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Hello, everyone. Welcome back to the new academic. You're off skis. See, um I do understand that. I ask is he's got misleading, but we decide to stick with the brand name. Uh, discuss it sounded quick. All, uh, but yeah. This year we're starting off with many more. New series is pre med is the surgery is the final TZ preclinical. And, of course, the ask easy itself, which is going to be next next semester. So today you guys have tuned in for a finance easy session. So a final TZ session is a SBA based content lecture that covers all the principles that an undergraduate would need to know, uh, for that particular specialty and this is specifically suited for revision sections broke a revision tests all progress test mainly. We have it here in our union university. So we've hoped to cover the step off. Don't mention, oh, sessions. So just a quick word from us one. This medical protect protection services they help with defense against medical lawsuits. 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A slight would be sent to those who feeling the feedback from do email us for any questions or queries and remove your skis. E and outlook don't come from your spam a junk because we have seen that it goes into this spam. So when we email of the slight check your junk emails, uh, for this for e mails from us, and please do sheriff's on her social, we truly appreciate any public city that we could get and let move in. Our cardiology specialist to kind of take over the session now moving is a 40 or medical student and has a special interest in research. Audiology on endocrinology. Surprisingly so. Morgan, take it away. Thank you. for the head reintroduction rebound. So let me just share my screen. Uh, can you see this? Yeah. Okay. Okay. So welcome, everyone today will be starting off our finals. Easy. Syriza's Roman mention starting off with cardiology. Um, so for those who don't love me, my name's moving on today. I'll be delivering up segment of the cardiology for finals on. Do you still into our session on Thursday where they'll be a cardiology part to for finals. Okay, so we I am to cover the continent about one hour to one half hours, so please stay tuned. And if you have any questions, please put in the chat on the moderators from the, uh, ct team will be more than happy to, um, answer those questions. So today are just the kind of topics I'll be covering today. Starting off with hypertension and finally ending off cardiomyopathies on. I'll just be doing a series of SVU questions that you guys can have the opportunity to answer it on these simple And then I'll follow that up with an explanation. So, without further ado, this is the first question someone can launch the poor. So you guys about 40 to 60 seconds to kind of onto the question you guys, please refrain from writing on there screen. It's kind of distracting. Okay, let me and the poor there. So, um so most of you said, uh, ramipril on be followed by a close second, which is, um, not a peon. So let's see. So before I show, the answers are just briefly mentioned. Question. So it's a 65 61 year old Caucasian moment male who attends for an animal health check on his clinic. Pressure is 1 46/98. And then, um, military BP monitoring is requested and arranged, which shows average reading off 1 41/94 which confirms that he has, in fact, hypertension. And he has a past medical history of type two diabetes and asthma. So most of you did get the correct answer, which is around there. And the key thing here is that regardless of a patient's age, if they have the, uh uh, type two diabetes, the Type two diabetes, that is a factor. That's a factor that is considered when starting medication S o. It's a Lipitor's or angiotensin receptor blockers off sliding Can anyone tell me on the chapped? Why is inhibitors are preferred over a lot of being, even though he's greater than even those older than 55 years. And you went on the chat. Does anyone know? Brilliant. Yes. Exactly. Most of you got it. Yeah. So it is really protective. And it showed it showed to have good outcomes in patients with co existent diabetes as well. So, uh, question she gets launched the ball again. It's our just briefly. In the interest of time, I'll go to the question as well. So question, too, is a 52 year old male who attends connected to poorly controlled hypertension. Kindly on ramipril. A lot of bean on in the commode clinic. BP is 1 56/94. Patient denies any weight gain. Mood changes on the blood test results from below. Given the likely diagnosis, What is the most appropriate first line investigation? You can't stop it there. So, uh, most of you have said, um, it's, um the first line test is a lot stronger Iranian ratio. Um, which is, in fact, the correct answer. So Well, that is, uh, don't be the most of you. Um, so as you can see, this is primary. High powered Austrian is, um, also known as cones Concentra, Um, which is basically when you have a increased production about last room, um, usually due to, um, adenoma of the adrenal gland, resulting in hypertension as one of the consequences. And you also get hypokalemia. So if you look at his history that there are in fact to differentials for hypertension and hypercholesterolemia, which is Cushing syndrome and cones on, the only way to differentiate is that I've said that the patient doesn't have any waking or mood changes. So in, uh, Cushing's syndrome, you would get like, um, a central obesity, and you also get mood changes. So since the patient doesn't have, it's more likely to be, uh, constant room. And the first line test is the plasma aldosterone running ratio. Um, I just wanted this question is more endocrine focused one, But I just wanted you guys to kind of be aware of the end of crime causes off secondary hypertension. So if it was was, Cushing's dexamethasone would be the first line renal biopsy. If it's glomerulonephritis on 24 hour urinary, metanephrines would be if it was a few cramps. Chromos i toma and uh, yeah, so that further do I just get onto the first topic? So hypertension eso The basic difference between a sodas primary and secondary primary is the most common. Seen about 90 to 95% of patients with hypertension have primary potential. It's also called essential, and there's no single known disease or cause for primary hypertension. It's complex physiological process involving multiple organ such a Z thing kidneys on other many organ systems, which is why it is is quite common on. Then you have secondary hypertension, which is which has a secondary disease presents kind of underlying disease process that contributes to developing it, which I'll come on to talk about in the next light. So cause of secondary hypertension. As I mentioned a little disease, you can have grammar nephritis. Uh, patients who would, you know, um, present with the free ticket on frantic picture, depending on, um, type of tremor nephritis, Adar, polycystic kidney disease and renal artery stenosis and pollen. And Fridays also is another real cause of secondary hypertension. And then you have underlying causes such as I mentioned cones. Cushing's pheochromocytoma and acromegaly begin. In the case of Acromegaly, it's, um, increased growth Um, factor and sorry growth hormone and insulin like growth factor release, which kind of cause you to retain a lot of sodium and everything which causes plasma of all, um, expansion on leading to secondary hypertension. And then, of course, you have the other causes, like and said's, um, look a corticoid pregnant in pregnancy, you get a plasma volume expansion in pregnancy that can contribute to secondary hypertension. You