Lo
kV hypertrophy
8egurg lnLo Lhe LA causes
LA dllaLaLlon. 1he Lv Lhen
has Lo pump blood lnLo Lhe
aorLa buL also Lhe blood
LhaL regurges lnLo Lhe
aLrlum whlch causes LV
hypertrophy and
pu|monary congest|on
Cccurs when Lhere ls kV
d||atat|on leadlng Lo a
change ln anaLomy
Causes CongenlLal
sLenoLlc valve
8heumaLlc fever
Calclflc valvular
dlsease
CongenlLal
Carclnold
syndrome
8ubella durlng
pregnancy

8heumaLlc fever
rolapslng mllLral
valve
8upLure of pap
muscle or chordaLe
due Lo Ml
Cor pulmonale
Ml
ulmonary
hyperLenslon
lnfecLlve
endocardlLls
S & S SAu sLory
-usually no sympLoms
unLll severe
-Syncope (exerclse)
-Anglna
-uyspnoea
-slow rlslng caroLld pulse
-faLlgue
-syncope
-rlghL hearL fallure
-ralsed !v
-Lhrlll
-palplLaLlons
-dyspnoea
-laLlgue
-ulsplaced apex
-rlghL hearL fallure
-ralsed !v
-palpable llver
murmur Mlu S?S1CLlC L!LC1lCn
Mu8Mu8

besL heard ln Lhe aorLlc
area and radlaLes Lo Lhe
caroLld
Mlu S?S1CLlC L!LC1lCn
Mu8Mu8
LefL of sLernum 2
nd

lnLercosLals space

An S?S1CLlC Mu8Mu8

loudesL aL Lhe apex and
radlaLes Lo Lhe axllla

An S?S1CLlC Mu8Mu8

8esL heard on lnsplraLlon


2. L|st causes of va|vu|ar stenos|s

8heumaLlc fever
LndocardlLls
MlLral valve prolapsed




DIAS1CLIC MUkMUkS

1. Descr|be symptoms and s|gns of aort|c regurg|tat|on and m|tra| stenos|s, the|r causes and
character|st|cs of the murmurs and |nvest|gat|on f|nd|ngs

uurlng dlasLole, Lhe A-v valves are open and Lhe seml lunar valves are closed Lherefore open =
sLenosls and closed = regurglLaLlon

MI1kAL S1LNCSIS ACk1IC kLGUkGI1A1ICN
ueflnlLlon CuLflow of blood form Lhe LA ls
obsLrucLed whlch causes LA
hypertrophy as Lhe pressure
lncreases. ConsequenLly, pulmonary
pressure lncreases and also Lhe
pressure ln Lhe rlghL slde of Lhe hearL
causlng r|ght heart fa||ure
8eflux of blood from Lhe aorLa Lhrough
Lhe aorLlc valve lnLo Lhe Lv. Lv has Lo
work harder Lo pump blood Lherefore LV
hypertrophy buL Lhls [usL lncreases
demand of cardlac perfuslon whlch leads
Lo card|ac |schaem|a
Causes -8heumaLlc fever! -8heumaLlc fever & lnfecLlve endocardlLls
Slgns &
sympLoms
u|monary hypertens|on:
ma|ar f|ush, dyspnoea, cough,
haemoptys|s
k|ght heart fa||ure: fat|gue,
oedema, ra|sed IV
AI: pa|p|tat|ons
Increased pu|sat|on]pound|ng of
the heart
Ang|na
dyspnoea
Murmur MID DIAS1CLIC MUkMUk
openlng snap
low plLched rumbllng wlLh bell aL apex
wlLh paLlenL on Lhe lefL slde

LAkL DIAS1CLIC MUkMUk




Plgh plLched
LefL sLerna edge (4
Lh
lnLercosLals space)
paLlenL leanlng forward and holdlng
breaLh ln explraLlon
LCC ln slnus rhyLhm: 8|f|d wave, r|ght
ax|s dev|at|on, AI
1a|| k waves and |nverted 1 waves due Lo
Lv hyperLrophy
Lcho Allows assessmenL of valve
calclflcaLlon and wheLher Lo do valve
replacemenL or balloon valvoLomy
vlgorous cardlac conLracLlon and dllaLed
Lv
Cardlac
caLheLerlzaLlon
D|asto||c pressure |n LA more than LV

