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Name. Um I'll give that a minute or so for everyone to get uploaded. Let me see if I can see the meant yes, people are joining. That's good. Feel free to answer anything in the, ask anything in the chat. Uh It's gonna be interactive. So make sure to, to put your answers in the chat when if I ask anything, um feel free. I don't know if you can um meet yourself. I don't think you can on this, but yeah, I'm monitoring the chat on my ipad next to, next to my computer. So I will pick up anything that comes through. So just ask away. Um And don't, and I'll interrupt myself. I answer the question. It should only last about an hour this talk. Um So I won't take up too much of a good time to get back to the all important revision that you got. Got to do. I'll just give it another half a minute or so. Um All right, let's get cracking on the main presentation. So we're gonna talk about cardiology. I'm gonna cover four uh pretty large areas of cardiology, uh survival of diseases, cute corny syndrome, heart failure. Heart arrhythmias, um, bread and butter of cardiology that, you know, for your finals, um, were focusing more on the management of each condition rather than diagnosis investigation because hopefully it should be pretty good by that by now. Right. First question, um, to get ready on the mentee, I'll open it in a little bit, so have a read. Um, I'll give you a, a minute or so. As I said before, anyone, if any was joining, feel free to ask anything in the chat. Yeah. Just gonna open the mentee. There you go. It's, it should be up on your phone now. So get ready to answer. I'll leave the question up here. Uh huh. See if it's times up good. Most people got it right. Let's move on to the next one. We'll explain. It will go through all the questions as we go through the presentation. So don't worry if you got that one wrong, I'm gonna open the mentee quickly. Yeah, it's the countdown. Not this. That's the question again. Good. Most people gonna get correct. Very good. Next question, I'll open the mentee. You're good. Let's have a look. 321 good. Maybe these questions are a bit too easy for everyone. I can see who's in the lead. Looks like Jed would close behind this. Do not cheap. Good, good, good. Uh I got two more questions to begin with. So this is the next question. Let's say we'll be going through all the questions and why they're correct answers correct by, you know, the other answers are not correct as well. So, don't worry if you're not sure. Menti, yeah. Your time's up. Yep. Good. And the last one now, yeah. Pretty nasty looking scg. He's got the. Mhm. Openly. Uh, 20. Thank you. Mhm. All right. Let's have a look. You could have a little bit more split this time, but still most people getting it right. Um That's all the questions we can see you on the Who on the quiz, huh? Well done. Well done, Jed Word. You're the winner. Uh Anyway, uh it's good. So everyone was doing quite well on that quiz. Um which is either you're very clever or I'm not very good at writing hard questions. Um So now we're going to get into the meat of the lecture. So the four conditions that we're gonna cover, as I said before. So we'll start with the valvular disease is, and this is the question that we had, which was mitral regurgitation was the the answer. Um And the other question which uh lady with aortic stenosis and the treatment that she should be offered would be a topic. We'll explain why. So we'll go, when we're talking about murmurs, we'll go back to uh back to basics, the back what the heart sounds are. So the two heart sounds, the lub dub is caused by the mitral valve closing and the aortic valve closing So the love is the mitral valve and the dub is the aortic valve and this is S one and S two. Anything between S one S two is sisterly. So that's ventricular systole when left ventricle pumps out the blood into the order and around the body. So that's what we mean. My sister li and everything outside that is diastole. So if we're looking at the cardiac cycle on the left, when we're thinking about aortic stenosis, first of all, um we have blood coming in from the atria into the left ventricle passes through the open mitral valve, which is the beginning bit of dastardly. And then you get the closure of the mitral valve, which is S one. Um And at the same time, the aortic valve opens. However, in autistic stenosis, as you know, the aortic valve doesn't open much, it just opens a little bit. It's kind of calcified. It's a congenital defect, defection of the aortic valve, whatever the cause, maybe it doesn't open as, as it should. And as a result in systole when the, the French court is pumping out the blood, not all the blood is getting out because the valve doesn't open properly and you get back from all that blood as it's trying to be forced out that narrow gap essentially. And that's when you get your murmur. So it's ejection, it's an injection, systolic murmur because it's when the blood is being ejected out during systole. Um and as you may as you probably know, it radiates the carotids. And so you get that crescendo, decrescendo sound um insistently. So between S one and S two. So you should hear S one murmur S two. So it's Lub dub. Lub dub. That's what aortic stenosis sounds. Sounds like anybody stethoscope on, on the aortic area as a result, some complications that you're gonna get with aortic stenosis because of the blood, not math blood is getting around the body. You're not perfusing the brain as adequate as you should get syncope, dizziness, palpitations and getting China as well, especially on exertion. I can get my accordion function, the um uh the coronary arteries come off just above the aortic valve um and the aorta. And so if the blood's not, not enough blood is coming out of the water out of the left bench, going to the or turn into the coronary arteries, not going to confuse the heart well enough, which can lead to complications such as M I and you get left ventricular hypertrophy. You with the aortic stenosis where the walls of the heart in inside get enlarged and you get basically smaller um left bench, cruel but stiffer walls and thicker, harder walls. The left ventricular hypertrophy. What's your management of aortic stenosis? Sue? And obviously, you start with a history exam. You want to do an echo to assess the severity referred to cardiology's treat any heart failure. Are we going to do any surgery when, when do we not do surgery. So you can either do open heart surgery or tabby or attract is called transcatheter aortic valve implant. So, if a