can also get you know, things like you Columbia. You get protein urea, things like that on then, uh, combined. Or a contraceptive pill, which is due to increased levels of circulating estrogen on obviously cooptation availed as well, which is usually see if if a patient has a young one, said how attention, it's just a possible differential for it. So if you take hypertension, nice guidelines in UK define it as a clinic clinical reading that's consistently greater than 1 40/90. Or there's something called 24 hour party pressure monitoring, which I mentioned before in the question, which is called ambulatory BP monitoring. So this is for Go step, another where it's because of something called white coat hypertension. Usually, when patients come in to the GP surgery or what not, they get a rise in their BP. But otherwise, in a normal setting, it will be normal. So this is to kind of reduce the over diagnosis of hypertension. So what they do is they measure over a period of time and get an average reading. So generally, if a patient has a 24 hour BP greater than 1 30/85 and they are less than 80 years of age on and they have significant cardio cardiovascular risk factors if they have things like renal disease, diabetes, Um, or if they have, um, cardio, they have ah, um cardiovascular. Sorry, 10 year risk greater than 10%. There is also criteria for you to immediately start medication. Um, otherwise, you would consider lifestyle modifications first. So generally, if you have hypertension, it's usually asymptomatic, and it's usually seen in routine annual checkups of patients. But it can become symptomatic, especially at very high levels like greater than 200 over 1 20 millimeters of mercury on patients would usually present with science of end organ damage like visual disturbances. He's honest on even headaches. Um, and the as I mentioned, the first. The gold standard for diagnosing is 24 hour BP monitoring. You also look for other factors that can contribute to our attention as well as contribute to a cardiovascular disease. So you check for renal disease using urine dip. Um, and using these as well. Check this has any dyes or anything like that. And this renal disease could be caused by hypertension, or it could be even as a result of hypertension. So that's important to keep load check for diabetes using HBA one C check with the patient has hypolipidemia using a leap lipid profile. And also you can check for the C G. So when you have because of hypertension, you get increased after lords. Yeah, your heart has to work harder to pump against the higher BP. As a result, you get to hypertrophy. So a particularly left ventricular hypertrophy on Do you see two or cures complexes on the CT traces and you can earn increased risk of developing ischemic. Cardio sees well. And as I mentioned, if you have emergency hypertension, if you're presenting with end organ damage. It's good to do fundoscopy to check for hypertensive retinopathy so you can check for any papilledema and inflamed hemorrhages. Cotton wool spots, things like that. And then finally, the treatment. You know, you as I mentioned before, your factor in when to start medication, Um also encourage patients to, um, modify the risk factors like exercise. Um, it well on reduce. Um, sorry, smoking sensation. And also looking for complications of hypertension. So, um, so this is a brief kind of, ah, flow diagram off the medications that you can give, so I wouldn't go through this entirely. Please feel free to have read of it on your own time. But basically, uh, you if a patient is less than 55 years of age or patients that started two diabetes, as in the question you've given a Sinemet or ARB um, you would given Airbnb usually if patients can tolerate is inhibitors, for example, if you have a dry off and switch them to 100 tensing receptor blocker. But if they're greater than 5, 55 years of age or their an Afro Caribbean patient with no type two diabetes, you would start off with calcium and channel blocker like I'm not a pain and a second step. If the competition is still not controlled, you guys better that ties. I'd like diuretic. Sorry, You would add, um, calcium trying on channel blocker. If you already on ace inhibitor and vice a lesser okay, and then and the dad step, you would add a ties. I'd like diuretic. And finally, if that that still hasn't, um, um kind of released the BP into a maintenance level. Um, you'll patient would have resistant hypertension. Therefore, you have to kind of consider for the treatment, and that's depend on the potassium level. So if you have one of the side effects off, out after and antagonised such as, Ah, spironolactone is hyperkalemic. So you know, hopefully they can lead to dangerous arrhythmia. And so if flotations protesting levels less than or equal to 4.5, you would start them on it. If it's greater than 4.5. The risk of developing hypertension me a a desert, you would give them out for beat a blocker, and you would also, you know, getting over specialist review. If bad pressure is still not controlled. And similarly, to the second question, if if if the doesn't know if you have ruled out primary happens as a cause, you would want to consider because the second pretension by doing for the diagnostic test like I mentioned. Okay, moving on to the next question. Someone launched the pool. So 65 year old after a Caribbean woman intense for a review at the heart failure clinic. Um, despite treatment with, um and can someone launch the poorer? It's anyone there. Okay. Yeah. There you go. Eso? Yeah. Despite treatment, symptoms have failed to improve. She continues to feel breathless and requires 4 to 5 pillows to sleep at night echo shows and ejection. Fraction of 34%. Just occasional signs of partner edema. Given this information, what is the next most appropriate management for this patient? This is more of a tricky one, but have ago, okay? No, What? I think I'll stop in the so most of you have said, um, sacubitril of a sudden as the first option, followed by the docks, tin and hydralazine. Okay. Interesting. Okay, um, so if I go through the question again, So, um, this patient is basically having heart failure symptoms that I haven't resolved despite being on three lines of treatment of start to lines of treatment. And he you know, she's having signs of dyspnea orthopnea. So she's requiring 4 to 5 pillows to sleep at night and neck. Oh, shoeing heart failure with reduced ejection fraction on the chest X ray showing Palmer erythema. So the answer is actually, um, hydralazine with nitrate. And this is simply because individuals from a black Africa are being background. It's preferred to start them on hydralazine with nitrate because it's zurd to have, um, better outcomes for this patient population. But other options could be the drugs in a swell, but that's usually in patients with existent. And if a major operation you'd give sacubitril of are certain if patients aren't, there are very they're having problems with the ACE inhibitors are taking on also cardiac resynchronization therapy, which is also option. If patients are having signs of a wide Curis that could indicate a left bundle branch block things like that. Um, yeah, so this is the next question you lost the pool. So 70 year old woman with a two year history of heart failure tens for a review. Um, patient says that she experiences no symptoms at rest on. Their walking to the shops can make quite breathless. She can make breakfast in the morning by yourself. But how sure such a cleaning or a struggle according to the New York Heart Association classification, What stage is she? Give it a go, guys, move a bit of a tricky