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syndromes. I I So we've got kind of genetic shock. We've got higher called the lien It shop got distributed shock. I live about obstructive shop. So cardiogenic shock cardiogenic shots Basically failure of the pump of the heart, the heart that put value of the pool So that could be due to things like my paddle In fact shirt a rhythm years Canada caressed There's two examples so uncanny cardiogenic shock. What what happens is I mean, our table pressure cardiac out for BP drops whereas the pulmonary artery pressures central venous pressure increased when I was in medical. Uh, the beauty mean our table pressure, BP. So BP you can measure just with the BP go up. It's an easy measurement to see how well you're going to be perfused me 90 or pressures got specific formula, which is a systolic plus twice, two times Dysport divided by three. And that gives you mean I feel pressure, which is a better man reading. But will you kidneys and your brain and except for being confused, so obviously, if the pump failing, then everything the BP, output, everything's gonna go down where because the polyps failing The blood's going to backtrack because it backtracks. It goes black, backtracks in the left ventricle left atrium into the pulmonary pulmonary vein. Pull me out trick. So therefore, the pulmonary artery pressure increases and again it back track. Since the venous system that venous pressure increases, that's where you get certain symptoms like raced JVP um Yep, that's kind of shop Hyperbole make shots that's different too. Carried a cardiogenic shock Will happily me a pin There could be something like hemorrhage the I'd rations Could be diarrhea idea nearly ostomy the higher dose to me again. This you mean? I feel pressure and cardia output and BP drop. But in this department, artery pressures and your central venous pressure also drop because this reduced volume in your circulation was in cardiogenic shock. It's not reduced for you is more the point failing distribute of shop So this conclude anything from neurogenic unaffected sepsis. And this is basically when you have a decreased vascular tone and again something like sepsis and flex, it should leap leaky capillary which can cause third space loss it and then you've got obstructive shop final, which can be obstruction, could be Cut it pumping out because intrusion heart, um, pulmonary saddle pulmonary embolism have pneumothorax, and this you can output would decrease. But your central venous pressure when we are tree pressure's a little log increase so that the of measuring your heart out pull the venous pressures that can all give you an indication of war. Which kind of shock you did. The patient could be it. And also look at the rest of the clinical examination history as well. So it's pretty small, so shocked the patients so causes heart failure. So many causes heart failure in this, like such a common condition, it's very important to know so most common ischemic heart disease So that, um, join a, um I there all causes of heart failure. They read the Mircette again. If you had escaped heart disease, you can and you have a fibrosure Look at my cardio. You get a written here, Um, all the things like electrolyte imbalance, these eiroy cause a with, um years. So that's again cause of heart failure. Valvular heart disease again. Lot of patients. Aortic stenosis is most common bug in heart disease from prosecution at the the Lt Well, course, the heart failure. Um, it could be a cute eso think that endocarditis just had an IBD You, Um Oh, it could be Or trauma again if you had a heart attack. Um, I on you could get my regards from that. Uh oh. Chronic. And then a pulmonary have tension. So again we go big population people smoke you end up getting will call cor pulmonale a woodchuck over later on. Pulmonary hypertension again because heart failure, constitutive or restrictive pericarditis Not as prominent a pericardial effusion. And then problems with the heart muscle that to my card. Um so could be again ski me a dilated. So will be in your perfect or alcoholic Again Certain books are accepting which used the breast cancer viral, muscular, dystrophies hypertension Lot of patients are hypertensive that because left ventricle Habitrol be on. But then again, hereditary. Is that okay? He told you so easy with looking things I love The surgical sips will be a surgeon and you burn a useful tool. But again, you can also look at things being common. Cause of less common causes. The company course is also coronary artery hypertension. Uh, valvular heart disease less common things. We think that congenital heart disease kind of mouth these rheumatic fever, rheumatic heart disease. So just to go over some physiology, which I always like whenever I'm teacher like to go back to what? I understand some of the physiology that's relevant to that condition. So cardio helpful is heart rate time Stroke, William. So heart rails is your heartbeat number of beats in a minute. Um, stroke volume, volume of blood pumped out about ventricle beat. So