Cardiovascular 20

Question 1

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

End-diastolic volume

what valve opens?

Answer 1

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 2

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

mitral valve opens

what volume?

Answer 2

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 3

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

End-systolic volume

what valve does what

Answer 3

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 4

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

(where the aortic valve closes)

what volume?

Answer 4

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 5

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

how to calculate stroke volume

Answer 5

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 6

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what is (the difference between the end-diastolic and end-systolic volumes)

Answer 6

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 7

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

how to calculate ejection fraction

Answer 7

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 8

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what is ratio of stroke volume to end-diastolic volume

Answer 8

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Volumes:
  o End-diastolic volume (where the mitral valve opens)
  o End-systolic volume (where the aortic valve closes)
  o Stroke volume (the difference between the end-diastolic and end-systolic volumes)
  o Ejection fraction, which is the ratio of stroke volume to end-diastolic volume

Question 9

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

Systolic blood pressure

where on curve?

Answer 9

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

Question 10

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what pressure Is the (peak of the curve)

Answer 10

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

Question 11

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

which valve represents Diastolic blood pressure?

Answer 11

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

note: This was a little confusing at first but if you look at the diagram is makes sense

Question 12

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

which blood pressure represents (where the aortic valve opens)

Answer 12

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

Question 13

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

which valve ?s at End-systolic blood pressure

Answer 13

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

Question 14

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

which valve dose what at End-systolic blood pressure

Answer 14

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressures:
  o Systolic blood pressure (peak of the curve)
  o Diastolic blood pressure (where the aortic valve opens)
  o End-systolic blood pressure (where the aortic valve closes)

Question 15

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what are the Pressure-volume relationships:

Answer 15

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 16

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

The end-diastolic pressure-volume relationship (EDPVR), which describes ??

Answer 16

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 17

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what describes ventricular elastance?

Answer 17

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 18

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

o The end-systolic pressure-volume relationship (ESPVR), which describes ?

Answer 18

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 19

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

what describes contractility

Answer 19

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 20

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

The effective arterial elastance line which connects?

Answer 20

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 21

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

???? connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of ??

Answer 21

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Pressure-volume relationships:
  o Systolic ejection, which has fast and slow phases
  o Diastolic filling
  o Isovolumetric contraction and relaxation
  o The end-diastolic pressure-volume relationship (EDPVR), which describes ventricular elastance
  o The end-systolic pressure-volume relationship (ESPVR), which describes contractility
  o The effective arterial elastance line which connects the point of end-diastolic pressure and volume to the point of end-systolic volume, and which is an approximation of afterload

Question 22

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:

Answer 22

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

note: this is obviously confusing since dearnged is using the term stroke work for both total and the area just in the PV loop, looking at the picture, it looks like stroke work is just the pv while total is potential menchical work plus stroke work

Question 23

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:

Answer 23

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

Question 24

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

 Stroke work, which is the total area of the ?

Answer 24

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

Question 25

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

total area of the P-V loop??

Answer 25

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

Question 26

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

Stored “potential” mechanical energy (in the LV wall), which is the area under ??

Answer 26

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

Question 27

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

area under the ESPV??

Answer 27

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

• Areas:
  o Total mechanical energy (stroke work), which consists of:
   Stroke work, which is the total area of the P-V loop
   Stored “potential” mechanical energy (in the LV wall), which is the area under the ESPV

Question 28

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

examiner comment

Answer 28

Draw and label a left ventricular pressure volume loop in a normal adult (40% of marks). List the information that can be obtained from this loop (60% of marks). 2017 march and 2008 march

Examiners comments 2017
Many candidates lost marks for poor quality diagrams with inaccurate labelling. An accurate diagram was required. Many answers lacked sufficient detail regarding contractility and afterload

Examiners comments 2008
Candidates were expected to draw and label a diagram showing the relationship between pressure and volume during the different phases of the left ventricular contraction and relaxation (or systole and diastole) Good answers to this question consisted of a well-labelled graph with appropriate scale on both x and y-axes showing all the important events during systole and diastole of the left ventricle. The common omissions were rapid and slow ejection phase during systole, when aortic valve closes, stroke volume, ejection fraction, end-systolic pressure volume line showing the contractility of the left ventricle. Some candidates appeared to have confusion about which line shows contractility and which line shows left ventricular after load. Syllabus C1c Reference: Kam 1 st edition 115-121 Guyton 11 th edition 110 2 candidates (66%) passed this question

Question 29

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Determinants of mmyocardial oxygen demand

Answer 29

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Heart rate
preload
contractility
afterload
Cost of electrical conduction
basal cost of cardiac metabolism

deranged

Question 30

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Determinants of myocardial oxygen supply