one moving. Well, they're answering. That question is, if you three questions that have popped up in is, uh, alongside on Arnie and wouldn't that increase the risk off and your Dema Arnie the order night? What's here? Not familiar with that air in our in Isaiah. I think that's a little round certain. Okay, Sacubitril, um I mean, as far as I know, um so in terms of I think from what I've read, usually give it if they're not tolerating, I mean, guidelines differ from hospital to hospital, but from what I know, generally, um, according to nice guidelines, is that you would give a secret of acid and if patients are not current off, is inhibitors. But I mean, new studies are kind of popping up, showing some bit of Assad and have an advantage. So I think it's it's, um From what I personally know, I would, um, say that go for an army if not the intolerant of this inhibitors also just addressed another question. Ah, one of the questions Do you stop a centimeters and woman off childbearing age? Eso a Sinemet is there are There are studies that associate it that there are studies that have, um suggested a separate. Those can cause two after Genesis in the first trimester. So particularly women off childbearing age who are planning on conceiving. Generally, you should stop the Lipitor. Yeah, the key. What is planning and sieving mean Child bearing age? But that's only so much you can do in terms of education and stuff. But they need to have this kind of talk with your GP or specialist moment. Just one last question. I got the previous question if the patient was in Africa or even what would have been to correct that line treatment, so if the patient would have I mean it depends on the factor. So basically, as I mentioned before, if they have a, um uh you could give them Aberdeen if they have Ah, um, you know, heart rate, Sinus with them less than 75 BPM. And the ejection fraction is less than 40%. But it also look for, you know, the CT complexes. If there are any signs of a left bundle branch block, you would give CRT cardio bricks immunization have if you give ah, uh, digoxin, things like that. So I would say in a patient, Usually I haven't given any more information regarding that except the background. But if they have ah, hardly less than 75 in Sinus rhythm is. Well, I would possibly give them because the ejection fraction is less than 40% as well. I would go for everybody. And the hydro hydralazine is based on the nice guidelines, isn't it? Yes. Yes. Okay. Isidora. Yeah. Okay, so let me share the results. Okay, so it's a close time between B and C, which actually you guys are thinking along the right lines. Perfect. So majority is stage three, but on fortunately it is stage two. I'll explain. Why So if I just take, um, the NIH classifications, which are explained doing more details to stage one. Patients are with no symptoms comfortable addressed, no problems on the other extreme. There's only stage one before, so four would be the extremely symptomatic. So they're extremely symptomatic. They struggle with daily living. Um, and pretty much, you know, quite, uh, burden. And then you have stage two and three in between. And what is similar to both of them is that patients are always fine at rest. What what happens is upon limited physical activity in Stage two, if you get symptoms of heart failure like breathlessness, that would cast found stage two. But if it's less than ordinary activity, physical activity, it would be stage three. Okay, So if you, as you can see in the question stem that I I lighted to the patient when it's quite quite moderate, physical activity like walking to the shops can make a breathless but very mild kind of activity, like making breakfast. It doesn't really affect. You can make it by herself. Don't any problems, but house shows we can can be quite intense. That was cleaning. It's a struggle. So which is why it's stage two, okay? And yeah, if you guys have any questions regarding that, I can answer that later. So basically heart failure, defined as a single room where the heart is basically unable to maintain a sufficient cardiac output to meet the demands of the body. Okay, this is either a systolic problem with the heart. Count upon properly so that stroke volume is reduced. Or basically the heart is unable to relax properly, so they're finish filling. Volume decreases as a result on their output decreases. So fighting heart failure, it's there, many like classifications for it. So you have. Firstly, I'll go through heart failure with reduced ejection fraction. So this is due to systolic dysfunction, as I mentioned, so anything that causes damage to the myocardium such a Zen myocardial infarction can cause it to, um, not function properly there by reducing the contraction and therefore cardiac output and generally defined as ejection fraction less than 40% on then heart failure with preserved ejection fraction. So in that case, that's due to diastolic dysfunction, so the contraction is more or less normal. But you are sorry the heart is struggling to relax properly, and this is to to reduce compliance of the ventricles, usually due to stiffening, so things like hypertrophic obstructive cardiomyopathy can cause stiffening the myocardium chickens. A zit result. The heart really can't stretch, and it doesn't feel properly. So when it doesn't feel properly, the amount of blood that can inject decreases and usually ejection fraction is kind of maintain through a sufficient, more, more less insufficient level off greater than ankle to 50%. Uh, but it's still not as it's quit adequate compared to a healthy human being. On the of course, you have the left sided heart failure, which is basically anything that can cause cause increase after Lord. So any any systemic hypertension can cause, um um, really, due to increased offer, you get resistance and therefore the heart can struggles to pump out, and as a result, you can get back flow into the primary system there by causing signs off primary Dema and symptoms like, um, breathlessness, especially on exertion. So you get this here you get on top layer, which is basically patients aren't able to like on the like flat because of the fluid accumulation causing released gas exchange. They struggle to breathe. I was just similar to a park system or not. You noticed it disappear, which is basically patients wake up in the middle of the night really breathless because of this again with these gas exchange because of all the family fluid in the interstitial space. And as a result, patients usually in orthopnea they really need a few pillows to sleep at night. And that is primarily consequence off left sided heart failure. And then you also have right sided heart failure. So anything that causes increased, um, increased resistance or increased after Lord to the pulmonary system anything like, um, uh, cracked hospital regarding patient tricuspid stenosis on that can lead to just back flow into the systemic venous circulation, thereby causing signs like, um, race JVP could have if it goes into the Patrick Vein system in called Hepatomegaly Ascites on it was into your extremities in cause peripheral edema and can also get a cough is, uh, but that's mostly with primary pulmonary edema. Visit will be in less side of heart failure and then you also have biventricular heart failure, So left sided heart failure can have a knock on effect on the right side, causing to develop right right sided heart failure. If the left side isn't adequately ejecting, it can cause consequences to the right side because it can't come to the left side. Um, and they also have high output heart failure, any any instances that causes the heart