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with morning, everyone. We're really delighted to have Ms nearly 60 d a. With us today. Senior clinical pharmacist Um, the topic going to be on cardiology on following lectures will carry on about drugs that will affect the heart on if your new please make sure you watch out the feedback for near which will be shared in the chat box near the end of the lecture. And also put your name of university the year you're in and the location urine in the chat books as well. If you have any questions, wait until the last 20 minutes off the lecture. Unless there's interaction during the talk, then you can, um New Tarceva. Thank you so much. So I will let the doctor start. Thank you. Good morning, everybody. Thank you all so much for joining the session today. I am aware that obviously we've got lots of different years. I'm turning into the lecture today so hoping that that this lecture will kind of bring everybody up to a baseline and everybody to sort of remind themselves about the basics of cardiology because this is gonna be really vitally important when we talk about how the drugs actually affect the heart. So we really need to know about how the heart functions when it's well in order to then know why and how do the drugs affect the heart the way that they do? And others say this is an hour's lecture and we could go into so much more detail as we go along. Sir, Um, consider this almost like a whistle stop talk, audiology and a bit of room minder for yourselves. So in terms of the outline off this lecturer in future lectures, it's going to be about the anatomy of the heart, the circulatory function, the electrophysiology of the heart, the conditions which affect the heart drugs for the heart. And then we'll also have some case study sort of towards the last few sessions as well. So now let's talk about the anatomy of the heart. I'm sure many of you may have already had sessions where you sort of dissected what the heart muscle looks like on day. In that sort of things, you can really see all of the vessels and see the coronary arteries. Look at the able turned everything like that. So let's talk about the muscle cause this is actually going to be again really important when it comes to them when it comes to the drugs. So the heart is essentially a muscle and it's made upon muscle called the myocardium on. We're going to take a closer look at that in detail. So this myocardium is actually responsible for the force off the contraction. And as you know, the heart's in close in a protective sex call. The pericardium was well in that and that can get inflamed. In course, things I pericarditis a Xyzal which is wise, important know, and that the heart is enclosed in this pericardium, so looking at the normal function of the heart, So this is sort of like a dissection of the highest rated middle eso. As we know, the heart has got more chambers. You've got two Atria and you've got to ventricles. And if you want to take a closer look at the actual structure of the heart, are here. You can see here that the atria here is quite thin. The muscle off the 80 here is quite thin, whereas the muscle off the ventricles is quite fake. Now this kind of serves as a purpose, Teo enable to pump the blood around the body as well as to the lungs as well. And this is going to be important when we actually look at the arteries. And when we look at the structure of the veins as well. So in this picture you can see that the blue areas essentially I'm show you where deoxygenated blood is. And the deoxygenated blood that flows into the heart will then go to the lungs to then be oxygenated, and then that then comes back through those pulmonary veins to them be pumped around the body by the aorta. So, as you can see here, you got your inferior vena Cavor, and you go you superior being a table or a swell. So they carry the deoxygenated blood from the body and what it does, it goes into the right atrium and it goes through the age of actually quite nicely. About 80% of it actually goes through without any sort of influence. It just goes straight through that 80% of the blood go straight to into the ventricles. The last 20% of the of the blood is essentially pumped through to the ventricles. And that's why it's really important that we've got these bowels that are separating the age and the ventricle to prevent that back flow off. The blood coming through says you can see here on the right hand side you've got your tricuspid valve and on your left hand side, you got you you go in mitral valve. So the blood then is in your right ventricle, and then it gets pumped out in for by the pulmonary artery to the lungs. Um, and in the lungs that you will have your your exchange of you know, you you can see it's your glasses exchange. Very. Um, that happens because this actually carries a lot of carbon. Dioxide's is very high in carbon dioxide. Um, and it's actually very interesting because when you look at the function of arteries and veins put the pulmonary artery is the only artery toe actually carry deoxygenated blood to the lungs. Apart from that or other arteries are go away from the heart. So this is the way that I always remember it are fees away arteries always away from the half. The pulmonary vein, however, carries oxygen. Eight. A blood to the left hand side of the heart, not the only one that does so again. So this is really this is really important. When we're talking about the disease is the functional diseases that can affect the heart. So when we're talking about the thickening or valves where you got stenosis, that happening in the valves is Well, it's also really important when we talk about things like heart failure because that's where you've actually got, um, where you've got a dysfunction off the off the ventricles, which are then causing this heart failure to happen. So now this slide just essentially shows, um, the the flow off the blood from the main arteries all the way to the veins. So, as you can see, the arteries is like your biggest. Your your biggest muscle is very thick. That's your biggest, um, a vessel that you're going to have. It goes from the artery to the arterials to the capillaries when you get the exchange and then from the capillaries, it goes from venue ALS to a vein. So the blood flow from the body back to the heart goes from van. Use minor veins, major veins being a carbo. Okay, the blood flow from the heart to the body goes from the major artery. So we're talking about, like the water to the minor arteries to the arterials and the capillaries, where you then get that exchange. And this