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out of here. Send this off for just a quick talking to Congress and drives. It's something that is component exams coming in real life, and it's quite serious as well as it's working a little bit. We got asked about it in our files, so hoping this is usual kind of geared towards. We need to know that one. On what? College finals? Hopefully, we'll be okay. Any questions about the child shot out? Go a couple of pas in cases about at the end? Um so, yeah, let's get started. It's just really started on that one this year I worked in cardiology, so hopefully continues to get your stuff. But it was the next question, you know, with one somewhere else that could be helpful. Just start going to go today. So start with a couple of SPH is to come see what we know. Go in the chat talk, then go through what it is. Country. How to spotting play on where the tests have treated what? Go on, then finish office in cases which hopefully can come here for what we've learned. Um, here's the first FDA. This has got a bit better sorts, but Yes. Um, something. This is got a whole you can get going, get you a couple of this reading. And there we go. Last spoke was a whole Yeah. If there are any issues, you can always stop on. The ball is anonymous, so just give it a shot. You don't go. Every wife stuff is right. Brothers master know where to get better. It's only talking about I'll leave guys about a minute. It is getting rave ancestors gonna get this. Oh, really? Start to realize, well, travel that's coming. Coming very seriously once a day. Yeah. All right, I'll end up on now, you guys. So you got, um So the correct answer for this is a, um The reason is we'll go through the talk later is the A. C. S is defined basically, by a rupture of the coronary plaque on There are rare recorder's. It will go through. This is May want to know is not being so troponin is an enzyme that's released with cardiac cells die, which is the part that's infarction on any stamina, especially both talked infarction. So both of them cause it raised report. Um, number three, um, a normal coronary angiogram rules out a C s. Similarly, to are necessary is incorrect because there are other causes off. Yes, yes, that aren't necessarily marrow, doctor. Ease on Raptiva plaques to just leave it on all comradery. That doesn't mean that you're you're healthy. I think it was d so well done. Um, may I was a much more short of classical symptoms of a CSF crushing chest pain. Go to the jaw on females more likely to show. Um, I haven't noticed, but, um e stem it presents exclusively with ST Elevation. Sustain is obviously do with ST Elevation, But there are a few other things that that you have extra G. Is it true that rare about 14 up? I will go through them throughout the talk. Um, so not to this is more case kind of management of medications. While so get rid of this one and give you this Go. I'll give you guys a little longer. This spend longer case? Yes, anytime. Okay. Guessing that about 10 15 seconds. Think my few pounds right now being Yeah, in the post results. So the dose of this one is he So let's go through the northern part of the Flexeril. It's a hear something from one stage one jar. Remember what we said about our troponin is released when cells infarct darling in stable angina. There's no death of any cardiac cells. So the troponin didn't released. This guy's promoting the sky high. So that's why I got no unstable angina. He's got 10. Study be the pathology Most likely involved the left anterior descending artery. This is incorrect because you need to look at the EKG. Leads to more effective. So the left anterior descending artery is represented by lead to be 123 and four mg. Um, which is the front part of how the interior side hazel changes. It needs to three of them, which are the inferior leads to the heart, which is supplied most only about a right coronary artery. Um, so that's something that we see it all the time in the stages of a CSS. Want to know I didn't get all that see his troponin sky high. I will talk about kind of how to differentiate between different problems. That's a bit later. So well done. Um, people have i d s so he doesn't need a PCI at some point, but not immediately. So in in Venice tell me you can wait a little bit longer in a steady you need to be PC. I kind of a sad because it's quite dangerous, but I understand it is less fatal. In the meantime, you can afford to wait a little bit basically, Um, mostly easy. So this is correct because these four drugs here's a sedentary beating blocker. July platelets on a high dose statin. These drugs that we give everyone after they've had a C s and that hasn't helped improve your lortab itty about various different mechanisms which would go through a little bit. Um, lovely. So the PC I cut wood anymore? It's not in terms of time. Yes, the time I get to it later on the chest, any. It's typically 12 hours after the chest. Pain starts on in instantly. And, um, I'm thinking of joining these three days. I will get through that. You don't make sense. Uh, so there's a couple of taste questions to start things off. So what actually is ATS? Let's get back to basics. So the top photo on Ryan side is a normal, healthy coronary artery lot of love and get the heart. There's no limitation of myocardial perfusion. It gets in the opportunity needs on the heart is nice and healthy. The middle photo is what's called a stable coronary syndrome, So this is somewhat stable. Angina. Um, this is when there's a plaque in the marrow in the artery and now only might not. It gets through the heart. This means the rest get enough blood. But when you exert heart demands more oxygen, there's enough blood to supply the oxygen it needs. So you get chest pain on exertion, which is statement on joint. The bone photo represents what's happening in in a C s. So this is when the plant ruptures on. This can happen at any time. It can happen at rest or exercise, but most of the rest we don't really know why it rupture, but they tend to randomly, basically to the end of the ileum. Your lining is disrupted and play with activation and the coagulation cascade at first. Well, so you get a clot that blocks off the blood supply to the artery, and that's why I get this chest pain at rest. And then acute coronary syndrome. Okay, on a C s represented in freedom from your waist actually going from the least bad. Too bad. So number one is unstable angina. A lot of them involved. Most of the time, this clock, this plaque rupture unstable angina. That's still enough blood getting through the rupture for you to have some supply to the heart wasn't so hard, isn't it? And study. There's a blood, but there is still some blood going through. So some cells die, but not the full thickness of the myocardium, which is what causes ST Depression t wave inversion, the CJ, Um and let's see the same, which is when it's not about getting through, you know, completely blocked off. And the heart is just like a basically didn't have any blood in the heart cells die on the full thickness. Infarct of them are cardio is what causes ST elevation of the CD. Um, so you mentioned to start, but most of time, the knowledge is a plaque rupture. But sometimes most common younger people that could be other rare. It was, is so commonly what we see on the ward is young blokes who have been taking a poke, um, and that causes your coronary arteries dispensing on. It's the same effect off a plaque rupture. Basically, your heart can't get any blood on the cells die. So that's why you can have a North Korea 100 g. Still, at least yes, Another fairly long course is envelope from A F. So these most