to perform at a high level than normal. So things like anemia when you have increased metabolic oxygen demand because you're not supplying enough excision, so your heart has to work harder. Tired toxicosis is so increased, tired home one can increase. The activity of the heart is working and Paget's disease of the Born there so many because of her heart failure. But I won't go through all of them. So in terms of diagnosis, the gold standard is anti probably MP or being be so this is a molecule is released in response to ventricular stress. When the heart's under pressure from other increased after load, or anything that causes it to work harder than usual, it will be increased in chronic, hopefully especially to be raised. And then you can also use echoes. Make a cardiogram to determine the level off heart failure to determine the ejection fraction. Are there any to look for any valvular abnormalities that might be contributing to the, uh, um to the heart failure? If it's one of the causes. Usually go for transthoracic echocardiogram, which is easier. Just basically, the jelly scan is what they call it. Then there's a transesophageal echocardiogram as well. So this is this is more, uh, more for clear, a way of getting a picture of it. So basically, it kind of, um because in PT transthoracic, you have the ribs and the lungs. Interfering is well, so to get a better image, you do a transthoracic transesophageal take a cardiogram, and also you have a PSA mentioned SCG switch your left ventricular hypertrophy. Is that things like my cardio hypertrophy in response to things like hypertension on. And I'll come on to talk to you about the science in the chest X ray. So in terms of treatment, there's two ways you can go about it so patients can have acute heart failure. So acute heart failure is a medical kind of emergency. Where, um, the heart goes into a period of eso because very symptomatic and the heart goes into extreme decline in function and this could be either the level so it could be due to some kind of infection, or it could be due to uh, patient having chronic heart failure. But they have a decompensation of it due to something like an ischemic event like my cardio infarction and causing them to have an acute decline in cardiac output. And therefore you get signs of symptoms of heart failure, but it will be very rapidly on rapid onset. So you get things like flash for my redeemer. So patient, for example. In in fact, I saw a patient as well who was completely fine the previous day. No, no display. And what the North or me? A. Nothing. And then in the morning, they woke up with extreme shortness of breath on extreme signs of flash bone marrow edema. So this is a medical emergency that requires emergency treatment so that you require oxygen. According to British Taurasi guidelines, if it's or two sets are less than 94% you get them oxygen. You give them look direct extension. I refresh my kind of, um uh, remove the excess fluid CPAP continuous but positive every pressure if they have respiratory failure, coexisting and also continue normal meds. Teo continue a senator's spironolactone, but be warned patient who are on Peter Block is usually if there are signs off, a low heart rate is less than 60 or 70 off the any signs of shock or their signs of heart block be the block is our country indicated to keep that in mind, and then you have chronic heart failure. So this is for the long term management. First line is it's inhibitors and meter blockers, and these have shown to have significant advantage, improving long term mortality on def. That's if patient don't really they respond to it. But the heart failure symptoms kind of progress. The second line would be spironolactone, but I've got to start in there just to, uh, remember guys. There's a new priest risk of hyperkalemia using when using two of these drugs, and I mentioned, it's ah can have very bad cardiac consequences so important to measure potassium levels in patients taking these drugs, especially if it's for heart failure. And then, as I mentioned, you can add on therapy, usually by specialist according to the different criteria. I won't go to them again on. You can also offer vaccines so you can offer an annual influenza waxy in and a one off a pneumococcal vaccine as Well, so these this's a chest actually showing some of the science off for Marie Dema. And this is the kind of, um um a new monitor I like to use its it We just ignore the p. So the e supposed to be thinking, But so far, your Dema be for curly be lines when the interstitial DEMARs if you can see there's, like, horizontal kind of patchiness to it, which signifies interested Dema cardiomegaly So increased the increase in the cardiothoracic ratio greater than 50% compared to normal. Uh, you have upper lobe diversions, so you get something. So due to ah, especially gravity, you get fluid mostly building up to it's the bottom to the partner. Your veins kind of drift upwards to kind of, um moved two areas with better gas exchange, which is what's called a pill of diversions are particularly seen. Maybe I can convince you guys, this is upper lobe diversions, but it is quite difficult to see on obviously profusion as well, too, You know, it's not really present in this picture, but you would get things like planting with the cost of any angles. Okay. And as I mentioned, I won't go through this again. Just just keep note in close to they can do most physical. Sorry. They can do, um, basic physical activity without any problems. But when they tried to put more effort in the kind of developed symptoms on their normal isn't a magic at rest. Um, and class three, is that even slightly kind of? When you slightly exert yourself, even you would get symptoms. Uh, and, um, that is the demarcation of those two. Okay, expression. Someone could launch the pool. So 38 year old female patient presents to any complaining of numbness and weakness on the right hand side. And the Italian doctor notices she has difficult speaking clearly on examination, you know, marks on arm patients. Basic labs include heart rate of 78 BPM pressure 1 38/93 respiratory rate of 18, breath for a minute. Temperature 38.6 or two sets of 95%. On on on examination, she's paying for red lesion on the hand. Given the life a diagnosis, what is the most likely positive organism? Yeah, I think we'll stop that. So most of you have gone for be so really insist. That is the correct answer. So this is a not a very typical presentation of infected and Akalaitis. So the patient has had has signs of the stroke. So numbness, weakness. And this Altria on this is because one of the vegetations so most likely to be on the left side of the heart, possibly the above um, which will which has caused and vegetation to form an emboli on go and large in one of the arteries of the brain and causing a stroke. And, um, something, you know is marks on her home. There's a track marks indicating that she is an IV drug user. Um, and she has been for red lesions, One of the consequences, Um, one of the signs of symptoms. And you also have a brace temperature. So the most common cause, um, a causative organism is stuff warriors especially seen in those with IV drug users. So, um, well done, guys. So the other ones, I'll come in to talk about it a bit. So, um, in terms of positive organisms I mentioned about stuff or eus, you have stuff epidemic. This usually, um um valve replacement surgery opposed replacement surgery or when the patients have been dwelling lines. Strep president's linked to poor dental hygiene because the cost of organisms usually found in the course off. Sorry, the dental flora on that can lead to, um, people