AF Association Pulse Check Event

Myself and some of my colleagues recently relinquished a Saturday off, and braved the icy cold (read: British) weather to try to meet with the public, and raise awareness of atrial fibrillation through a project spearheaded by the AF Association.

I didn’t organise the event, but was kindly invited along, and jumped at the chance to help some of my amazing Cardiology workmates by checking pulses, and recording rhythm strips using the AliveCor mobile ECG monitor (which I have previously reviewed here).

AF is an atrial arrhythmia, wherein the sinus node does not cause appropriate, rhythmic depolarisation as it normally would. Rather, multiple foci activate, facilitating a motion akin to ‘quivering’, which raises the risk of embolism through the inefficient pushing of the blood into the ventricles. It’s an incredibly dangerous problem if left untreated, so it’s vital that it gets detected, and preferably this would happen early.

NormAF

I go into detail about AF, it’s mechanisms and ECG presentation in this study guide, so have a look at that if you want to understand it further.

As you may or may not be aware, atrial fibrillation is, globally, the most common clinically significant cardiac arrhythmia, and it is thought that whilst 1.2 million people (a conservative estimate) in the UK are known sufferers of the sinus node disorder, a 500,000 have it, and live undiagnosed. The estimated cost of AF to the NHS was somewhere in region of £2.2 billion, in 2008, and given that the prevalence of the arrhythmia has increased year on year, this number may well be higher now.

Obviously, this is far from an exhaustive exploration of AF, but hopefully it gives some insight into why it’s so important to detect and treat, and why initiatives such as this one are a good idea.

We set up shop in Frome’s Westaway shopping centre at around 10am, where members of the public who’d read about the event in the local newspaper were already queueing. We four clinical scientists proceeded to advise and check 85 people throughout the day. We had a surprise visit from Cardiologist’s Kitchen, too!

 

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Mary, of Cardiologist’s Kitchen fame, showed up to say hello!

 

Many people we talked to had little-to-no idea what the condition was, its risks, or how it was treated, so we used literature, ECG examples, and a scale model of a heart, to educate, and taught people how to check their own pulse before performing quick rhythm recordings which we analysed on the spot. More than a few people who attended had known AF, and their questions largely involved their current treatment, and the potential impact AF might have on their life. Most, however, visited so they could get checked over, hopefully putting their mind at rest, and learning something in the process.

We didn’t find any new atrial fibrillation (although we did discover two cases of previously undiscovered AV Block), but of equal importance to arrhythmia discovery, was the community engagement, particularly in a public setting. In clinics it’s easy to fall into a cycle with patients, due to schedules and time pressures, and whilst we all try our hardest to make sure everyone is treated individually, seeing the problem before the person is always possible. Interacting with patients on “their turf” meant the ball was in their court, if you like, and the sheer volume of people who expressed an interest meant it couldn’t have been further from a wasted day.

The feedback we received was overwhelmingly positive, and there was a recurring theme in the gratitude people felt for the healthcare environment coming to them, as oppose to the other way around. Many of those to whom we chatted understand the strain that hospitals and GP surgeries are under, and felt that visiting to be checked for AF, and other such things, would be inappropriate. In many ways, I suppose they’re right, too; regardless of the importance of finding these things, especially as they do not always present with obvious symptoms, healthcare centres, unfortunately, cannot cope with the demand a service such as this would present. To this end, I was glad to have ventured out to participate in this, an outdoor clinic of sorts, and educate the public on what to look for, as well as how they can guage their own heart rhythm and take some more control over their own health. I sincerely hope to do it again soon!

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The AFA is a fantastic charity, so it’d be great if you were to find out a bit more about them by visiting them here.

I’d like to thank my colleagues for asking me to participate, and generally being fantastic people, those who visited us and asked lots of challenging questions, and the kind souls who bought us ginger ale and flapjacks when the temperature reached what *felt* like sub-zero levels.

The statistics used in this post are taken from the BHF. If you want to take a look for yourself, visit the British Heart Foundation, here.