patient is symptomatic, you should always consider surgical intervention. So a patient comes with shortness of breath, angina, syncope caused biotics, stenosis. Then surgeon surgical option is always uh should always be considered. Otherwise, this is the nice guidelines that for patients with a symptomatic aortic stenosis and then defined by measures on the echocardiograph uh um such as which is the max the peak aortic jet volume and then the audit bowel area, the left ventricular ejection fraction and there's any symptoms and mask on exercise testing or BMPs is twice the upper limit of normal. You don't have to remember these off the top of your head. Um But yeah, just to make you aware is the platform being weird for anyone else. Is everyone able to see um the slides and animations? Okay, happy. I can see it. Phone on. Okay, let's crack on. I don't know what's what's wrong with those down and Daniel uh um open heart surgery versus tabby. So, um the this is taken from the European Society of Cardiology. Um and they suggest that every patient above 75 years old should be offered a tabby as first line. Um anyone below 75 years and obviously you need to be fit for open heart heart surgery can be offered the surgical repair. Um And obviously, patient's, I'm not suitable for open heart repair, gonna have a tablet if they're less than 75 as well. So that's got of 75 years old. So that's the aortic stenosis in a nutshell, whistlestop tour. So we're now into mitral regurgitation. So, back to our cardiac cycle, blood comes from the H H year left a chair into the left ventricle. This is industrially plus through the mitral valve, you get s one which is the mitral valve closing, but it might be about mitral regurgitation, it stays open still. Um And as a result during systole, when the left metrical is contracting, yet blood going the wrong way. So it goes back through the open valve causing the regurgitation murder. And this creates the turbulent blood flow and you get to your pansystolic murmur which is heard loudest over the micro area. So as I said before I or ticks notice the crescendo decrescendo. Um This is what we it's like a single harsh sound in mitral regurgitation, also known as Pansystolic. I've tried to depict it with like same the lines like that. Whereas Isaac stenosis crescendo decrescendo the way to tell these two apart. If you're in your case is if you're in your um on the wards or whatever, usually the mitral regurg just heard loudest over the Machu area and or you heard loudest over the aortic area. So if you hear a systolic murmur, then you wherever you can hear, the loudest is most likely going to be mitral regurg or aortic stenosis. So, if you can't tell the difference between the crescendo decrescendo murmur and also the, the aortic stenosis can read it, the carotid as well if you can help anyway. So I talked a little bit there complications, you get back, flow of blood up into the lungs. So if the blood's going all the way back, it's gonna back up into the pulmonary veins. Go back into the lungs. You get primary Dema um and the the symptoms from primary Dema shortness of breath thought you get dilatation of the of the left bench cool because it's working next time and the pumping the wrong way. What's your Mandarin? Same as before history. Damn. Do an echocardiogram see how severe it is. Refer to cardiology, treat any heart failure, treat any palm redeemer and will they need surgery? That's the question for the cardiologists and cardiothoracic surgeons just a quick, quick one to go on aortic regurgitation. So this is a diastolic moments of the ones before the mitral regurgitation and aortic stenosis are systolic moments. This is the diastolic moment. So going back to the cardiac cycle very quickly. Once for the last time, the blood comes from the H M two left ventricle, get the closing of the mitral valve, which is s one get opening of the aortic valve, blood passes through, get closure of the aortic valve. However, it doesn't close properly because you got aortic regurgitation, whatever the cause, maybe rheumatic fever, um, congenital malformation, whatever it is. Um And the blood comes back. So it gets pumped out from the left Frenchman Sicily, and then it comes back because the aortic valve is not closing properly. And so you get your murmur after the S two, after they ought to get far, was closed and then you hear the turbulent blood through. So it's an early diastolic murmur, loudest over the left stone allege and third intercourse of space because if you imagine all the on the blood is coming back from the aortic valve. So if you think of where the heart is placed in your body, the blood is coming back that way. So you would hear it louder. So the left sternal edge and the third intercostal space and the way to tell it's a diastolic murmur is you hear S one S two and then the sound which is the early diastolic murmur and you can always time it with the carotid pulse. So if you feel the pulse, so when you're feeling the carotid pulse, that's, you know, that's sisterly. So if you hear the murmur after you feel the pulse, that means it's the diastolic murmur. If you're hearing the murmur with the pulse, this is systolic murmur. So, what you should hear in the aortic regurgitation is Lub dub Lub dub to S one S two mama complications that you're gonna get with the aortic regurgitation because the heart is working harder to get all that blood out again. It's just coming back, get heart failure. So how do you manage it? History exam, echo first card or just treat the heart failure? Do they need surgery? This is aortic regurg man, this is all the signs that you can get with the aortic regurgitation but not going to make you remember them. I just want you to get you to remember three for your paces Warhammer pulse. That's your collapsing pulse that they make you do in the cardio exam. Corrigan's next sign, which I'll show you a little bit. So that's hyperdynamic pulse in the neck in the carotid arteries basically. And the quick e sign is the pulsation in the nails as well. Um And the other ones you don't really have to remember. I hope this works. This is what the Corrigan's sign looks like. This is a hyperdynamic pulse in the neck. That's a classic sign of aortic regurgitation. And the reason why you get the hyperdynamic um pulse, you get the hyper dynamic circulation because all the blood is coming back, the heart is working much harder to get it all back out the right way. You get the hyper dynamic circulation, you get that pulse that you can see visibly like that, right? That's a that's