This presentation about Cardiac Physiology, Cardiovascular Monitoring and pharmacology for experts

1. Cardiac
Physiology ,cardiovascular
monitoring and pharmacology
Firas Aljanadi
RVH
23rd Oct 2020

2. Cradiac
Physiology
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3. Physiology
• Cardiac functional characteristics
• General cellular morphology
• Cardiac muscle cells, sarcomere
• Force production
• Cardiac muscle electrical activity
• Action potential
• Cardiac cycle
• Preload, contractility, afterload
• Myocardial O2 consumption
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4. Cardiac function
• Inotropy or Contractility: Loss systolic HF
• Lusitropy or Relaxibility: Loss Diastolic HF (HFpEF)
• Chronotropy or Automaticity :Loss loss of
underlying rhythm
• Dromotropy or conductivity :Loss 2nd or 3rd HB
• Bathmotropy or Excitability : Loss more in paediatric
as primary rhythm disorder , (tapping the heart )
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5. General cellular morphology
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Force production

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Action Potential

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16. Cardiac Conduction system
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17. Cardiac cycle
• Cardiac Cycle Divided into seven phases (and
duration of phases)
• 1)Isovolumetric Ventricular Contraction (0.05s
• 2)Rapid Ventricular Ejection (0.15s)
• 3)Reduced Ventricular Ejection (0.15s)
• 4)Isovolumetric Ventricular Relaxation (0.08s)
• 5) Rapid Ventricular Filling (0.10s)
• 6) Reduced Ventricular Filling (0.19s)
• 7)Atrial Systole (0.10s)
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CARDIAC CYCLE

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20. CARDIAC PRESSURE–VOLUME CURVES
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22. PRELOAD
• Represents by the end-diastolic ventricular volume;
• Represents the ventricle filling .
• Influenced by
 LV compliance
 Blood volume
 Atrial systole
 Length of diastole
 Factors that affect this relationship, such as mitral stenosis
and ventricular hypertrophy, will affect preload.
• The Frank-Starling curve
Frank-Starling relationship
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24. CONTRACTILITY
• Ability of the myocardium to pump blood without changes
in preload or afterload;
• Influenced by
 intracellular calcium concentrations
 the autonomic nervous system
 humoral changes
 pharmacological agents. Metabolites ,Co2, hypoxia
• A sudden increase in contractility with unchanged preload
and afterload will result in increased stroke volume by
ejecting more volume out of the ventricle .
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25. AFTERLOAD
• The pressure the ventricle must overcome to eject a volume of blood
past the aortic valve.
• Afterload is most often equated with ventricular wall tension. Represents
by end-systolic pressure .
• Influenced by :
 SVR
 LVOT,AV area
 LV wall stress (tension)
LaPlace’s law: Circumferential stress = Pr/Th
where circumferential stress is the wall tension, P: intraventricular pressure,
r :ventricular radius, and Th: wall thickness.
 wall tension is the primary determinant of oxygen consumption.
 hypertrophy or thickening of the ventricular wall
 as a result of or to compensate for systolic failure, the ventricle will
dilate.
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27. Factors affecting oxygen delivery and consumption.
S M Tibby, and I A Murdoch Arch Dis Child 2003;88:46-52
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
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28. Myocardial oxygen supply and demand
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30. Oxygen Consumption and CBF
• Heart weighs about 300 g or approx. 0.5% of the total body mass
• Oxygen demand of the heart accounts for 7% of the resting body oxygen
consumption , 5% of the cardiac output.
• The normal myocardial oxygen consumption MVO2 per minute is approx.
8 mL O2/100 g .
• The MVO2 is primarily dependent on the coronary blood flow (CBF) and the
removal of oxygen from the coronary blood as follows: Arterial (CaO2) contents
minus Venous (coronary sinus, CSO2) contents:
MVO2 = CBF × (CaO2- CSO2)
CBF = CPP/CVR
CPP=DBP-LVEDP
 Poiseuille’s Law = ∆P / R
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33. Cardiac
Monitoring
Pulse
Rhythm
BP
CVP
PAP
SaO2
CO / Svo2
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34. ECG

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Arterial blood pressure
Invasive or non-invasive
MAP = DBP + PP/3 or MAP = [SBP + (2 × DBP)]/3

36. • ABGs
• Pulse oximetry
• Inaccurate in (Hypothermia, Peripheral vasoconstriction, non pulsatile CPB,
Raynaud’s , anaemia, nail polish, nicotine stains , Jaundice, methylene blue,
hypotension, bright light, high carboxyhaemoglobin )
• Svo2: Measurement of body oxygenation
• LOW Svo2: low delivery low CO,Hb,SatO2
• Increased consumption: fever, shivering , pain
• High Svo2: increased delivery , less consumption
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37. Venous pressure
• Central venous pressure (CVP)
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38. Pulmonary arterial
catheter:
• Allows monitoring of CO/CI
• PAP,PCWP,PVR,SVR
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CVP ~ PAD ~ PCWP ~ LAP ~ LVEDP ~LVEDV

40. Parameters
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120 kg M Post
CABG oozing
CVP almost 0
with BP 100/60
HR 120 bpm on
vasopressors
and SVR in
maximal limits
.What is SV ?
What’s next
step?

