زكاة العلم الدكتور محمد البيضاني

A 62-year-old previously healthy man is brought to the emergency department because of severe headache and dizziness. He has no chest pain or dyspnea. He takes no med-ications. His blood pressure is 186/98 mm Hg; his heart rate is 56 beats/minute and regular. The presenting ECG is shown in Fig. 1.15. Which of the following actions is appropriate? A- Initiate antiplatelet therapy with aspirin and clopidogre! B-Initiate antithrombotic therapy with heparin C- Initiate anti-ischemic therapy with intravenous nitroglycerin and a beta blocker D- Proceed directly to cardiac catheterization if ST-segment/ wave abnormalities fail to quickly normalize with anti-ischemic therapy E- Obtain a head computed tomography scan

Cardioversion : synchronised DC shock (elective DC) use to get sinus rhythm like in AF , SVT. Defibrillation: asynchronised DC shock ( emergency DC). Used for VF and pulseless VT.

What is the difference between cardioversion and defibrillation?

During stress ECG tests - ST elevation good indicator of location of ischemia according to the leads involved - ST depression indicate ischmia but poorly localised the site of ischmia Examples - st elevation in inferior lead during stress tests indicate inferior ischmia - st depression in inferior lead during stress test indicate ischmia but may be no related to inferior wall.

Which arrhythmia do you see in this strip?

Cause of bradycardia in acute occlusion of right coronary artery (RCA)either due to - decrease blood supply to the SA node which get about 60% of its blood from RCA - heart block due to diminished blood supply to the AV node which get about 85% of its blood from RCA - or due to high vagal tone which has high afferent fibre in inferior and posterior wall of LV.

Posterior MI manifested by following ECG finding (roughly): - prominent R wave in V2 - ST depression - upward terminal T wave - ST elevation in posterior leads Notes: - posterior wall get its blood supply either from posterior ascending artery which is branch of right coronary artery and branches of circumflex artery - posterior MI either isolated in 5% ( occlusion of posterior ascending artery ) which missed each in the ED - posterior MI usually come with inferior MI ( same criteria for posterior MI with inferior wall changes) - Posterior MI may come due to occlusion of branch of circumflex artery and usually come with lateral wall. - posterior MI like other wall infarction need reperfusion therapy. - don’t take posterior MI easy sometimes leads to cardiogenic shock. -

A 57-year-old man with a history of hypertension and elevated low-density lipoprotein cholesterol presents to the emergency room with the acute onset of sub-sternal chest pressure, dyspnea, and diaphoresis. His blood pressure is 158/96 mm Hg, and the heart rate is 92 beats/minute. Physical examination reveals clear lung fields and no cardiac gallop or murmurs. The ECG shows sinus rhythm with a prominent R wave in lead V2, and 2 mm of horizontal ST depression in leads V1, to V3. Which of the following would be diagnostically useful to plan a course of action? 1- Repeat the ECG with right-sided precordial leads 2- Repeat the ECG with V7, to V9 leads( posterior leads) 3- Await results of serum cardiac biomarkers 4- Obtain a chest computed tomography to assess for pulmonary embolism

A 57-year-old man with a history of hypertension and elevated low-density lipoprotein cholesterol presents to the emergency room with the acute onset of sub-sternal chest pressure, dyspnea, and diaphoresis. His blood pressure is 158/96 mm Hg, and the heart rate is 92 beats/minute. Physical examination reveals clear lung fields and no cardiac gallop or murmurs. The ECG shows sinus rhythm with a prominent R wave in lead V2, 0.5 mm of ST elevation in lead III, and 2 mm of horizontal ST depression in leads V1, to V3. Which of the following would be diagnostically useful to plan a course of action? 1- Repeat the ECG with right-sided precordial leads 2- Repeat the ECG with V7, to V9 leads( posterior leads) 3- Await results of serum cardiac biomarkers 4- Obtain a chest computed tomography to assess for pulmonary embolism

Fluttering of anterior mitral valve leaflet due to aortic regurgitation

According to (my opinion )about ECG above - irregular - no P wave - fine fibrillation waves in lead II and V1 - wide QRS which take pictures of LBBB( deep S in V1 and rS in V6 or wide R in lead I and avL) This is slow AF wit LBBB. Note : regularisation of Atrial Fibrillation either - return sinus rhythm which appear clearly ( regular and P wave in V1 and lead II). - or become complete heart block which appear 1- regular due to escape rhythm from junctional area( regular , heart rate 40–60 bpm and narrow QRS if there is no bundle block) 2- fibrillation wave still present which appears clearly in V1 and lead I Note: regularisation rhythm of patient with AF on digoxin therapy this is digoxin toxicity with complete heart block until prove otherwise.

الكارديولوجست يكول af with complete heart block انتم شنو رايكم

Amidarone causes prolonged QT but don’t caused Torsade De Point

If you want to do open heart surgery for valve replacement or other issues for patient with risk factors of IHD especially DM , you should do coronary angiography to see if there is diseased multi vessel to do CABG by the way. On other hand if you want to do CABG for patient with - asymptomatic sever valves disease - moderate with symptoms valves Disease You should do valve replacement at time of CABG

Conditions don’t need prophylactic antibiotics for bacterial endocarditis - rheumatic heart disease - mitral valve prolapse - bicuspid aortic valve - calcified aortic valve - congenital heart disease (ASD,VSD) - hypertrophic cardiomyopathy Conditions need prophylactic antibiotics - previous infection with endocarditis - prosthetic cardiac valve - prosthetic material used in valve repair - unrepaired Cyanotic congenital heart disease - repaired Cyanotic congenital heart disease within 6 months - repaired congenital heart disease with residual defect

55 years old male did PCI for acute inferior MI. After few day he develope Dry, thick, and raised patches on the skin.These patches are often covered with a silvery-white coating called scale, and they tend to itch. These features pass with psoriasis. The patient didn’t had like these features previously. After careful drug history one of his medications is beta blocker which one of causes of psoriasis. We told him to stop beta blockers to see the response. Fortunately the skin manifestation passed away. My massage beta blocker can causes psoriasis and the feature may appear after MI as the patient start with these drug

Don’t use dihydropyridine calcium Chanel blocker like Nefidipine or amilodipine in heart failure or angina without beta blocker As the causes reflex tachycardia and precipitate angina and heart failure

Drugs that improve survival in heart failure - ACE inhibitors or ARBS - beta blocker ( only metoprolol succinate, bisoprolol and carvedilol ) - potassium sparing agent like sipronalctone ) - isosorpide dinitrate. Drugs that improve the symptoms - digoxin - diuretic - intropic agent ,,,,,

Factors associated with bad outcomes after MI - age more than 70 - history of DM,HTN and angina - BP less than 100/60 mmHg at heart attack - heart rate more than 100 bpm at heart attack - weight less than 67kg - anterior MI or new LBBB - more than four hours from the onset of symptoms to consultation مع هذا كله الاعمار بيد الله عزه وجل 🌝

Thrombolytic therapy is indicated in - acute ST elevation MI - new LBBB due to ischmia - posterior MI which appear as 1- ST depression in V1,2,3 2- prominent R wave in V2 (R/S more than 1) 3- upwards terminal T wave 4/ ST elevation in posterior lead Note : thrombolytic therapy not indicated in - no ST elevation MI - unstable angina