All of medicine in 12 hours…

1. All of medicine in 12 hours… Dr. Alan McLeod (F2)

3. The Plan Day One • A systematic approach • Chest Pain • Acute sob • Chronic sob • Haemoptysis • TATT • Painful Limb • Breast Pain • Emergency management Day Two • Maximising your marks • Swallowing • Change in bowel habits • Hepatomegaly • Abdo pain • Pregnancy / Birth • Recurrent Infections • Headache • Stroke • Pharmacology basics

4. 2 Minutes 10 Causes of Chest Pain

5. Puzzled? You Need A SYSTEM…

6. Puzzled? What do I do?

7. I GET VINO…

8. 2 Minutes 10 Causes of Chest Pain

9. Chest Pain? Where’s that wine…

10. Ischaemic Heart Disease • Approx 1/3rd of all male deaths • Approx ¼ of all female deaths • Atheroma of coronary vessels

11. Right: Right Ventricle, most of Right Atrium, Part of Left Atrium Left: Left Ventricle, part of Right atrium, most of Left atrium Left circumflex: Left margin of heart and its entire posterior wall, Left atrium, posterior IV septum LAD: Anterior 2/3 of IV septum, anterior portion of LV, whole apex

12. SA Node: Right 51-65%, Left 35-45%, Bilateral <10% AV Node: Right 80-90%, Left 10-20% ALL HIGHLY VARIABLE!!!

13. Coronary Arteries: Fill During DIASTOLE

14. Arterial Disease Arteriosclerosis • Thickening and hardening of wall • Reduced lumen • Reduced flow • Reduced elasticity • Reduced contrractility • Diabetes • Hypertension Atherosclerosis • Commonest cause of arteriosclerosis • Specific disease • Tunica intima • Mostly large and medium vessels • Small in prolonged systemic hypertension

15. Atherosclerosis • Changes in intima  thrombus formation • Reduced lumenal size • Poor perfusion/hypoxia • Tissue death • Loss of elasticity • Aneurysm formation Smaller vessel atherosclerosis • Ischaemic heart disease • Most strokes • Peripheral heart disease

17. Plaque Formation

18. Plaque Formation

19. Plaque Formation

20. Plaque Formation

21. Plaque Anatomy Plaque Anatomy (early) • Free Lipid • Foam cells • Increased myointimal cells • Collagen • Disruption of internal elastic lamina Plaque Anatomy (later) • Collagen cap • Extracellular lipid mass • Foam cells • Myointimal cells • Disrupted internal elastic lamina • Pressure atrophy of muscle  collagenous replacement

22. Atheroma – Risk factors Non-preventable • Increasing age • Male sex • Family history Preventable • Hyperlipidaemia • LDL and Cholesterol • Hypertension • Diastolic most important • Diabetes • Smoking

23. Fold Fibrous Pericardium Myocardium Pericardial Space Layers of the Heart Endocardium Parietal Layer of Serous Pericardium Visceral Layer of Serous Pericardium

24. Compare Skeletal and Cardiac Muscle

25. Muscle Comparison

26. Myocyte Action Potential NAK-CAKKK

27. In Detail

28. Pacemaker Action Potential Membrane potential (mV) 0 Ca++ In K+ Out -40 -80

29. Comparison of action potentials

30. Excitation-contraction coupling • Electrical signal • Stimulates contraction Generally • Signal causes depolarisation • CA++ entry results • Causing contraction • In The Heart • Calcium induced calcium release • Act Pot from SA Node

31. Excitation-contraction coupling SAN L Type Calcium Channel Excitation Ca++ Ca++ Ca++ Ca++ SR Ca++ Ca++ Ca++ Ca++ Ca++ Ca++

32. Excitation-contraction coupling L Type Calcium Channel Ca++ Ca++ Ca++ Ca++ SR Ryanodine Receptor Ca++ Ca++ Ca++ Ca++ Ca++ Ca++

33. Excitation-contraction coupling L Type Calcium Channel Ca++ Ca++ Ca++ Ca++ SR Ryanodine Receptor Ca++ Ca++ Ca++ Ca++ Ca++ Ca++

34. Excitation-contraction coupling Ca++ Ca++ Ca++ Tropomysin Ca++ SR Ca++ Ca++ Ca++ Ca++ Ca++

35. Excitation-contraction coupling Ca++ Ca++ Ca++ Tropomysin Ca++ SR Ca++ Ca++ Ca++ Ca++ Ca++

36. Excitation-contraction coupling Ca++ Ca++ Ca++ Ca++ Tropomysin Ca++ Ca++ Ca++ Ca++ SR Contraction CA++

37. Describe Sliding Filament Theory

38. Sliding Filament Theory http://uk.youtube.com/watch?v=gJ309LfHQ3M&feature=related • Calcium enters • Binding sites on actin uncovered by movement of Tropomyosin / troponin complex • Myosin binds to site  powerstroke • ATP binds to myosin  release from binding • ATP  ADP + Pi – cocks myosin for another Powerstroke • Continues as long as ATP and Ca present

39. Sliding Filament Theory

40. Normal Lead 2 A Segment is Shorter than an interval

41. The Normal ECG PR interval: first deflection of P  first deflection of QRS • 120-200 ms (3-5 small sq) QRS interval: first deflection of QRS  end of last deflection • <100 ms (<3 small sq) QT interval (QTc is QT corrected for heart rate). Start of QRS  end of T wave • 360-440 ms (<11 small sq)

42. Additional Abnormalities • Pathological Q wave • Duration > 1 small sq • ST Depression • 1mm or more over isoelectric line • ST Elevation • 0.5mm or more below isoelectric line • T wave abnormality • Normally upright in I, II & V1 – V3 • Normally inverted in aVr • Variable in others

43. STEMI and NSTEMI STEMI • ST Elevation MI • ST elevation on ECG • Positive enzyme tests NSTEMI • Non ST Elevation MI • No ST elevation • Positive enzyme tests

44. STEMI and NSTEMI A: Normal ECG B: ST Elevation C: ST Depression ST elevation in response to Isoelectric line (I) ST Segment A I P T QRS B C

45. Evolution of ECG Changes in STEMI • Minutes to hours • Peaked T waves • Hours • ST elevation • Hours to days • T wave inversion • Loss of R wave • Days • Pathological Q wave

46. Cardiac Enzymes

47. Fibrinolysis • tPa • Streptokinase

48. ACS? GO CARDIO ABCD

49. 2 Minutes 5 Causes of acute Dyspnoea

50. Acute Dyspnoea? Need alcohol!