of the time go up to the brain and cause strokes. Which cheek heard about before? But very rarely they can get in coronaries on block off the formularies without plaques. So basically the message there is just cause. Sometimes my old they don't smoke, except for it's actually could still have the CS. If the chest pain sounds to call in the blood test in the cities. Look, um, so that's what I see It is now, How do we spoil? Yes, yes. So there is a very classic symptom of a C s. You know, it's easy to recognize, so you get this central crushing chest pain radiating to the arms and the jaw. It's very severe, narrowing 10 out of 10. It's no relief by the door GTs, right? They have their joiner. Uh huh. When it is pain, this is what's called ischemic chest pain, and they should be reading that was basically, for something going on in your heart, something that's really important with a C S. If you get just want to know, like features eso. This is nausea, you swept. You feel anxious. You look pale and things are really important to notice because you can't think these. If you got chest pain, you can think that might sound a little bit again. It sounds crushing. History can be a little bit, but if someone's sweating that pale, they're nauseous. Vomiting that should you do something to you about is getting all. It's important thing to talk about your history. Um, last we talked about first FDA is about some MRI's, so these are really important to recognize as well previously were under recognized. So the more common in diabetics, every people on the woman, and this is when you get an MRI without chest pain. It's been weird. You just basically get the autonomic features that happened suddenly, so someone might get some ones that, nor just sweating, feeling crap, they might get some tummy. Being on people like this is just on your radar to do any CT because it might be enough. Takes two seconds and 80 J. You might have just stopped having a home. So that isn't Is that the main way to make the time? Just quickly. There are really any signs in a C s. A pop in your stomach. Features of talked about before. What you're kind of looking for now the dog knows is is a lack of bones. Swifty for adult had no air entry on one side of your chest that would maybe isn't going about your ex or prove infusion. And that's normally you have an old physical donation. She get in, There isn't anything. Positive points takes. Yes, the diagnosis. Um, so there's the symptoms. How do you don't get intestinal? So we got so we think it might have any CSF. This is getting sounding chest pain. Seen you two different. Firstly, do any CJ on? Certainly think about doing the truth. Holding blood test. So what about the CT first, If your dizziness yes, are simple, once you get the basics of them down basically importing to know about how to diagnose a C s. Is that the changes of what we could territorial. So we talked in the first FDA on the second SBA about different leads being department, even arteries and heart. Um, this is what this picture here shows. So let's see here. So the blood start. He had changes in needs to three and a V F. These are the leaves. Look at the undecided part city in fear border, and this is supplied most of the time by the right coronary artery. So if this are is blocked, you're gonna get changes in these three leads similarly in The lady said that they won't disappoint about half of the left ventricle, which is the front of the heart. The anterior side. This is represented by the one to be four. If you're energy is blocked, you get changes in these leads. And lastly, just circumplex artery which comes off of your left mainstem. And this is represented by the lateral leads to a V E L V 5 96. Your question. I want to make it two left on that You're on knishes. Follow yes, because of your dermatomes and things like that because of the heart survived by your t one t four. The survival roots. So if you got irritation there, it's spread to your skin nerves. Basically, it'll be sound very technical, but that's way too expensive. Terms of T one t four t shirt on. I'm very good. Um, so that's the total full bloom it pretreated you change. It's in a C s, the second to notice that they're dynamic. So what that means is that they change over time lows of things because ST Depression and T wave inversion in the CDs in a C s. What you get is the change is getting worse and better over time as more cells die Or is the self recover This clinic injury eso one of the keys that you need to do is going to be seeing you every single day, so it's hard to see if they're getting worse. We're getting better. And that's something that we'll talk about the next flight. So that's the basics of EKGs in a C s. The principles you to understand. Let's talk about what we see in studies. So staying nice and easy, you get ST Elevation basically eso of a second two minutes you get after the elevation. So this is your two seconds on the left side. It's mostly flat. Your ST segment rises in a couple of minutes in the leads representing the artery is blocked off. Um, and it's defines of rise. I think more than two small squares in the chest leads on one in the family. So 12 a V out ABF the changes, then I don't know that can happen over time. So they get worse. Basically, the next changes that's important to know about is what's called a she weight. So you see here that inside of curious complex goes shopping up. This is all to wave is when the first deflection in the QRS complex goes down. And this is indicating that you've had an MRI has been there for some time on these. Stay there forever. Basically what? You've had an MRI, so there's something to look at the C G. Um, the next day or two, you get some tea weapon version of um and after that, the change is kind of get better over days. Eso This is why you should you change is a really, really important for monitoring everything today so you can see what stage people at the hospital because if someone's come in, let's say they're very good. I didn't live. There are doctors. They coming up with two days of chest pain and they've got senti weight reduction. It doesn't mean that they have not had a stem E it means that they might have just you matched Mr Boat. Basically, it's important to be aware of that stuff. So that's elevation. There are times when you could have a steady you don't get ST Elevation. Um, so that anyone tell me what they think is going on on the C. C. J um, the troponin Royce. Um, I'll talk about later. Good question. Good question. So, yeah. So these monsters, Yes. He's almost, like not good. It's for, um, ST Depression. Turn the around one year, I thought so. This is what the posterior stemi looks like on a CD to talk about how the 12 cc only looks at the front. The side on the underside of heart doesn't have any leads that look at the bad part. Um, so what we get when you get post here, it's telling back side of the heart dies. There's nowhere to sense that directly on the sug swelling gets worse with reciprocal changes, which is when you get stuff is upside down on the other side of the C G. So that showed very nicely on the CT. So we talked about how the 123 and four present the front of the heart, and if you would have a standing in that of the heart you get ST Elevation, you get T wave inversion. You get a few ways if you have a steady on the back of your heart instead of ST Depression in their C elevation, you get ST Depression because it's mirror instead of you words. So the lead, the first deflection going down you get really tall are weak. So these are the ones that you can see mainly in the three here. These women have been a stroll on his old easy J