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12.11.22 Ward notes

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
    • Responsible for warmth
  • Ultra-slow histamine-selective C fibers
    • Responsible for itch
  • Tactile C fibers
    • Sensual touch
  • 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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