Fiji School of Medicine
MMed (Anaesthesia)

CARDIOVASCULAR MODULE

This module is designed to be completed during tutorials and in your own time. It is important to keep a record of the time spent on these activities and also to record the various sources of your information in the box provided. Please hand this module to your tutor when you have completed the activities. It will be returned to you after marking.

Complete the multiple choice test and submit for marking before moving on to this problem based learning case.

Amendments 2004/Nargis Ahmad

This module has been updated with suggestions for additional reading material

Aspects of Myocardial Physiology Bulletin 20 and 21 Parts 1 and 2 Available from RCA website

Current Concepts: Management of Anticoagulation before and after Elective Surgery
Kearon C., Hirsh J.
N Engl J Med 1997; 336:1506-1511, May 22, 1997. Review Article

Care of Patients Receiving Long-Term Anticoagulant Therapy
Schulman S.
N Engl J Med 2003; 349:675-683, Aug 14, 2003. Clinical Practice

HeartFailure
Jessup M., Brozena S.
N Engl J Med 2003; 348:2007-2018, May 15, 2003. Review Article

Lowering Cardiac Risk in Noncardiac Surgery
Fleisher L. A., Eagle K. A.
N Engl J Med 2001; 345:1677-1682, Dec 6, 2001. Clinical Practice

Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery
Mangano D. T., Layug E. L., Wallace A., Tateo I., The Multicenter Study of Perioperative Ischemia Research Group
N Engl J Med 1996; 335:1713-1721, Dec 5, 1996. Original Article

Current Concepts: Preoperative Assessment of Patients with Known or Suspected Coronary Disease
Mangano D. T., Goldman L.
N Engl J Med 1995; 333:1750-1756, Dec 28, 1995. Review Article

Drug Therapy: Prevention of Infective Endocarditis
Durack D. T.
N Engl J Med 1995; 332:38-44, Jan 5, 1995. Review Article

Medical Progress: Valvular Heart Disease
N Engl J Med 1997; 337:32-41, Jul 3, 1997. Review Article

Valvular Heart Disease in Pregnancy
Reimold S. C., Rutherford J. D.
N Engl J Med 2003; 349:52-59, Jul 3, 2003. Clinical Practice

Special Article Cardiac Scoring Systems – What is their value? S.Ridley

Anaesthesia Volume 58 Issue 10 Page 985 – October 2003

A Systematic Approach to cardiovascular pharmacology
BJA/CEPD reviews/Vol 1 No 1 2001

One of the sessions in this module will be an ECG quiz, please revise your strategy for analysis of an ECG early on to get the most of this session.

You will also formulate a protocol for investigation of cardiac disease, based on your reading. This will be a group exercise. Similarly you will devise protocols for antibiotic prophylaxis and management of patients who are anticoagulated. These are to be applicable to local needs and resources.

There is lots of reading so you may not get through it all, but remember to read critically and bear in mind what you’ve being doing in Public Health!

Nargis Ahmad

Loata is a 74 year old lady who lives with her daughter in law. She has difficulty walking because of her arthritis. She has come into hospital for an elective cholecystectomy.

Tutorial 1:

In your group, discuss the best way to assess this lady's cardiovascular fitness for anaesthesia. Make notes:

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Summarise your conclusions in the space below.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

In your own time, read the following article:

Compile a list of any concepts you don't understand - these will become your learning issues.

The aged cardiovascular risk patient
British Journal of Anaesthesia; London; Nov 2000; H-J Priebe

Available at

Make notes on the learning issues you identified from reading the preceding article:

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Before you can understand the effects of age on cardiovascular function, you need to review your knowledge of normal cardiovascular physiology.

Before your next tutorial complete the following tasks:

  1. List the factors that determine cardiac output:

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  1. Define preload, afterload and myocardial contractility.

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  1. Describe the factors that control preload, afterload and myocardial contractility.

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  1. Explain Starling’s law of the heart.

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  1. Describe Guyton’s cardiac output curves and explain factors that affect them.

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  1. Describe and explain venous return curves and correlate these with the cardiac output curves. ______
  1. Describe the pressure-volume relationship of the ventricle and its clinical applications.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Tutorial 2:

Problem Based Learning Case (continued):

Loata tells you she gets breathless when she lies flat and when you examine her she has pitting oedema to her ankles and bilateral basal crepitations.

With your group, review the set reading and the completed task and then discuss the pathophysiology of congestive cardiac failure.