suffering from infected good and tap it. And the quantity is is a result. And you also have strep Bovis, which is going to colorectal cancer. So as I mentioned, um, the different presentations, um, stroke is more less less typical. But you have the other ones, like Also, there's no strain religions in clubbing and spend hemorrhages in terms of diagnosis. There's three do criteria. So if if this confirmation off the pathological criteria, which is if there's any, uh, positive evidence off any, uh, microbiological science off any vegetations any emboli that's taken during cardiac surgery or during autopsy that confirmed the diagnosis. But other than that, um, there's a major and minor criteria. So if two of the major criteria positive or five or just five of the minor criteria, or simply one major criteria and three of the minor criteria that would confirm the diagnosis of infected and the card itis so make structuring waas two positive blood cultures. And, um, except for instances for concerns about typical positive organisms. And you would also look for in the car in involvement using echo and the mind, uh, criteria. As you can see, I I wouldn't go to that on just in the interest of time. Interval. Respect of the biggest one is a previous history of infectivity. Cardiges, prosthetic valves, IV drug use, congenital heart disease, rheumatic heart disease, and tattoos are piercings in terms of management. Um, for needing valves. The line therapy is amoxicillin on. You get flu clock cillin for staph. Um, staff. If the staff is a positive organism, bins are penicillin for more sensitive strep. If they're less sensitive, you would give pens are penicillin and low dose gentamicin. And they also have as a result of surgery if they have any valvular incompetence. Aortic abscess on brick earned able I any risky complication. Okay, uh, got a short, um, sport diagnosis here. Can you guys tell me what the first picture shows? Just on the chat. Okay. Someone said Oslo's nodes. Okay. What's the same gene religions? Okay, Um, what if I say this is, uh, this is painless. So that just the first picture. Eso The first one is in fact, in religions because it's usually found in the palm Tina apathy in ambulances. And it's painless, while the second one I'm sure you can guess is also those nodes. These are painful, usually found in the tips of the fingers. The last one, I'm sure you guys way have guests little hemorrhages because of the employees that are thrown off the vegetations. These can collect in the peripheries on in the nail beds, causing these kind of, uh, streak like projections to appear in the fingernails. Okay, we want to. The next question is, um, one launch the poor. So 64 year old man presents do any with three hour surgery of acute severe chest pain that radiates to the back auscultation diastolic moments heard best at in two seconds to cost you a space right. Sternal edge Patient is a chronic smoker. Past medical history includes hypertension, which takes I'm not a mean basic labs. Um, from heart rate of 95 the pressure 1 30/78 respirator of 18 temperature of 70 37.6 and two sats, 95% on a regular. The likely diagnosis. What is the most appropriate diagnostic investigation also? Can you guys separately on the chat? Tell me what this, uh, mama is What? What? What is causing? The mama says, Well, you could degree. Good. Perfect. Yes. Said I started Mama. Usually, if it's approximately the Arctic route, it can cause, uh, degree. Good. Okay. Brilliant. Uh, I'll stop it there. So most of you have said, um, ct on geography, followed by transesophageal Echo. Okay. Quite close. Okay. Million. Um, okay. That is, in fact, correct. Yes. So this patient is presenting with signs of aortic dissection tearing pain that radiates to the back on sides of the aortic regurg and also risk factors like hypertension and chronic smoking. And the important thing here to load is the patient. Is he Madonna, be stable. The BP of 1 30/78. So this patient is stable. It's in those patients. The first line investigation would be CT angiography. Okay? Or for patients before going to surgery, process the state of the Arctic dissection. They would have a CT angio. Um, okay, have a question for you is if the patient had a BP off, Let's say 70/60. 60? Yeah, 70 or 60? What would be the put on the chapped? What would be first line investigation be cancer ST. Okay, it's gonna be a bit of a debate on this. Um, Okay, so one said tonsils Ecig said transesophageal Oh, Okay, so it's a clinical diagnosis. Okay, um, abdomen. Okay, so everyone's, um Okay, So abdominal ultrasound. Not really. Because I would be if there's a triple. Not really that section. Um, the correct answer is, um, just come on to talk about now is transesophageal echocardiogram. So if patient is hemodynamically stable, this is the first line goes standard. Okay, Um eso one of the biggest risk factors. Hypertension, which I mentioned it. The question the other ones include trauma connective tissue disorders like more fans, Ella's Danlos pregnancy and syphilis Onda physical features. Um, so the tearing pain, um, aortic regurg on you get the past deficit as well. Onda unequal, um, pulses, depending on where the terrorists, okay. And in terms of diagnosis, CT angio is the gold standard if you want, but I have to stable on D can also do at on tests. Yes, You can do a chest X ray, see signs avoid and media Styler on and we see GI especially if there's a a proximal aortic dissection. You might get the inferior ST elevation pattern okay on. In terms of treatment, that is slowly depending on the type of aortic dissection. So that classically used one is the staff of classification, where Stanford a includes past in the clinic and him off the aorta. If the ascending aorta the staff would be would be the descending aorta. Okay, um, and in terms of Sanford A, which is a surgical emergency, so they would need a prompt surgery and they would also need I be better blocker like a better long to make sure the BP is somewhere between 100 120 millimeters of mercury systolic. But in Stanford, be could be conservative management with Byetta blockers. Okay, so this is just a brief diagram. There's also debating classifications well, just just depending on whether it's progressed from the sending to the, um beyond the Arctic Arch to the descending aorta. So that would be type one if it's only present in the ascending me talk to and if it's present in only the descending detect three. But the Stanford is the classic one. So a Z can see if the first picture shows a chest X ray showing. So get the technical here, and you can kind of see Abidin get Steiner because of it. And, um yes. So this is a CT scan showing, um, aortic dissection. Can you guys okay? I think also question before is Well, can you guys tell me what type of that section this is according to the Stanford classification Bible? Yeah. Brilliant. Yes, exactly. So this is type A. Use this a day. Send in your job and you can see in the darker hypodense one. That is the false Luminant. This is the true Lumen to basically get a tank intima. And you get blood pooling in there. And it's usually from boys is a bit, which is why it's dark in appearance. And this is fresh blood on due to the pressure from this force. Lumen, it kind of compresses against the Truman making It seems smaller. You have the primary arteries here. Okay, Next question. Get someone watch the pool. Thank you. So 48 year old man presents Do any with an acute onset chest pain if she describes as crushing, um, and states of the Creon radiates to the job. The pain had come on while I was lying in bed just off the, uh um, having his dinner