a quick overview of the three uh murmurs, the three valve conditions that we've gone through Um So this first question was much regurgitation. Uh Lots of things pointing towards it as most people got correctly symptoms of problem edema because all the bloods going the wrong way back into the lungs. Um You've got risk factors for developing the disease here. Got that much Rodrigo agitated regurgitation murmur, which is that pansystolic murmur. So here s one pansystolic sound s too and loudest over the micro area and you get the chest X ray which is confirming your primary edema. So this is pointing you to mitral regurgitation. It can't be any of the other options. It can't be right heart failure because right heart failure wouldn't really cause primary Dema because it's the right side that's affected before the blood gets the lungs. So right heart failure will give you more signs of peripheral edema. No questions in the chat about that. But please feel free to ask any if you, if you'd like. Our second question was aortic stenosis. Uh uh woman, they've got symptoms of legislation. So, shortness of breath angina and walking upstairs got the ejection systolic murmur. Um And I've thrown in if people knew before, but the V max in on the echocardiogram is below the criteria that the nice guidelines. See if the nice guidelines give us if they were asymptomatic. But um so if you remember from my previous slides, um this should be about five if they're asymptomatic to consider surgery, however, they need surgery because they're symptomatic. They've got shortness of breath and chest pain which has caused from this murmur from, from this condition. Um, finally, they're above a, above 75. So A TV is the option that should be considered rather than the open heart replacement. PCI. Is your treatment for acs and you wouldn't watch and wait because I just said that's symptomatic you need to treat. Right. That's viable. A disease is very quickly. Um, Any questions on that? Please do, let me know, just wait for like half a minute. If anyone's got your questions, I would like me to go over anything again. Good. So we're on to A CVS. Now. What will be covering the stem, ease and stem ease and a little bit of an unstable angina. So this was our question and the answer was B which I think everybody got correctly. So you need a primary PCI within 100 and 20 minutes. So what is A C S stemi and NSTEMI and unstable angina? Everyone should know the symptoms of, of uh of A C S central crossing, chest pain, radiating the jaw and left arm, sweating, pill, shortness of breath, got some nausea, vomiting, dizziness, syncope. And if it's really, really bad, they might have graduate and accept shock. What need to do? Everyone should know this need to do the E C G first. I need to take a blood sample and do the troponin. This is stemi. Lovely. Pointed out. For you this anterior lateral stemi because it's in the anterior and lateral leads, chest leads. What's the treatment is the mona bash? Uh and we'll go through the acronym um in a bit. Um So this is your interim treatment before we get to our PCI. So, um if the onset of the symptoms, so the church crossing, chest pain, sweating, dizziness, etcetera is less than 12 hours ago then and only if primary PCI is available within 100 20 minutes in the hospital that you're at. Or if in the community, the ambulance can take, take them to a heart attack center or whatever, where they can have the PCI within 100 and 20 minutes, then you should go for the PCI. However, if the symptoms are like this um with it less than 12 hours ago, um but primary PCI is not available within 100 and 20 minutes. Um Then the, the answer to this is free, been a license. So clot busting drug to try and dissolve the clot that's in the coronary artery if it's more than 12 hours. So what the symptoms started more than 12 hours ago. So they might have had the chest pain and then it's maybe went away. Um And then like it's come back again. Um And then DC was like, not that bad. And now, then now you see ST elevation. So you would consider doing a PCI or Coronary angiography if there's still evidence of my cardio ischemia. So they're 12 hours more than when the symptoms started, but they're still having chest pain or they've got ECD changes or the troponin is tripled or whatever. And you still think that there's a ski me a going on as you consider doing um angiography and having a look at the arteries, coronary arteries um and open them up with the stent if needed, right. This is that Queenan mona bash, you might have heard of it. So on the left, the mona bit is the acute setting. So when a patient has the chest pain has the ST elevation. This is, this is what you need to do straight away. Um In the meantime, while you're waiting for your PCI, so we will give morphine to help with the pain, give it IV oxygen if your sats are less than 92%. Um We don't need to give oxygen if the SATS are fine. Two nitrate, what I mean? But it's the duty and spray under, under the tongue. We can give IV nitrates, I need to give you anti platelet therapy. So that's your aspirin 300 mg. So that's for all patients should perceive aspirin 300 mg plus another anti platelet. So this neither Ticagrelor or clopidogrel. This is the higher dose. So this is your mona is your while you're waiting for PCI. If, if it's a stemi and this is for your after PCI. So your treatment long term treatment of, of the heart attack, prevent it from happening again. So, beta blockers, uh ace inhibitors, you want the patient on um anti platelet therapy after the initial um am I? So that's aspirin? 75 mg. They need that for lifelong. You can give clopidogrel or take a gila um the lower dose of 75 mg of clopidogrel. And that's for just the first year and then you can discontinue the clopidogrel and continue the aspirin lifelong. They need to hide those statin and you can give Heparin while they're in hospital. So it's, this is a low electra weight heparin, fondaparinux given sub cup. Um and it's um and you give it to help dissolve the clot in, in the artery, right? So that's mona bash, that's the treatment of A C S um moving on to N stem ease. So that's you get all these symptoms, central crossing chest pain rooms and left arm dizziness, sweating, pale, not looking great. A lots of pain. Um But the STD might not show anything, might show ST depression. As you can see here. It could be some T wave inversion. So when you're looking at T wave inversion, you should always compare to an old E C G because some people might have T waves. Um T wave inversion is idiopathic T wave