on. That's basically the up down she weighs on instead of t wave inversion. At the time, it was really shocked. Reason. T weight and these are all basically obstructs changes the mirror image on one question eso This could be an end study. It is very difficult to tell between posterior am I a steady under. Instantly. What? You'd be looking for different ages between the posterior standing and then sent me It's number one. You get this, the to always. Which I knew you wouldn't get an anesthetic. He just got a nasty to Russia on in and steady. You probably gets, um, S T wave flattening this in t wave inversion. Where's unless you get the T waves going shopping, right? Um, yes, please. Phone. So you can do what's called V 79. So these are what's called the posterior chest leads on. These are just just be going about. And it shows you ST elevation because they look at the back side of the heart and everything is done. I think you don't see too you something to be aware off. Um, yeah, These are intravenous on that to kind of keep in mind. Posterior studies are very common. It's just something to be aware of. So that's ST Elevation on post area Stephanie's. There's one more way, and it's usually, uh, a steady constantly, which is, um, if I don't cook new left bundle branch block. So this is a very typical pattern that you will see. Uh any CJ's eyes. One curious complex there T wave inversion some of the lateral leads and you get these real deep brought recurs complexes with ST Elevation. This is left on the branch block. And what this means is that the left bundle branch. So the electrical wire that supplies the left ventricle is basically not it's really called. It happens loads of hypertension in old age arrhythmias, chronic angina on also in a C s like studies. So if you decided dcj 10 minutes ago is normal, they've got chest pain. And you see that this what it means is that something's going on in the heart over 10 minutes to completely knock your liver under Raj on what means is the hot water was probably died from a four thickness. In fact, I can, um so that's very simple. Nulified Branch Block is a steady into proven otherwise. Um, but the problem arises is when you have an old level around flock. Um, I'm talking about left one of us brought on to in a little bit later off. We've done that. Don't really the only one bottle. I'll get you question that we see a new life on the book is really easy. Oh, I left my other brother. What is difficult because we can see the left one branch block. You already have some ST Elevation. You can see here the one before you already have one. Like she weighs, Seeing hard to tell that something for ST Elevation if they've already got left on a branch block and you do any CT and still on the blood work. So what you do is you could do something called the scar Boss criteria. I don't think you get also the finals. Um, it's something that probably that would mean that's something to be aware off. Um, and it's really useful because it helps you tell when someone's having a steady who's already got a branch block. So another one is called a rescue elevation. More than 1 m just means is that when the cure US complexes to conceal it, at times I get up. If the T seven is also elevated more than one millimeter Bally's he basically having a mild. So let's look at this level on the head. Look at lead one top left. You can see that the your excitement curious complex to go up a normal bowel abroad. Flock, You have some ST Depression. This is what you would expect if you have new ST Elevation when the cure, it is also going up. That's bad news. Number two is when you get ST Depression in the one to be three. So let's go back to this EKG. You can see if he wanted to be three. You have ST Elevation is no one of them on a bad book. You can't comment on that. What would be worrying is if you're ST segments in the want to be three were newly depressed. That would mean that there might be another evoked happening on would raise your suspicions of an MRI. Um, and lastly is what we call discordant ST Elevation more than five millimeters. So let's go back to this PCG. Look at the want to be three. We want to be three in. See that there is elevation on a discordant What is that? The cure is complex is a pointing downwards on the ST Elevation is going up. So they're going to sit way. Um, but what's know where it is that it's less than five millimeters. So It's less than one big square. If you had ST Elevation is we can see here is more Momix where that might mean that there's an emery going on. Okay, so I don't think you need to learn all the heart is something to probably just like I don't even know. I just give it a little bit. You You probably about 30 seconds in real often people it if you know about fast this card to criteria, it's useful on you. Look pretty small. So, um, so things to talk about depression about level, Um, how important is regarded steadily. Uh, I can't remember. I just plug it into Medco on it would do it for you. Um, some starting to question It tells you that it's already back home. Um, I kind of really just about aware of it. Comes with you. Um, so I'll let one of us is right now. So the classic thing that people talk about is is William and narrow. Um, So what that means is, William, It's left on a branch block because William has LDL's in the name. It's just like a little what? I mean, did you get that? Don't you in the chest lead in some of the right hand side. Just need to see, you know, maybe on W um and you get them. So w in an m for William in the last leads. So you can see here. It's like a numb. That's what I wanna rock blocked, basically, and it's just a lot of recognition. The pathophysiology general reasons for this, but it's just about kind of know how to recognize it. Um, yeah, right on around block looks a bit different on you Get It was called like a bar us our pattern being lied morning to be four, which is like a little squiggle. She's something to go in parenting issue. Better have a face for that, unfortunately, but it's kind of turning into your brain. Um, on Epitol has been very useful on. Told us how to use this. Got all the criteria. Think you're not probably better for the talk started. Thank you very much. Lovely. So that is steady or any C g. Nothing. Simple number one best information. Which is what 99% of your stuff is gonna be No two posterior stemi. Another three left one branch block using your scalp or two criteria. Um, I don't go to Don't notice you got the EKG. Got stuff? You don't get any more blood tests. You could just get a true thing. So what about in stable angina instead? So it is a little bit moderately. They both share the same features. So you get changes the represented scheming or four partic thickness in function of the color of the myocardium. And this is manifest as ST Depression, which is on the bottom left hand side. I don't know what is up slightly and downs with the years just the ST segment is depressed. That's enough. Tonight, um, on T wave inversion or T wave flattening. Um, so we can see here, too. Fatty waves that right now, investigators of the bomber on this represents both in instantly and then unstable angina. And he contacted partly. Did you, uh, also really have nothing? Just I don't know why that you consulted have no changes. But this is when you kind of need to think a little bit more about what's going on. Basically, so it's strictly for a few reasons. Number one STD changes at the same number two. There's a thing of pushing for a Prolia is that those things can cause, um, versions of himself. One old study call t wave inversion. The way you were told, difference would be the time