diagram dishes how they're essentially linked together. And that link is essentially what happens in your lungs as well. So it's really important to understand the vascular anatomy off the veins and the arteries and the capillaries. So as you can see here that they're different, they're different layers of that. The arteries have, and there are different layers that the veins have. It's well, you've got this external elastic membrane, which is helping to almost regulate that pressure that is happening and allows the arteries in the veins to sort of expand and contract and naturally, within the arteries in the veins there are receptors, and when we talk about and sympathetic person but the ticket of a shin and when we talk about again things that nitro suck side and all those sorts of components, you'll then be able to sort of really appreciate why it's so important to have an elastic memory, why it's important to have that in a smooth muscle in the internal elastic membrane is well, And then, naturally, you got the Lumen in the middle, where you tend to get most of your atherosclerosis sick. Process process is happening as well, which can then lead to which condemned me two diseases. That's where you get most of your scheme. Urine. Those sorts of things as well is, you know, here the arteries don't actually have a valve. Here it is, actually the veins which do have evolve. Um, that's to prevent any backflow. And remember what we said about the veins carrying, um, the coating the blood back to back to the heart and what we don't want to happen is getting that back flow of blood, which is why we've got which is one. But there's valves. There will you will be our trees because the office also taking bearings. They're essentially that thing. The arteries, They're the ones that essentially have that pumping action. They didn't require valves because they've got such a force behind them. The blood that's called that's in the arteries have got so much force behind them. But there's no requirement for valves to actually be there because there won't be any backflow, okay? And obviously, as you notice here, the capillaries don't have any muscles and they don't have any vowels. And that's again to help with the exchange that you got that So two and 02 exchange, that's happening. And it also helps, obviously with the filtration of off ions and those sorts of things in the couple of these as well. So now let's have a look at the coronary anatomy because we've talked about how the heart is a muscle that essentially pumps blood to the heart, to the lungs. I mean, that sort of thing. But actually the heart itself needs its own blood supply, right? The heart is a great job for all of us and has, um, pumping the blood around the body. Well, a lot of times people don't realize, and especially patients obviously won't know this. They don't realize that the heart actually requires its own blood supply to keep to keep working. So, as you can see here, you've got your two main branches that are encompassing the heart. So you got your right coronary artery and you've got your left main coronary artery. Now your left main coronary artery splits off into two. So you've got your circumplex coronary artery, and you got your left, anterior descending coronary artery. Now, these are the coronary arteries. Where were we went? Patients describe having a heart attack. You've noticed the patients are having a hard time. These are the arteries which essentially get blocked. Because if you think about it, if you've got on arthrosclerotic process is happening in his very small coronary arteries and say, for example, you got a small blockage here, right? And this. These cardio arteries are supposed to be supplying blood. Uh, you know, to the hot muscle itself. If you were to have a blockage here, you're gonna have a whole host off dead muscle that's here. You don't reperfus it in time. And this is one of the reasons why I actually, when patients have a hard time, the probability off them having heart failure after having a heart attack is also increased. So you'll find that a lot of patients have had a heart attack. When they do an echocardiogram, you may notice that they may have some left ventricular systolic dysfunction. Um, and that made me to an element of heart failure. You do get some patients who can recover from heart failure, especially when it's mild heart video. When they have that secondary echocardiogram, you can see that they're ejection fraction. So that's the amount of that that's being pumped out of. The hot is actually come back to normal now. Normally, you wouldn't expect injection fraction to be 100%. Nobody's ejection fraction is ever 100%. You'll always see it somewhere between 55 60% and that's being pumped out of the heart on in terms of an ejection fraction. So when you've got an ejection fraction, which is less than 55% that's being pumped out from your heart. That's when you can classify into mild, moderate and severe heart failure. And that's where again your drugs really come into play. And that's why it's really important to understand the coronary and that to me of the heart, because effects so many things. These tiny little arteries affect so many things that happened with the heart that the heart's like lime essentially now a lot of the time and the most one of the most common types off heart attacks that you'll find tends to be in these and either in the right coronary artery or the left anterior descending coronary artery. So when I so I used to work in a cardio unit, it was a specialist. Pharmacists. And a lot of the time I would see, um, blockages happening and left anterior descending coronary artery. The most trickiest part where to sort of resolved is the circumplex coronary artery is quite a tricky part to sort of insert a stent when you're talking about heart attacks. But we'll come on to that until not more detail in future sessions. A swell. Okay, so let's kind of go on to now about the electrical stimulation off the heart and how that's what happens to the heart is my agenda so means that it can actually, it has its own electrical system and which is initiated by the S. A note you know, s a note contains these myogenic cells which which initiate and the electrical conductivity of the heart which aids to, um pump the blood from one area to another area. So, as you all may already know, So you go from the s a note. So that's your sign your atrial node, which is located in your right atrium. Atria on, then that then goes to your ab know So that's your atrial been trickling node on. But it's exactly it's exactly where it says