because you can't get out put and then ejection fraction injection fraction is you, uh, stroke volume divided by endocrinology volumes. The end diastolic volume days. The mark of look left it in the ventricle at the end of diastolic just before the left ventricle contracts. And so this is the frank styling. Um, So this basically says the law says that frank starting law says big, more. The ventricle, the heart dilate, doing vastly more blood to risk the stronger the force of contraction. But then this eventually part Oh, so eso then you be heart's not going to put for that blood. If it goes beyond a certain point and again in patients with heart failure this is a bit lower than that. For then, this is why we give diuretics and heart failure to do stop volume in there. And so, yeah, so distributive. Mawr. You expand the heart. They're stronger, the force of contraction. And she drank startling, So it's quite pull it in stunt and happy. So how failure again? Another way to look at things could be low output. Heart failure High up for heart failure. It's a local, obviously kind of helpful goes down, Um, but the demand problems that was normal on the heart's unable to meet that demand. So that could be again, like scheming heart disease, hypertension, far your heart disease, most high output heart failure. Um, so the cardiac output is normal, but the body's demands of the blood it's cool. Now this could be beings like hypothyroidism because you don't increase metabolism. Anemia, uh, pregnancy. You have a V fistulas, and part is easy. Paget's disease. Interesting, because what happens in patients of passes disease is obviously they've got this high turnover in their bones, so that got quite big bones. So then therefore a lot of their blood goes towards into the bones, rods and dressed the body and then therefore, you end up with, um, a high apple half again. You can look that systolic. This is diastolic heart failure. Since it started out, Builds impaired contraction. Hearts quite dilated. Uh, the injection fractions with juice. Where in diet that heart village impairment in the relax. A shin feeling in this because of hypertrophy on the injection fractions of using normal. If you remember, ejection fraction is a stroke body and divided by the end diastolic volume. Um, Sinus symptoms quite similar. Ah, the bmp that we measured. Low testing heart failure is more elevated systolic. Um, I'm not sure why you're well, I found, um And then again, things that system heart's really it could be prior. Um, I where is, like, Diastolic will be older women could be obesity, hypertension, and then again, based on severity again. So is it compensated? So they able to manage with the heart failure was a deep compensated. I mean, if you're seeing them, probably hospital is probably going to decompensate to, uh, you can look it left or right sided. Heart failure. Um, again, the lower pole helpful. Accused versus chronic systolic. Mrs. Diastolic lost different ways of looking at heart failure. Um, again, The know the way they look at it is, uh, half a day with preserved ejection fraction over these injection. Fraction was way tonight. So taking a history from the patient heart failure in certain things, you want to, uh, So the things you want to cover still, symptom onset was a gradual or abrupt since in duration. How long have they been having those images? Full? Any, Except it's abating. Factors relieving factors, exercise tolerance if the symptoms worsen. Night on. When's the last time after they've been admitted? Little with the heart failure. Um, what are they? Hard. I see you level too little sweet care. So the heart failure. Any associated features. That's just chest pains. 14 fever, malaise, syncope, any recent changes in medications. So inside you, we've drawn of diuretics, custom tailor blockers. So these were very important questions to rule Enbreled out whether it's heart failure that's causing the shortness of breath and symptoms on what the cause is of this heart failure could be Well, the question is, you may want to ask you how the pillows do you sleep with. Do you get of the night flight of breath. How far can you walk on flat without stop in Able to walk around the supermarket able to get out of the house So he's going for questions so Well, what we do is the New York classification for heart failure. So your cost warn is order. Physical activity does not cause the tea pop. Titian's John You cross to order Never got it does not cause it again. Visit does not cause I do 50 pop it this way. Whereas a cluster is less than or no physical activity on plus four is that rest. So I think known difference when it becomes class three and then whatever plus four plus full support So can I examine so certain important things? So the sweaty, clammy basal constrictor always a dilated So let the couple of refill pulse put pressure um temperature JVP apex beat Oh, there's no Come on on Uh, just like the diastolic radiated with little distant memory Radiate third heart cells Procardia rock chest signs about two maybe perfectly demon Um