frame. So stepping has to you have inversion after a few hours after a few days. Sorry. Whereas unstable angina and steady called to live in. But right away, Um, loads of things called a conversion There. Is there a lot of time. So peas left ventricular hypertrophy left on a on a block. The difference between this and unstable angina and and instead me is that you get what's called dynamic changes. So they change over time so the two inversion might get better or make it worse. You know, you have cells dying or if you know, if if you have changes, stay there forever. That probably means that it's not in excess. Okay, um, number three days you change is so how do we go about telling someone's got to be exciting? Chest pain, eating cheese a little bit. You don't know what's going on. This to a conversion. Give you seven, John. Understand? It could be nothing. Yeah, Into school. so we don't that's running a little bit. Start to talk. Opponents and ends are released When my cardio dies, so are you. In a study for study, it's not really in until I'm Joanna, because there aren't any death of my car to themselves. When morning honey um, dies. What you get is represented by the red line on this graph, so you get a very sharp rise in your troponin that could go up. Thousands and tens of thousands is, like off the scale. Settle slowly or two weeks on. The use of that is what you can do. It do repeat measurement potent to show that cells are actually dying. So let's say you take a proponent. It's a little bit raised. It could be something about that a little bit. What you could do it in front tiredness is wait three hours. Do it again. And if your troponin sharp, it means that they're still sounds dying. And what opponents leaking into your blood, which indicates an acute coronary syndrome by instant worst time. The difficulty with proponent comes with the fact that things also raise your troponin, Um, so anything that's strange, your heart was racing or proponent. I'm not sure why, but peas if they're big enough heart failure. Arrhythmias, pericarditis already. Your department, um, troponin is eliminated in the kidneys. So if you call CKD or anti I even apart opponent, it's not clear from your blood. The difference is, is that these causes down here don't cause this rise. And for one or two opponent as a C S does. So this is where the value for a Petri protein measurements comes in really, really handy when you're not sure what's going on. So if you do department and it's a little bit raised, you see when these two bones in effect, it could be anything. Basically, you repeat it in three house, and you see if it's shark. That means that's themselves still dying, and it's probably on studying. Worst time on If the proponents about the same, it might go up a tiny bit or a mind going down. It's probably something else. You don't need to worry. The value that we used to say that there's been like probably changes 50% some labs. It doubles cause they used to slightly different components. I have not given exact definitions here because it's just more about the principles of how to understand troponin results. Basically, now I've been here now on upper limit to driven so dependent of everywhere blood test in there. It's not just got one upper limit. Like I know a CRP is below 10 normally or whatever. And then if it's raised, it's raised troponin external out where I work, they let the range is 2 to 260. And what this means is that below the lower limit said, too. It means that there's definitely no cardiac damage. So the 99% of people that they've tested they don't have any troponin released. There's no cardiac damage to the heart, completely healthy above the upper limit. So again, 260 in my lab of it could be other stuff. I was where is indicative of cardiac damage? So that's enough. Troponin released that it wouldn't be one of these things here causing, um, arteries. And proponent is gonna be a big heart attack, basically, so you don't need to repeat the moment because you know what's going on on. That's what a Valium repeat measurements come in. If the proponents within this kind of middle range, where you're not sure what's going on. If it's within the range, you repeat it in three hours and see if his rhythm and if it's written sharply, send all of 50%. It'll doubled. Um, then you could be sure that there's an acute coronary syndrome happening soon and study or something. Uh huh. So that's troponin is to get your head around really important. People did find it all the time, and you could not treat some of the heart attack we treat her heart stopped wrongly if you don't know how to interpret. So it's not about the exact values. It's more just about the principles of this rise and fall. And the other thing is great Children. So that's a better world and everything. This is it simple. Just kind of a lot of stuff is not easy. So you got some with chest pain sounds. Skin it. You don't need to be on the west elevation. There you go. Got study. Off you go. You do any CT? They've got no ST Elevation. They've got some feelings. Having chest very in 71 conversions from the ST Depression could be an unstable angina or could be in Anistan any. So you do it on. And Stemi has heart proponent on unstable angina have no parents. Okay, so that's how to spot a C. S there. Any questions before we got 103 days? Yes. Did not qualify. Appreciate it. But the main principles are department to understand, Not the exact time use was a dynamic rise. So that is shown here by this red line on the graph. Dynamic rise means it rises the time. Basically what? We used the definition of dynamic where I work, it's 50%. So if it was 100 150 that's a dynamic rise in other labs. It might be doubled. It just depends on what the medicines that they use. Um, we're a zip it, bro. Less than whatever your reference range is for. This is not a dynamic rises. Just insignificant rise. Um, there is a medical schools. Uh huh. Is irritated. Cough. Yeah. So where I work, it's 57. Another last 100. Um, if you got a question about the shooter, you what it is I'm in the time frame is three hours. So again, that's where I work In other laugh, it's six hours, but most of the time it's three hours. So 50% of the three hours is what we use. Uh huh. Wise. What I say we talked about a dollar nose. Yes. So how do we treat a C S three immediate management docs is not need it. It's all the same, no matter what they say. Yes, you have important principle with a C s treatment. If everyone gets the same stuff, they just get it over different timeframes. So So your investigations. Someone's got a skipping sounding chest thing. You doing STD That's have after you to do. You don't wanna do some blood tests, so you're doing component if they've got so it's keeping changes. You could do a lipids because this is showing risk factors for heart disease. You could do a glucose. Diabetes is another risk factor for heart disease. You do you any because if they need to undergo gram or a PCI, they inject contrast on. If you've got naked kidneys, you can't have any couple trust. Say you need to know what I mean. You don't do a full block out because again and cold when they could do an underground PCR. Um, you can lose blood on you bleed. Say, just need to know what's going on. Um, it was brought up about 22 only girl earlier as well. And this is where the full blood count comes in very handy. So there's a blood clot of the mountain who has, um, a skillet chest pain lost mine. Um, so the team where inversion as an ST Depression we thought he was having and stuff because it's a potent was raised. Well, it turns out that he was actually anemic, Um, and all he's got Type two