it is it between the atrium and the the ventricles said that so then you got go from your essay, know to your ab node, and then you go down the bundle of his and obviously you got a left bundle branch right bundle branch. And this is really important to know, because when we come on two talking about the CGs, you might notice that patient may have a left bundle, branch block or right bundle branch block. And that's why it's important to know the electrical conduction system of the heart, because that's where it's going to to tell me how you do and then resolve it and then you go to Then you go down to the back injury fibers, and that's where your kindey fibers condense. Help to contract the ventricles, too. Then pump that blood around the body. Now what's really interesting about the heart? Is that a love? When you look at the heart like an actual heart you probably he can tell that is made a pawn off multiple layers that sort of slide on to each other. So So the way that I always thought about the heart muscle is if you were to put your hands next to each other like this, and you were to just glide your hands over into locking like this. That's essentially how the fibers of your heart are are together. They're like this. There are gaps in between because you need the electrical symptom stimulation. And, as you know, on the electrical stimulation happens by a by a sign UPS is on, do you know? So that says, that's why the heart muscle is actually connected like this is actually really interesting to see how strong it is. But how these gaps actually allow the electrical conductivity off the heart to essentially happen in this diagram here on the side kind of shows you how smooth that sort of that that muscle is and how it's sort of just interlocking and gliding over each other. A swell. So if we were to take a closer look at the heart to see what it looks like as you can see here on the outside as we talked about before. You've got this pericardium power. Pericardium can become inflamed a Z. We know, for example, with the cove it vaccines. You know, some some patients have had episodes off off pericarditis. And then that's when you get that inflammation off the information off that off that soccer's well, which can be which can be resolved there are there are very sweet of resulting get maybe, and states and and culture seen those sorts of things. But I can well, come on down. Date ones. You've got your second layer off pericardium. And then inside you got your visceral layer off pericardium and then finally, but your myocardium your my cloudy, um is where you get your electrical conductivity happening. Electric conductive. It does not happen here. It happens here. And then finally your thin lining of your heart, Which is your endo called the um Okay, so if you were to zoom and further into that, you can see here this is what I was talking about having these inter kelated discs okay, within the myocardium itself. So when you're looking at these myocardium is you've got these that junctions here, which are a lot for the electrical activity of the heart. This is where you sort of get your exchange off calcium and sodium and potassium happening. To initiate a action potential in these individual cells, the action potential in these individual cells essentially form the larger picture off what a knee CG essentially looks like. So again, this is a really important to sort of determine and understand how things like calcium channel blockers work. And I'm not talking about things like, um, a lot of peeing were talking about things like the rap A mill and diltiazem, because we will obviously want to go into the drugs will talk a lot about diet hydrocodeines a nondihydropyridine, and that will make it clear to you the types of calcium channel blockers, which then can actually affect the heart. And it's really important. The the reason why these calcium channel blockers are really important is because within these cells you've got ligand gated calcium channels, okay, and it's very important that you have that exchange between calcium, and so do you to initiate the action potential. While while ago too much into that is quite heavy, you may have committed. You may not have covered it, but we can go into that a little bit later on. If you've got more questions on that in the in the question section. Okay, so here what I was talking about when it comes to your action potentials on, it's all about where you get your influx of your sodium and your output of your of your potassium and calcium coming back in with with the sodium. And it's about the number of calcium's and the number of surgeons are so that's all being exchanges Well, if their exchange doesn't happen, then you're not going to get an action potential. You're not going to get any exciting function that's happening in the heart, either. So that's why it's really quite important to know how these action potentials exacted printed action potentials work. And that's why it's important when, especially when you're looking at blood tests to know about extracellular calcium interest on it. A custom extracellular, um sodium and interested in a stadium was well, because it gives rise to things like SIADH, which actually does affect the heart. And the number of times or I've seen this in practice is actually quite a shock shock, Quite shocking. USC in primary care. You tend to see it more in the hospitals. A swell, but it's the calcium that's really important for the excited function off the heart. Without being without the calcium, you're not going to get any action potentials actually happening at all on. As I said before, this is what forms your your SED. So you got your P wave, which is essentially your atrium contracting. You got your QR arrest, which is essentially your ventricles contracting and then your t wave, essentially, when everything is relaxing and it's going back to stage one. Okay, um, so as a sensitive. So we go back to the conduction now, so you've got your so we go back to it. So now you've got your essay node going from your ab. No, down to your bundle of is going to your kindey fibers and then you get the contraction. Obviously, there is a slight delay that happens, which allows for the ventricles start she fill with blood by allowing that dilator delayed to happen. It means that you're getting the most pumping out of your heart. Because if there isn't that delay that happens. And actually you're not getting any blood kind of coming out of your heart. And that's where you can also have problems. And that's why again be knowing how knowing her action potentials come together