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Hello, everyone. Welcome to the first taste. It's event. We will be starting shortly. Just give it a few minutes, right? Okay. I think we can make a start. So everyone, welcome to the first a sitz event. My name's Daniel. My final your student for your medical student. Some here with some other people from the team. So Bill on the beer here is Well, so today we're gonna be going through cardiology. So, uh, here's our progress test teaching schedule. So over the next four weeks, what we've done is we put together a program that teaching sessions, just gearing up towards the first progress test. So I'm not sure how many of you go to Cardiff, but in about a month's time, we're having off this PT so essentially every Sunday and there's the evening. From now, seven PM will be here on the same zoom link covering a different topic. So we're doing this in collaboration with metal, so a tienda will provide you with a link to meddle. So if you would just fill in the feedback form your get access to the size afterwards. So I think that's everything and we can begin. Okay, so for cardiology. I think that these are the key topics that it's, uh, good to be aware of doing into PT. So we haven't our today, so I just want to focus on the very core topics. But what we see is a big topic area. So we're not gonna cover absolutely everything, uh, these the ones. I hope to cover it in the time For those ones which I might not cover, we have enclosed some summary slides at the end of the power point, so they have basically just a high yield information of what you need to know. Um, so you can just review that in your own time and obviously last note, you have any questions? Okay, So without further ado, let's just get into it. So we have a pool function, so you should be able to select your answers, and then we'll kind of go through it. So Allison is 53 year old woman in Africa are being percent. She's presenting to the GP for medication review. So the GP noticed is the boat pressure was last reported two years ago, so she proceeded tape about pressure on that comes back as 166 over 92. So they do repeated readings on both arms and gives a similar result. So what would be the most appropriate course of action? So beer should hopefully load up the pole and your baby is awesome. Okay, so it looks like a split between B and E, with the majority of people choose mg. So So the answer that I have is be so just coming. Actually, stop the Pollner smoke shin. Okay, so that goes there. People think that is the most appropriate answers. So essentially, what this question is testing is your knowledge of, you know, making a diagnosis of hypertension. So actually, the answer here is be so it's off for ambulatory monitoring and then follow the patients in a week. So the reason we do that is because nice, basically have quite serious for diagnosing hypertension, So they basically say that either. So what we need is both a clinic reading of greater than 1 40/90 on. In addition to that, we need an ambulatory monitoring to make the diagnosis. Um, so it's important to note that these figures here 1 40 systolic and 90 diastolic should be taken separately. So safe that just the diastolic was raised, that it was still because it's hypertensive. But yeah, essentially, we need both a clinic. So we need a clinic reading on about home weeding to make the diagnosis. And so the reason for that is basically to a camp, a white coat, hypertension. So that's this effect where pit basically patients may be a bit more stressed out in clinic on, so their BP is just gonna be a bit higher. So if we did the ambulatory reading and it was greater than 20 systolic or 10 diastolic when compared with chronic reading, then that would be suggestive of white coat hypertension. So, um so yeah, be aware that you need those two readings in order to make it, I notice. And then, from there you can go and start treating. So this table is also important because it shows you the the lower and upper limits for the staging of hypertension so clinically would be relevant. Because what's the weather this stage 12 or three, or determine whether you or for medications or not on then also, if someone is presenting with stage three hypertension. So either a systolic of above 1 80 or diastolic of above 1 20. Then you need to think about whether they need an emergency assessment. So someone's actually on. Well, that could be normal for the BP to be raised of it, Um, particularly that already on a background of hypertension. But if they were having symptoms or signs of target organ damage, such a visual changes, Um, or if they have signs, are fundoscopic just papilledema, um, what they could be having urinary symptoms or chest pain that it was anything like that. Then you'd want to get them in for emergency assessment on Stage three. Hypertension convulsive be caused. We cannot be called malignant hypertension. Okay, so hypertension most commonly is essential hypertension, meaning it's your pathic. There's no known cause. It's just something that happens with age on some other risk factors. Um, on 5% of the time, it could be called secondary hypertension, so that's basically hypertension with the underlying cause. So if I ask, I think there's a comments function. If you could just lists, um, causes or secondary hypertension. Yes, they were getting quite fused. Concentra um, pregnancy, renal disease very good medication. Yes. So you basically you've hit the nail on the head so you can see here. That's so because the secretary hypertension, you can divide them into renal causes. Such a renal artery stenosis, and they're crying causes such a poor me hyper aldosteronism, which I believe is the most common. You promise that, Uh, um and there's medications just reported cords and other medications, for example, antipsychotics on the pregnancy as well. So I think the most important thing to be aware of is kind of renal and end of crime. So hopefully we have unanswered quite a lecture coming up, so we'll go into those a bit more. But today, we're just gonna focus on essential hypertension. Okay, So starting off, we taken a clinic pressure reading, and it's come back is greater than or equal to 1 40/90. So pay attention to this greater than or equal to sign. So, you know, if they give you something on the borderline, then maybe expected to know what to do. So after that, as I said, we're gonna offer ambulator your home BP monitoring. So if that comes back, is below 1. 35/85 that's great. You don't have to offer any any medications. Don't even that's off the lifestyle advice. You just monitor the patient. So in general practice, they like to have, um, BP readings every year. That's cool. Patients. Uh huh. If you get a BP reading of greater Than or equal to 1 35/85 then that would be cost is Stage one hypertension. So from there we would consider offering medications. If the patient is below 80 years old on day, have one of the following risk factors. Start Sorry they fulfilled one of the following criteria is so if they're diabetic, have renal disease. If they have a cure risk of above 10% they have established cardio vascular disease or if they have target organ damage. So, for example, retinopathy. So where you can remember that is just doctor Q E t. So if they have one of those things and they're below eight years old, then we would offer medications. And if their BP is over 1 50/95 then that would mean that they have stage two hypertension. In that case, with the treat patients regardless of age. So if you think about this, by implication, someone is about 80 years old, and they, um, they were stage one hypertensive, then you wouldn't treat them. And that's just because of the risks associated with anti hypertensive therapy in old age. So, for example, patients may be more risk of fools on that would obviously carry carrots own risk. So it's all about weighing up the the benefits of the risks when it comes to all foreign treatments. Okay, so following up to the first question. And so, uh, this Alison, 53 year olds Africa or B in the center is the same thing. Basically, um, she has a curious to 12% on, and now we've done the ambulation monitoring, and the BP comes back. Is 1 45/87. So what would be the most appropriate management's we open the pole for? That's is the pole open. Okay, I'm just, uh continue, because I'm not sure if the polls working. Oh, there you go. Yeah. So it looks like the most populous is gonna be see, and then some people chosen be a swell. So if you're following the previous slides. Then you know that this lady is below 80 years old. She has a cure risk of above 10%. So therefore we're going to be offering her medications. So the question is which medication to be offered her. So the correct answer is to prescribe a lot of being. So the