Make notes:

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Tutorial 2 (continued)

Discuss various treatment options and explain the effects of each therapy on cardiovascular physiology.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

In your own time, research the learning issues identified during the previous tutorial and review those aspects of cardiovascular physiology which came up in the discussion.

Complete the following activities before the next tutorial.

  1. Explain the factors that determine systemic blood pressure and its regulation.

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  1. Describe total peripheral vascular resistance and factors that affect it.

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  1. Describe the general mechanisms involved in local vascular control. ______
  1. Describe the essential features of the microcirculation in relation to its structure, fluid exchange (Starling forces) and control mechanisms present in the pre and post capillary sphincters.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Tutorial 3

Loata tells you that her doctor started her on a Propranol for high blood pressure two months ago and she hasn't felt well ever since.

  1. With your group discuss the pharmacology of beta blockers .

Relate this to Loata's case. ______

  1. Discuss the mechanisms and physiological consequences of 1, 2, 1 and 2 receptor blockade.

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  1. Classify  and  receptor blocking agents according to their action, reversibility and chemical groups.

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  1. Discuss the pharmacokinetics of  receptor blocking agents and apply this to their clinical use.

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  1. Discuss the pharmacodynamic and pharmacokinetic implications of  receptor blocking agents.

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  1. Discuss the clinical uses of  receptor blocking agents and their side effects.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

In your own time and before the next tutorial:

  1. Classify the modes of action of the anti-hypertensive agents. ______
  2. Describe the pharmacology of agents which block the release of transmitters at the adrenergic nerve ending.

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  1. Describe the mechanism of action of vasodilators such as hydrallazine and diazoxide.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Tutorial 4:

Review the completed tasks from the previous tutorial and the work you completed independently. Problem Based Learning Case (continued)

You request a preoperative ECG for Loata and you notice frequent ventricular ectopic beats

  1. With your group, discuss the ionic basis of spontaneous electrical activity of cardiac muscle cells (automaticity).

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  1. Describe the normal and abnormal processes of cardiac excitation.

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  1. Explain the physiological basis of the ECG.

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  1. Describe the factors that may influence cardiac electrical activity.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

In your own time and before the next tutorial:

Describe the structure and functional significance of the contractile elements of cardiac muscle and how they differ from skeletal muscle.

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Describe and explain the mechanical events of the cardiac cycle and correlate this with electrical and ionic events.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Tutorial 5:

Review the completed tasks and any learning issues from the previous week's tutorial.

Problem Based Learning Case (continued)

Prior to surgery, Loata experiences palpitations and an ECG shows a run of ventricular tachycardia.

With your group, complete the following tasks:

  1. Classify antiarrhythmics by their electro-physiological actions.

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  1. Discuss the pharmacological basis of anti-arrhythmic propertiesof lignocaine, including its pharmacokinetics.

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  1. Discuss the pharmacological basis of the use of digoxin as an anti-arrhythmic and its toxic effects.

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  1. Discuss the side-effects and problems associated with the use of anti-arrhythmics during anaesthesia.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

In your own time and before the next tutorial:

  1. Describe the function and anatomical location of baroreceptors

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  1. Explain the role of the autonomic nervous system in controlling systemic vascular resistance and redistribution of blood volume.

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  1. Explain the neural and humoral regulation of blood volume.

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Date: / Time Started / Time Finished / Total Time
Resources Accessed (Textbook, Journal Article etc

Tutorial 6:

Review the completed tasks from the previous week.

Problem Based Learning Case (continued)

During Loata's surgery, you notice the appearance of ST depression on the cardiac monitor. When you reassess the circulation, her finger-tips are cool and her systolic blood pressure has fallen to 70 with a tachycardia of 130.

  1. With your group discuss the cardiovascular changes resulting from haemorrhage and hypovolaemia.

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  1. Discuss the effect of positive pressure ventilation on cardiac output.

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  1. Discuss the cardiovascular effects of the anaesthetic agents you may have used.

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Discuss the various methods of measuring blood pressure and the physical principles involved.

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Assignment:

A number of scoring systems have been developed to assess cardiovascular risk related to anaesthesia and surgery. Discuss two scoring systems. These scoring systems may not be appropriate in your clinical setting. Design a scoring system that might work for you and discuss how you would test this system.

OR

Explain the cardiovascular changes accompanying the process of ageing.

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FSM - M.Med (Anaesthesia)Cardiovascular ModulePage 1

Dr Bruce Lister Revised Dec 2003/ Dr Nargis Ahmad