version. And if they flipped from the previous E C G, then you can make, you can probably say that this patient is having an end to them. I mean, if they have new left bundle branch branch blocks, that's always pathological that if it's new. So as I said, compared to your old E C G S, the main thing with an end stemi is if you can't see any ECD changes or E C nonspecific ST depression, maybe something you a version need to do a troponin anyway. Um And if it's sort of elevated, like quite markedly elevated or they have dynamic changes. So what I mean by that is the first, you always take 22 openings, first one and then six hours later take another one. So if the troponin the beginning is is normal, but then the troponin is like tripled or quadrupled or whatever after six hours, then you can say that's on, they have an ongoing end stemi even if they might not have any E C G changes. What's your treatment? Motor bash pretty simple. Um Same as the stemi. There's a little other thing which is um it's a school called Grace School. It predicts your mortality from A C S. So you should calculate this. It depends on the past medical history and everything, age, etcetera. Um And if the grace score is high, then you can consider doing angiography um to put in a stent recap of the motor bosch should draw this into your memory. Um Probably be asked in paces, probably will be asked in your, in your um in your exams as well in your written exams. Um And your ps psa you might be able, we might have to prescribe dual anti platelet therapy. Never know. Um Good. It's just the last thing. Unstable Angina. So how does it differ from an M stemi and a stemi? Um So essentially you have minimal inclusion in the artery and you don't get any necrosis. So you can have E C D changes, you can have the ST depression T wave inversion. You won't have a ST elevation cause that's a stemi. Um But the trope in, in will have, will be normal and no change in the troponin from the first six hours. And that's because you don't get any necrosis of the myocardium. And so if you don't get damage to the myocardium, you're not releasing any troponin. Um And so therefore, we classes unstable angina. So they'll have the symptoms, they might have the ec changes, but they won't have any change in troop. And because there's no necrosis of the myocardium in an M stemi, you have necrosis from a severe inclusion and a stem is complete occlusion. You have transmural narcosis which causes the ST elevation right back to the question which everyone got right. So, and explain that quickly with the car wrecks and chest pain, central question, chest pain got stemi given you that in the question, what's the definitive management? So what would you, what you'd give in the mean in the first, when you first see it's patient is your mona of the mona bash. That's the morphine. If there are lots of pain, oxygen, if the SATS are lower than 92% nitrates, either either your sublingual when you're due, antiquated therapies. So your aspirin and your competitor away or take regula, the definitive management is the PCI within 100 20 minutes. Good. That's A C S. Any questions? Otherwise we'll quickly move on to talking about heart failure. So I'm just gonna cover the medical management of heart failure. So what drugs you want to give and a little bit on poor me. A demo caused by heart failure, how to manage it. This is our question. They have palm edema. And so I need some treatment which a lot of people got correctly towards heart failure. So it's a condition where the heart can't meet, the, can't generate a cardiac output enough to meet the demands of the body. Uh And we diagnose it by uh uh symptoms, exam echo. Um And the category um the thing we look at most in the echo is the left ventricular ejection fraction. And depending on what the election fraction is, is how we class the heart failure. You might've heard of HEF hef, hef more f um The main main thing is Heparin FTF but so the left ejection, left ventricular ejection practice is less than 40% class as heart failure with reduced ejection fraction. And you know the symptoms, you get short of breath, Dhiman, peripheral edema, sleeping with lots of pillows at night. Pirates is small nocturnal this opinion and you do history exam, BNP uh E C G chest X ray echo to get the diagnosis. So I'm gonna focus more on the medical management of heart failure. So, symptomatic control for both this, I'm going to speak about hef ref and Hedgpeth. So we're not going to really worry about the thing in the middle. So in both reduced ejection fraction and preserved ejection fraction, um you need to control the symptoms. So if they have Dema or pulmonary edema, peripheral edema or pommery Dema, you need to give you loop diuretics. Um Do you get in control of the symptoms? So these and then I'm moving on to other medications. These medications are called disease modifying medication and they're only really beneficial if you have reduced ejection fraction. So, preserved ejection fraction is really all about symptom control. Um And then you can whack them on the other, these other medications if there, if the ejection fraction goes below 40%. So you need to give you a teeny bit which first line has the most Prague mystic benefit, beta blockers and I lost her and I antagonists after that. So it's spirinolactone popolo potentially you could use there's some new drugs on the block. Um You may have heard s of SGL two inhibitors. Um they block a glucose transporter and the network of the kidney, um, make you pee out, um, all the, all the sugar, um, use the diabetes and it's also shown to be, um, quite good in heart failure as well. The medical manager, it's a disease modifying medication. Um, and there's a combination here which is, um, so give you trouble with Valsartan. Um, this is if maybe they're intolerant ace inhibitors, um, that you can consider this. So you'd start it. So this is a ARB and this is another kind of um uh drug and you start this instead of your ace inhibitor. Um if they can't tolerate it or whatever, um you can have some devices or that you could use so you could implant and put in a nice C D. So if they have heart fair and they have V F or V E T in the past and they get symptomatic with it, then you can put a nice C D and shock them out of the rhythm if they go into that. So that's the medical management of heart failure. Um So it's simply control with all patient's with any heart failure and just reduced ejection, faction of these three main drugs I want you to, to be aware of that we should use. Um And there may be some new fancy