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