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SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

 

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The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

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Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

  1. Be prepared for anything and everything, including waiting around for a long while
  2. Practice analysing ECGs until you hate them
  3. Practice performing ECGs until you hate them
  4. Go with your gut as much as you can during the practical exam
  5. Bring lunch
  6. Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

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Review: Epicardio Simulation v1.5 (Full Version)

Download for Windows/OSX:

  • Trial (Free)
  • Paid (£149-£215)
  • 60% discount for full-time students

Developer: Epicardio.Ltd

After my review of the temporary access trial of Epicardio Simulation (which offered a great deal of praise, I might add) I couldn’t wait to have a look at the full version’s features. I still can’t afford it yet even with the 60% discount offered to full-time students, but thankfully, the good people at Epicardio.Ltd allowed me to access the complete package so that I could review it. As I’ve already covered some of the functions of the program, I won’t re-tread old ground, but you can check out what I thought of the trial version here, and consider this a continuation of those original opinions.

So, what functionality is offered by the full version? Let’s go over it now.

The previously-unavailable tutorial section has some marvellous interactive elements; a view of the electrical action and a live ECG accompany the written tutorial pages, allowing the user to view the very thing they’re reading about in real-time. The procedurally generated ECGs are very accurate (I’ve measured them), but if you want to see a genuine patient-obtained trace recording, then one is included with each arrhythmia, too, which really helps with comparisons to the actual recordings one is likely to find in practice.

Almost everything you can think of is covered in some capacity, both on its own, and linked with other, relevant arrhythmias, so you really get a feel for just how interwoven some conduction and rhythm abnormalities can be.

A marvellous inclusion is the level of interactivity within the tutorials; degradation from VT to VF, for instance, is displayed live on the ECG strip and the defibrillator (that I didn’t really have cause to use in the trial version) can be charged, and a shock administered, altering the rhythm strip as it would a real patient.

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The pacing tutorials are easy to use and easy to follow; they walk you through the physics of single and dual chamber, as well as biventricular pacing. In using them to learn the basics of pacing, I can appreciate how effective the arrhythmia sections are and how useful they would have been during the early days of my studies. The interactivity of the aformentioned tutorials remains, too. Placing a pacing wire in different sites allows the user to view live rhythm changes, and sensitivity, HR and pacing rate can be toyed with so as to identify intrinsic rates and pre-pacemaker abnormalities such as 3rd° AV Block on the real-time trace.

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The test area throws generated ECGs at the student, and offers multiple answers from which to choose. Much like any degree-worthy multiple choice test, they range from incredibly easy to downright tricky, but a review section allows you to view the areas that might require further learning before each future run-through. As with the main bulk of the software, measurement calipers are useable during the test, allowing for some precise questions to be given.  Importantly, this software allows and encourages repetition; fundamental to successful learning. It may seem obvious, but I noticed that my understanding of unfamiliar areas increased the more I explored them. What won’t be obvious, is just how quickly this occurred. With the addition of the test function, the user can consolidate what they have learned at their own pace, and not have to exit the program find a different testing app.

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My time with the trial version of Epicardio only threw up a couple of minor issues. Whilst these are still present, they detract from the simulator even less than before, due to the myriad of extra content present in the full release. My only new problem came in the single chamber pacing tutorial, wherein I was instructed to reduce the pacing rate to 45bpm, yet I couldn’t lower it past 50bpm. This made it impossible to view the intrinsic rhythm of the digital patient (the point of the page in question’s existence), but only in this instance. It’s worth pointing out that regular updates exist to iron out glitches such as this, so errors needn’t remain for long.

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If, like me, your learing speed is increased by doing, as oppose to just reading or seeing, then you’ll find this tool invaluable. To be able to safely induce life-threatening ventricular rhythm is, understandably, an uncommon occurrence, so a method to facilitate this, and things like it, is always going to be welcome for students. In Epicardio, however, you get so much more than that. Pacing of all types is covered in depth, real and digitally created ECGs, and an effective test facility really do set this above any of the other programs that I’ve used. It’s also incredibly simple to get the hang of, too. The things it does well far outweigh its minor issues, so I can wholeheartedly recommend this program to everyone who wants learn about cardiac arrhythmia and interventions. Whilst the implementation of a 60% student discount brings the price down to the £59-£89 mark, it is still expensive, but you really do get what you pay for.

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Tetralogy of Fallot

Recently, in a Holter clinic, I dealt with an 8 year old patient who was on the road to recovery after a diagnosis of congenital defect, Tetralogy of Fallot. As a result, I got hold of the most interesting ECG I have recorded to date.

Background

ToF is a rare congential defect affecting the heart, that results in an insufficiency of oxygenated blood leaving the heart through the systemic circulation. Thus, it is considered a cyanotic disorder.

The disorder affects roughly 5 in 10,000 infants, and has an equal gender distribution.