drugs which really, really be initiated by a cardiologist specialist and if they need one in I C D. So what does palm edema caused by an acute heart feel, exacerbation looked like it might look like this. Um You get upper low blood diversion so that you see prominent vessels at the top in the upper lobes. That's what I mean by that. You can get interstitial Dema that's, that's your curly be lines which you can see on the side in the interstitial here. These lines, that's your curly be lines, you'll get your back wing shadowing. So you can see on the, on the side it um pure effusions, which is they have a poor effusion here. Um Sorry, I'm just, oh sorry, I didn't see all the chat questions coming through. Um Let me just finish the chest, the chest X ray and then we'll answer them so poor effusion which you can see in the costophrenic angle or you can, this patient has one here and obviously an increased cardiothoracic ratio, right? So I'm going through the questions now. Um Why is to be greater than 75? I think it's just because um I don't know, I don't really know why they've made 75. I don't think it's arbitrary. I think if they were very fit um eight year old, they could have and if they could survive open heart surgery, then you should consider doing open heart over Tabby. Um um I think it's just sort of a rough guideline but it um I'm, I think it's because like if you're above 75 more like to be more co morbid and not as likely to survive open heart replacement. Uh, so does it not matter if the symptoms, but one hour ago or 11 hours ago in regards to PCI access? Yeah, that's what the guidelines say. So, uh so the patient could have, could, I mean, they could have like a chest pain, I don't know, 11 hours ago, which I didn't really think much of. Um, and then they come into hospital cause it's getting worse. Um And then you do an A C G and they have an ST elevation and then you can do the PCI in 100 20 minutes and you would go for the PCI basically. So, yeah, it's just, it's not, it's what the guidelines say, but it's just like if they have ST elevation, they're still in pain, troponin changes, then you want to go and do that PC I, if you can anyway, can you explain diagnosis when there's chest pain and new left bundle branch block? Some sources say STEMI whereas others say end stemi? Good question. Um I'm not, I'm not entirely sure, I'm not, we're cardiology. I'm not cardio soak up. I don't know why STEMI will cause left bundle branch block. I just got, we just talked about any new left bundle branch book is, is bad. Um So I'm really sorry, I can't really answer answer that question. Um Unfortunately, I will, I can maybe look up after and um I can send out the, the answer to that afterwards. Do you give disease modifying in preserved heart failure? No. So in preserved heart failure, um it's all about symptomatic control and there's no evidence that the disease, these three drugs, um we have any prognostic benefit in preserved ejection fraction. Good answer questions. So that's your chest X ray going back to the primary dina. Um I'm sorry, I'm just checking the chapters anymore. Uh So this is not on the X ray films. So you get the more prominent upper low vessels that you can see. You get the back wing shadowing curly be lines, blue or effusions and cardiomegaly. So we should see on the chest X ray. How do you manage it? So this is if a patient is acutely unwell with for me, edema, so you see them in A and E you see them on the ward, they've had an acute exacerbation of the heart failure to do the basics. 1st 80 A pro A T E assessment. One of the vitals get IV access, get basic blood stroke and doing A B G maybe. Um uh put them on some oxygen, easy do chest X ray to confirm the diagnosis. I'm going to talk about the drugs that you can maybe that you would give in this case. So the main drug is your loop diuretic frusemide. You can give 40 to 80 mg IV over five minutes. Um Then you measure this, you measure the effectiveness of truce in mind by monitoring them urine output. And if it's poor, you can maybe give an infusion as well or double the dose. If you're given 40 and give another 40 you can also give some nitrates. Um You can try it sublingually first and then give it IV it's not helping. The BP should be about 100 and 10 systolic for you. Um to give the nitrates and why nitrates good that cause invasive and reno dilation, which reduces the workload to the heart, which causes the oxygen requirement. And therefore, um and if you, because obviously when your heart failure, then um you the power work more. If it does, if it's not crying as much oxygen as before, as a place for morphine of the patient is quite breathless and if it's distressed with their symptoms, so it helps um depress the respiratory drive. Um So it can help treat symptoms of breathlessness, maybe given anti emetic with it as well. It's a couple mind so that those are the main three drugs that you would be considering. So frusemide, definitely you give all patient's like give it IV nitrates there. BP is about 110 systolic um and morphine as well for breakfast. Patient's so back to our question, this patient has signs and symptoms of primary demand that acutely short of breath, they have buy beers of crackers, there's a place for wall feet, another set because they're breathless and distress. Past medical history indicates they might be in heart failure. You can have some nitrates. BP is good and your chest X ray is telling you the diagnosis. So you have Premier Dumb and the only treatment with IV fruits and Mike some nitrates and morphine. Uh So these three drugs are your prognostic um disease, modifying uh medication for chronic heart failure. This is acute exacerbations. They wouldn't be given in this acute scenario. This is your treatment for stemi or end stemi. Uh You wouldn't there be no role for beta blockers um in, in acute heart failure as compounds make things worse. Uh And you wouldn't give the fruits my door in this um answer. Uh It has to be given IV it works quicker. All right. So that's heart failure. No more questions. I can see. Um Now, last section, uh we're doing quite well for time or someone when you use bumetanide. So, bumetanide is basically the same as frusemide. So you can use it instead of frusemide. Um It just more hospitals are likely stop, stop furosemide and it can be given IV as well. Frusemide. So you can use bumetanide in chronic heart failure as your uh loop diuretic at the top for symptomatic control. It's the same as frusemide. Um And do you ever add spironolactone and premier edema? Uh not in the