no heart sounds auscultation Accordion popularity is a difficult topic. And then if you want to do another talk on that is quite detailed, so I won't cover Cystitis. Is diastolic moments like today and 34,000. So we're going to start today to get it more detail than happy to come back into another talk or not, Uh, fill left ventricle. There's left sided failure. So that's looking left versus right. So unless I failure is progressive damning of blood with the pulmonary circulation as a quite a consequence of diminished BP for so left side failure book blood always backtracks. Backtrack. Since that pulmonary circulation pressure, the pulmonary rains transmitted into the computer reason then arteries. Uh, this least appointment congestion and poverty. So pulling the demons make sense. Uh, I think it's so heavy, wet lungs to get breathlessness and on orthopnea. So that's when lying flat practice, not journalistic near. So that's when they wake up in the night gasping for breath. So decrease got a couple reduction in renal confusion so we'll get the folks is very important left. I have really and actually this causes activation of the reading Budget. Tests about lost phone system are friendly, sister. They might run from pre critical years on again. This causing attention salt water, and then this makes the problem even worse, cause then they retained fluid on that. If you remember the front styling little, they're going up and plateau in on the curve. And again, they've know that heart failure patients have got poor heart function anyway, So they'll be further down on friends down and can't remember uh, pulmonary edema. So just going over the rent and I And attention, aldosterone sister is quite bought. Understand? Because obviously some of the medications we give to interact with this system. So what happens is your liver makes under intense energy. Now, when the BP, when the kidneys detected low BP, low profusion, they released renting runnin converts and the intensity gentle and your attention one and then understanding one that goes to the lungs and a 600 tens of bendings um, convert, for instance, in 100 s and two I'm just tension too. Then goals and acts on your blood vessels to constrict them. And this hopefully because you can be set this low BP, it will construct the blood the blood vessels on to try and get the kidney confusing again. It will also go on after your adrenal gland on it will release Aldosterone Mr the German fellow Willie's. I'll toss the road, um, on Aldosterone and then go back to kidneys. Acts on the others are the store, except in the kidneys. On it will cause sodium. So salt water retention is option and therefore your intravascular volume will increase and again you go constriction of blood vessels. So that's how the rainy and engine testosterone system works. And again, if you left sided heart failure causes you left heart is left ventricle. Shouldn't perfused kidneys. You have the rain in the grass system kicks in so that that this is a little picture to arrange your left side, I'm going to write some heart failure. So usually it's a consequence of left sided heart failure. Right. So she got this pulmonary hypertension wrong with the blood, back track and lungs, get COPD patients or called pulmonology. So I'm doing a talk and COPD and I'll call this bit more beat up, then full basically COPD patients. Some of them can get point. We have tension. Then this one called right eye heart failure. Because you're right. It was pumping blood towards a high pressure pull me actually similar to lessen heart failure in hypertension But other causes Pulmonary embolus see a line Coben patients probably the heart disease and then again, congenital heart disease. So these were patients because the blood back trucks into that body. These are the patients that come in with ascites perfect Dema about a spinal mentally uh, grace JVP So these patients were on a monitor the weight Because seeing you trying to get all the fluid off investigations and heart, they're they're important. So easy. Jesus port to the full riots that left sided Definite structural feed our strain Any skin? Yeah, chest X ray for blood counts or for any anemia using east That's a left properly could cause kidney take a I see. So we know. Then again, the medications given your heart failure can maybe can function well so it's good to get baseline function If you're worried about scheming and than opponent GP Lundell do be in peace. And then again, if you were upset, sees again things I investment o'clock dieters, if you got the risk factors could be doing but coaches and then it's always good to look upon the system. She went loss. They have a copay and see if they need not a copay for discharge to look at their ejection fraction. And then again, if you're worried about screening, could imagine. So here's a me See, jeans and patients that might be heart failure so they could have heart block. We could have irregular rhythms. Air. Oh, big tea. Um, yeah. So heart failure, Chest X rays Placid 8 80 that you could signs on a chest X ray. So