to form your easy Jesus important present. You can pinpoint whether there's any sort of metric tachycardia is happening, you know, which are causing your patients that symptoms on. But it's why these sorts of things are really important. Okay, so in your one heart be this is essentially what happened. So you've got your age old depolarizations so that we did that we mentioned before where you've got your contraction off your atria then then obviously that's your 20% that's being pushed into the ventricles. Yeah, because 80% has already gone in there. And then your ventricular depolarizations, which is that going to be your pumping of the ventricles to go to your lungs and to the rest of your body? That happens. And then you got better treat every polarization where everything just is there, where everything is nice and relaxed them. And in some cases you can see a you wait, That happens. A Xarelto. Now the EKGs and she described a net movement off those I ins across the membrane off this cardiac muscle cells. And so, when I mean by irons were talking about there's Calcium were talking about the potassium were talking about the sodium was Well, this is why it's actually really important. Um, when patients initially are admitted into hospital with any kind of, uh, with any kind of cardiac dysfunctional suspected cardiac dysfunction. When you order that all set up blood, we always make sure that we also have things like magnesium in There was well, because magnesium is actually related to calcium, right? So if you've got a low magnesium a while you are very high. I might need him a swell that can actually predispose you to having a lot to different types of arrhythmias is on when we go on to that, when we talk about with me is. But that's why when I was working the Contras, you know one thing that the cardiologists would always say, Let's get that magnesium above one. They always want the magnesium above one. That's it. So that's a very important thing to sort of remember when it comes to when it especially when you're going on placements in that sort of things. What is that function of that magnesium wise are so important because you don't want any arrhythmias happening is the same thing with with potassium because potassium is being exchanged in these excited torrey cells. If you have a very low potassium, we've got a very high potassium. You can also get these arrhythmias happening as well. And this is where it becomes critical. Like potassium is so critical, Teo to the heart that that that even when the patient has a very low potassium some and and when you got left ostium you want to be able to give an infusion off a tasi, um, into the body on. But you have to do in a safe way. But if you have potassium high concentrations, normally your cannula is in. Your is in your wrist here. That's not going to cut it. When you've got a high, a high concentrate of potassium, it actually has to be in one of your major things of it has to be over here. Otherwise you're going to get a very irritated skin on. But it's going to cause a reaction and that is not something that you want to happen. So you have to be very safe when you're sort of giving these protests. Um, infusions the number of times I have stopped a consultant. See? Stop you putting it in the wrong cannula and then I I don't care. We need to get potassium in the patient's body. Well, yes, but you've got kind European. You need to put it up there. Otherwise you're gonna have other problems. You're gonna make sure that the vein is actually big enough to take that. How aggressive. The concentrated potassium could be a swell on. And this is all about how we it relates to the electrical signal here and you'll see on the EKG too. Okay, so what else can regulate the heart? So we really, really zoomed in. And we're really, really focused on the excited Torrey cells how the blood flows through the heart, how the blood, how blood gets to the heart for its own for its own secretary function. And we've also talked about, you know, very basically how sed sort of work. And later on down the line, we'll actually go into easy G's in a lot more detail on one of my colleagues. She will be a sure she will essentially tell you all about how STD's work about the leads and everything like that, and why their place, where they're placed in that sort of thing. That's well. But there are also external factors which regularly the heart. So what else can regulate the heart? So let's go to starlings Law. So Starlings Law essentially said, as the heart fills up with more blood when the heart is really lax and this is one is in diastole, the heart contracts harder and palms up war blood during contractions, which is systole. This sounds like a very obvious thing. I know. Obviously at the time, this was something which was unknown. And when we talking about pressures in the heart and then that's why it's really important when we're talking about the pressures in the heart. Because if the heart is contracting harder and palms up more blood during contractions sisterly that can actually give rise to the increased cardiac are poor. Um, we can also give advice to higher BP is well, if you look at the, um if you look at the pressures within the heart itself. The right hand side of the heart actually has gotten less pressure within, within the within the chambers, in the left hand side, as you would expect. Um, so we're looking at it between about three about three millimeters of mercury on in the right hand side and not the maximum. And then you got about 8 to 12 on the left hand side, and that's the that's That's how different the precious can be within the heart itself. So when we're talking about what else can regulate the heart were talking about the cardio vascular center in the medulla of the brain is where it all happens. Okay, so this is being in trying to everything that's happening in your body. So you've got your pressure receptors in the A water in the carotid artery. You chemo receptors are there a swell? You also got a temperature receptors which happened in your muscles and your so your stretch receptor that happening in your muscles or is all all of these imports right? These are all the external factors can actually regulate your s a note. So how quickly your heart is going to be beating but also how slowly your heart could be beating a zwelling. So this is where your parasympathetic and your sympathetic nervous fluids happens on your essay node. Okay, so this is just a more detailed diagram off. You know, this is the card a regular routine center in the medulla. Okay, um, and you've got your