Answer 30

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Oxygen content of blood
Coronary perfusion pressure
Anatomy
Metabolic activity
Autonomic control

deranged

Question 31

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Heart rate

Answer 31

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Both ventricles beat at the same rate

deranged

Question 32

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Preload

Answer 32

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Both ventricles usually have the same preload in the normal heart;

deranged

Question 33

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Contractility (dP/dT)

Answer 33

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

left
More contractile

RightLess contractile

deranged

Question 34

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Afterload

Answer 34

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

left
High afterload, and therefore high oxygen demand (more work done to overcome pressure)

right
Low afterload, less work done to overcome pressure

deranged

Question 35

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Cost of electrical conduction

Answer 35

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Both ventricles have approximately the same content of conductive tissue, and in any case this does not contribute significantly to the overall oxygen demand

deranged

Question 36

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Basal cost of cardiac metabolism

Answer 36

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Both ventricles contain the same type of tissue and the basal metabolic rate for myocardiom in general is the same (8ml O2/min/100g, at rest)

The left ventricle contains more muscle mass, and the net basal consumption is greater

The RV has a lower muscle mass and consumes less total O2 because of this

deranged

Question 37

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Oxygen content of blood

The ?? aortic blood supplies both ventricles

Answer 37

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Oxygen content of blood
.
The same aortic blood supplies both ventricles

deranged

Question 38

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Coronary perfusion pressure

Answer 38

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Coronary perfusion pressure

left
High afterload, and therefore high subendocardial systolic pressure (thus, lower blood flow during systole)

right
Low afterload, low subendocardial systolic pressure, and stable blood flow throughout systole and diastoles

deranged

Question 39

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Anatomy

Answer 39

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Coronary perfusion pressure

left
Anatomy Two major arteries (LAD and LCx)

Right
One major artery (RCA)

deranged

Question 40

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Metabolic activity

Answer 40

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Metabolic activity

Left
Owing to oits greater mass, the LV is more metabolically active than the RV

Right
RV has lower net metabolic activity

Both
Both ventricles have a high oxygen extraction ratio, and the only way to satisfy increased demand is by increasing blood flow.

deranged

Question 41

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Autonomic control

Answer 41

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Autonomic control
Coronary arterial vascular resistance is under autonomic control, which is similar for both ventricles

deranged

Question 42

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

Examiner Comment

Answer 42

Compare and contrast the supply and demand of oxygen for the right and left ventricle. Appears to be a unique question
2016 aug 7

An integrated answer to supply and demand of oxygen was expected, as a comparison between the right and left ventricles. Many candidates concentrated on differences not similarities. Myocardial oxygen demand was in general poorly described. About 85 - 90% of oxygen demand is for internal work (major determinants wall tension 30 - 40%, heart rate 15 - 25%, myocardial contractility 10 - 15%, basal metabolism 25%). 10 - 15% of oxygen demand for external work or pressure volume work, determined by MPAP x CO.

It was expected answers would comment on the phasic nature of coronary blood flow which differs between left and right and the consequence of this to subendocardial oxygen supply during systole usually. Coronary blood flow is affected by coronary perfusion pressure (determined by aortic pressure and RV pressure) & coronary vascular resistance (determined by autoregulation, metabolic factors, humoral factors, nervous control interacting with local endothelial factors)

Generally, coronary blood flow is tightly coupled to oxygen demand/consumption due to high basal oxygen consumption (8 - 10 ml/ min/100g) and high oxygen extraction ratio (75%). Better answers noted that oxygen supply can only be increased to cope with increased demand only by increased coronary blood flow.

deranged

Question 43

Define preload

Answer 43

• Preload can be defined as:
  o Myocardial sarcomere length just prior to contraction, for which the best approximation is end-diastolic volume
  o Tension on the myocardial sarcomeres just prior to contraction, for which the best approximation is end-diastolic pressure

Define cardiac preload and describe its determinants 2015 aug + 2010 mar

Question 44

Define preload

Answer 44

• Preload can be defined as:
  o Myocardial sarcomere length just prior to contraction, for which the best approximation is end-diastolic volume
  o Tension on the myocardial sarcomeres just prior to contraction, for which the best approximation is end-diastolic pressure

