Cardio Physio

8/4/2019 Cardio Physio

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What We Talk AboutWhen We TalkWith Medical Students

MJ JoynerN Charkoudian

TB Curry

JH EisenachEA WehrweinMayo Clinic

Rochester, MN


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Raymond Carver

Cover of novel:What We Talk

About When We

Talk About Love

Photo of Raymond Carverfrom WikipediaFreely available at

http://en.wikipedia.org/wiki/Raymond_Carver
http://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carver


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Haruki Murakami

Cover of novel:What I Talk

About When I

Talk AboutRunning

Photo of Haruki MurakamiFreely available athttp://en.wikipedia.org/wiki/

Haruki_Murakami
http://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakami


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Med Students: FAQ

Can you post the slides on the web?

Can you post the answers to the quiz on theweb?

Will this be on the test?

Why do we have to know X when my clinicalpreceptor tells me its not relevant to medicalpractice?


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Information Smoothie


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Information Smoothie: FAQ

Can you post the slides on the web?

Can you post the answers to the quiz on theweb?

Will this be on the test?

Why do we have to know X when my clinicalpreceptor tells me its not relevant to medicalpractice?


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Can We Go Home?

Gary Larson Far Side cartoon of

teacher in front of class. A studentis asking Mr. Osborne, may I be

excused? My brain is full.


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20 Questions AboutExercise & Respiratory Physiology

for Medical Students


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# 1What is the Fick equation


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#4Can Avogadro explain why each

gm of hemoglobin (HGB) can bind~1.35 mls of O2?


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#17Is the main cause of increasedlactic acid production during

exercise hypoxia in the exercisingmuscles?


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#182-3DPG (2,3- disphosphoglycerate)causes a right shift in the O2-HGB

dissociation curve.Why then is the curve shifted to theleft at extreme altitude?


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#19You are 70% saturated while

mountain climbing in the

Himalayas.Why are you becoming apneic atnight?


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#20What feature of the Avian lung

permits birds to fly over Mt.Everest?


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Advantages of Questions

They are different

No hiding in comfort zones

Focus on ideas

How much of what we are currently teaching iswrong?


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We Made Too ManyWrong Mistakes

Nitric oxide

Acute respiratory distress syndrome &ventilators

-blockers and congestive heart failure

Viagra

Vascular endothelial growth factor

Yogi Says


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Questions: The Internet is YourFriend?


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Readers Digest Version

http://www.merck.com

Regulating Blood Pressure:The Renin-Angiotensin-Aldosterone System

From Merck

Freely available athttp://www.merck.com/mmhe/sec03/ch022/ch022a.html
http://www.merck.com/mmhe/sec03/ch022/ch022a.htmlhttp://www.merck.com/mmhe/sec03/ch022/ch022a.html


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Lab Based Demonstrations in the MayoClinical Research Unit (CRU/CTSA)

Mental stress

white purple pink


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Chart Window

HeartRatebpm(

V)

-2

-1

0

1

2

MS

MSRecovery

ArtPressuremmH

g(mmHg)

50

100

150

200

:50 11:40 12:30 13:20 14:10 15:00 15:50 16:402 3 4 5

8/28/2006 2:15:34.725 PM

ECG

Art.

Line

Stroop Colored Word Test

59 129 74

128/67 167/92 157/80

Instr. Stress Blood

draw

Recovery

From Joyner (unpublished data)


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Cardiac output during handgrip


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Intermediate Phenotype

Figure 1.From Eisenach, J.H., and Wittwer, E.D.

Exp. Physiol. 95(7): 757-764, 2010.Available for fee at

http://ep.physoc.org/content/95/7.toc
http://ep.physoc.org/content/95/7.tochttp://ep.physoc.org/content/95/7.toc


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HTN Risk & Responseto Acute Sympathoexcitation

Figure 1.From Matthews et al.Circulation110:74-78, 2004

Freely available athttp://circ.ahajournals.org/cgi/content/full/110/1/74

CARDIA study

BP responses tostress

Sympathoexcitation

Risk of future HTN

SNS involved in/riskfor hypertension?

BP, blood pressure; HTN, hypertension; SNS, sympathetic nervous system
http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74


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Building Highways vs.Providing a Road Map


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MAP=CO x TPR

Feedback control by Baroreflexes

CO, cardiac output; MAP, mean arterial pressure; TPR, total peripheral resistance


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Gore Diagram

EDV, end-diastolic volume; ESV, End-systolic volume.

From Gore, unpublished data.


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Using the Gore Diagram:Explain Why ~50% of Patients WithHypertension Fail Monotherapy

With Diuretics?


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Carotid Stimulation in Humans?

Figure 1.From Mohaupt , M.G., Schmidli, J., and Luft, F.C.Hypertension50: 825-828, 2007

Freely available athttp://hyper.ahajournals.org/cgi/content/full/50/5/825
http://hyper.ahajournals.org/cgi/content/full/50/5/825http://hyper.ahajournals.org/cgi/content/full/50/5/825


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Carotid Stimulation in Resistant HTN

Figure 2.From Mohaupt , M.G., Schmidli, J., and Luft, F.C.Hypertension50: 825-828, 2007



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Figure 1a.From Epstein et al.Circulation40: 269-276, 1969

Freely available athttp://circ.ahajournals.org/cgi/reprint/40/3/269

This Was Tried In The 1960s!
http://circ.ahajournals.org/cgi/reprint/40/3/269http://circ.ahajournals.org/cgi/reprint/40/3/269


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Figure 1.From Schlaich, et al. Hypertension54: 1195-1201, 2009.