2. D|scuss the management of a pat|ent w|th a card|ac va|ve defect

A) 1reaLmenL of underlylng cause
8heumaLlc fever - penlclllln

8) revenLlon of compllcaLlons
Al - ulgoxln & anLlcoagulanLs
uyspnoea - frusemlde

C) valve replacemenL surgery
18AnS SL1AL 8ALLCCn vALvC1CM?: CaLheLer lnserLed lnLo 8A vla femoral veln
and pasL Lhe mlLral valve, balloon lnflaLed brlefly Lo spllL Lhe valve leafleLs and LhaLs
lL!
CLn/CLCSLu vALvC1CM?
Ml18AL vALvL 8LLACLMLn1: lf Lhere ls regurglLaLlon presenL Loo

3. Lxp|a|n the ro|e of ant|b|ot|c prophy|ax|s for endocard|t|s
ConsulL mlcroblologlsL

4. uescrlbe Lhe dlfferenL Lypes of prosLheLlc hearL valves

Mechanlcal
More durable
More Lhrobogenlc
need llfeLlme anLlcoagulanLs
Louder hearL sounds

1lssue
uegeneraLe afLer 10 years





























CCNGLNI1AL CAkDICVASCULAk DISLASL

1. G|ve a d|fferent|a| d|agnos|s for centra| cyanos|s


2. L|st factors that may cause congen|ta| heart d|sease
MaLernal rubella (uA)
leLal alcohol syndrome
MaLernal SLL
uowns syndrome (Lrlsomy 21)
1urner's syndrome (coarcLaLlon of Lhe aorLa)

3. Def|ne and exp|a|n the e|senmengers syndrome and exp|a|n why th|s worsens the progress

When Lhere ls a lefL Lo rlghL shunL (uA, vSu, ASu), Lhe pressure wlLhln Lhe rlghL slde of Lhe hearL
lncreases causlng hyperLrophy. Also Lhe lncreased flow Lo Lhe pulmonary vessels resulLs ln changes
Lo muscle hyperLrophy causlng pulmonary hyperLenslon. LvenLually pulmonary pressure exceeds
sysLemlc pressure causlng reversal of Lhe shunL whlch Lhen causes cyanosls (bad prognosls)

4. Descr|be s|gns and symptoms, patho|ogy and card|ac consequences of these congen|ta|
heart d|seases
vSu ASu uA lalloLs 1eLralogy Coarc of aorLa
uLllnl1lCn LefL Lo rlghL shunL
LvenLually rlghL Lo
lefL due Lo
elsenmenges
Lherefore cenLral
cyanosls
LefL Lo rlghL shunL
whlch leads Lo
pulmonary
hyperLenslon
1he ducLus
arLerlosus
connceLs Lhe
pulmonary arLery
Lo Lhe descendlng
aorLa. lf lL remalns
paLenL = Lv
hyperLrophy
1) Cverrldlng
aorLa
2) 8v ouLflow
obsLrucLlon
3) venLrlcular
sepLal defecL
4) 8v
hyperLrophy
= rlghL Lo lefL
shunL
=narrowlng of Lhe
aorLa whlch
lncreases
formaLlon of
collaLerals whlch
can decrease renal
perfuslon and
develop sysLemlc
hypoLenslon
S&S Small vSu:
AsympLomaLlc
ModeraLe vSu:
laLlgue, dyspnoea,
cardlac
enlargemenL
an sysLollc
alpaLaLlons/Al
uyspnoea
ulmonary
lnfecLlon
no slgns uyspnoea
laLlgue
CyanoLlc
Syncope
SquaLLlng
Clubblng
polycyLhaemla
PyperLenslon
Weak delayed
pulses
8adlal Lo radlal
delay
murmur

S. L|st other comp||cat|ons of congen|ta| heart d|sease
uevelopmenLal delays
LndocardlLls - keep good oral healLh and avold cosmeLlc procedures

6. uescrlbe lnvesLlgaLlons LhaL can be used Lo conflrm Lhe dlagnosls of congenlLal hearL dlsease
CPLS1 x-8A?
LCPC
LCC
CA8ulAC CA1PL1L8lSA1lCn

7. Descr|be the ro|e of surgery
vSu - ModeraLe or large vSu's should be surglcally repalred before Lhe developmenL of severe
pulmonary hyperLenslon

ASu - should be repalred before Lhe age of 10

uA - premaLure lnfanLs wlLh uA are LreaLed wlLh lndomeLacln whlch lnhlblLs prosLaglandln
producLlon and sLlmulaLes ducL closure. ln oLher cases, Lhe ducL can be llgaLed surglcally. Surgery
should be performed asap and no laLer Lhan 3 years

Coarc of Lhe aorLa - surglcal exclslon of coarcLaLlon and end Lo end anasLamosls of Lhe aorLa

1eL of falloL - compleLe surglcal correcLlon of all four problems