and by So that's when there's not a limitation of the blood to my cart in by blockage in the artery. It's when there's a lack of blood from hyperfusion from somewhere else. So it might be your anemic, and you don't have any oxygen in your blood anyway. So even if your arrest, you got to have enough to surprise heart, um, it happened in sepsis court. Well, where you might be tempted shock your blood vessels all dilated, and you can get the blood to your heart basically, and that's a type two. Um, I it's important to know about because we treat it slightly differently. So, for example, this bloke easily neck upstairs. We have stopped his anti platelets. We've stopped his anticoagulants because they're just gonna make it worse. What you do, you need to replace his blood. So that's all about treating the cause. Basically, in a time too, right? So So you've done your investigations. You don't go into your treatment. So this is what you do kind of a junior doctor. And if you see someone, this is what you do by yourself. Basically. So if actually you want to talk the meeting in pain? So what we give IV morphine on metoclopramide metoclopramide is an anti emetic. We mentioned that you feel sick when you have an A. C s. So you want to stop that on morphine is also a drug that makes you feel sick. Sick of the metoclopramide, you give the medical right because it works For me, it's an antibiotic that works by blocking dopamine receptors on your peripheral organs. Um, so your a one C's release these chemicals don't mean when they were upset, and that's since my brain, they make you feel sick. Metoclopramide blocks the release of these don't actually have you accept. Basically. So that's all Number two is, GM said. Let's try. Try not draped. This reduces your pre load. So this is a V no dilator. What it does it dilates your veins, reduces the amount of blood going into your heart so your husband won't less heart on. This reduces the oxygen demand on your heart on you cannot get this is a spray underneath the tongue. Or if that doesn't work, you can do an infusion. But you would be doing that itself is an infusion. That's why I couldn't see a decision to make. That's just something that you could suggest, or something that you can do if the sublingual b together help, Um, then you want to give him something to basically help that blood clot that you're having in the artery. So you give us to aspirin initially, Um, and you want to give them another anti platelet, but the precise short of that company later. So the initial one is just after on blast. These oxygen said he's been acronym called Mona, which was morphine oxygen, nitrates on. Now questions only given if you're high pox sick. So if you have too much oxygen in my it's dangerous because it generates free radicals, which that damages your heart even more so you want to give him oxygen if they're below the target. Saturations basically, um, take a question here through to make that spread. Yes, so they get 300 of aspirin straight away, which is what a loading dose, and then every day after that, they get 75 mg of aspirin. So you just give them that big of aspirins trail with basically, um, so that's one issue. By now, you should have an idea of what's going on. You got the C G. You should have got to put it back. Um, if you have the C G. And it's a stunning, you can stop what you're doing, and you just need to start treating that basically, and they need PCI. If you've got your SED, it looks a little schematic. You need to wait for your components, which is lucky because unstable angina and then step be treated exactly the same. It's less urgent. You can afford to wait for your components. Um, you just crack on with giving him the rest of the drugs. Before you do your PC, I go through what he's our next. So we've done the immediate treatment. No, it's going to a stone. So this is nothing simple. Basically, this is the time frame that was mentioned earlier. So Number one, the first question to ask, is deficient and start 12 hours ago. Um, does anyone I wanted? That's a 12 hour call. What? Aspirin into the first treatment? Yes. I mean, yeah, it's all the same. You know, she asked about what it is. Changes? Um, yes. And he said he changed my stopped, Which is which is kind of the underground. Want this survey? Typically 12 hours. It's the amount of time my cardio convert so before it's in recoverable. You can't do anything about that. Even if you do PC, I get roughly back. The heart muscles just not could give miss the boat. Basically, um, so do you have have been stemming or two? A PCR. So you give him aspirin initially, then you give him another treatment. But we'll talk about anything PCR after, um so we'll talk about the reasons behind doing each thing as well, so hopefully I'll explain things. They're 12 hours is the time frame for which, um, hard to diet, and there's no point recovering it. There's no stop because, um, sometimes you do have after 12 hours, and this would be if you've still got heart muscle. There isn't dead here after 12 hours, and this could be told by if you're still having chest pain after 12 hours. If you're still having chest pain after 12 hours, what it means is that there's still myocardium that's dying. Um, so there's still some tissue to salvage, so you can consider doing PCR after 12 hours if someone's still having chest pain. But that's kind of very, very minor. Basically, um, things that question is, can you get to a capsule within two hours? I don't know why this kind of exists. To be honest with you, it seems the arbitrary in the UK Most people will be able to, um, so working in a district, any hospital, we send people with studies straight over to a big surgery center with cattle out. It's about half an hour drive, Um, so most people with standing the arts will be yet and went 12 hours to play that. So this might be one off role to get around or press a gram? Uh, the ones that use different anyway. Work. So I've been getting, like, a specific want to know, just pick one. And Benadryl is nice. Easy to remember is most other things as well. Uh, they get PC on so they get going to blow into the artery blue now up and fix the blockage on that PCI. The cardiologist will give them something unfractionated heparin, which is an anti coagulant and helps break down the coagulation cascade. It's happened around that clot, so that's not something that you would give yourself on. But it's something to be Well, yeah, if you've missed the 12 hour window on carpet to pizza have been two hours. You can do what's called fiber glasses, so this is a drug given to break down. The clot could alter place. This is given instructions well, and it's basically the same principle PCI with just with with drugs. Basically, it's less effective than PCI on the bleeding. Risk is higher, which is why we don't do it very much because the bleeding risk is higher. You give them their second anti platelet after they've had the fiber rely a test because you want to make sure they're not gonna bleed out basically on. Then the cardiologist will give him a different time of anticoagulant called a fund. A paradox, which is slightly less effective on for Actually did have, really, But it's the uterus is higher. You want to talk about the style, basically, but this one on the right is kind of minor. Most people don't get that. This is on the left is what people get in the UK you've had a study basically only spent the study, Um, let's talk about unstable angina and in studies. So we mentioned that the management is Wes rushed. Basically, it's not. It's not urgent, so no one will give him the second plane that straight away. So I get into a little graph