important points are age on ethnicity, basically. So in people, Africa are being descent First, lying anti hypertensive therapy is, uh, constant channel blockers such as a Model T. Okay. And the reason for that is because we know that people of Africa are being descent typically respond less well today, since it is okay, So we look at this flow shot here, I would say this is a very high yields kind of flow charts with you in a year to you just looking to get some points where you can, you know, looking through too much work. This is one of the key things that you couldn't really just Oh, get understanding of of, you know, treating hypertension. So if the patient is aged less than 55 years or they have type two diabetes, that first time would be in a centimeter. So a centimeters are preferable and talk to diabetics because they are renal protective, so they're good for the kidneys. Um, if the patient started on nation hip, it earn they having side effects and they don't want to continue with that. Then they could be switched to an ARB. So an angiotensin receptor blockers such as losartan, um for another one, if the patients is 55 years or above, or they're African American descent us and said then first line would be a constant channel blocker, such as I'm going to being okay. So for second line therapy, then we'd up for jewels therapy. So combining two different medications. So if they started on an ace inhibitor, then we'll give them a counselor, channel blocker or a buyer's. I'd like diuretic, and if they started on a constant channel blockers first line and then weeds give them either C plus a. So combining with an ace inhibitor ARB in each other, they being on or C plus D. So we tend to use stars. I'd like diuretic such as indapamide, as opposed to truth, I said. I diuretic section spend a few Mathias I just because of the side effect profile of those true diarrhetics Think that quiets nasty drugs? Um, so we tend to stay thighs. I'd like diuretics. Okay. And then third line will be triple therapy with a placebo, plus d. So this one over here, I kind of struggled to get initially, but I think if you if you just remember, that food line is a placebo, plus D, then second line is just going to be any to off these, and one of them has to be the one that you've already started on. So if they're still not controlled on triple therapy, then you go to for triple therapy. So adding in either an alpha or beta blocker based on the potassium surface above 4.5, then you could prescribe a carpet, but that's a little bizarre. Prolong. It was below 4.5 equals 45. Then you could have spread doctor masters because this is potassium, sparing diuretic, good place. Actually raise the potassium levels. So the target is very important to be aware off. So if they're below 80 then it's 1 40/90 above 81 50/90. As I said this certain risks with on hypertensive therapy and older people. And then if they have a point of getting you to see it is 1 40/98. They also have diabetes, then strict targets. This is always important to be aware off kind of lifestyle advice to any patient that we're gonna be treating. It's gonna be given lifestyle advice just very important for him to follow. Um, I don't think it's something that could particularly test on a PT, but definitely an awesome Is that insurance? Be able to kind of recall the correct lifestyle modifications. So we need to be aware of the risks associated with untreated hypertension so it can affect all of these different organs and probably more so cardiovascular help could be affected with coronary heart disease, renal failure, chronic kidney disease, get peripheral vascular disease and increases risk for things like section or abdominal aortic aneurysm. So we're gonna look quickly at rest and opathy on also strokes. So particularly hammer adjective oaks, such a severe actually stroke. Um, so this here is fundoscopic. So I'm gonna ask you guys, if you could think of what's under this label, so it was probably chance of this one here. What do we think is under under this neighborhood? Okay, sometimes I can't soak a piece of people say flame hemorrhage. Yeah, that's the right answer. Okay, uh, how about this one? What do we think? Those kind of specs off? So is a cotton war. Extra days cause a world that's a rule. Okay, so actually, these are extra dates on. Do have a guess what these are. So these are course of what's what's Yes, then lastly what? We think this might be referring to this thing in the center here. Okay, so that would be showing popular. Dema. So I think there is some confusion with regards to extra days and caught on wall spots. So quarter wall spots a copy, Of course, by SK me A to the retina. Where is these accidents? I just kind of protein deposits, but can occur, So I think just appearance wise. If you look at the court on wall spots, they're more kinds of the bigger in size, and these accidents tend to be more like a speck speci appearance. I guess you could say And over here, this papilledema just means, basically is blurring of the margin of the optic disc. Um, and it's because the optic this is swollen. So overall, this would be break for hypertensive retinopathy. So it's always important to look in a patient's eyes they are presenting with hypertension. Absolutely. That's for no, no can't routinely. But if they're having excessive the high readings that you should look in their eyes just to see if you can visualize any papilledema Uh huh. On. But just to know is, well, papilledema could be caused by malignant hypertension. Um, is your path of intracranial hypertension and this other forces well, so it could be caused by space occupying lesion? Um, no other kind of more neurological causes. But what I wanted to get across here is that at this point, where we can see these changes so bleeding onto the retina, which is basically this flame hemorrhages and we stopped brought hemorrhages or these kind of areas of ischemia leading quotable sports that basically means it's quite advanced hypertensive retinopathy. So that would come on there the the category three. According to the key wackness staging, um, Stage one would just be cognitive arterial narrowing. You'll see a change on the light reflects, say, two would be this arteriovenous nipping and then says history. You see these changes and four would be popular diva. So if you can see papilledema than it's definitely very severe, you want to get senior involvements. Assume it's possible. Okay, so another question. So listen is concerned about her risk of having a heart attack in the future. Already taking I'm all the being blood pressures are well controlled. She wants to know if there's any additional measures which she could be taken to reduce. Your risk of having a heart attack, Securest began, is 12%. So what additional medication can we prescribe? Call, please. Okay, so yeah, so it looks like most people are going to say atorvastatin, which is absolutely correct. So just bend or so. Yeah, that's the right answer. It's What's that? It's so this is basically testing your knowledge of primary prevention of cardiovascular disease. So Q risk basically is, Ah, scoring tool, which is recommended by Nice. So it's just something that you can pull up on your computer, takes into account of different factors on bit, produces a number which basically represents the risk of the patients having either a stroke or, um, I in the next 10 years. So based on that, we can decide whether to give thumb lipid lowering therapy, which would be atorvastatin 20 mg. That's gonna be the starting dose. After that. You do want to check the lipids at three months on. Do you want to aim for greater than a 40% reduction in non HDL cholesterol? So, um, if it's if you're not getting that level, then you can up the dose and titrate it. So I've seen patients were on the atorvastatin 40 on, but obviously we don't by specialists, but you could just titrate up. So it's far as blood monitoring. He wants more into a lefty's, uh, baseline three months and 12 months on. But the key point here is that there is There is a kind of allowable level of rise inhale T, so as long as it's not going above three times the upper limit of the reference range, then that's fine. You can continue it, and you'd expect it to come down then on. There are other indications as well for you, Or was that in, um so if they're having Type one diabetes for more than 10 years, I think on. But also if they have kidney disease and the far is look is lower than 60. Then you could prescribe for prevention. And they could also ask, You know, what's the mechanism of action of atorvastatin? So hopefully she knows his anticoagulant duct days inhibitor, so it's inhibits the intrinsic story. The in Georgia nous production off cholesterol, so the aim of statin therapy is to mitigate the effects of