sensory fibers on, You know, you pass sympathetic there, fibers. We're looking at cranial nerve 10 here, which is your vagus now. And you will be sympathetic. Never. Your sympathetic now five is is well, which is which is all to do. Read your postganglionic cells on when that's where you get your sympathetic know fiber sort of innovating your essay. Noda's well and naturally, you've got your sympathetic nervous system. So this is your flight or fight? Don't forget, right? You're 52 fights into the center which essentially can also a release more adrenalin from the adrenal medulla, which also innovates your essay A z Well, so there are so many external factors, which sort of impact on your essay node. And that's why when you do things like when you do things, that when you do things that exercise you'll notice that your heart rate is going up is because your S a note is getting all of these inputs from your sympathetic person pathetic system on your sensory five years from your from your barrel receptors as well from your chemo receptors as well, which is about a P h. All of that. It sort of regulating whether your heart is going to be faster or whether it's going to be slower, a swell. So overall, your parasympathetic system is the thing that controls everything. Overall, when you get a D fees in your person that did drive, that's when your heart rate will go up. If you didn't have your parents sympathetic nervous system there or your sympathetic nervous system, your heart rate would be about 100 without your parasympathetic systems off regulating and you're you're you're signing atrial night. So that's why your parasympathetic dominates when your parasympathetic system dominates. That's when you've got your heart rate off 60 beats committed. Okay, so that's the kind of part rate that we sort of that was sort of a me now and send the in patients who have had passed out so heart failure or anything like that you do want it to be that way on. And this is why you will see when patients have got dysfunction of the sign of atrial node. This is when you and this is when you got particularly no harm, very. You'll get a you know you'll go to cardiac center your get a peacemaker inserted. You pacemaking is regulated, is artificial, obviously is regulated for the heartbeat to be our 60 BPM, so you'll end up very good. They're very steady. Um, and every time that the the pulse of anybody's got a pacemaker is always 60 BPM. Okay, so you're essentially almost over riding your parasympathetic system, um, artificially with the pacemaker in order to, in order to make sure that your heart is getting the innovation that it needs to them from the regimen body. So, as I said, with a person pathetic system, you've got your vagus nerve, which decreases the heart rate. You sympathetic cardiac nerves increase your heart rate and also increases the force of your contraction as well. So, as I mentioned before, your um, your vagus nerve, our form sign ups is with the post ganglion cells in the essay node and the Aviane node. And this, chemically, it causes acetylcholine to bind to receptors on the heart or m two receptors we spend decrease the heart rate. And with the sympathetic system, this is why the sympathetic from when you got your postganglionic fibers. So you've got a release off more adrenalin that happens here, which increases your heart rate. So this is where we're talking about chronotropic. Chronotropic means crow know time, right? So that's your rate and force of contraction, which is I know Tropic. Okay, so then you've also got your viral receptors, and your Virasept is essentially they take care of the home. You setting mechanisms off your BP well again. Well, again, go into the blood Blood pressure's in more detail on, but the pressures are sort of influence that. But when you've got an increased that pressure is your Virasept was going crazy in your aorta is safe. Ah, Does it increase? BP is increase BP. So this sense So this sense, like, uh, a message to the cardiac center to say Well, we're well you. They have detected an increase in the BP. We've got uncrossing the cardio A couple you know, we need to do something about this. So then what happens is that what this homeostatic mechanism happening by the person pathetic system with them will decrease the cardio helpful increases that razor dilation and then the BP drops. When you got home, your face is is then restored. And the same thing happens when you got a decrease in your BP is well on disses where sort of your kidneys and your adrenal glands really come into play here because, as you know, your kidneys, your your adrenal gland. And last week did you release of the Lord Jenaline on the normal jenaline would obviously increase your sympathetic drive. You said that that Dr will essentially increased that BP and therefore you get increasing your cardiac output and you've got your razor constriction happening as well, because of the bargain receptors that have detected that. And then your BP increases and then you get home, you upsetting Reckon ISMs. Um uh, put back into place again. We're going to go to this a lot more detail when we talk about a centimeters and control of BP. So this is just a overview of it so that you've got a very basic understanding, Um, off a BP on down how BP sort of works. So you haven't understanding the way you do things like a sin Hypotears and calcium channel blocker sort of workers. Well, okay, so that's the end off this lecture. And I would like to welcome any questions that you may have a think, Um, I think I'm bang on time here, so I'll just stop sharing. Oh, thank you so much, Doctor. Um, so everyone, if you have any questions so far about the the basic anatomy and physiology of the heart, feel free to amuse yourself. We've got hand from sorrier. Yes. Thank you for today. Selector. Very informative. I was wondering, you know, when you mentioned about potassium and when you want to increase the level potassium in the body, you don't put into a cannula that's on your wrist upon the arm. Is that is, um Well, I knew you said that is due to the wrestles a bit bigger on the arm. Is it only just for potassium? Or do you have to take into account for other electrolytes? that you want to balance is well, that's a very interesting question, actually, depends on the concentration that's actually within that infusion bag. So normally what we use is in the in the hospitals, you've got the administration policy, and the administration policy will sort of tell you for phosphate and for my four phosphate for magnesium and for potassium, which brings that they're supposed