Define cardiac preload and describe its determinants 2015 aug + 2010 mar

Question 45

List the determinants of preload

Answer 45

• The determinants of preload, if we choose to define it as a volume, are:
  .
  o Pressure filling the ventricle:
   Intrathoracic pressure (high pressure decreases preload)
   Atrial pressure
   Atrial contractility and rhythm (SR increases preload, AF decreases preload)
   Atrioventricular valve competence (mitral and tricuspid stenosis decrease preload)
   Ventricular end-systolic volume (increased end-systolic volume increases preload by adding to venous return)
   Ventricular compliance (decreased compliance decreases preload)
   Right atrial pressure (high right atrial pressure increases preload)
   Mean systemic filling pressure
   Total venous blood volume (increased volume increases preload)
   Venous vascular compliance (decreased compliance, i.e. venoconstriction, increases preload)
   Cardiac output, insofar as it supplies the total blood volume
  /
  o Compliance of the ventricle:
   Pericardial compliance:
   Compliance of the pericardial walls (decreased compliance decreases preload)
   Compliance of the pericardial contents (increased contents volume decreases preload)
   Ventricular wall compliance:
   Duration of ventricular diastole (a longer diastole increases preload)
   Wall thickness (a thicker wall decreases preload)
   Relaxation (lusitropic) properties of the muscle (poor relaxation decreases preload)
   End-systolic volume of the ventricle (i.e. afterload) - increased end-systolic volume decreases preload

Define cardiac preload and describe its determinants 2015 aug + 2010 mar

Question 46

List the determinants of preload

examiners comments

Answer 46

2015 aug Q15
This question required synthesis and application of knowledge derived from multiple sources rather than regurgitation of a published list in a text. Many candidates failed to recognise that venous return is not the only determinant of preload. Most candidates failed to discuss determinants of venous return. Factors such as contractility, afterload or chamber filling and emptying can all impact preload. In addition to listing determinants the question required an explanation of their relationship with preload (e.g. the direction of change). A discussion about the determinants of cardiac output was not asked for as did not score marks.

“better answers included discussion of the effects of afterload, arrhythmias, and valvular pathology. A distinction between the factors determining left and right ventricular preload would have demonstrated a more sophisticated understanding of the physiology”

2010 march Q21
A definition based on stretch of the isolated myocyte prior to contraction, and extrapolation to the human heart, was expected. Surrogate measures of preload used in clinical practice needed to be explained and related to the definition (for example, end-diastolic volume and central venous pressure). The Frank-Starling Law was relevant to discussion of the significance of preload to cardiac performance. A diagram illustrating the interaction of important factors would have been helpful in answering this question. At a minimum, detail should have included atrial contractility, diastolic filling time, ventricular compliance, and the determinants of venous return. Better answers included discussion of the effects of afterload, arrhythmias, and valvular pathology. A distinction between the factors determining left and right ventricular preload would have demonstrated a more sophisticated understanding of the physiology

Define cardiac preload and describe its determinants 2015 aug + 2010 mar

Question 47

Important points

2016: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory
Pressure (PEEP) I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2009 march 17 Describe the physiological consequences of positive end expiratory pressure. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

Answer 47

Summary of examiners comments over 3 questions (cardio resp, all and all)
Include; lung volume, dead space, arterial pO2 and intrapleural pressure.
Include effect on cardiac output, blood pressure and oxygen delivery.
The physiological impact of lower levels PEEP in a young healthy person is different to that often seen in the critically ill and this was not appreciated by most candidates.
—-
A definition of PEEP is a useful way to start this answer and this was missing in more than half the answers.
Many candidates incorrectly concluded that PEEP would increase afterload and decrease pulmonary vascular resistance.
Some candidates provided description of the cardiovascular effects of Valsalva, which was not part of the question.
It was expected candidates would also mention physiological effects on other organ systems such as potential cerebral and renal effects.
Points required included a definition of PEEP, both intrinsic and extrinsic
Respiratory including increased FRC, increased compliance and decreased work of breathing.
Cardiovascular consequences include decreased venous return and subsequently decreased cardiac output and an increased pulmonary vascular resistance.
Renal consequences include decreased renal blood flow and increased ADH Effects on intra-abdominal pressure, hepatic blood flow and the beneficial effects in cardiac failure earned marks.

Question 48

2016: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory

Respiratory effects of positive pressure ventilation:

Answer 48

Respiratory effects of positive pressure ventilation:
* PEEP increases functional residual capacity (FRC)

• By increasing FRC, PEEP:
  o Increases alveolar recruitment, which gives rise to:
   Improved V/Q matching
   Increased total gas exchange surface
  o Increases lung compliance
  o Decreases the work of breathing (done against compliance)
• Positive pressure may also redistribute lung water out of the lung interstitium
• Excessive positive pressure leads to
  o Overdistension and lung injury
  o Worsening V/Q matching
  o “Biotrauma”, i.e. cytokine leak and extrapulmonary organ dysfunction

deranged 2016 and 2014

Question 49

2016: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory

Cardiovascular effects of positive pressure ventilation:

Answer 49

Cardiovascular effects of positive pressure ventilation:
* Effects on the right ventricle and the pulmonary circulation:
o Increased intrathoracic pressure is transmitted to central veins and the right atrium, decreasing right ventricular preload
o Increased intrathoracic pressure is transmitted to pulmonary arteries
o Transmitted alveolar pressure increases pulmonary vascular resistance
o Increased pulmonary vascular resistance increases right ventricular afterload
o Thus, increased afterload and decreased preload has the net effect of decreasing the right ventricular stroke volume.