atherosclerosis. So that's basically the accumulation of cholesterol in the inner layer of the vessels. So over time there's information processes and they can lead to plaque formation within the vessels. Back was narrowing of the best sores, and then it can cause it's skinnier to the organs which it in supplies. So this risk factors which one modifiable So these ones are modifiable, and the normal fibril, um, was the age. This process happens in males that happens more soon. Ethnicities on then. This triad, which we refer to as metabolic syndrome, would also be kind of compound in those X factors. So hopefully with it's that in therapy you'd be able to reduce risk of all of these different things because essentially these a degree of atherosclerosis we just contributing to, you know, the the heart thinking about the brain with ti, a stroke that peripherally with peripheral vascular disease and then also quantum reason. Serifis Kia. Okay, so sleeping with Allison, she's not presenting to the GP five years later. Now she's complaining of pain in the center of her chest. So this, well, walking upstairs, she states the seven out of 10 in severity and radiates to the neck and jaw. It's associated with sweating and nausea. So when she rests, her symptoms go away within minutes. And she also notes, is that these episodes are more frequent, warm weather and if she gets angry, so let's just get some more responses to that. So what do we think? So it looks like, see is kind of overwhelming, a popular. Some people think it's the so yeah, essentially, that's correct. Want to prescribe DTN to be taken as required? So if we look at the symptoms, what she's basically having here is unexamined on Ultram pain. It's called the AC sounding, so it says that it's in the center of her chest. It's radiates to the neck and jaw um so we have an exertionally can get sounding chest pain. So basically that history would be consistent with stable angina so interesting the stable angina could be exacerbated in warm weather also could be associated with emotion and heavy meals. So the first line therapy for stable angina would be a GT and sprayed for immediate symptom. Really? So the criteria for diagnosing, stable and China would be three out of three of the following things. So either pain or discomfort in the chest, neck, your shoulders or arms so you can see that Spicer broad distribution. It can even be with the upper abdomen as well. So females to have a kind of atypical presentation of paid in there off abdomen, um, you'd expect it to be exertionally in nature on day. You'd also expect it to go away within five minutes with either rest or GT n spray. Oh, gee, 10 is a basic I. Later the mechanism will be that it basically invasive dilates the coronary arteries and a liar. It's more blood flow on, But yeah, it can be a typical angina that satisfies two out of three of those things. So when investigating a patient was stable. Angina always referred to chest pain clinics so they can basically do a full kind of work up of the patients on Do a coronary angiogram it necessary? That's the gold standard. First line investigation also wants to 12 of the C G, which is also gonna be first line just to see if there's any skin changes. Um, which could be resulting from a previous cardiac events but stable angina. We wouldn't actually expect any changes on the 12 the BCG, and then you can also just do a kind of work up of blood. So for blood currents, you might be looking for some anemia you in east and maybe electrolyte abnormalities, which could be, you know, coursing or worsening the the events on. Then you just want to scream for other risk factors. So, uh, we'll co morbidities rather so Hey, Jay, one c looking, they're if they're diabetic or prediabetic. So for the management of stable angina, you want to think about it is what can you do to immediately relieve the symptoms and then what's gonna contribute a longer term symptomatic relief so immediately the patient will be extra skied GTs of Mr Outright nitrates, either in the form of a spray or tablets. It's very important to safety. Net the patient and tell them to take it. Prn's as required. Their symptoms haven't subsided within 10 within five minutes. Then they can repeat that, and then they should wait another five minutes. If the symptoms are still bad, Bending's a call 99. And then, at that point, you may be thinking about what is this A. C S. Is this acute coronary syndrome? So for longer term symptomatic relief, then we can opt for either be two blocker or a calcium channel blocker is first line so quick examples would be bizarre. Prolol lot of being second line would be combination therapies of your therapy with bisoprolol, and I'm not. I'm not being And then, further to that, there's still not controlled. Then you'd consider triple therapy. So adding in isosorbide mononitrate swore bradying and that at that point you'd also referred to a specialist for consideration for intervention as well. So either PCI percutaneously coronary intervention or coronary artery bypass, and then also secondary prevention is important, so given that they have a degree of atherosclerosis that predisposed to further cardiac event, so you'd want to give aspirin sent by milligrams atorvastatin. Hopefully, they should already be on that. You can prescribe the higher dose to 80 mg that also ate inhibitor, particularly the diabetic. Um, and then Atenolol was Well, obviously they should. They should already be on a piece of blocker. So you can remember that with the four aces. Okay, so now we're with David to 64 year old man. He's presented with a four hour history of a severe central crushing chest pain, which is radiating to the neck. He has a history of type two diabetes and hypertension and the 20 pack year smoking history. That's well, the the city is recorded and history colon levels are measured. So what do we think is the most likely diagnosis? So these are the troponin levels you can see here. That's the normal. That's what it is on. You can see the E C G bit more clearly there, so see what? The colitis? Same. It's quitting mixed D and C so see? Yeah, that's fine. So yeah, that's correct, actually. So the most popular answer is D. So that's correct. Correct answers and stemi and then some people also thinking it's steady, So that's pretty good. So basically what this question is about his acute coronary syndrome, so that comprises and stemi stemi and unstable angina. So based on this question, so the history sounds like cardiac chest pain, as I said, severe central crushing radiating to the neck. He also has risk factors for Type two diabetes, hypertension. It was a smoker, Onda. So based on the history, it sounds like acute coronary syndrome. And then we have the components. So the proponents are elevated. So basically what that means is is we know were speed and am I So my cardio infarction literally means that that of cardiac muscle. So it means that basically, when cardiomyocyte it's apoptosis, they release bio markets, which is troponin, creatine, kinase and other ones well into the bloodstream. And that's what we can look at to see if there's been an am I. So it just based on the troponin, we can narrow it down to stemi or instead on. Then we just have to look at the CT. Um, so the EKG here is basically a normal E C G. So just to quickly run through how you interpret it so you can see the rate is about 100 BPM, basically 300 divided by the number of small squares we could see. The rhythm is regular. We could see the Sinus rhythm because there's people age of curious complexes and T waves. And there's no evidence ST Elevation or ST Depression on biologics. The T waves look normal so that they do it all. So, in conclusion here with elevated troponin and, uh, normally see GI, this is an stemi. So So this table here is very useful for distinguishing the three conditions which come under a C S. So the key thing to understand this, that's basically with unstable angina and normal ST elevation and I. There's a partial occlusion of the coronary arteries, but with stem me, what's happened is a plaque may have ruptured on then basically, a thrombosis formed around the plaque, and that's causing complete occlusion of the coronary artery. And that's leading to the depth of the of the cardiac muscle, basically, so we basically have to look at the biomarkers and the C G. So as I said it, the bio markers are elevated then we can narrow it down to being an am I. Then we also have to look at the EKG changes as well. So in unlabeled angina and non ST elevation am, I would expect to see either normally CG or some nonspecific changes such a T wave inversion. If it's unsteady, then we could also be looking for ST Depression. But if the C G has any sign of ST elevation in two more continuous leads mean, for example, the one b two b to