to go into, generally speaking, with low concentrations. There are a lot fine through the cannula in your wrist. Pataki's potassium, especially because I've seen the corrosive effects that potassium can have. But for that one, especially, it does need to be through the larger vessels for magnesium tends not to be. Thank you. Talk said. Um, if you've got a question, you can either write them in the chart for me or feel free to, um, you to yourself and, um, speak Okay, that doesn't seem to be much questions on the basic basic anatomy and physiology. Got one West Yeah, treatment for high potassium. Oh, now you're asking the good questions. It It's a treatment for high potassium. Um, tends to be a way it depends on the reason for the high potassium as well, eh? So when you're looking at on, this is where you're interested and extracellular Uh um, uh, you're interested in any exercise in the knowledge becomes really important because, say, for example, if a patient's got high potassium of say, you know, let's say, let's say is 5.6. So it's like in the mid range. It's know particularly high, but it's not within the range of about 5.65 from seven. But then you notice, for example, the patient is actually severely dehydrated. And then you might actually want to give more fluids in that patient. Um, a few patient has got very high, very high potassium than you looking at casting gluconate. 10%. You're looking at salbutamol nebules as well, which are very useful because we're south beach monitors. It pushes potassium back into the cells that came from in extra Sevilla to interest Edwina. Okay. And then you also give insulin a swell, and that's how you manage hyper clean me A in patients. Thank you, Doctor s. So we have about 20 minutes if you like to, uh oh, you got a question. I was going to say if you would like to go over anything specific we can, but we got question now. So how can electrolyes cause arrhythmia and influence the heart rate on how they affect my cardio? Um, action potential. Okay, so this is a very good This is a very good question. And this is when you really have to get into the each individual cell off the heart. So there is, um, something that happens inside the what we called sarco cosmic reticulum off the the my cardio. So you've got your t tubules on, but within within the cell itself. And you've got, um, Ligand gated calcium channels, which are in the war. Okay, um, what essentially happens is you get an influx off calcium from the interstitial fluid during excitation, so your heart is excited on, but it triggers a release off calcium from the soccer pleasant maternity reticulum. So this is inside off my cardio themselves. Okay, that's inside of the cell. And I would say also have a look, a diagram of this because it's going to make more sense when you look at diagram. Okay, um, then you've got because of this release off, because, see, um, from the soccer plasmid reticulum that free calcium activates contraction off the individual Meyer filaments of the heart. That's what's then causing the excitation of the heart when you get in. And that's what that's what that's sisterly. Okay, that's sisterly. Um, when you have, relax a shin so diastole That's because you've on uptake off calcium theon. Calcium that happens by the sarcoplasm in particular is like is like a cycle that happens. Okay, And, um, this this, um this exchange happens by the sodium calcium home. So you exchanging your calcium for your sodium. Um, and this is why there's ligand type. Custom channels are really important. So this is really going into the nitty gritty off each individual. Hartsell eso what I would probably what I would say is, what's really good? What a really good book for this is Rangan Dale's. It's got a really nice diagram. Pharmacology has got really nice diagram in there because you actually need to see the diagram to truly appreciate where it's happening, because there's, ooh mean right in. We've gone from the heart as a muscle down to the myocardium, which is the which is a big part of the muscle into the myocardium even further to look at each individual. Um sarcolemma. So that's your sliding off the deciding off the off the muscle cells and each if you if you think of each finger as, like my card yourself inside that you got you mitochondrion, uh, you got your sarcoplasm it yourself or plasma reticulum. And a lot of that exchange happens within that self ligand gated channels off within that sell the exchange, the exchange of the sodium and the exchange of the calcium happens within that cell. So that's what it says. So that's what happened. So how do you know if the hyperckemia is from interest? Annular or extra cellular, eh? So most of time, in fact, all of time is going to be from extra cellular and that that that's where it will be, It will be extra cellular that because I see any way that you can sort of that you can sort of manage it because you're trying to when you're pushing the potassium into the cells, the potassium can they be utilized by the cells. And that's why you're trying to get the exercise regular potassium back in. And don't forget that things like your real tubules. Also helping the exchange off a taxi. Um, so you can get rid of potassium in that way as well. And I'm going hand up. Um, from listen, you can, um, use yourself. It's Doctor. I have a question concerned. They put a potassium poem casting potassium poem. Um, what during the for a realization you have for the replacement off the sodium by the consume before we start going faster. What is the mechanism when replacement on the change off the rich, there isn't Have no sure. Quite understanding your question. I'm really sorry. Yes. What I'm saying is that ah, so your potassium form, which will have the replacement by the costume. Okay, influx, they say strange. A speed start to increase. But at the beginning, it's lows before you have go to higher speed. What is that mechanism? What's the moonlit, the increasing speech. Okay, so I think I think I understand what you're what you're trying to We're trying to say, Um Okay, so the sodium potassium, um, it's supposed to maintain the internal concentration off the potassium irons. Um, higher than that in the surrounding fluid. Okay, So your surgeon potassium pump. Like you said, right you're exchanging. That's Sadie, Um, for the potassium so that you're having less sodium a class or less potassium in the outside than the inside. Right when it comes to the excited torrey function. Okay, When it comes excited, Tori function of your heart is your calcium. That will initiate it. Your potassium, if your