acute setting, but yes, afterwards when they're stable. Um and you've sort of treated the primary Dema with your direct IX. Um Maybe you can add it on as well. So the frusemide is not helping. It's not really doing that that much, but I, I wouldn't really use it in the acute setting, but yes, it has a role in chronic management of heart failure, right. The last section on heart arrhythmias. So I'm gonna cover these, um, so these arrhythmias. So af atrial flutter S P T s and V F and B T, this is our question and the answer was C and we'll explain why that is at the end. So I'm gonna give you a um a way to assess um tacky arrhythmias on the E C G. So first thing you need to, to ask yourself, is it fast? It's low. So this is fast because it's tacky with me with, is it regular? Yes or no? If it's irregular, then it has to be af atrial fibrillation because no other fast arrhythmia is going to give you an irregular pulse like a f second thing you need, you need to ask if it is regular. So if it's irregular, you stop and you say it's a yes, this is not, this is like a general rule rather than it doesn't have to be followed. It might be something else. But if it's, if it's irregular, then you can stop there and say for you all over the, it's a f if it is regular, then you look at those QRS complex complex is, are they narrow or they broad? If they're narrow, then we can think of a chill flatter. We can think of atrial tachycardia. You can think of AVNRT and A B R T which US PTS and obviously need to know if it's sinus sinus tachycardia as well. Is it broad? So most of the time it's VT Ventec ventricular tachycardia or could be a weird S V T with an accessory pathway pathway causing broad complexes and then a sort of a subsection. If you find a broad complex tachycardia, can anyone tell me what percentage of all broadcasters tech card is R V E T? Take us just put it in the chat if you can. That was it's possible. That's right. 80%. Someone said 90 yeah, close. So 80%. So if you see a broad Krampitz tachycardia, you can say 80% probably it's probably 80% like that. It's going to be meaty. If they have ischemic heart disease, they've had a previous um eye or left ventricular dysfunction, their heart failure. What percentage of all broad complex tachycardia? RVVT 95%. So if you have a broad complex tachycardia in a patient with a history of em, eyes stents heart failure, you can say with 95% confidence that they have VT this is what looks like. And the way to confirm that they have V T is to see if there's any independent P wave activity present. So if, can you see any P ways within the tachycardia? If you can't, then it must be et, and then if it's not, if you answered, knows all these questions, then um it might be something else weird and wonderful. So, can anyone tell me what this is? So we're gonna try and go through that. Um, the method I told you. So, first of all, is it fast? It's slow, it's fast. Is it irregular or regular? It's irregular. So you stop there and say it's a F. So this is a F, it's irregularly irregular. There's not really any P waves. Um You can stop there and say it's a F. So this will be a fast af basically, this is not SPT because it's irregular. So we go back to our thing. Is it regular or irregular? Irregular? So it must be a F, do you see at the end here? It's irregular. So this fast af anyone tell me what this is again going through that, that method. So, is it fast or slow? It's fast? Is it regular or irregular? It's irregular. So it's a F. Exactly. So even though the complexes abroad, it's irregular, there has to be a F and this is a F with left bundle branch block which is causing the widening of the QRS complex is. So it's irregular. So it must be a fast af now this one fast or slow, fast, regular or irregular. Tell me. Yeah. So there's someone said S V T. So this is an S V T. Yep. So is it irregular or regular? Is regular? Is it narrow or broad? It's narrow? So this is an S V T or AVNRT? So this could be a young patient with palpitations. Um Not feeling very well. What was the first one? The first one was a F, it's just one. It's, it's irregular. You can see on the rhythm strip up on the bottom over here is irregular. It's quite fast. So you can't really see the irregularity but it is irregular. Does that say? Yes? Uh So this is S U T. It's very fast. It's regular, it's narrow. This is E V N R T. This is actually taken from a real patient that uh saw my trust. Um So this is a really CG that um actual patient not taken from Google images? Is it faster? It's slow? It's fast. Is it regular or irregular? It's regular? Is it narrow abroad narrow? Does, does that mean this is another S V T? Right? Can you tell anyone tell me what this is? Someone's got the right answer. It is flutter. Uh Daniel, I'll go back to your question in a bit. So this is atrial flutter. Um And the way that you can tell is got the sore tooth pattern, it's going at 150 BPM and it's a 2 to 1 So what I mean by 2 to 1 is to flutter waves to one QRS complex. This is classic atrial flutter, 150 beats a minute, 221, so two H L flatter waves of one to the one QRS complex, it's fast, it's regular, it's narrow complex. So therefore, it's pointing to S V T or Rachel flutter and you can see the flatter ways which gives it away here. Um Atrial flutter always to, to one. Um No, not always, but this is like classic atrial flutter, uh which is a 2 to 150 beats a minute. Um because the h uh the way to sort of tell if it's, um if it's atrial flutter, you wouldn't really do in practice, but the way that probably diagnose it is to give them adenosine and what that does it gets rid of, gets rid of most of the QRS complex is and slows the ventricular rate. So you'll see like the flutter waves going up 300 BPM. Um For every uh Q R S, I don't have a picture. I'm sorry, but um basically let you get rid of like to, to cook it. Curious Publix here and you can see like the flatter weights more clearly and that can give you the diagnosis of atrial flutter. I hope that makes sense. Um Daniella going back to your question this one here. Why is it not sinus tacky? Because it's a bit fast for sinus taxes. It's probably going at 100 50 to 200 beats a minute. Um, and it wouldn't fit with the symptoms. So this, this patient would probably be symptomatic with it because it's going so fast. Um, but yes, it is a bit difficult to tell from a sinus tachycardia. All right, let's crack on. Can you tell me what this is? Is it fast? Is it slow? Is it regular? Is irregular? Is it narrow? Is it broad? Good? Someone said, someone said VT um mm someone said red, right bundle branch block but not something answers. Unfortunately. So this is V T. So let's have a look at it. Is it fast? Yes, as fast. Is it regular or irregular regular? Is it narrow abroad? It's broad. And what do we say about broad complex tachycardia? 