be three or if it shows a new left bundle branch block, then that would be a diagnostic for ST Elevation. Am I? So I hope, I explained that isn't enough. Um, it's just to be with T wave inversion. As I said, this is a non specific sign of skinnier. But don't be caught out because there is a normal degree of T wave inversion that you can see in a V. R. V one and three. So over here you can pretty much just see an AB are. But we look at the one it's kind of flattened and lead to respond, so don't be caught out by that. So when it comes to the clinical features A C s. So a lot of these conditions will present similarly So, um, obviously the chest pain, which is kind of essential heavy, crushing, radiating, um, many can also see shorts of breath sweating, nausea and vomiting. Palpitations on this classics kind of sense of impending doom. So basically, anxiety can also see, um, you know, patients may be hypersensitive, which would be, you know, the chemo is and I feel unstable. Then maybe Perry arrest situation. And you also want to think about what signs you may hear a hospitalization, for example. They can have mitral regurgitation, But I wish all cover and a few slides. So, um, bear in mind as well that's women. And I bet it's gonna have a slightly different presentation. So basically, diabetics, if they have kind of uncontrolled blood sugars over a long period of time, have a problem with it autonomic functioning. So they have a silent am I. So they may just present without chest pain, but they may have sweating, nausea, vomiting, so on. So as far as investigating a C s. Very, uh, we definitely the 12 BCG. It's also very useful to have continuous cardiac monitoring just evolved any to look for any evolving changes on the EKG. Um, so we would also want to see the biomarkers. As I said, we need the proponents know where there's actually being in, Um, I other by Marcus that we can use to be crowding kinds and suggests used to be used, I believe, but basically it's not. It's not specific, I think, for for death of cardiac cells. So but But it is still used in in terms of looking for reinfarction So in the period of, uh, kind of days after, because the troponin stand to stay elevated for a long time. So with regards to imaging, then we would definitely want to do a chest X ray. You know, any patient is presenting with a chest pain? It's sensible to do a chest. Chest X ray in acute situation was a short of breath. Um, and then coronary 100 bomb A swell. We shall come on two. Okay, So just to kind of go through e. C G. Is very quickly. Um, obviously should memorize the territories of any C g on Do know what's on atomical area of the heart they could correspond to on what's, um, vessel. It's implicates. So, for example, the inferior aspect of the heart is supplied by the rights, coronary artery and so on. So when we talk about ST Elevation is important to know exactly what we're talking about. So we measure from the end of the curious complex of here to the end of four. Sorry. From the start of it, from the end of the tourist complex to the end of the T wave on, we're basically comparing this level to the ice or electric line. Seeing, if it's rare, is available below. So with the C G changes, there could be kind of evolving changes when you think about stemi. So the most initial sign will be hyper a Q T waves, and then over hours in today's in two weeks it will evolve. So start off with hyper kid, see waves, and then you get this ST elevation. You can get a new life on a branch block, and then later signs would be T wave inversion, and you can also get these pathological Q waves. So if you could just see those on in CG than that would be indicating old established infarct. So just to run through some of the CGs, I think we are running a bit shorter time, so I'll just kind of run through them myself. So what you can see here is widespread ST Depression, so we can see in these one to be to be six a swell. So basically, that's, uh, instead of me affecting the natural natural territory. The implicates, the left main coronary All ST we can see here some ST Elevation in these 23 and 80 s on also somewhere Citrical changes in means one and 80 El. So it's important to know that you can have those reciprocal changes in the what would be the electrically opposite leads. So if it's the wheezing ST elevation in the inferior leads that you could see some reciprocal changes in the central actually needs and don't be caught out by seeing some ST Depression as well. And then just fixating on that, um, ST Depression is combined to a particular region that it's likely to be that it's that it's basically was separable change rather than just representing. And then instead, it's always just look for ST Elevation. It's subtle So here, just quickly see ST Elevation very marked in its one be tuned to be five. Well, that would be left main coronary artery occlusion. And over here, this is basically just example left bundle branch block. So if we look at the one and b six, I'm sure you know William and Marrow. So William corresponds. Booth left one of our block and marrow where he walked the one with the up, and he said it would be down. That would correspond with why it's one of our block. Okay, so Okay, um, that's the question. So let's load the pole. So 58 year old females they're presenting to the beauty with mild upper abdominal pain. She's being experiencing it for the past six hours. She raised the pain three out of 10. Otherwise, she feels well in itself. The past medical history includes peripheral arterial disease, type two diabetes and hypertension. On examination, pulse is regular heart rate of 65 oxygen saturations and 92. You send a set of routine bloods and performance. Did you show ST Elevation in needs to be too to be three onda, also a left bundle branch block. So Which of the following treatments would you offer to this patient? Good. Okay. Um, so it seems to be split between a A and B. Now, can we wait for the whole to reach 50%? People have been saying that. Closing of it. Yeah. Yeah. Sorry about that. It's just that we're a bit Russia time, but that's final go with. Yeah, but it Well, you can. That's one. So, um, how many people? Just so much. It was split between a Andy, which is why I would have expected. So, actually, the correct answer here is the So obviously what we're looking at is stemi. So the question here is you know what we're gonna prescribe. So the difference here is it We're prescribing gcn aspirin, then basically what we're gonna get battled easier. So if you look at the history here, it actually just says that she's having a mild upper abdominal pain on day. She's know, rating it that highly on. Otherwise, she feels well herself. So basically, here it's not a severe pain, so we don't need to give IV morphine. So let's talk about no, um, management of unstable angina and steady. So, um and this would also apply force same as well. So in any anyone presents with a C s, acutely, we're gonna think about Mona. So Mona stands for morphine in severe pain. Otherwise, like we mentioned in the question, paracetamol would be sufficient. And then we get oxygen. If the d separating nitrates for energy. Easier. But no, they would be contraindicated if the patient is hypertensive, because it's quite supposed basically, I latest it. We don't want the food that brings down the BP and then a would be aspirin through your mammograms off. It's a lot patients, um, and then also another anti platelets. So options that could be prep it a girl price. Well, we'll take a brutal So, um, different hospitals have their local guidelines. Generally, tropical would be preferable that they're high bleeding risk. For example, if they're already taking a last regulant, uh, press girl, we generally given if it's big a PCI later on which will go into and then more neck. So the last c is anticoagulants. So before the paradoxical office, a lot patients, and then if they're gonna have PCI, then we can give unfractionated taproom. Okay, so it's also important know we need to ask for anything GTM Because patients, if they if they already have GCN on them, then they might have already taken it. So we don't want to go over those that what you hear. So for one stable angina and s stemi, we would initially kind of think about more AC, but then inform their management and determine whether they need to have PCI or knots. We have to calculate the great school, so that's basically it's cool, which is recommended by Nice. It's estimates six month mortality on basically classified patient, since either clinically unstable, intermediate or high risk. Oh, low risk. So the patient's currently are stable, meaning that he went in. And if it unstable, what they you know, maybe they have syncope. So that loss of consciousness then, in that case, you'd send for immediate