prasugrel kind of long nobody. You give them for the paradox. So that's an anticoagulant that helps them break down the coagulation cascade in the artery. And number three is all about estimating who's gonna die from that unstable angina or the instantly to prioritize you get a PCR first so everyone would have energy to get PCR. But you want to work out with a higher risk of dying. Basically, you do that. It's called a great school, just like I don't know what's on it. The Congress just never use that. They just kind of do what they want. Basically, because I called, You know, it's nothing that it more with the sore stuff. If your exams, this is whatever. So if you can't let this score on Medicare or whatever you won't be asking resulted in examination, rescue was really mean on the risk of dying within a month. Within a month is medium to high. You don't do PCI within three days. Um, PC I've given actually detect rid of the cardiologist. That's not something you would do. They just get a piece of a good three days with one of you, basically, if that he would have probably unstable so that shocked that language is low. You could do PCR sooner, but that's very rare. Three days, something to learn from state Georgia on against me. If they are low risk, so they're probably not gonna die than the risk of PCI are always the risk of the diet. Basically, from the study once take a giant said you leave them alone. You see, there's a lot of patients, um, and you can start if you need a PCI later. Horrible. So that is an instant. Any harm? Stable angina. Um, what about stretching kind of TV? A five or a little bit? Yes. And tp a is the place. Streptokinase is an older, drug strapped economy. Is is it's derived from bacteria. Um, have similar. They make me ta in them. The reason you don't have tachycardia is is because what you've given it once your body makes antibodies to it so you can't get it again so that so you give him strapped economy is for a study, then they have a stroke next week. You kind of bug of yourself basically, because he's talking to me. What kind? So that drug is kind of in the past, we don't do anymore. It's what about to place Now, um, so start immediate treatment of a C s. So to make it simple, everyone gets 200 units, everyone gets anticoagulants for the parents were frankly, to taper in on. Most people get PCI know, many people get glasses off. They just happen in different timeframes, depending on the clinical Need. Another way to think about a C S management is what about using a Diet Coke? It's from this stuff. That's what you need your treatment. We then had some questions about long term treatment of 80 s that star. So he's really reported. So this is what's gonna make people live longer and better after it from a heart attack. There's no point doing on your fancy stuff going into saving her arteries and then they die six months later because it will. No, no heart, basically. So that's what you would do and her. So this is to see if somebody pharmacy died on, see if they've got heart failure. Then you could start on the appropriate treatment. You don't want to start them on four different drugs, so these are really important is probably helping your exams. So number one is an ace inhibitor or angiotensin receptor blocker. These prevent your left ventricle from remodeling. So what that means is, after it's died, the heart was still tries to build back in a disorganized way. On the bad thing is inhibit to stop that and leave your heart muscle is these. Increase your chart. These improve your elective time that you live. Number two is a bit of walking. This decreases the amount of demand for the sympathetic nervous system or your heart beats that strongly. Doesn't need as much blood to be getting a crucial charity Number three is up to. So this after July and he played treatment. Statistically, you're and your second anti like that. You get both of them for 12 months on. After that, the bleeding risk of both of them starts to outweigh the benefit of both. Um, so then you switched them toe aspirin only for the rest of their life on this stops been talking, their artery getting bigger. It starts swelling up again last week. This is mostly what want a high dose statin. So this is what some atorvastatin, Um, this is the most important one because there's new research about shows that statins stop your coronary plaques from bursting. So if you start someone statin there, every high risk of having a plaque rupture to start a key to get into, um and basically on this, um, kind of smaller stuff to my style. Stuff that cardiac rehab. This is like exercise classes, which are really useful stopping smoking, living healthy, basically. Um, so that's a long time Months with PCs. Yeah, I went off that he has 12 months that should be breathing a shin and doctors join. That's the treatment based gets you kind of the immediate stuff. What you could do, what the cardiologists would a on, then what we do after tell people live longer. Let's talk about something to go wrong after you've had a heart attack, because this is also being able to get back into their different weight. I do it in two things. Every bad stone for three. This is stuff that kills people from a heart attack. As we said, your heart's condone I and you could be perfectly fine. But if you have one of these things going, basically you're toast. You have chronic arrest, um, saying heart attack your heart. Electricity gets messed up and you have a a rest for a systole, and I never until you have candidate shop sort of leave. It was covered yesterday about Dylan's talk, but basically this means your heart can pump blood. Um, any of your organs? Uh, you Your organs failed and you die. It's really hard to treat. We seem to be with the ward. They don't tend to do very well. Your left ventricle can rupture on this sounds bad. And it is really bad. Basically, blood flow from your left ventricle into your pericardium. You get having out your heart can't beat anymore, and you will die of contradicted shock on that issue. Kind of draw the blood out. Basically, um, nothing's in town. It's just not a sports explain it really on last. Another bit of bad news is what prevents sexually effect. See my hours apiece you get a whole between the two between two ventricles blood flows from your left internal to your right ventricle because the pressure the ventricles higher, um on basically means that your heart can probably blood is all going to the right heart. You get pulmonary edema, you get heart failure again. You will not be doing so. That's number one bath stuff. The hands Number two is A with me is conduction issues. So these are really common. Basically, any with me under the sun can happen after a while. Touch. You've messed up the electrical wiring. Everything is already called, especially Bradley Arrhythmias. Slow heartbeats. These are common after an inferior because most commonly, we said right for reality supplies the the three part of heart. Uh, the right coronary artery also supplies your essay, and that's a sign of a true if you messed up by blocking its electricity, your heart will be a slow, but you get brand economy is so hard box. So it's better idea, basically something to be said about that on these other things that don't be fair to anything else. So pericarditis. Very common chest pain, ST Elevation to treat it with him. Profit Basically much rotations. They don't want to about rupture. Get on this side. Too much regurgitation you get the same murmur is a VSD seeming to do the echo dress. This injury, which is kind of examine favorite. It's not very common veterans that time, but I think they're like because it's