80% of et so you can say with 80% confidence is, is VT um I haven't give you any history. So they might have had ischemia heart to see or whatever. But I there's a, in the CT, there's a circle here which is circled P wave, that's an independent P wave. There's also maybe a P wave potentially here here as well here. So there's independent po of activity. So this must be ventricular tachycardia because we've gone through our algorithm. So there's broad complex tachycardia with independent P waves. This must be VT anyone tell me what this is. And yes, V T again, there's monomorphic VT. So faster, slow, it's fast. Is it irregular or, or regular? It's regular, that narrow abroad. It's broad. 80% of E T I don't give any history. So you don't know if it's 95% VT. You've got some P waves as P wave may be here. Um And uh there's maybe one here as well and it's a bit difficult in this one, but there are some P waves lurking about um repeat parts of independent p ways of viti. So in Viti is the ventricles that are going fast. And so it's the ventricles are masking the actual activity. So the hr still plodding along at whatever the rate is because your sign or H one node is, is uh making that rate. So the sign of H 10 is going at 80 BPM, you'll see those P waves at 80 BPM, but the ventricles are going fast and therefore you have those P waves masked by these QRS complex is basically. So your sino intra node is influenced by the vagus nerve, uh sympathetic system. So that that in a normal, working hard, that conduction would um the sign of intra note conduction would determine the heart rate. But because the ventricles are going fast by themselves, that you will see the curious complexes and you see the P waves going out whatever the heart rate of the patient is. Lastly, what is this? So this is V F. Um And this patient will be dead. Basically, you shouldn't be doing the C G, you should be doing a L S or whatever. So never do an E C G or on the patient like this. So they won't, they won't have a pulse on this patient just going to touch briefly on the management of H fibrillation. So that's, that's how we do E C G s and see what is more. Um I hope that helps. I hope that the algorithm I've taught you helps to have a look at E C G S um and see what the rhythm is. It's about A F. So you can get a F from on any other underlying cause such as sepsis. Uh And if the patient has long term A F or parasites, morayef, then you need the main, the main important thing, important thing is to anticoagulated patient for stroke reflexes. Then that's um dependent on your chart vast score which get the school of how lucky you are too to develop a stroke. If you have a F, if it's higher than one in a man and two in a female, then you should consider anti calculation and need to balance that about balance that against the has bled school, which is their risk of bleeding and the two sets of drugs that you can use to manage A F. So you got your rate control on your rhythm control. Um And uh I use either use B C D for rate control. Can anyone tell me what any of these drugs are B C D? I can give any of them? Maybe you can be. See maybe. Yeah, B is beta blocker, beta blockers. See his cows and Planet Bookers and D is digoxin. So your calcium channel blockers, you have to use the wrap meal and ties. Um um They are rate controlling calcium channel blockers whereas you, I'm not appealing. Um Nifedipine work on the, on the blood vessels and cause phase of dilation. So has to be the rate control, the rate and uh custom channel blockers. So wrapping or two tires up. So you would use, you start off with using one of these drugs. Um Most commonly we use beta blockers. If they can't tolerate beta blockers, you give the calcium channel blockers. So they've got a smell for whatever reason. And then digoxin is used. If they have a F and they think about it as if they have a weak heart, then you use the digoxin. So if they have a heart failure and they got a f for uh severe scheme of heart disease, you can consider using digoxin. So that's great control. And if so beta blockers not working, you can add on the digoxin, we can add on um custom channel blocker as well. So you start off with one and then, I don't know. Oh, I'm just giving that way. Um Can anyone tell me any rhythm control drugs, which I hope you didn't see that my acronym is be safe. Mhm. Just so we're almost at the end. So just plan for it. Um, so, uh sorry. Yes, I misspoke Gazal. Um, you wouldn't use them both together. You wouldn't use a beta block and wrap them together. You would, what I'm saying, the combination is you'd use, you try a beta blocker first, that's what you give the digoxin as well and you or you try a calcium channel and then your next adam will be digoxin. Um So I misspoke, I didn't mean you shouldn't use a beta blocker and wrap uh calcium channel blocker together. Uh And yet, so uh going on to the rhythm control. Um You can use beta blockers also served as a, with a controlled drug I put in sotalol, which is a non cardio selective beta blocker. Um And then amiodarone is useful chemical cardioversion. If a patient is unstable with uh uh flecainide is pill in your pocket. So it's used in good heart. So like uh patient's that don't have a past medical history of ischemic heart disease or heart failure or anything like that, you can use fleck and I which is quite good at controlling the rhythm. Um and then electricity. So that's your DC cardioversion. If the AF is causing him him a dynamic instability, then you'd cardioversion. Um Yeah. When do you rate control with the control is it always, so you always rate control, you'd always get one of these. And then if, so rhythm control, if they're hemodynamically unstable, you would go for DC cardioversion, you could go for um Yoda and chemical cardioversion. Um And then flecainide is used in, in younger patient. So you, you want and like with, with symptoms. So if there's a young patient with symptoms of power existent A F or whatever, then you, you can use flecainide to convert them back to sinus rhythm. Um But if, if they're like a um more elderly, then you can maybe just consider rate control and if they're asymptomatic with it, then you won't have to convert them out size if you anticoagulated them as well. So the main complication of stroke of, of A F is causing a