angiogram and PCI Um, if they're in the middle category. But if the intermediate or high risk, then you do underground piece I will send to two hours, and if they lower risk patient, then they can just be managed just with Mona AC. It's just exclusively medical managements. So this food jar here basically illustrates what we're doing. So, uh, once we have the diagnosis and stimulant stable angina, initially we just get aspirin 300 with the grounds on. That's a crackle into that wins, if clinically unstable. As I said immediate PCI and that that point, we could give the second that's and platelets the intermediate or high risk. Then within 72 hours, want to give them a PCI in the second answer platelets. Then if the low wrist, then we can just check the medical managements. Okay, so Stemi management, as I said initially, is pretty similar. So morphine, oxygen, nitrates, aspirin, another two platelets, um, and then for the anticoagulant unfractionated happen would be given because that's preferred PCI. And then we can also think about giving this the like a protein to be three inhibitor, which also just helps the balance a calculation. Okay, so on 84 year old male presents that UTI, with ongoing left side of chest pain, radiates to the draw. It started 11 hours ago. He has a past medical history, or hypercholesterolemia on the C G is demonstrating. ST Elevation is 23 and 80 s serum troponin. Zarrella baited that nearest PCI center is nice sickness away. So what's the most appropriate management in this patient? Okay, yeah. So it's looking like people are going for a and see Children is why would they expected? So this question is basically testing. You know, the criteria for PCI, so Yeah. Brilliant. So people think it's a and then followed by See, So basically, yeah, the answer is a immediate transport for PCI, So P size the gold standard treatments. Basically, it involves inserting a catheter by the radio from all artery and, um, putting instance to unblock the coronary vessels. So the criteria for you know where the you send the patient with Same for PCI is that their symptoms on session it being within 12 hours. Onda, assuming you have access to PCI within 120 minutes. So we look in this question says the nearest PCI stent, it's 90 minutes away. Onda, These symptoms started 11 hours ago, so that would satisfy this criteria for getting that PCI. If they if they're not eligible for PCI, then in the first instance, you go for fibrinolysin. So you basically have them also plays well tenecteplase which are basically clot busting drugs on D see if they can dissolve the clot. But what you're going to do is monitor the C G. And if they still have residual changes, then at that point you can transfer them for PCI. So, um, this approach are here. Just illustrates that. So once we diagnose the stemi, the first thing is giving aspirin 300 mg. Then we consider have this symptom started within the last 12 hours? Is PCI available within two hours? If yes, then we can go ahead and to coagulate them. Um, Andi, give him the second dose of platelets and get them PCI. Um, however, if they're not allegedly will, then we give them the second anti platelets, followed by fibrinolysin. Is that that fails. Then we goes PCI. So the question could be testing. This stays here. Or it could say they've had five renal insists. And now what did you do again? You would never do five minimizes again. So, really, at that point, the only option is to transfer them to PCI. Okay, So 51 year old now was admitted with severe chest pain. ECD in troponin is demonstrated. Answer a natural stemi. He's prescribed morphine. GT n aspirin Price girl. He undergoes PCI All days later, he's well enough to be discharged. His past medical history includes hypertension hypercholesterolemia. So it was already taking ramipril and the atorvastatin. So which additional medications come we prescribe for him to take? Um, postdischarge? This one looks to be pretty split. I don't know. People's taking the time. Okay, I think that's fine. So basically, it was split between be on B, We be just throbbing was popular. So that's correct. It's be, um So basically, this is just testing where you know about secondary prevention, uh, pulling that Emily. So the patient's already taking ramipril. And that's what was that in So basically postdischarge patients should be on the six days. So in addition to the four days we had earlier, we're adding in being another anti platelet on. Also, if they have signs of clinical heart failure, Chaka Monte later, then we can also put I/O of the steering antagonist so spironolactone. But basically the patient should be on aspirin, 75 mg lifelong. Another anticipate that so that would be determined based on the one they had the hospital and that would be continued for you. Um, they should also be on an ace inhibitor atenolol. So it was stopped in 18 minute ground. So that's the secondary prevention dose. But as I said, they could be given spironolactone or turn on it needed other important things that offer cardiac rehabilitation therapy. Um, less kind of program which educates votes, exercise and lifestyle. Um, just manage their comorbidity is and the other risk factors. Good. So a 65 year old man is on the ward recovering from ST Elevation, uh, from a stemi five days into the recovery to report sudden onset shortness of breath, particularly when lying flat. He also reports developing wheezing cough examination reveals distended neck veins and aboard able passes Starlix murmur. So, based on the information provided which of the following pathology is the most likely explanation for the patient's current presentation, people think if you go for dress the syndrome yeah, okay, so let's see what the final wars finals. The war's okay, be transitioned her. Okay, so I think that basically, people people would be aware that Dresses syndrome is a kind of post M I complication, so that is commonly tested. But That's not what this this'll presentation is. So dress this syndrome present similarly pericarditis it would present with a kind of low grade fever pain, which is positional. So I think it's things worse on meaning. I think it might be relieved on leaning forwards. Um on. That's basically an auto immune process. So that's not what is happening here. Um, so if we look at this history, basically this is describing a patient who's developing signs of heart failure, so Oh, it was I haven't gone through that yet gone through that yet, so I could come out of that. But also, this person is having a pansystolic movement. So if you know your members, you know, the parents of salt murmur is pretty much associated with ventricular septal defect. Um, so, yeah, I can see why you chose dresses syndrome at actually, yes. So dressing room would be associated with the pain. Worse online flats. But you'd also expect to see the kind of pleuritic chest pain worse on breathing in um, the fever with that as well on that would be 2 to 6 weeks post am I So it wouldn't be this this suit basically so VSD. Basically, it's resulting from a schematic change here to the intervention just at them. So blood, conversely, pass through there that causes those symptoms of heart failure on Do you all set up that current characteristic murmur? Um, so the complications of them are you can think off as early and late complications, and then you can break them down into whether they are peri cardio electrical, uh, structural. So pericardial problems to be post and my pericarditis. So that would be similar to dress the syndrome. But that would be presenting earlier on, uh, saying in the week after and I that has to be benign Citrus manager supportively And then the other things you may expect to see would be tacky and bradyarrhythmias so placidly heart rockin particular pollens. When in theory am I because the right coronary artery supplies the patient, uh, ventricular nose back because heart block and then other things as well. So be ST as we discussed valvular problems. Mitral regurgitation on the left ventricular fruit of war rupture which can cause cardiac tamponade, are basically which is you'd recognize from back Striant of hypertension, muffled heart sounds and raised a BP. Okay, so the later complications would be a dresses syndrome, a Z we discussed and then hot failure and also left ventricular aneurysm could occur as well. Okay, so I was going to cover her heart sounds and murmurs, but I think because we're kind of pushing at the time, we're going to skip over these today just because on my slides it does explain it pretty well for the, um so I'll just skip over this, but essentially s three is it can be a normal variant. I'll just do it very briefly. So, Esther a occurs No 0.1 seconds off the ehstuhs. Just really just really this course by about rapid ventricular everything. So it can't be a normal