potassium is too high, is because you're starting protesting poem. Can't regulate it well enough in order to be able to, um, diminished that, um, diminish that arrhythmia from happening. I hoping that sort of answers your question. Yes, Doctor. You do. Okay. Every only goes also go hand from Claudia. Yeah. Hi, doctor. Um, I was wondering if a patient is suffering from, like, liver failure, and they have ascites on what know and they're saying that they're Q r. Interval is prolonged on. Obviously, you know, you want to give medication to a set, um, reduce the edema, but you also don't want to affect the q R interval. So what would be the best treatment or solution? I guess that how would you correct the electrolyte imbalance, but also not effect the q r interval? Okay, So I mean, generally speaking, the first rule. This is what this is what I was always taught. The first rule is always to correct the electrolyte imbalance. Because if you don't correct the if you don't correct the electrolyte imbalance. And that's one of the reasons why you're actually gonna have this thing is two are the problem with the Q r interval. So first, rule off anything is always correct. The electrolyte imbalances get that sorted out first, and then you can see what is happening with your, uh, what is happening with the easy G. So if they've got if you got things like liver failure on if they thought what was the other thing that you mentioned? Sorry. Liver failure. And, um, they had ascites and prefer a team like you were gonna. So if you call ascites, then with ascites that this is way, this is where you have to really have to connect different different parts of your physiology, right? So when you call, ascites is a lot because off the imbalance off, uh, off the fluid in your body. So that's why you what things? That albumin, which helps with ascites or if the ascites is so bad, then obviously you call your sitting atop the acidic tap will essentially drain that ascites away. Um, but you still have Teo correct that electrolyte imbalance more than anything. So that's why if the albumin doesn't work in patients and especially they've got and then if it got severe, um, ascites and they always do a cytic top. You really want a cytic top going? You still have to replace with albumin, and you still have to replace with, um fluids as well, because if you're removing from it from the body, you have to add your fluid back in. Otherwise you're gonna have a name balance and actually last intercourse. That's one, of course, more problems. Unfortunately, a lot of the times when it comes to giving albumin is very It can be difficult because of manufacturing issues. To get the right percentage of albumin that you might need on the percentage of albumin that might need is dictated by the consultant anyway. But essentially, what they'll do is that if somebody's got ascites and they got liver function and disregulation, you're gonna also give high high doses of spironolactone a Z well, spironolactone and high doses off lactulose as well. Because the lateralis actually helps with with the ammonia in the body, that is sort of built up due to, um uh uh due to the ascites. So a cytic top albumin lactulose high dose spironolactone as well is going to be really important. Obviously, if the patient has got hypertrophy mia, you're gonna you're gonna have Teo make sure that he's giving fluids on top of that to make sure that the potassium was wanted. They will always monitor the potassium in the hospital anyway, but it's about the risk versus the benefit. You have to think about what is the thing that's really that's gonna potentially kill the patient first, right? That's what you sort of have to think about. And in patients like that, they'll always be hooked up to a EKG monitor. Always. We even do that when we're giving magnesium infusion because that's in the guidance and the guidance. It says that if you're going to give if you're going to give a magnesium, which is greater than I think, there's two minimal Polina, then you have to make sure that they are hooked up to any CT machines that you can check if there are any CT changes that are happening because of the infusion. And that's why it's actually important to know what the rate of infusion off the what the rate of the infusions going to be. Because if you give something very quickly, then you're going to cause a lot of problems because the heart is not able to cope with the amount of blood. So with the amount of fluid that's then being introduced to the body almost artificially because it's not within its own capacity to detect it, so think about it. This is where your Virasept is a fiery because you are putting an infusion, and if you put it in suddenly, then your hospital bill it where has ordered this sort come from on. That's why you do it slowly so that the heart and then cook with the increase in the fluid that's happening in your body, you're increasing your volume in your body is, But it's not happening. Yes, thank you. That was very cute. Thank you, doctor. It's so much. Doctor, you've got another question from Mohammed. Will treating hyper telling me about interstellar shift mechanism affect the capacity of potassium in the sell on that will lead to abnormality off potential inside the cell. That's a really good question. And I'll be honest with you. Um, I haven't looked into it that I haven't looked into it to that degree, whether it could cause it, Um, partly because in my mind, I in my mind I think we've got so many transporters intracellular e that sort of exchange. I owns a lot the time, but that is something that I would have to look into myself on being honest. I'm not going to I'm not going to try to. Tiopronin did answer. Um, thank you for that. You've got a question from Lorna. Can you please explain how magnesium is used to lower high BP? So magnesium isn't used to, um, lower high BP. Magnesium is there to make sure that you don't have any arrhythmias occurring. So and again, we'll go into this a little bit more because all the islands they are related to each other in one way or another. So my kidneys, magnesium, calcium, phosphate, they're all related to each other. So if one of them goes down, another one's going to go up with. One of them goes up, the other one's gonna go down, Which is why it's really important when you are when you got patients who have got cardiac disorders that you've got that you've got your you got your sodium, potassium, magnesium and you're adjusted. Calcium also checked for those patients because they're all related to each other. And in fact, on we'll go on again. We'll go