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