variant and younger people, But older people that can be indicating heart failure. Best for, On the other hand, a curious just before last one. It occurs in late vastly, and it's always pathological, and courses for that could be hypertension, able to extend it a cyst or a hypertrophic cardiomyopathy and then moves. I was just going to cover the common murmur. So, uh, basically the ones, in fact, in the left side of the heart, um, definitely suggest that you kind of read through these. I'll just talk about able to explain OSIs assassin. It's common. So you know, as the name suggests, is basically narrowing the aortic valve. So it's a new generation systolic murmur. Um, it's high pitched, so this is started. Movements tend to be of a higher pitch just because of the the nature of the blood flow, and it also has this crescendo decrescendo quality to it. So the the picture of the moment varies with speed. So that started kind of quick. Sorry, the started slow, and then it speeds up, and then it slows down at the end. So the moment and radiates the carotids. It's associated with a slow, rising pulse. So basically, on a cardiovascular examination, when you lift the patient's arm and feel the pulse, that's what you're feeling for. Um, that's basically, uh, sorry. No, that's, uh, that would be able to grieve your decision. So just forget. Forget said that, uh, causes failed six nose is pretty age related. So just video pathic a calcification of the valve or rheumatic heart disease on One useful thing to remember is, um, syncope, angina, distance of patients with aortic stenosis are sad, so they have exertionally symptoms such a syncope, angina and disappear. So that would be suggesting the or six doses with mitral stenosis. You get this mile off flush. That's why I just put this here is basically discoloration of the cheeks. And also this is a very useful rule for distinguishing whether murmurs are on the right side of the left side. So right sided movements allowed on inspiration was left sided, allowed to some expiration. And also just know the anatomical land marks on pretty much between those two things. You can narrow it down at all. It's likely to be. But as I said, just have a read through this and we'll probably get you to understand. Think the common members. Okay, so 61 year old presents with angina breathlessness that rest. He's diagnosed with a lot of snow cysts. He has no pasta, medical history undergoes and open aortic valve replacements on has a mechanical valve implanted Which of the following drugs would be most appropriate for long term? That's a calculation after the surgery. Yeah, that's correct. So basically it's warfarin, so I just want to put that in there because I didn't mention it, but it's stenosis. So, basically, in younger patients for valve replacement, we can still use a mechanical valve. They prefer Teo by prosthetic valves because they have a longer half life of the problem with them is that they, um you know, blood clots can form around. So you do need to anti quietly patients so that you're minimizing that risk of stroke. Uh, so you basically give them warfrin? You came for iron are between 2.5 to 3.5. Used to another SDA. So just looking at the time, we are running over a little bit. So while do is I'll try and wrap this up in the next 15 or 20 minutes. Um, absolutely Want to drop the metal ankle? Maybe in about 10 15 minutes? Yeah. So 62 year old with breathlessness, which is exacerbated. Uring sleep. There's a persistent cough productive or Fourth East. You to have a history of hypertension. Diabetes is a raised A B. Being the best regarding a consultation. We got an answer program key. It's out of agents, which, for the investigation would be a key diagnosis down here, so yeah, the Boston around, people choosing. See, um, and that's correct. So basically, these this history would be consistent with heart failure. So he's having some respiratory symptoms which are basically caused by back flow of blood into the palm of circuits because the last side of the heart can't pump adequately. Um, so basically, we need to order transthoracic echocardiogram just to visualize the heart's on. Also, that so that we can measure the left ventricular ejection fraction should be very essential for diagnosing heart failure. Categorizing it is well, so Harvey is basically defined is where the cardiac output it's can't meet the metabolic demands of the body. So, um, just briefly in a normal heart, be when we have increased feeling as Frank Stalin's wore this increased contraction but in heart failure, this either being a systolic diastolic compromise, which is leading to inadequate cardiac exports. So initially, we have compensated Americanisms to try and push up the BP. So try and push up the cardiac output, which is running on the attentional This drooling system walk at a column me release. Um, but basically, in the short term doesn't be effective, but longer term interest released though worsening of the cardiac output due to remodeling of the heart. Um, the risk factors are behind that. A seven out of what we discussed previously. Um, so when we categorize heart, baby, here we think about it is I'm systolic with diastolic on dose. Systolic is also called with reduced ejection fraction, so that being below 40%. And it's typically caused by damage to the monocytes. So that could be what about around the misty make heart disease? Um, and diastolic is also called with preserved ejection fraction. So with the ejection, fraction is about 50% on gets basically indicating the vegetables are unable to relax for me so they can't pump enough blood out into the systemic circulation. And then we can also think about left sided. This is right, sided. Often the to code cyst or left side is even cause right sided heart failure. But, you know, briefly left sided heart payers was by backflow. Um, the symptoms that you see are caused by back flow is the pulmonary circulation. Um and so that's what causes thie. Cough with pink for the sputum, the shorts of breath on exertion. Orthopnea you can get paroxysm or nocturnal this near, which is basically so the night time waking. And then, um, if if that's backing up into the pulmonary circuit, causing pulmonary hypertension than that can cause right sided heart failure. So that's going to cause back into the systemic circulation on the other side. So basically that cause leg swelling to pee. It'll the Dema Ascites fluid accumulation abdomen on also raise JVP. So there there's those symptoms there. So investigating heart failure, the two key initial investigations are anti, probably MP and then following. That's, um, a transthoracic because the ground. So if the NT program key comes back, it's raised, then it would be a case of specialist referral and transacted echo in six weeks. So that's what the nice guideline suggest. If it's just high, then we can arrange for specialist assessments and transthoracic echo within two weeks to that's basically, hopefully they get you well, they would definitely give you some reference ranges for that comes, but just note that, um so they could potentially Christiane physiology. So BMP is basically a compound release from the heart in response to stretch particularly bad trickles and basically the higher the BMP the poor. The diagnosis Other important test would be probably the CGC May seaboard complexes may see left ventricular hypertrophy and then also some routine bloods. And also you'll see changes on the chest. That's right. So a second if your your male is presenting to the e. D with severe breathlessness on fatigue, his heart rate is 90. His respiratory rate is 20 to his BP is 128 over 84. Saturation is 95 is temperature is 36.8. On examination he looks I nosed and he has an elevated JVP auscultation You've been here by basal crackles. He has a history of aortic stenosis. So this is the chest X ray. So what medication would be most appropriate to get here for initial treatment? Yeah, so that's absolutely right. So the majority of people saying see, So that's correct. Basically, this patient is fluid overloaded, so we need to give him a diuretic so brutalized and leave diuretic destruction and take some of that fluid out of him on use those symptoms. So basically, what we're looking at here is acute decompensated heart failure. So the changes he has you on X ray are, um you can think of is a B C D. So I have that on this slide. So a sense All the ola oh Dema um And it would take maybe a batwing distribution. So if you look here, you can see some kind of slight sparing of the upper lobes could securely be lines. Which of these kinds of lines here which basically indicated this fluid in the lungs. Um cardiomegaly. So what we look at is the cardio thoracic ratio. So we'd expect that typically to be less than Northpoint's five. It's greater