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


    • 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


    • 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