Available for fee athttp://hyper.ahajournals.org/cgi/content/extract/54/6/1195

Renal Sympathetic Interactions
http://hyper.ahajournals.org/cgi/content/extract/54/6/1195http://hyper.ahajournals.org/cgi/content/extract/54/6/1195


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Renal Denervation Suppresses SystemicSympathetic Activation

Figure 1.From Schlaich, et al.

N. Engl. J. Med. 361: 932-934, 2009

Available for fee athttp://content.nejm.org/cgi/content/extract/361/9/932
http://content.nejm.org/cgi/content/extract/361/9/932http://content.nejm.org/cgi/content/extract/361/9/932


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Renal Denervation for ResistantHypertension

Figure 2.From Krum, et al.Lancet 373 : 1275-1281, 2009

Available for fee athttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltext
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltext


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Questions & Medical Ignorance

Figure 1.From Witte et al.J. Investig. Med. 56(7): 897-901, 2008.

Available for fee athttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics

__in_Medical_and_Premedical_Education.4.aspx

C & th R t t
http://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspx


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Comroe & the Retrospectoscope:How Did We Get to Heart Surgery?

Noted investigator atPENN and UCSF

Developed CVRI

Focused on integration

Concept of theRetrospectoscope

Comroe and Dripps (Circ.Res. 35: 661-669, 1975)


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Breakthroughs are Incremental& Take Luck

1 giant leap tothe pinnacle?

Or climb thesteps up theback of themountain?

Adapted from Comroe and Dripps (Circ. Res. 35: 661-669, 1975)


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Comroe & the Retrospectoscope:How Did We Get to Heart Surgery?

About 50 of 100 key discoveries had amajor luck component

Many of the targeted discoveries were

targeted towards other thingsMost traced to a fundamental discovery

X-rays are a typical example

One of the only truly comprehensiveassessments of how medical advanceshappen


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Why the Retrospectoscope?

Non-linear nature of progress Warn the students about the nature of future

change

Undermine the Central Administration and theireffort to manage research.


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We Made Too ManyWrong Mistakes

Nitric oxide

Acute respiratory distress syndrome &ventilators

-blockers and congestive heart failure

Viagra Vascular endothelial growth factor

Yogi Says


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Physiology as Narrative

Oxygen supply vs. demand and coronaryartery disease

Kinder gentler ventilation in acute

respiratory distress syndromeSurfactant

Nitric oxide

Reductionism is rarely the answer!

Coronary Artery Disease vs Cancer:


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Coronary Artery Disease vs. Cancer:Oxygen Supply vs. Demand as Narrative

Figure 6. From Heron et al. Deaths: Final Data from2006. National Vital Statistical Reports 57 (14), 2009.

R d Di t V i


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Readers Digest Version

http://www.merck.com

Regulating Blood Pressure:The Renin-Angiotensin-Aldosterone System

From Merck

Freely available athttp://www.merck.com/mmhe/sec03/ch022/ch022a.html
http://www.merck.com/mmhe/sec03/ch022/ch022a.htmlhttp://www.merck.com/mmhe/sec03/ch022/ch022a.html


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Why Not a Traditional Presentation?

We are members of the SNS vs. renal camp We wanted to make this talk about approaching

the unknown vs. reiterating the known

Consistency is the Hobgoblin of small minds--

Emerson

H D Y St d SNS S t f BP?


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How Do You Study SNS Support of BP?

Ganglionicblocking drugs

Sympathetic &parasympathetic

ganglia

How much does BP

drop after ganglionicblockade?

Change in MAP With Ganglionic Blockade


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Figure 4.From Jones, et al.Circulation104:2424-2429, 2001

Freely available athttp://circ.ahajournals.org/cgi/content/full/104/20/2424

Change in MAP With Ganglionic Blockadevs Sympathetic Tone

CP1311815-44
http://circ.ahajournals.org/cgi/content/full/104/20/2424http://circ.ahajournals.org/cgi/content/full/104/20/2424


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SNS Activity and TPR


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Total Peripheral Resistance & MSNA

5

10

15

20

25

30

10 20 30 40 50 60 70 80

MSNA (bursts/100 hb)

TPR(mmHg/L/min)

r2 = 0.37r = 0.61

From Joyner, unpublished data


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Not So Fast!

Do These Relationships Hold in Women?


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Do These Relationships Hold in Women?

Figure 2.From Hart, et al.Hypertension53: 571-576, 2009



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Old Irish Saying:Is This a Private Fight

or Can Anyone Join?

Can We Go Home?


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Can We Go Home?

Gary Larson Far Side cartoon of

teacher in front of class. A studentis asking Mr. Osborne, may I be

excused? My brain is full.

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