on examination. He was profusely sweating and will be uncomfortable on examination. Course crackers can be heard and both lung basis on a pansystolic moments that she's not on expression. Even the likely presentation. What is the most likely cause? Okay, Yeah, I will stop that, then. Okay, so, um okay, so interesting. Split. Okay, Most of you have gone for left. Anterior descending, followed by right coronary artery. Okay, right. So you can see this patient is having an a acute coronary syndrome, most likely an m I. So, in fact, if under Karzai's ruled out on, but you can see that he's having course crackles heard along basis and the pansystolic murmur, which is louder on ex experience in Can you guys tell me what kind of what moment this is? Sorry. What is the cost of his mom? Yeah. Brilliant mind to regard. Yes. Exactly. So my very good is causing backflow into the primary vasculature causing course crackles because if food and the interstitial space on it's louder on expiration. So if you guys know, um are the pneumonic rile right sided murmurs are louder on inspiration left side and murmurs mitral regurg is heard better on expiration. So and then you have to figure out why the mitral regurg which, Which kind of, um, arteries coronary artery supplies. The, uh, basically the popular A muscle that supply that is responsible for the mitral valve. So most of you said a lady. But unfortunately, the correct answer is right. Coronary artery. I'll explain why so basic the right coronary artery in about 70 to 80% off individuals, it it gives rise to the posterior descending artery on the posterior descending artery supplies. The, uh if you're part of the heart and it supplies the posterior medial popularly muscle off the off the mitral valve. So, um, and then the remaining 20% off individuals, it's actually in the left circumflex. Okay, so the correct answer is right. Coronary artery. So, in fact, that any blockage of that will cause, um, infection off the, uh, the the area supplied by the fact the posterior. Sorry, the area, which encompasses the posterior media popular muscle. And as a result, you can have a rupture causing this regurgitation. Okay. Um okay, So acute coronary syndrome. So it can be split into three forms. So there's unstable angina and stemi stemi. Okay, So unstable angina is basically when there is a, uh maybe a trump. It's forming because of plaque rupture, but it hasn't caused sufficient enough of it causing a ring but not sufficient enough narrowing. Which is why you get just being addressed because you have uncreative demand and you can't meet it because it's the narrowing on. Do you get a little bit? Respiration attracted. You get chest pains. That's where you get chest pain at rest. I come on, talk about, um, and stable angina later. But the criteria is that there isn't sufficient enough ischemia infarction to cause troponin to be released. The problem is usually negative, but there's some criterias if easy, estrogen can be normal. But if there's signs of ischemia like TV inversion, honesty, depression with negative triple in that's confirmation of months ago angina, and then you have instant me, which is a bit more of an occlusion that causes some endocardial Oh, damage to the, uh, my cardio. As a result, you get raised. Troponin is why it's troponin positive, and you get signs of Excuse me. A. On the CD can be normal as well, with no abnormalities. But it typically would get even inversion. And it's the depression on that. Finally stemi, Uh, this is, ah, a full blown infarct where you have complete occlusion on this is a transmitter. Oh, infarction, Which is why you get a very large increase in troponin on. Do the EKG changes would be a confirmed STD elevation or could be hyper Q T V eight is well, so when he comes to acute coronary syndrome bit about the pathophysiology. So in any of the cases, it's just you have arthroscopic park developing with the's a logical aging on what happens is that ruptures becomes unstable and that forms of trumpets and thrombus can cause an occlusion. Know if it's a partial occlusion, as I mentioned, it would cause Micardis Kenya, um, and therefore course unstable angina or and stemi. But if that's completely occlusion cause an infection, which is the case for stemi those clinical features you guys know it by heart, but I'm sure you know about hot. So the chest pain radiation made it into the jaw. Um, left arm or neck? Does it disrupt? It's crushing elephant sitting on your chest on it might be even left side as well. So it might slightly could be even even confused with prudent just being, um Also get difficulty breathing, sweating. They'll nausea. Vomiting. Okay. And I talked about the diagnosis to the C g eyes to confirm the diagnosis stemi and stemi or stable angina. And you'd also need cardiac. Marcus is work to confirm, So you need to criteria. So you need the CT changes and dynamic change in troponin. Okay, so not just a normal changing proponent should be a very big increase in the troponin between 22 instances. Okay? And you can also do coronary angiography as wealthy, low down the extent off vessel blockage difficultly. You put a catheter down really large three put in a contrast, and you'd use x ray kind of visualize the coronary arteries and see how where the blockage is on possibly intervene as well and risk factors. I'm sure you guys know these by heart now no gender, family history, smoking, diabetes. Hypertension of the city is a very, very linked. Okay, so the coronary, 10 trees. There you go. So I want to spend too much time on this. I'm sure most of you guys know the surgeries, but basically an inferior any ST changes in the inferior leads which include to three a v f. This is supplied by the right coronary artery and or left circumflex. But I'm going to write contradictory. Then you have the anteria Septra leads, which is which are the precordial or limb leads. You want to be four, which are supplied by the left anterior descending artery left, anterior descending coronary artery. And then finally, of the lateral leads which encompass V 536 as well as one and a video. And these are usually supplied by the left side of complex or the diagonal off the left. Anterior descending. Okay. And just a slide on Ah stemi. So, as you can see, can you guys tell me what type off? Um uh, Stanley, this is on the chat. In fear? Yes, exactly. Yeah. So this is a concern in leads. Do the ATF? Um, you can notice a, um ST segment elevation. And when you are diagnosing steady generally as a rule, this is how I look at it. Um, you take the little it's which are these ones, Um 123 and the heavy ones if there's a greater than one million with the rise. So I generally take one box if there's a greater than one box rise into adjacent ones. So as you can see here, it's two and three. So two adjacent wants to confirm, so a single one would not confirm stemi need to. Adjacent at least two adjacent. Uh, limb leads ST Elevation to confirm or ST elevation off two boxes. Two millimeters in these precordial chest late. So we want to be six slightly different. So you need greater than two boxes to confirm, um, stemi in the anterior or lateral stemi. Okay. And so in terms of management. So I'm sure you guys are where initial management. More nice go go. Standard acronym. You get morphine. Patients are in severe pain. Oxygen. As I mentioned, the four dose that's a less than 94% nitrates, ktn sublingually, um, and but you have to be warned and there's a risk of hypertension. So a patient, if a patient is likely to go into shock, be very off giving Judean in that case on, then finally, aspirin 300 mg. And if a patient is confirmed to