obviously a lot of the older Dina. So wings be is curly, be lines. So interstitial Dema c is currently cardiomegaly so classically say half of the cardio phrenic size. It has a bigger one half of the diaphragm. Then can you wiggling? Remember, I've been call pa. This is a PHS to trees. Um, I think ST t the heart looks bigger. Um, and then zd is dilated permanent little vessels. And this could be from pulmonary hypertension on des perfusion. That's just going through what I get pulled me demon, uh, so causes a pulmonary edema s. Let's like heart failure A with me as so if you get some pulmonary edema. Think of it is heart failure. Similar medications. So hcg so cause a politically a minute miss half. Then a heart failure left ventricular failure. Blood backtrack into lungs. Could be sepsis, causing them to be short breath. Always move out. Um, again, Sepsis can cause heart failure. Excessive it heart failure. Thyrotoxicosis Does it go with their on thyroxine or anything I've learned previous history of star had called hyperthyroidism always shedded tear teas And again, sometimes it's a kidney functions Body patient doctors gets good so it could be IV fluid. Certain good goes a long way to go into pulmonary team. It's gone. That's a BMP and the problems with the bean and heart failure on, uh, again, all the horses have raised being Pete, so it might not just be out. There could be peace. AKI z pulmonary artery Attention, sepsis, COPD. So all sorts of things can cause race. Be a piece of that's why you don't do it in cost long acute setting. It's more of a GP. So again diagnosed heart failures. The CT chest X ray is the most important thing in the easiest thing to get initially and then they can be in PM GP land Echoes. Uh huh. So again preserved Ejection fraction. So optimistic that patients sentence science according heart failure Preserved ejection fraction. Quite poor because it's basically if the stroke volume less more than 40% Typically, elderly female patients could be hypertension. Uh, frequently sedated by air. Eso again like, say, present Just first is about 50% will go diastolic heart failure. And then a lesson for person is systolic uh, reduced ejection fraction heart, Bailey. It's just starting now. So, um, I have pulmonary edema. Could be quite scared. You see the first time. Especially like night shift and roll. Easy thing to do is what we call, like a lot elemental pee So sitting patient all give the motion So, uh, get IV access, Okay? I mean, this is part of classic in the guidelines, but you don't normally start off, get no. Kids want to give them diuretic. So fears more so. Well, a mental pee exams, opiates. Been on your life, you'd speak to senior. So, uh, l is full lived or it takes and it's the morphine. And it's the nitrates. Always oxygen piece of position. Another No pee. And then they get heart failure. You want to do a cardiac monitoring sug catheter to look at the kidney function? Urine output? Um, you got, uh, if you're worried about your demon, it's not getting better with for his mind. Everything and, you know, see, see you maybe given seat up and again if the hypotensive I'm thinking about iron drops, so get out and see, you know, see, see you involved in a leafy was in all them getting treated on the ward. It's not adequate and therefore escalations, whichever escalation status is our long term with heart failure. So again a senators and beat the book is start one from that time. So beat boxing voice your angina Asian, which isn't fluid overload with diabetes and then think about having direct extension. And again, if the beat a book was contraindicated, you can use this stuff called a copper deed. So just to go about pharmacology of the drugs and heart failure, a signature prevents conversion of angiotensin will tend to tend to This. Prevents the construction off the effort janitorial, um, and left the reason why under tension, too, is the body makes instance, too, because you get and it isn't doable. Constrict the effort, arterial. And therefore, this will increase the glomerular pressure. Um, but obviously we don't want that. We don't want construction with vessel. Especially have her attention, which is again comment on more conchos heart failure Is that called? You don't want to treat blood vessels any further so that so basing it itches quite porn on, but again, actually, quite usual starting to glacier diabetes because it's renal protective on do stocks You get importing losing their property, which again, diabetes on dysrhythmias is the after load. So again, avoiding being just a notice on. But again if they go Okay, I have four days images, so I think I missed whenever you get patient, where they can stop those down books down Bruce days diarrhetics Asendin just metformin and states to stop those down drugs. So, basically, which is one of them, um hypokalemia going to give a signatures? Uh, warned the patient of first dolls hypertensions the little bit lightheaded take their first dose, uh, on a vaccination dry cough. So it's just called Strike up in there for you. If the patients