41. CO
• Fick principle 1870
• Thermodilution
• Doppler ultrasound
• Pulse contour analysis
• Bioimpedance
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44. Classified:
 Invasive-Intermittent bolus pulmonary artery
thermodilution, Continuous pulmonary artery
thermodilution
 Minimally invasive-Lithium dilution CO
(LiDCO), Pulse contour analysis CO (PiCCO
and FloTrac), Esophgeal Doppler (ED),
transesophgeal echocardiography (TEE)
 Non-invasive-Partial gas rebreathing,
Thoracic bioimpedance and bioreactance,
endotracheal cardiac output monitor
(ECOM), Doppler method and Photoelectric
plethysmography.
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48. Cardiac Pharmacology
• Aspirin &Antiplatelets
• Heparin & LMWH
• NOAC & Warfarin
• Fibrinolytics & Antifibrinolytics
• Statins
• BB &Ca blockers
• ACEIs & ARBs
• Nitrates
• SNP
• Adrenergic agonists
• Milrinone
• Nitric oxide
• Diuretics
• Digoxin
• Amiodarone
• Lidocaine
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49. Aspirin
• Felix Hoffmann
1899
• primary and
secondary
prevention of
CVD
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50. Antiplatelets
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• Pimary and secondary prevention of CVD (CAPRIE trial)
• ACS (CURE trial)

51. Heparin &LMWH
• Heparin: MPS
• DVT,PE,UA,CPB,(m)valve
• Monitor APTT, - HIT
• Protamine sulphate
• LMWH
• Longer HL,
• more effective,
• ACS,DVT
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52. NOAC
• AF
• DVT
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(Arterioscler Thromb Vasc Biol. 2015;35:1056-1065. DOI: 10.1161/ATVBAHA.115.303397.)

54. Warfarin
• “sweet clover disease” 1920s
• Wisconsin Alumni Research Foundation (WARF)
• Dicoumarol in 1941
• Warfarin 1954
• DVT,PE,AF,mValve,LV thrombus
• Cautions : Hep failure,PU,
• Interactions
• INR
• Reversed by vit K ,FFP,PCC
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56. Fibrinolytics
& anti-
fibrinolytics
Aprotinin
Tranexaemic
acid
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57. Statins
• HMG-CoA reductase
inhibitors
• Cautions : hepatic imp, Pregnancy
• SE: Myalgia, rhabdomyolysis ,hep
imp, nausea, vomiting ,abd pain.
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59. Beta-Blockers
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61. Ca Blockers
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62. ACEIs &ARBs
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63. Nitrates
• Smooth muscle relaxation
• Coronary vasodilation
• Reduced pre and after load - reducing myocardial O2 demand
• For : Angina ,
• Cautions : HCM,AS, glaucoma , hypovolaemia
• SE : postural hypotension, tachycardia, headache, flushing,
palpitations , methaemoglobinaemia
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64. SNP
• Relaxes art. Smooth muscle reduce
sys. & pulm. afterload
• For Refractory HTN
• Cautions: hepatic dysfunction, light
• SE: Tachycardia, headache, dizziness,
cyanide toxity
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Dopamine Dobutamine Dopexamine Adrenaline Noradrenaline Phenylephrine Isoprenaline
Receptors D, β1,α Β1, β2 Β2,DA1 Β1
Low dose β2
High dose α
α1 α1 Β1, β2
Uses LCO,
Inotropic
support
LCO,
Inotropic,
Stress echo
Inotropic
support
Anaphylactic,
bronchospasm,
inotropic,
cardiac arrest
Low SVR , Acute
hypotention ,
on CPB
Brady not
responding
to atropine
Cautions Tachy,
pheo,
MAOI
Tachy,
pheo,
MAOI
HOCM,AS,
Pheo,
thrombocyto
penia
HTN,
Pheo,
glaucoma,
DM
HTN,high SVR Hyperthyroidism tachy
Side
effects
Tachy,HTN,
Vaso-
construction
Tachy ,HTN Thrombocyt
openia,
tachy,
N&V
Tachy
,arrhythmi,
HTN,
metablic
acidosis
HTN,Tachy,
peripheral
ischaemia
HTN, Headache,
peripheral
ischaemia
dysarthymias
-Dose
dependant
effect
-Via central
line

67. Milrinone &Amrinone
• Phosphodiesterase III inhibitor  increased cAMP
• Inodilator : Increase contractility, dilate vessels  decrease after and
pre load
• PHT , RVF
• Cautions : HOCM,AS
• SE : Tachyarrhythmia , hypotension , thrombocytopenia
• Adding α agonist
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68. NO
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69. Dieuretics
Loop dieuretics, Thiazides,Manitol, Spironolactone
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Diuretics

71. Digoxin
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72. Amiodarone
• Class III antiarrhythmic as per Vaughan Williams
Classification
• Blocks K channel- refractory period
• Delay repolarization , prolonge AP, AV conduction , QT
interval
• Used in : Junctional tachy, AV node entry, SVT (60-80%
effective), Vent tachyarrhythmias (40-60% effective)
• SE : Liver toxity, interstitial pneumonitis ,lung fibrosis
(most serious SE, can be rapidly progress, RF : lung
disease, dose> 400mg /d, recent pulmonary disease)
, corneal microdeposits, photosensitivity, Thyroid
disorders , bradycardia
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73. Lidocaine
• Class Ib antiarrhythmic
• Shorten AP duration
• For : VT ,local anaesthesia
• Cautions: hep dysfunction, HB
• SE: Dizziness, confusion,
paraesthesia, convulsions,
hypotension, bradycardia
• 1% 1ml =10 mg , 2% 1ml=20 mg
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76. Thank you
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