have a standing, you would give us take a second and the platelets are low or computer girl. So you would give a trumpeter girl stuff to grow if a patient has an increased bleeding risk. Okay, in terms of steady management, um um, collect the goal. Standard recommended is PCI. So PCI if the presentation off the patient is within 12 hours off symptom onset on DPI, see, I can be delivered within 120 minutes, compared to the fibro know listens can be a minister and if he says, not possible If you can't get them to ah center in within 1 20 minutes, you would offer them fibro know. Uh, this is okay. And then in terms of instant me and unstable angina, you give on bit from being like fondaparinux and that before deciding on a intervention, you would calculate something called the Great Score, which is a risk assessment tool basically looks at factors like BP. SED changes proponent changes to assess the risk of the patient in terms of the condition. So if the patient is unstable, you would give get them too urgent. PC I on you give pursuit girls as well if they're at an intermediate or high risk. So that's more for more risky scenario you would give them you do coronary angiography and possible follow a PCI within 72 hours and prasugrel low risk. You manage them with a catalog or clopidogrel. Okay, so in terms of my complications there, there are a lot. But I've put a few here. So one of the most common causes of death, it's cardiac arrest post in my, um, one of the most common complications because you can get something like, Yes, there's also pericarditis depending on the timeline. So usually a few days after you get a coupon card itis due to, um, like you get inflammatory kind of inflammatory response to the pericardium as a result of the kind of like the myocardial damage on, but that causes a coupon for it is and then later you can go to six weeks later. You can, uh, um get dressed this syndrome and also ready or even years like avian block. So if you have a particularly an inferior ST MI that can cause on baby and block that heart failure of the most common aside mentioned about the biggest causes of systolic heart failure. In fact, ondas I mentioned mitral regurgitation because of, um, usually posterior media hyperpoly muscle rupture, urine, infarct of the right coronary artery. So, uh, let me go on Teo, talk about stable angina. Okay, so basically, the PATHOPHYSIOLOGY is when there's an imbalance between the myocardial oxygen demand and supply. Okay, so the supply generally decreases because if you get this plus critic plaque formation which narrows the coronary artery supply decreases and your demand, it may increase when you do strenuous exercise or anything that any any conditions that cause you to have an increased demand. Uh, any demand from the heart can cause, um, stable angina form. And because of this narrowing, you can't really get enough of a blood supply which results in, um, increased and anaerobic production. A sorry anaerobic, um ah, anaerobic respiration, which results in black information. And that results in the pain that patients experience. So in terms of the features of the classic features are pain or discomfort in the chest. Your arms, um, you also get pain. The pain will be on exertion. A supposed to unstable angina, which is at rest. And it's the pain is relieved, um, at rest or with something called DTN. And there's different between typical and atypical. So typical angina would encompass three of these features. All three of these preachers of represent for 200 stable angina for atypical. Only two of these have to be present to keep that in mind important thing. And then the classical diagnosis is using CT coronary angiography to kind of estimate the the narrowing of the amount of narrowing there is in the coronary arteries and the c G. A day I mentioned. There's any scheme era, you see, Um um, ST Depression, developing version, things like that. You have to do stress echo, which is not invasive, or you can opt for in days in coronary angiography as well. On these are the risk factors which are very similar to this. Yes, Okay, So in terms of medication, um, the first line is you either go for a bit of blocker or a nine nondihydropyridine calcium channel blocker. Okay. And this is something like verapamil because you want to kind of because basically relation. And you want to cause negative cornucopia and Truvia's. Well, So you were trying to reduce the myocardial oxygen demand. And you're you are increasing the supply as well about causing the visit dilation. You can offer one of these, um, second line. You would try to do a therapy. So, um, but you have to be one. If you're If you're already on a beta blocker, you would not give something like Rapid Man. Um, big. Um, you will not give drop. Um, but you would offer some, uh, dihydrofolate in cats and channel blocker like I'm not a mean. Okay, um, and can can anyone tell me on the check? Why, that is What's the importance off giving a diehard a period in instead of 100. And I had a period in with meter locker. Yeah, Brilliant. Exactly. Yeah. There's a risk of asystole to go in the heart block because they're both negative chronotropic. So you don't You don't want to get them. So you would give something like I'm not a mean, which would cause a dilation, cause eso the beta block of introduce the, um, my cardio demand by reducing the heart rate while the visit relation kind of increase the supply. Okay. And everyone gets ah, um um GM for symptomatic relief. Because, you know, when it enters the bloodstream, nitric oxide's produced, which causes with the dilation. Okay. And it does a secondary prevention or patients should give should be given aspirin and statin because it's reduced cardiovascular risks. And also, you can consider on the long acting nitrate of everything in the car and does things like that if they are on one therapy. So if they're already on a bit of locker or calcium channel blocker and they can't order it, the any additions. Okay, so yeah, so not really limiting because it's got a heart block. Okay, So final question for you guys, We almost at the end again. Someone wants the pool. So yeah, I think I can finish, um, right on time. So Okay, so 38 or year old woman complains of progressive shortness of breath and chest pain over the last few weeks. She can't works, is an accountant and had recently lost. I don't. As a result of the CO B 19 pandemic she subsequently seen by the consulted cardiologist on, he explained to her that she has a disorder of the heart muscle. Given the most likely diagnosis, What is the most appropriate treatment? Okay, okay. So in the interest of time, I will stop it there. Okay? Okay. Before you share the results, can you guys tell me what kind of disorder this's woman is suffering from? Good silver. Okay. Perfect. Exactly. Exactly. So most of you did. In fact, what supported management, which is the right answer? Um, so alcohol, septal ablation, surgical mymectomy back to me. That would be indicated in hypertrophic obstructive cardiomyopathy and fluid restriction IV. And on really clickable here. Ah, so, yes. So it may stay. Treat my supporting management. Okay, So I will briefly go through cardiomyopathies. Um, So I decided to kind of go with the wh classification. It's just a bit more confusing than the conventional one, which divides it into hokum. Dilated, restrictive on others. But I told him I just talked about this. Um, So there are two types primary and secondary. Primary is just a disorder off the myocardium itself. No other systems, but it really involved and disorder of the primary myocardium. So genetic will be hypertrophic. Um and they