Download Toronto Notes for Medical Students 2008 by Rebecca Colman PDF

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By Rebecca Colman

The Toronto Notes 2008 contains interesting new alterations that would additional support scholars organize for the Canadian and American clinical licensing assessments.

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Ht8twnIim Rate control (using ~ers, verapamil, dittiazem, or digoxin alone or in combination) vs. rhythm controllusing an antiarrhythmic drug chosen by the treating physicianl. IIIain outcome: Overall mortality. There were more haspi· tal~ations and adVerse drug effects in the rhythm' control group. ConcIuIIon: Rate-control was as effective as rhythm-control in atrial fibrillation, and may be better tolerated. Anticoagulation should be continued. PriIllllY prevention of Itroke in patients with etrIal fibriHation The Cochrane Ubrary, Issue 3, 2003.

Randomized. 5 years. f'lItienm 4060 patients (mean age 70 yrs, 61% male, 89% white) with atrial fibrillation and ahigh risk of stroke or death, in whom anticoagulant therapy was not contraindicated. ht8twnIim Rate control (using ~ers, verapamil, dittiazem, or digoxin alone or in combination) vs. rhythm controllusing an antiarrhythmic drug chosen by the treating physicianl. IIIain outcome: Overall mortality. There were more haspi· tal~ations and adVerse drug effects in the rhythm' control group.

0 vs. OOI). Total cost was also significantly lower in the intervention group ($5410 vs. OO6I. In addition, the measurement of Btype natriuretic peptide significantly reduced the need for admission to hospital and intensive care. The 3O·day mortality rates were similar (10% vs. 45). ConcIUlkms. In patients with acute dyspnea, measurement of B-type natriuretic peptide improves clinical outcomes (need for hospitalization or intensive care) and reduces time to discharge and total cost of treatment CI0 Cardiology and CV Surgery Cardiac Diagnostic Tests Toronto Notes 2008 • available teclmologies: • Holter morutor • battery operated, continually records up to 3 leads for 24-48 hrs • symptoms recorded by patient on Holter clock for correlation with ECG findings • continuous loop recorder (diagnostic yjeld 66-83%) • worn continuously and can record data before and after patient activation for symptomatic episodes • external and implantable devices • external devices can be transtelephonically downloaded • implantable loop recorder (ILR) - implanted subcutaneously to the right or left of the sternum; triggered by placing an activator over it; anterograde and retrograde recording time is programmable; cannot be transtelephonically downloaded; left in place for 14 to 18 months 'I Echocardiograph Transthoracic Echocardiography (TIE) • ultrasound beams are directed across the chest wall to obtain images of the heart • indications: evaluation of left ventricular ejection fraction (LVEF), wall motion abnormalities, myocardial ischemia and complications of MI, chamber sizes, wall thickness, valve morphology, proximal great vessels, pericardial effusion, unexplained hypotension, murmurs, syncope Doppler Ultrasound • method to assess blood flow patterns, direction and velocity • indications: documentation and quantification of valvular insufficiency or stenosis, intracardiac gradients and estimations of blood flow and cardiac output • an integral part of TIE and TEE Transoesophageal Echocardiography (TEE) • ultrasound probe inserted into the esophagus to allow for better resolution of the heart and its structures • better visualization of posterior structures, such as left atrium and mitral and aortic valves • invasive procedure, used to complement transthoracic echocardiography • indications: intracardiac thrombi, tumours, valvular vegetations (infective endocarditis), aortic dissection, aortic atheromas, prosthetic valve function, shunts, technically inadequate transthoracic studies Stress Echocardiography • echocardiography in combination with either physiologic (exercise treadmill testing) or pharmacologic (dobutamine infusion) stress • validated in demonstrating myocardial ischemia • provides information on the global left ventricular response to exercise • regional wall motion is analyzed at rest and with stress Contrast Echocardiography • contrast agents injected into the bloodstream to improve imaging of the heart • conventional agent: agitated saline (contains microbubbles of air) • allows visualization of right heart and intracardiac shunts, most commonly patent foramen ovale (PFO) • newer contrast agents are capable of crossing the pulmonary bed and achieving left heart opacification following intravenous injection Intracardiac Ultrasound • ultrasound probe inserted into the heart (usually the right atrium) • used in interventional procedures such as transcatheter atrial septal defect device closure Intravascular Ultrasound • ultrasound probe inserted into the coronary arteries or other vessels • occasionally used in coronary angiography to improve definition of coronary lesions Toronto Notes 2008 Cardiac Diagnostic Tests Exercise Testing • exercise testing is a cardiovascular stress test using treadmill or bicycle exercise with electrocardiographic and blood pressure monitoring • ACC/AHA 2003 guidelines for use: • patients with intermediate (10-90%) pretest probability of CAD based on age, gender and symptoms • complete RBBB • ST depression 1 mm ST depression at rest, complete LBBB • note: less useful in cases of marked resting ST-T abnormalities, LBBB, digoxin use, less accurate in women • exercise test results stratify patients into risk groups • low risk patients can be treated medically without invasive testing • intermediate risk patients may need additional testing in the form of exercise imaging studies or cardiac catheterization • high risk patients should be referred for cardiac catheterization Absolute Contraindications to Exercise Testing • • • • • • • • acute myocardial infarction (within two days) unstable angina not previously stabilized by medical therapy uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise symptomatic severe aortic stenosis uncontrolled symptomatic heart failure acute pulmonary embolus or pulmonary infarction acute myocarditis or pericarditis acute aortic dissection Relative Contraindications to Exercise Testing • • • • • • • • left main coronary stenosis hemodynamically significant aortic stenosis electrolyte abnormalities severe arterial hypertension tachyarrhythmias or bradyarrhythmias hypertrophic cardiomyopathy and other forms of outflow tract obstruction mental or physical impairment leading to inability to exercise adequately high-degree atrioventricular block Prognostic Markers • maximum exercise capacity, markers related to exercise induced ischemia (exercise induced ST-segment depression, exercise-induced ST segment elevation (in leads without pathological Q waves and not in aVR) exercise-induced angina, and inadequate blood pressure response in post infarct patients • abnormalities in exercise capacity, systolic blood pressure response to exercise, and heart rate response to exercise are important findings.

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