High takeoff- Elevation of j point (junction between QRS and ST)
- Reflects early repolarisation
- Makes the ECG looks like ST elevation and might be misinterpreted as AMI.
- Causes:
- Normal variant
- Younger patients
- Identification:
- Usually follows an S wave
- T wave maintains independent wave form
- No reciprocal ST segment depression
- If in doubt, compare with earlier ECGs
Omacor - NICE MI guidance recommends that patients consume 7 grams Omega 3 per week
- From 2 to 4 portions of oily fish or prescription of Omacor 1 gram / day
- GISSI-Prevenzione trial
- 11,324 patients who had suffered an MI within the previous 3 months
- Omega-3 acid ethyl esters therapy significantly reduced total mortality and cardiovascular morbidity
- Half the patients were treated with one Omacor capsule a day for 3.5 years in addition to standard care
- Patients who took Omacor were about one-third less likely to have died from an MI than patients who had not
- Initiation of omega-3-acid ethyl esters supplements is not routinely recommended for patients who have had an MI more than 3 months earlier
NICE dietary advice post-MI- Patients should be advised not to take supplements containing beta-carotene
- Patients should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk
- Patients should be advised to consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fish
- For patients who have had an MI within 3 months and who are not achieving 7 g of omega 3 fatty acids per week, consider providing at least 1 g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years
- Initiation of omega-3-acid ethyl esters supplements is not routinely recommended for patients who have had an MI more than 3 months earlier
- Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils)
Stenting patients in AF
- Triple therapy:
- Aspirin 81 mg once daily, clopidogrel 75 mg once daily, warfarin
- Target INR of 2.0 to 2.5
- Continue for 4 weeks, then stop clopidogrel
- Drug-eluting stent instead of a bare-metal stent => continue with triple therapy for 3 or 6 months
Drug-eluting stents - Paclitaxel (mitotic inhibitor) or sirolimus (antiproliferative)
- Prevention of restenosis
- Limits the growth of neointima within stents
- Both may raise risk of thrombosis
Junctional rhythm - Cause
- Automatic tachycardia
- Escape mechanism during periods of significant bradycardia with rates slower than the intrinsic junctional pacemaker
- Characteristics
- Rate of 40-60 beats per minute
- Narrow QRS complex because the ventricle is depolarized using the normal conduction pathway
- An accelerated junctional rhythm (rate >60) is a narrow complex rhythm that often supersedes a clinically bradycardic sinus node rate
- Less commonly, the AV junction develops abnormal automaticity and exceeds the sinus node rate at a time when the sinus rate would be normal
- Most often observed in the setting of digitalis toxicity, recent cardiac surgery, acute myocardial infarction, or isoproterenol infusion
- ECG
- Inverted P waves from retrograde conduction
- May be interspersed with normal P waves
- Or may be no P waves at all
C fibre pathways- C fiber nociceptors
- Responsible for the second, burning pain
- C fiber warming specific receptors
- Ultra-slow histamine-selective C fibers
- Tactile C fibers
- C mechano- and metabo- receptors in muscles or joints
- Responsible for muscle exercise, burn and cramp
Spinal sensory pathways - Spinothalamic
- Lateral: Pain and temperature
- Anterior: Crude touch and pressure
- Dorsal column
- Light touch, vibration, proprioception
- Also tactile pressure, barognosis, graphesthesia, stereognosis, recognition of texture, kinesthesia, two-point discrimination
Devarication of rectus abdominus - Superior to the umbilicus, some people have a congenital defect that results in a wider gap between the muscles
- As a result, when a patient flexes the abdominal muscles as when doing a sit-up, the rectus muscles spread apart (divaricate)
- The divarication is made more obvious when the patient lifts their head or legs off the bed when supine
Notes - Pulse in AF
- Irregularly irregular in rate AND VOLUME
- Due to beat-to-beat variation in end diastolic volume
- Pulse deficit
- Difference between pulse rate and heart rate
- Because some heart beats don't open the aortic valve
- Pain and pleasure go together
- Pain and stroking are both carried down unmyelinated C fibres
- Subtle jaundice can only be seen in sunlight, not artificial light
- Spider naevi are only ever found in the drainage area of the SVC
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