are really sorry. Logistic, right? Ventricular displeasure. These are both. Most part is more dominant. So a RVD for those that don't know it. It's basically when you get fatty or fiber fatty tissue the position in the myocardium on your mixed just dilated and restrictive on did you have acquired like takotsubo and peripartum? Um, and confusingly mixed that. The to dilate and restrictive also included in secondary, which is why it gets a bit confusing because they can have an environmental factor as well. In addition to genetic, that can cause these conditions to kind of develop, especially those are genetically prone and they have environmental trigger possible infection or anything can cause on these stalkers. So they dilate and restrictive. All support putting put on the second. Well, um, primary is usually because of, um um, it exactly cons actually are because of a mutation. The secondary There's infective eso with Coxsackie virus can get. Remember these storage like excessive iron and hemochromatosis infiltrative. So when you get, um, a low doses you get, um, a low protein, the position? Because starting now. But these are particularly, uh, in fact, it can cause a restrictive Got enough of these inflammatory sarcoidosis. Nutritional deficiencies. You can get in with beriberi timing, deficiency and the crying like diabetes part toxicosis and ordering you like sle. Okay, so I won't go through all the cardiomyopathies. But I'll just talk about the important ones that you guys probably need to know if your finals hokum, um, is one of the biggest causes of sudden death and collapse in young adults, especially young athletes order some more dominant, as I mentioned, and it has something called the pathophysiology is concentric hypertrophy. So what happens is the second year, which are the contractor. Proteins are arranged in a parallel kind of like on top of each other, which causes it to for MRI looked very thickened myocardium. And eventually you get deposition off different fibers and that causes fibrosis, which can cause it to on. That's why you get, uh, we can develop that started dysfunction and heart failure with preserved ejection. Fraction is one of the causes, and as a result, especially, you get something in normal patients, patients that have hypertrophic cardiomyopathy can develop something called hypertrophic obstructive cardiomyopathy, which is basically when they get a symmetrical septal hypertrophy. So their septum, um, starts growing on. And that can cause obstruction in the outflow tract in the left ventricle. And as a result, you get the obstruction, and you can also get my to regard to well, because of something called systolic Um, anterior motion off the mitral valve. Um, it is a phenomenal, you see a swell on. As a result, you can hear a murmur as well. So you hear on ejection systolic moment that I don't know it, which is similar to out external assists. But differentiate, you have to know how to differentiate between out external asses and a hokum, Mama, Anyone but on the chapped. I don't well, come with. It's fattening. Yeah, yeah. So basically, if you ask the patient you squat, you kind of really increase the venous return. And what would happen is in your neck stenosis you would kind of increased the If you increase the blood flow back into the heart squatting, you would increase the blood flow into the left ventricle. And when you have increased blood this war chance of turbulent flow, especially if you have stenosed or narrowed aortic 12th. And that would cause more turbulence. And therefore the moment would be louder. Or what happens in hokum is that when you increased blood in the left ventricle, what happens is your ventricle kind of expense and be out the distance between the septum and the mitral valves kind of increase, which is awful, a track that the distance increases. So there's less transfer turbulence floor when you have increased blood volume. Um, and as a result, the moment gets quiet that so that's kind of how you differentiated okay on. But you could look for the c G changes so you can have a talk your eyes complexes because left ventricular hypertrophy looked for you can check with echo cardiac MRI on then management would be, ah, surgical. My tummy, which is basically a cardiac surgery where you remove excess septum on D, can also have call several ablation, basically inserting alcohol to a tube. And it kind of kind of destroys the myocardium in a controlled manner because have drugs like Peter blockers to kind of use the my cardio demand because of the increased volume of muscle. Now, okay. And you're dilated cardiomyopathy, which is the most common cardiomyopathy seen on this is the central hypertrophy is it's opposite off hokum. Basically the sock AmeriCorps teens are putting Siris, so they kind of make it grow outwards. So instead of take a, uh, they go longer and basically your heart wall things a bit, and therefore you get reduced contraction, which is why you get the systolic dysfunction and you get features of, um, systolic heart failure or heart failure with reduced ejection fraction. And you get S E, which is the Gallup rhythm. And some of the causes of this you perfect alcohol cooks. It could be very, very toxic on and medication like doxorubicin. And you'll get a balloon appearance on chest X ray because of the expansion. And then you have two types restrictive on. There's also very partner cardiomyopathy. This is usually seen towards the end of pregnant women pregnant women to his end of the pregnancy in the last month or so or five months after the pregnancy, because I believe in expansion that causes changes to my card him on. Then you have restrictive cardiomyopathy, UH, which is usually you to either fibrosis for infiltration, which causes systolic and diastolic dysfunction. As a result, there's cardiac size of the heart is normal, but it's systolic and diastolic function is intense, so infiltration got a moderate. Proteins like you normally produces with causes it to become more stiff and post radiotherapy. You can have fibrosis causing stiffness, and I finally you have a cold, sober cardio monte. So this is the ethical ballooning of the Myocardium. You get an octopus ship. Basically, you get a hypokinetic region towards the apex, off the heart to the top part of the hardest. You're contracting normally, so it kind of contracts and looks like up his head. And then the bottom is the does the apex. It is a type of diuretic, so it's are contracting properly. It looks like an octopus, kind of like their legs, which is why it's called The Octopus a ship. And this is usually due to physical or psychological stress. A Z I mentioned it a previous one question. If patient, if they have significant, mostly trauma, like the loss of a loved one or physical stress that can cause him to suffer from this. And this can often be confused with acute coronary syndrome as well. Um, which is why it's important to, uh, use diagnostic techniques, like, even echoes as well, just to confirm. And you also see ST Elevation on the C G, which might be also confused nations well, and your features of heart failure. And as I mentioned, treatment is mainly supportive. So basically trying to overcome whatever trigger there is for the cardiomyopathy and get them managed. So that is it for me. Thank you for, uh, staying everyone. Oh, there you go. Um, right. Do you guys have any more questions? Seem to the, uh, feedback forms, Aaron working for some people. I mean, the best we can do is if you guys messages, um, after the session, uh, on our facebook messenger with we try to alter the the medal link and send it to you again with a look