clean and dry cough vaccination, tissue fishing too, and ARB which is 100 sensible. Sent a book. Be two blockers. So big blockers, work induced proportional rate of heart, uh, heart rate if it gives the heart more time to be in diastole and filled properly, uh, increase in this will increase my perfusion because the Micardis perfused you and ask me again. One side effects because insurance and giant distances. And be careful with patients glass and also prescribing with Carson Channel blockers such a still ties and most contraindicated. If I breathe in France in your drug use in patients who say beat blockers, contraindicated will not tolerated and then going over to diuretic side of being. So if yours minds look diarrhetic back from a sodium fluoride call transports in the Asian flu Pendley and the side effects with Here's My Is no extra electrolytes, sodium potassium because low electrolytes on again, it can increase toxicity. The digoxin, everything levels on, then touching, sparing diuretic. Since they got hypo Clean me give you these. That's Amelia, the mill, a ride which inherit sodium reception. Both act on additional public. You go on spironolactone, which is basically blocks. The water functions are strong and again going back to the brain and it says on national system for a block and your function and attention to on your block to function about doctor and then starting about. Some patients will complain of gynecomastia so they're getting protection. Spend our ticks along. If she dies, I directives. So this inhibits certain chloride contrast from the prostate conflict of you. So your testing sparing one's working additional conflict You Bill guys, I was working approximately that you feel so except these is low sodium looked at skin. It can precipitate counts and causing concerns. And then this is the non pharmacological things like, yeah, cut it Implanted cardiac defibrillators again. Dialysis might be important on a k I. And you can't get there in case I I use the heart failure and you might be thinking diet a fist. I had transplants. This is a single chamber implanted cardiac defibrillator. You can do change. One's a swell and by ventricular ones, so I wouldn't worry about implanted cardiac defibrillator is and all that other med school s a quick, quick, so shot pole. So which statement is true regarding Frank Stones law is a a decrease preload least the increased stroke volume and decrease contractivity. Is it be increased? Preload leads Teo increase preload Least increased trouble even increased contractivity is it c increased preloaded. Least a decrease. Trouble you can increase. Contractility was a day decrease. Preload least decrease trouble. Increased contract. Um, is that work in the poll people on several. The room. Is that working? Great. Um, I we don't think we can see the poll people have been putting down to this in charge. Yeah. I don't know how to work. Function of pull, maybe organizes. Okay. Triple. And so let's see. What you saying? Yeah, it's a multiple being, which is the correct um, so yeah. So clinical manifestation. Right side is 17 little edema brace. JVP old in both. Yeah, everyone saying day, Regina. See? That's right. Yeah, that's right. Sided Heart failure, right. Ventricular hypertrophy is a complication of war. Yeah, cool. Pulmonology. So patient tells you that he needs school pillows, four pillows sleep and I but professionally and see the rest of the question um, sleep in his recliner with the head elevated. This an example off PND, although near this is a miracle pill. Okay, so, yeah, it's a little tiny because parts is not just the signature. Remember, the definition of that is when you suddenly wake up in the middle of night gasping for breath. That's know what the question described. It describes that he's got short of breath when he lies down, which is orthopnea. The patient is taking another pill on collision dry cough. What's your view? Prescribing that yet majority going for the losartan. That's right. Each an ARB and the ejection fraction is Yeah, it's a majority people going to be, yeah, struggling down and I start billion And the patients start my new heart failure medication now has gone up from last year. Which drug is a responsible? Yeah, just that your patient. Sorry, Mr. Is This's got it right. Finally, uh, which are following is a potassium sparing diuretic. Yeah, well, you good day. Similar idea. So there's two classes sparing directives A lot film on amiloride. Ah, that Nazi. Um so, yeah, I thought I'd keep it quick and show on snappy, but don't let the questions were bit too easy. But maybe because the knowledge is quite fresh have just covered it might seem a bit easy. Um, but yet any questions anything anyone disagrees with in particular, uh, I don't have the feet, but link feedback would be what Appreciate it if one of the commitment is Canoga Nuys Speed Buck, Um, and I'm not sure where the recording will go. I'll put my email address on the chart, So if you have any questions later on, then feel free to write me an email. I'm I'll try and answer.