into this sort of later on, and this is because this is really important. You know, patients who have heart video because you can have something called cardia renal syndrome, where you are trying to strike a very fine balance between the regulation off the heart and also not overloading the kidney so that the kidneys are dying. So patients call it chronic kidney disease and the site CKD three your CKD four. But they also got heart failure, and they also overloaded um, with fluid. Um, you have to think about how you going to manage the diarrhetics because the diarrhetics could kill the kidneys, but they're going to solve the problem with the heart. So it's really important when this is why the drugs are really important is really important again to make sure you understand the basic functioning off the heart and the kidneys because it's so related to each other. So you're actually able to strike for fine balance. And that's why it's really important to ask the questions to yourself that what is the possibility watching to potentially kill the patient bus? Is it going to be that hard? Is it going to be the kidneys now? The really interesting thing about Diarrhetics is that when it comes to your kidneys, things like, um, things like loop diuretic. So we're talking about perusal. I'd and we met tonight. They can either kill your kidneys or baking kick, start your kidneys. I'll tell you a story that happened in In In, in the hospital room where I was working patient had very poor renal function, and we decided to give an infusion off bruise a wide and, you know, the patient had heart failure. They also had kidney disease, and we thought, Okay, let's give them an infusion of frusemide. Unfortunately, what happened? Waas. They gave the patient the wrong infusion rate, so it meant that the patient was being infused with frusemide at a higher rate by infusing the patient at a higher rate. Frusemide. You're obviously stimulating the kidneys to diaries more right. If it's going to diaries more, the possibility again is you're gonna kill the kidneys. They're gonna kick start the kidneys. Obviously, duty A candle says that we need to inform the patients in the family that we've given the wrong infusion rate. So we told the family, Okay, from where? Every sorry, we've given the wrong infusion rate. It was at a higher rate. We did a blood test, but guess what the blood test showed is shared. The her kidneys. Kidney function became so much better, so much better. So it can be really unpredictable sometimes what route directors conducive to the kidneys. So, like I say, it's not the magnesium that's going to sort of that's going to influence your your BP. The amount of fluid that you put in your body is going to influence your BP, for sure, and when we talk about cardiac, are what we talk about volumes of pressures and things like that, if that will become clear up, but that but But the infusions and the the actual I owns themselves won't increase the fluid in the body. Sodium does, because obviously we know that sodium and water go hand in hand. The more sodium you have, your more retention you're going to get in your body. Then that's why we say to patients who have got high BP who have got heart failure on, we say to them, low sodium diet with a low sodium diet, less take a raise, our know, microwave meals and things like that because we know our sodium was gonna cause retention. And it's the same thing where things like NSAID. It's because the effect that and sets have on the kidneys on with sodium and also, uh, yeah, with the sodium you're going to get that retention of water. That retention of water is then is going to increase the volume, Uh, your secretary volume inside your body, which makes it harder for your heart to then cope with their. It makes it harder for that blood to pump around the body because this thing has got so much fluid it's struggling, and that's where you get your edema in your legs and in your in your in your legs, your ankles, your thighs, your abdomen. And that's when. Actually, they're your choice of diuretic, then becomes really important as well. Um, so I used to run hot heart failure clinics on Gwen. You've got hot. But when I when I was running part, maybe a 10, it's, um, one of the things that was really vitally important was actually to counsel patients and how they know that they may be possibly getting retention off water in their body. Now, when they've got retention of water in their body, they have to do things like wanted to their way every day, fasting in the morning. If they've noticed that there that the retention of fluid is kind of going above, then me and it's pitting edema. Submitting a demon is when you press it down on your skin, it doesn't bounce straight back. It's like cluster seen, and that's how I describe patient. I said, This is how you can check with you. Got any fluid retention, you press down. If your skin doesn't bounce back up, it means that you've got some water retention happening there, Um, and if it goes beyond the legs, then that's when you really need to consider hospital admission because that's when you need to have a new infusion off ruse a mind and not see anything. This is symptom management, its symptom management. It's not curing. It's not curing heart failure because you, because you can't cure it like that. It's about symptom management, making sure that the patient doesn't have breathlessness and all those sorts of things from happening to them. Um, and and that's why I obviously can't sing. This patient's is so important. A Z Well, so I know it kind of went off for a bit of a tangent. Then it just with cardiology. You'll notice that amazing doctor everything is connected. Everything's connected to everything. And that's like cardiology is just so, so interesting on. Thank you so much for making it so interesting for us as well. I don't motivated to, um, revise that every morning. Um, so I think that's the end of the lecture on If there's no questions, we will end there again. Thank you so much for giving us the foundation. And hopefully in the in the coming lectures with yourself will go. It more into did on drugs of side of things. 100%. Yeah, we'll definitely be. That s o thank you all so much for staying Tuna. Hope it was interesting. And I apologize. There are some questions that I that I couldn't answer, but I hope you will sort of encouraging war two Also have a look, uh, and find The answer is to those questions as well. And you can light in the rest of this. Thank you so much for the poor attendance. So most think you can think. Think you Thank you. Bye bye.