like a classical thing. So you get It's like your auto means that you get a high. Yes, you get recurrent pericarditis and you get clear infusions. A few weeks after that and he treated with So by preference on last week is what's got a left ventricular on your wrist. So this is when you get blood in your progressively presents with pain. 6 48 weeks After that, you get ST Elevation on your SED. But it's there all the times that's not bad. Manic on. We need to take you to get the warfarin to break down the aneurysm. Basically, um, so those those complications, hopefully winter's We've been about an eye on the house, and that's two. Or boxing. This's questions. I think this is stuff that we'll see. Um, can you used? Uh um For what? In terms of exactly every other day you can? Yeah. Theoden. Between warfarin, The doctor is about the same. Um, some consultant warfrin some these docks. I wouldn't be making a decision myself, but yeah, you can use it up, but yeah, So this is the first case of these are more like a written down once. It is how I think that there's no poles. So have a minute was going to read this lovely. And that's, uh, let's show you the study that mass hands. Dear Dr Busy today we're gonna do about this is what will happen to you guys when you were here for until it's really scary. So his is easy. And here's the questions. So he's got some central chest pain. 10/10 reading into the arms of the jaw. Give you the CT J. So what are you using? Any questions? And I did a fantastic fantastic. You guys wanna completely not something. This is good night. Uh, yeah, Yeah. Interior stemi is the diet almost. It's very, very good. And you guys already played out. The second question is well, which is that the pathology is in his energy because he's got some escalation of each evening. Three before, which is the energy. So he's having an anterior study. So can we know it's a drug that gonna get him, You know, any Yeah, Morphine? Yeah. Asking 70 pregnant aspirin year. Yeah, yeah. Um I actually did happen. It you wouldn't give in a li. This is given by the cardiologists whenever you PCI Um, so yeah, he TSH is the answer Yes or G n more field and your independence. And then some cigarette with that oxygen. Only if I pox it So this black is my optic. So it doesn't warrant any warfarin any? Uh, Oxygen's all right. Yeah. Mine is used for the sickness. Um, number one. You get sick from the airline. Enough to morphine makes you sick. So we just basically just must be a lot. But I stopped that. No one fixing that. And 80 if he still feels like rubbish. Knee still has a pain is basically on. What is the definitive management of this problem? PCO I s o. I did have it for about What is that? About half. Now, um, he can get to a center that you got a cataract there because we have a civilization. That's a PCR. Uh, if it was within 12 hours, just just with one stone with chest pain, you could do so, um, PT eyes? Well, 12 hours, blocked arteries. Very good. Have you know which we got him up here? Um, but important thing tonight that comes up kind of common in women on what is that? You can only do PCR people if they're arteries partially blocked. So if you don't have risk of this, if you do it under, grab this guy, but his lady is completely blocked is a complete blockage. It it stops. You can't PCR Uh, That's because you can't force a stent through a complete blockage. You just basically mess up the artery and cause it to bleed everywhere. Really bad news. What you would do that is a CABG. So that's when you graft one of your veins of your legs. Were Lima who left internal mammary artery around the blockage? Um, you do PCI when they've got less than 99% stenosis. So when they got that, you're actually not force the the blue trip. So I think what the carpet is 75 to 99% stenosis. I don't think that's going to come from your exam store just the way you could do PCI or cabbage repeat size in most people. So that's what case number two, okay, it's been a couple of the street. Yes, and PC on undergrounds dumb if you want to tertiary center. So based with Cath labs that at the same time, because you need to see which arteries market before you does. I was going to block um, and if you live in, if you work in May of Detroit. General Cardiologist Do angiograms. They see which are trees? A messed up on that list on the milder. That's in an instant, you know, state lunch in a study. Um, it's a problem in general. So you basically want your problem? Is the gold standard for seeing a corneal trees? A CT for angiogram is used when you have, um, stable of job, uh, less risky. Invasive. You're on cheaper to quicker. It's on there to do the angiogram. So it's used in a statement. Angina. But when you had a heart attack, you just wanna get have a good look at the arteries. Your questions. Anyway, I've got time to read it. Um, so again, you know, just get you exactly where you go, Doctor. What's going on is the CT. You have a degree of the old meds on you find in the city from last week, which is completely just a reminder just fine. How did you get that worked on? Troponin is moderately raised, so Yeah, you guys are already, uh, miles ahead of me, basically. So this is my little bit to step question, which you get the final is quite a lot. So what is the most appropriate month plan for this patient? Any kind of weapon down. This isn't that Well, how are you today? Thank God you got a card or just ready. You thought that you saw this guy. So yeah, you don't know the moment whether he's got one of my joint study without holding could be raised because you're a star of the troponin curve or because I got something else going on. I think I read in the case that they have got no one in. Let's see what you get it. You don't know what I've got the weapon. So you don't treat them as a steady or unstable angina, which is really the same with 200 units. Followed rocks because they're hemodynamically stable pain relief, morphine and GTM on Do a repeat proponent in free house only. So seven point of the question. So you do it with a repeat bone in, and it comes back at 122. The previous is 104 have grace of school. Is low risk fund. A paradox is an anti coagulant. So it's a factor. 10. Any inhibiter or it's a direct thrombin inhibitors. It works with the regulation cascade that I love the fire alarm upgrade. The second after. A lot of these are all, um but you do it because you got the population cascade activated when you break the endothelium. So it helps stop the blood from basically, um, when you got to do, yeah, you give him aspirin as well? Yes. So that's the jeweler. And if it gets so the aspirin and the ground to capital, you know, um lovely. Yeah. You guys are on it so that you don't miss. It is unstable angina. And the reason is is because of the troponin rise, as we said, isn't significant. It's not 57 higher, but this would be used in my house. I don't think that I haven't raised forever. We'll see you safely say they got a new stable of Jonah. It's a rescue me on the 80 g on. They've got some kind of controlling noises. First was your best. You know what? Maybe there we go. Um, finished management. Perfect. Right. Well, thanks for all of them, so they don't need a PCR right away. The risks of PCI probably outweigh the risks to him having a death from that stable angina. So you do the medical management, so the medical management is just here. Um, so you do your five drugs, your 200 players aspirin to come, it'll grow. You do your Byetta marker, you do your Lipitor and you do the harder started, okay? And the other drugs that are gonna soar people out. Um, if you find it does not rise very quickly, does that mean it's