than or five. But then that would be. In the case of Cardiomegaly, we also expect the dilated up alot vessels and prop your Aleve fusion. So based on what can we see the cost? A frantic angles clearly north. Then lessen the casing A little effusion, so to manage someone with acute decompensated heart failure. So it's a just to say, become what that is So someone on a background of corner car failure, but they're kind of getting along. You could say that compensated, but then when there's an added physiological stress er so they could have had a cardiac events. It's just, um I could have some kind of infection that can decompensate them. And then they presented Cuban. So actually, we're going to manage them with fluid restriction on direct. It's a sweet said. Try and take some of the fluid acts of them. So there's, uh, a way of remembering it is Poole sort. So in addition to that, will sit the patient up to try and improve their events. Elation should get the fluid down to the bottom of the lungs and then also with your oxygen. A patient. It's just important to post. We monitor the oxygen saturations, and if they are deteriorating, your step up, then it's a noninvasive ventilation in the form of continuous, you know, you know CPAP on. Um uh, if that's not effective, then you consider intubation ventilation um, dobutamine eyes example of a minor triple medication, and that would be given in really severe cases, for example, of the patients and cardiogenic shock. Then you could get that long. Soon. Management would be with food restriction on dial, come onto that under chronic, uh, or a card failure. So joins a 62 year old male who stopped diagnosed with congestive heart failure two years ago, this condition has deteriorated considerably. Know experiences, market short of breath on minimal activities. Light activities such as walking from the bedroom to his kitchen would make it feel breathless is KERA helps him with most things that home, so he doesn't feel breathless at rest. But it does get palpitations sometimes. So what do you think would be the most appropriate New York heart's cast location for this book? Yep, that's right. So it's cost three. So basically, this is how we categorize. It's a class one would be. There's no limitation to physical activity. Class two would be that there is some limitation on strenuous exercise. Three would be that there's limitation with moderate daily activity, the gates and symptoms, Um, but four we should be the most severe would be the best symptomatic at rest. Okay, so chronic are failures, so this would be following along from you know, if you acutely treat someone who's coming with a Q heart failure, then you come here first to this but chronic management. So first time will be in a sentence in a piece of blocker, for example, Ramipril um, it's operable. It's important to bear minds. Patients asthmatic we don't want to prescribe. Prescribe The parole Second line would be in all the steering, antagonized spironolactone and then third line. It's quite bad. Then they can be referred for CRT or surgically. They can have on I CD inserted the drugs in complete, described if they have atrial fibrilation, that would be particularly useful. There's also IV Brady and some of the options as well, such as a security your valsartan. That would likely be, you know, a specialist supervision. If you want, you can look at kind of the situations, but they were prescribed them. Um, it's also important to ensure that these patients have annual vaccinations. So annual influenza vaccine and the one off new possible vaccine symptomatically if they're having people Dema so leg swelling, then they can begin for his mind. But that's not being shown to improve mortality. It's just something which is symptomatic relief. Okay, so we're going to cause the final topic now. Eso seventh two year old male, presenting with a two week history of shortness of breath palpitations. He has a background of angina pectoris. The hypertension is previously undergone cabbage so on examination and irregularly irregular pulse is noted that his the seizures reported. So what do we think? It's the most likely diagnosis? Yes, absolutely writes. The most common answer here is be okay, so I don't think that's gonna change. You will seem to think it's b uh, so I should show you the in synergy. So here, you can see, that's basically we have curious complexes. So we look at the rate, So if it's irregular, then we can can ease up and multiply by six. Um, way we can clearly see that the rhythm is irregular on different looking to see if the Sinus rhythm So are there any P ways know you can't really see any discernible P waves. Um, on. So you know that this is basically atrial fibrilation. So yeah, right. The irregular curious complexes absentee, which is pretty much diet, not state for atrial fibrillations. Um, so just the pathophysiology behind that is basically disorganized at electrical activity coming from the S a n least this kind of fibrillating off the atria on then you also have this irregular ventricular response is Well, um, over time, you know, you get poor feeling of the ventricles because you're not spending as much time in vast least back in me to heart failure on. But also, the other main problem with atrial fibrilation is because that the atria are just fibrillating. It shows the blood, and it couldn't predisposed to rhombus formation within the atria on that and then go up through the neck on because the skin extra call t A okay is the most common with me as well. So if you're gonna learn, I want to read me here. This is probably the once in our backs. Um, the courses of atrial fibrilation. There's a very good pneumonic. So pirates, um, the most common ones there you can see I involved skin it. Car disease. They have any valvular abnormalities with age. That's probably the most common cause ongoing. So there could be other underlying causes such as hyperthyroidism. Ongoing patients were septic. A swell can also, uh, going to f. Okay, So presents. As we saw the question presented palpitations, shortness of breath. Patients may feel they have an irregularly irregular pulse on, then Also, if it's caused by underlying conditions styloid disease, then you may see symptoms associated with that it's always important to bear in mind the red flag symptoms, which are basically adverse features which would inform the management. So if they're having any signs of shock syncope, am I or heart failure? Basically, which would be indicated by any of these things? Here we can categorize atrial fibrilation based on Weathers the first onset episodes, whether its parts is more, which would refer to spontaneously terminating episodes lasting less than seven days, whether its persistence. So that would mean it's lasting about seven days. Worse permanents, which would mean that's basically resistance or any kind of treatments in the patient's permanently in there. Good. So the investigations that we need to do would be a 12 with the C G. Um, we could get an ambulatory monitor, which is called a Holter monitor, which basically looks over 24 hours to see if there's any paroxysmal episodes way. We could also order serum electrolytes because, as we said, electrolytes completely exposed. And also, if you're concerned about another underlying cause, then we'll investigate. Based on that, separates are for firewood function test. We can also order cardiac bio markers that we feel your if you want to rule out any previous ischemic change. Um, chest X ray of the patients having kind of respiratory symptoms on the echo was well, would be helpful to visualize the heart, see if there's any valvular abnormalities, so F management can be a bit tricky because it is quite situational on. There's different factors to be taken into account, you know, based on the patient for this flow chart here, just a mess to simplify as much as possible. So the the key thing is that you can either go for a rhythm control strategy or rate control strategy. So is any Andreas speeches. So, as I said, signs of shock syncope, am I or heart failure? And in that case, always first sign you're gonna up for a rhythm control. That's the rhythm. Control could be either electrical or pharmacological, also called cardioversion. So the first line thing, if there's any adverse features, would be synchronized. DC Shock, which is basically electrical cardioversion on. Then, following that, you could opt for pharmacological cardio vision, which would be either an E or German or flecainide. So I have that on the next light, Um, so then, if there's no adverse speeches. Then you consider how long the symptoms have been going on for. So if the onset is less than 48 hours, then you can hope for either rate or rhythm control, with red control generally being preferred. But as I'm going to say in