stroke. So you need to anticoagulate them and obviously need to control the rate as well. So if you anti calculate them and control the rate, it doesn't matter about the rhythm because the heart would be fine with that rhythm with the A F rhythm is it's just if it's causing symptoms and maybe consider uh rhythm, rhythm control. Basically, I hope that makes sense. Alright. Last bit on S V T. So that's AVNRT. This is a nodal reentry. So the um the electric impulses going in like in circles around the AB node basically, which is causing a really, really fast heart rate. Your first point of call is a Tennessean and you can do your valsalva maneuver was while drawing up the adenosine. But most likely you would, you'd go for adenosine first. Um And um so Valsalva manoeuvre is uh you can get them to uh get a syringe and get them to blow and try and push the syringe up. That's quite a good, good way of doing that. But you need to give you a dentist in IV 6 mg initially that doesn't help. You can give it 12 mg every 1 to 2 minutes up to do doses and have a look at their response and your second line drug, if that fails, you can use amiodarone, give it as an infusion um as showed here. So that's a bit about SGPT. So I just need to remember adenosine basically 13 6 mg. Uh I think I had a P S A question on that. So remember the dose. So this patient, can anyone tell me what this patient has? What, what the C D is showing? So Donald said S V T, is it narrow or is it broad? Yes. Yes. VT 95 5% sure. As BTU see broad complexes and in regular, he has a past medical history of stemi. So you can 95% say the confidence that it's V T hold on and because the hemodynamically unstable, you need to give them a shock. So yeah, as I said, this has scheme of heart disease of viti 95% confident, unstable, they need to shock. So this is a broad complex tachycardia. So it's fast, it's regular, it's broad, 80% of et 95% of E T in patients with the scheming heart disease. So you can say 95% sure that it's VT. And can you see some P ways? Maybe there's one here, uh one here, maybe um difficult to say BD. One here, just a little bit there. Difficult to see. I'm not taught arrhythmias. Any questions on that is management for H flatter same as S V T. So um HDL flutters similar to uh atrial fibrillation. So you can give rate control uh such as a beta blocker. Uh and you need antibiotics. Uh atrial flutter gives about the same risk of stroke as a child fibrillation. So you need to antique, you relate someone with a chill flutter as well. You can use them rate controlled drugs such as Bisoprolol beta blockers or calcium channel blockers to treat treat 88 atrial flutter. Where is S V T is usually, is your identity, right? That's it for arrhythmias and that's it for the talk just last few questions if you want to hang on. Uh you can go back on the mentee meter and um let me see if I can take that along. Yeah. So this is not a like a fast question like how if you answer fast your points. It's just maybe I can help it. I was also good. But yeah, this is the question, sorry. Or if you don't want to use Menti, you can just put it in the chat. See a without, yeah. See you. Okay. Yeah. So if d is the correct answer, um a uh aortic stenosis can give you left ventricular hypertrophy. Um early diastolic moments h regurge. Um The main cause of aortic stenosis is degenerative classification, not rheumatic fever. It causes ejection, systolic murmur and it causes a crescendo, decrescendo, not decrescendo Christian. Next question. That's 17 90. Mm. So I've gone with Asian inverter. So this is the first line thing that you would use for heart failure and because it's the best prognostic value in heart heart failure with reduced ejection fraction. So you can give these this manner uh disease modifying drug because he's got reduced ejection fraction cause it's less than 40%. So it's a snip. This is what I've come with. Finally. One more UCG for you to do. Um Tell me what you do you use. I don't have a mentee for this because I meant to meter only gave me seven questions. This is the eighth question. So just write your answers in the chat. Just wait for advances. If anyone would like to see something different to device you tooth uh Verapamil, anyone going with anything else, someone's going to be two blocker, someone's going for amiodarone. So I've gone for Verapamil. Um So in this patient, they need rate control um because they're in fast af and obviously it would anticoagulate them as well. Um So your rate controlled drugs are popular and verapamil, we wouldn't give them a super low because he's got asthma. So the answer is verapamil, it's not amiodarone because um this is a, this is if they're unstable, it's chemical cardioversion, essentially. Um It's obs are fine. So you wouldn't need any cardioversion or any amiodarone and adenosine is treatment of SPT. So I only obstinately or a or e because he's got asthma would prefer good. That's all the questions. Thank you for listening. Um And please feel in the feedback which I believe is on um is on medal. If you click the feedback sections. Thank you very much for listening. And uh if you have any questions, please feel free to ask and email me as well. Uh And put my email on the chat and you have any questions about F one or applying to Dean Aries or any questions about finals, just shoot me an email. That's my email there for the second last S be a. Don't give beta block and a seam together. You would give it eight and uh both of them together. But I'm my quite the question was, what's the best product value? Uh The, the drug that you, that gives the most prognostic value in heart failure with reduced produce ejection fraction. And the answer's a senators. But you would give both and you would give you consider an adult stone attack genist as well. So loop diuretic sar um symptomatic control only. So it doesn't offer any prognostic benefit. Dyes are diuretics not, doesn't really have a place in um heart failure upside from reducing BP. And then you've got three that um uh like a disease modifying and 18 emitters that gives the most prognostic value. Cool. I'll just wait for extra minute or so. Um for you to fit in the feedback me, ask feet if you want to ask anything about final year F one. Anything else? Just shoot me an email. Thank you so much, Ben. I just hope refill. That's okay. I don't think there's anything else so you can leave it there. No. All good. Thanks so much. Yeah and yeah, the feedback being filled out. Is that all? Ok. Hair if Yeah. All good. All good. Thanks very much. Take uh you to see you.