unstable? Yeah. So this is what component is tricky. Um, so you have to have a C s is is very clinical in the diagnosis. Basic. So the kind of catch with women is that you have to interpret that in the right clinical context. So let's say this lady had no chest pain that easily was no. You did a troponin because you're just mad for some reason, and it was raised. So you've got another one in three hours, cause you just make some more work. Uh, and it's high. That is not the right clinical context for a C. S. What you need to do is interpreter with in the clinical context. So this lady has chest pain it sounds good. She has the CGM that look a schematic and she has a proponent. There's a little bit raised. Uh, so in that case, you can kind of say, hey, that she is having a cardiac event. But it's not on understanding because you're coming isn't raised. If he wasn't having any chest pain, wasn't having any are changes then? Yeah, I would definitely do the other courses of And also, I guess the, uh, the other stable angina they're going to still raised because of the other quarters. It's the lack of colon rise that means is unstable angina. Um, your dress is that Is that it's just pain. Well, who's right? Yeah, Exactly. Perfect. Perfect. Yeah. Would, you know, do a piece of cheese? Yeah. You In this case, you want what happens on the water? A lot is people who have got market corneal trees have this whole chest pain. You do any surgery when I'm having the chest pain and it looks really bad like this. You get worried. That just goes way. You do Another EKG on the HCG returns back to normal. That is what we call dynamic changes. Same as it has been some sort of blood supply issue to the heart were a couple of minutes. Well, they've been having the chest pain. You get the escape, it changes that chest pain goes away when the heart's. If I is better on the SED, revert back to your say you would want. It's very easy days. Um, start Russ. Not basically we've gone through it. Yes, it is. We've gone through how to spot it. We've talked about some of the things one of the CDs talked about keeping a close with her opponent, and hopefully you guys understand your bone, and that's one of the beauties want to get out of this and also keep a treatment. But, uh, the other treatment, it's just a different agency. That's how to keep it nice and stable. When you had, uh, the long term management is really important. Help save people's lives and complications could be bad on this fucking die. Your dissection. So dissection Tricky. Um, say do this and half in the PC change the accident, The dissection, attributing. Sometimes the New York sections you can get inferior, and I explanations. Normally the dissection universities will be no, because your arteries Don't know. Sometimes the dissection couldn't move up from your aorta into your coronary arteries. Um, which causes a steady one instantly. So when we talked about right to start to talk the rare recorder's of the study, it's a little dissection. That's because the dissection worked its way through the artery up your auto inject coronary arteries. But you just get asked me the same changes, basically. So if you got something with chest pain radiating to the back, um, their blood pressures drop lines. Are they pretty nasty on then? Esther Me? Don't worry about Intersection on of UTI's. Yeah, just walk back again. So this one was loads of the water. As I said, Uh, so you do it like you did before on any chest pain. It is normal. She starts having some chest pain, and the CT turns into this, which is where you got the actual depression into getting some ischemia. You would then do a repeat CT once had chest pain is resolved. If she still have these changes, Uh, that means that they're still damage or that the heart's still didn't own a lot, Um, or it's caused by something else. ST Depression is normally ischemia. If it was t wave inversion of the T wave inversion stayed at the whole time and didn't change when she had the chest pain when she was pain free. That would point to it being not dynamic on know a C s. So you don't do any CT when the chest pain is stopped. Onda her eating is not at all. What I mean is that the heart do have some time where it was compromised, which is why I get the skin changes. But the blood supply is kind of spontaneously reverted. So it might be that the plaque was really small. And it's just kind of dissolve by itself on those that kind of the beauty of a repeat EKG in a C. S. Because you can show that there's been a dynamic problem with the heart. Looks all right on how to differentiate from other causes off off to um okay, I think what I mean if it stays in my favorite TV ways. So five days of T waves, um, have a lot of different causes, it stayed is about it E wave. That's bad news. That probably means that you've go. So I think that you're doing ST Elevation and then depression, Depression, elevation. Could be lots of different things to buy a T wave. Um, if it stays, is my visit to wait? That's probably bad news, but it would all be about kind of clinical context of whether they still have chest pain, whether they have other issues. You changed that same time. Um, so, yeah, when I see my visiting ways, I just called Branch because I don't you know, girl. So I wouldn't worry too much about that. Basically, um yeah, is, But if the team I moved to the change stayed off the chest waders old, it's no, I guess wanted to make it doesn't change. So this is especially asking about other course of t wave inversion, um, lousy things and cause this I recommended going onto Web site called Life in the Fast Lane. It's like an alien website with a lot of the CT stuff. Type in life in the fast lane T wave inversion, and it will tell you Yeah, heart is your final time. That's great. Total because of the way and it goes through this dynamic stuff on this. Not stuff. Basically, if the T wave inversion isn't done on it, you'll find the to mean horses to go through it in this talk and face. But if you have any spare time and you're really bored Okay, guys, thank you very much for joining. Um, and that's the stuff. Um hey, is I think which one is the one that gets, You know what? He asked me questions. It is? Yeah, it's probably you. Walk, heard Can use it for some people. Fairly. I thought, uh, that very grateful hanging on very much for this now, Georgia. Um, yeah. Anyone watching TV show it gets filled. Those for them like that, especially the criteria and stuff. I need to go back. Go over them. The for the name albuterol. The breasts. Breath. It's one. It's got that yesterday. That stuff. So I don't know. Yeah, it's more mental. You know, I've never heard that, but I don't know why we're not talk about it, because we just get talking. 11 of roadblock. You can tap of the c t eight level block, but it's really simple. And then it got finals or whatever, but yeah, well, you look like a like a smile. Yeah. So you feel feel that because about one confirmed the feedback form that the cure rate and, uh, put the link up. The charges are recently just in case we want so on D, I think will send the site and recording out from that, uh, zero bind. More questions. Any questions over the way I'll put him out of the shop. Um, she may email if you want. Um, what's left? Want emails? Yeah. Yeah. If not, then they care for coming on. I think tomorrow there's a C G depreciation talk on. Then the day after, I believe progress through chronic quality diseases, there will be another easy. So after. So this could be a part of our cardiology a week. But you can see what they're based on on that. The general questions. Well, that's what God, which we said. Yeah,