• Effects on the left ventricle and the systemic circulation:
  o Decreased preload by virtue of lower pulmonary venous pressure
  o Decreased afterload due to a reduction in LV end-systolic transmural pressure and an increased pressure gradient between the intrathoracic aorta and the extrathoracic systemic circuit
  o Thus, decreased LV stroke volume
• Effects on overall cardiovascular function:
  o Decreased cardiac output
  o Decreased myocardial oxygen consumption

deranged 2016 and 2014

Question 50

2016: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory

Other organ system effects of positive pressure ventilation:

Answer 50

Other organ system effects of positive pressure ventilation:

• Raised intracranial pressure, if the PEEP is very high
• Water retention due to increased ADH release and aldosterone secretion
• Sodium retention due to decreased ANP release and aldosterone secretion
• Decreased renal perfusion and GFR (due to decreased cardiac output and increased renal venous pressure)
• Decreased hepatic perfusion and thus decreased metabolic clearance of drugs
• Decreased splanchnic perfusion, resulting id decreased intestinal motility and poor gastric emptying
• Decreased gastric perfusion, increasing the risk of stress ulceration
• Neutrophil retention in the pulmonary capillaries
• Impaired lymphatic drainage from the lungs

deranged 2016 and 2014

Question 51

2016: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory

examiner comments

Answer 51

2016 march: Describe the Respiratory and cardiovascular effects of applying 10 cm of PEEP (positive end-expiratory pressure) to a healthy mechanically ventilated adult. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

This topic has been asked previously. It was expected candidates could detail the impact of PEEP on a variety of respiratory parameters such as lung volume, dead space, arterial pO2 and intrapleural pressure. The cardiovascular consequences are well described including the effect on cardiac output, blood pressure and oxygen delivery. The physiological impact of lower levels PEEP in a young healthy person is different to that often seen in the critically ill and this was not appreciated by most candidates.

2014 AUG-3 Describe the physiological consequences of Positive End-Expiratory
Pressure (PEEP) I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

Most answers were quite brief and superficial. They simply did not cover enough of the required knowledge base to gain a pass mark. A definition of PEEP is a useful way to start this answer and this was missing in more than half the answers. Deficiencies in knowledge included even the primary respiratory and cardiovascular effects of PEEP. Many candidates incorrectly concluded that PEEP would increase afterload and decrease pulmonary vascular resistance. Some candidates provided description of the cardiovascular effects of Valsalva, which was not part of the question. It was expected candidates would also mention physiological effects on other organ systems such as potential cerebral and renal effects. This topic (Level 1) requires a detailed knowledge and candidates should read widely to gain the depth of understanding required. The core material is covered in texts such as Nunn’s’ Applied Respiratory Physiology and additional applied information can be found in a variety of texts such as Textbook of Critical Care by Fink et al, Irwin and Rippe’s Intensive Care Medicine or Miller’s Anaesthesi

2009 march 17 Describe the physiological consequences of positive end expiratory pressure. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

Points required included a definition of PEEP, both intrinsic and extrinsic. The important physiological consequences that need to be discussed are respiratory including increased FRC, increased compliance and decreased work of breathing. Cardiovascular consequences include decreased venous return and subsequently decreased cardiac output and an increased pulmonary vascular resistance. Renal consequences include decreased renal blood flow and increased ADH Effects on intra-abdominal pressure, hepatic blood flow and the beneficial effects in cardiac failure earned marks.

Question 52

2009 march 17 Describe the physiological consequences of positive end expiratory pressure. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

extrinsic peep vs intrinsic

2009 is also mostly in the above 2016 and 2014

Answer 52

2009 march 17 Describe the physiological consequences of positive end expiratory pressure. I think this is essentially a repeat of 2014 august, but 2016 has a completely different answer, need to make one good answer, 2009 feb

Deranged Discussion
The question did not specifically ask for a definition, let alone a definition of intrinsic PEEP, and so the trainees would have been quite surprised to find this among the essential points expected of a passing answer. In spite of these hidden gems, 40% seem to have passed.
Deranged specific answer 392 words below
Definitions:
PEEP (positive end-expiratory pressure) is “a residual pressure above atmospheric maintained at the airway opening at the end of expiration” (Joint Committee on Pulmonary Nomenclature of the American Thoracic Society and the American College of Chest Physicians, 1975)
Intrinsic PEEP has no official definition, but one example of a good description is from Brander & Slutsky (2012): “when expiratory flow has not emptied alveoli to their resting FRC values by the end of exhalation… [intrinsic PEEP is] the residual positive pressure within the lungs referenced to atmospheric pressure or to PEEP”