the next line, there are situations where the rhythm control could be more appropriate. And then, if the symptoms are lasting over 48 hours, then you opt for rate control. Strategy is first line because of the risk of thrombus being in the in the atria, which you don't want to dislodge by cardioverting them and then causing a stroke. So if the symptom onset is above 48 hours and know out of the speech, is that always, firstly great, control them on. We want anticoagulation, um a swell to get rid of any from verse and then following that, we can consider rhythm control. Um, you know, if they are symptomatic or if it's appropriate for the patients, so rate control is generally preferred. The aim is basically to get the heart rate below 100 allowed time for the vegetables to fill. Um, so the first line medication would be a bit of locker or rate limits and calcium channel blockers such as diltiazem and second line would be Jul therapy with any tool, um, bizarre parole, diltiazem or digoxin And and then when it comes to rhythm control, as I said, it can either be electrical or pharmacological. Um, pharmacological would refer Teo Black and I wore your drone with with amiodarone being preferred. If any structural heart disease is presence of happening about that abnormality is what they have. Um, you know, if they had half daily already, it's basically flecainide is a very negatively I trophic drug. Okay, so the situations where you would opt for rhythm control over rate control would be if it's a younger patient. So if they're so, if you think about it, if you rate control someone, there are gonna be side effects on that, so they're younger. Patients may want to do exercise and things, then be two blockers would limit. They're they're kind of functional level. So if there were younger patients, if they have also have less than 48 hours, they have no underlying heart disease that they have a structurally normal heart. Uh, and also, if it's a clear reversible causes a f. Then in those situations you cannot for rhythm control strategy fist, which can either be scheduled cardioversion or it can be with a pharmacological approach. So black and I'd it could be referred to a pill in the pocket. So it's basically an approach where, if someone the younger person is having paroxysmal episodes, then you can prescribe flecainide for them to take, you know, as they require. So when they see that they are going into the episode, then they can take it and it would help 3% of them and put them back into Sinus rhythm. Uh, okay, So 69 year old, uh, tends the easy with a five day history of palpitations, dizziness, just denying chest pain or shortness of breath. Onda. There's no history of syncope. Past medical history includes smoke, for which she takes regular salbutamol on back on that this only inhalers. One examination. The heart rate is 84. The blood pressure's 1 to 4/76 auscultation. The chest is clear. Heart sounds are normal. The Easter GI shows irregularly erect the chorus complexes in absence P raise. So what do we think is the most appropriate management. Okay, so the most popular options are a and be so that would be correct. So let's have think about it. So his woman's presented with a five day history. So importantly, we go back to our flow charts. We can see So a five year history means where about 48 hours. Are there any address futures? Well, we look, um, there's no chest pain short of breath and no m I no syncope, no signs of heart failure. So basically no adverse speeches and we're above 48 hours. So if we're following this, then we offer rate control. So the options there would be either this operable or diltiazem. We see patient is asthmatic, so that would be a clear contraindications for getting beat blockers. So therefore, the drug of choice here would be diltiazem. Okay, So the other aspect of atrial fibrilation management is cancer coagulating patients. So it's a chap, a scoring system, which I'm sure you've heard off. I'm not going to go through it, but you can see it clearly in a stable. It's worth learning this, I think, Um, knowing that if the score is one, then you consider anti coagulation and males. If it's two, then you could offer it in men and women. So basically, if you have a woman whose scoring one just because she's a female then you shouldn't talk for us. Um, and then the other aspects are S o with anti coagulation, Doc, Doc have the comforts, lines that result apixaban and the big trend of Doctor Van that we'll do X. They're not tolerating a doac or, for whatever reason, it's contraindicated. Think if this severe patted component that that would be a contraindication to the doc. So in that case, you can give Wolfram. Uh, they would need iron are monitoring for that. So that's the drawback on heparin can also be given a new onset. CHF. Okay, so this other tools that we can use for assessing bleeding risk So I think, in clinical practice is small, often the case that patients are just anticoagulated, even if they do have a slightly higher bleeding risk on. That's just because of the risk of an ambulance forming resulting in stroke. Um, but it's good to be aware that this hospital and now there's a new scoring system called orbit school, Um, which, which basically would indicate the patient's bleeding risk. I don't think this is This's ever being worth learning kind of letter for a letter, to be honest, Um, but just to be aware that it's three or higher than you could consider alternative stance a crack in a shin, Um, for the all the school A said, this is now recommended by Nice as it just a few months ago. I think support to seven. Then that will be high risk. Okay, so this is this is the last question to Davis, a 71 year old man who's knows how. Yeah, he had a t i A. Two weeks ago. It takes, and that might hypertension. But his other ones, Well, he's like his BP is once you 4/76 you were discussing management options with him. He's concerned about having stroke. What's his trial by school? Yeah. Okay, so it's kind of split between B. C and D. Um, so maybe I didn't put it on the screen for long enough. Um, where is it? There. So if we go back to the case so that is a 71 year old man. So how much is your scoring for a judge? Well, we can see for a judge. He's scoring one. Um, on, Then? Well, see, we have to do is take. He's had the TIA recently, so that would be two. And then he's also hypertensive. So even though he is, um, controlled, I think they do school for this point here. So that would mean his score is four. So just a recap. He has one for his age to foot having a tia and then one point attention. So that means school for okay, So, um, it's worth knowing about bradycardia and tachycardia. So I definitely recommend just going familiarizing yourself with these resuscitation council guidelines so they get the key points here. It's like we called you. All rhythms here always just be aware of, um, you know, if they have adverse speeches which are common to atrial fibrilation, tacky and bradyarrhythmias, then there's certain things that you need to do. So because that bradyarrhythmia or atrial fibrilation, then you shock them. Um, it was attacking reading here. Um uh, then you just follow that out with him, um, such, but you can see Ask that here, Um, on. But also, this is quite high. You'll just know the indications for pacing, but just follow the value, call you with them. So as promised, the start, we have these, um, the summary sheets. She cheats whether you want to call them eso. We've covered pericarditis dissection. A swell a zebra. Things going through today? Um, so, yeah, if you would be so kind. It's the filling. Be back for, um and we'll give you access to the slides after that. So thank you very much for coming on. Next session is going to be Thursday. It's gonna be respiratory. Mm. Seven PM Same zoom like that's Thank you so much. Everyone coming. We just wanted to give a big shots. Ought to metal. Um her Amazing. Because they allow you to provide feedback forms on access on devil lectures on our pop Inside on, The problems of different communities are taking like that Are upload the lectures on to that. So definitely try the mouth on. We hope to see you next time. Thank you so much and you can find our electron. There is well because annuals Very nice. He said that he's happened for it to be reported. Thank you very much, everyone. Um and I've just noticed Sorry, cause there's so many messages. If you've got any issues, just contact the sun Facebook, and we've got a page called Exit On. It's got a Welsh logo on that. So it's pretty with the dragon. Um, definitely. Have to see you next time. And tell your friends that everyone about it because of the end of the day Properties Urology of same everywhere. So definitely do attend on certificate people Prop for your pump Rodeo. Thank you so much.