Generally, four pathologies comprise ToF. Whilst all four are not always present, three can consistently be found. ToF is a progressive disorder, in that each pathology gives rise to the others.

The four principal defects are:

RVH

PVSTEN
L-R: Normal and stenotic PV

 

  • Pulmonary Stenosis
VSD
VSD supplying mixed blood via OvA

 

  • Ventricular Septal Defect
    • Hole in septum, due to malformation, causing oxygenated and deoxygenated blood to mix within cardiac structure
  • Overriding Aorta
    • Aorta is placed over VSD, transporting blood with low O2 content to wider systemic circulation

Cyanotic episodes require immediate correction, before surgical intervention.

  • High flow O2 administration
  • Physical positioning
    • Knees to chest
    • Parent cradling the child will illicit this effect naturally
  • NaCl fluid bolus
  • Vasopressor therapy
    • Increases systemic vascular resistance, shunting blood through pulmonary system.
  • Continuous ECG and SpO2 monitoring

Surgical intervention usually repairs the VSD and addresses pulmonary pathology, often at the same time.

Prognosis for ToF patients is generally very good.

  • Overall outcome improved since surgical treatment has improved
    • Survival of surgery is currently 95-99%
  • 36 year post-surgical survival is currently 96%
  • Patients who undergo surgical treatment are at greater lifelong risk of ventricular arrhythmia
  • Complications can arise as a result of a transannular patch repair, specifically;
    • RV dysfunction
    • Heart block (risk of HB has dropped to around 1%, in recent studies)
    • Heart failure
    • Recurrent or residual VSD

Hx:

  • 8 y/o
  • Previous diagnosis of ToF
    • VSD
    • PV Stenosis
    • Mild RVH
  • Treatment:
  • Transannular patch repair
  • PV Replacement

Medication:

  • Daily:
    • Atenolol
    • Aspirin

This patient was having a 24hr Holter recording to assess cardiac recovery after their most recent procedure; the PV replacement. Physical examination showed a RVOT murmur, whilst echocadiography displayed a mild RVH and PV regurgitation. Left heart functionality has been classed as excellent.

Previous ambulatory study has shown no arrhythmic action, save for that considered normal in a child of this age. No previous ECG recordings were available.

Upon monitor removal, a 12-Lead ECG was performed, the resulting trace was as follows:

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  • Sinus rhythm with BBB morphology
  • Sokolow-Lyon value of 36mV for RVH
  • QRS & ST segment abnormalities in all leads

Ambulatory analysis relating to the most recent study did not differ greatly from previous monitoring, showing occasional sinus arrhythmia and bradycardia, five non-conducted P waves were found, and two of these gave rise to periods of sinus bradycardia. All other instances were gradual onset/offset.

Nocturnal bradycardia reached rates as low as 34bpm.

What does everyone think of this ECG and brief ambulatory report? Let us know by leaving a comment below!

Heart

 

Review: BMJ Best Practice

Download the IOS app: Free

Download the Android app: Free

(In-app Purchases: £5-£60 approx.)

Developer: BMJ, London

 

BMJ Best Practice is an app that aims to aid diagnosis and guide the practitioner through the treatment process of a number of pathologies. Guidelines on examinations, tests and medications are provided across 977 topics. These are not all available initially; some conditions are presented as a free sample, whilst the rest must be purchased either in one go (£59.99), or by categories such as Critical Care and Emergency Medicine (£15.99), and Cardiovascular Disorders, Vascular and Cardiothoracic Surgery (£7.99). Institutional access is available, so if your trust/ university subscribes to the service, you can access all of the content for free.

BMJ Phone

 

These are the good things BMJBP does. Unfortunately, it does a great deal worse when it comes to every other aspect of its content and execution.

Whilst the level of content is very good, straightforward and to the point, it’s unlikely that you’ll actually get to see any of it, as the sample pages don’t always load, and when they do, they don’t save. Frequently, I left the app to take a call, and returned to it to find it had rebooted. In addition, whilst the developer’s ability to extract the subscription fee for paid content suffers no problems, their ability to supply said content is non-existent. I purchased the “Cardiovascular Disorders…” category for £7.99, and was told by the “My Topics” section of the app, that I didn’t own any of the documents, yet was told by the “Subscribe” page, that I did..! Either way, I couldn’t (and still can’t) view any of the content I have paid for.

I sent an email over to the BMJ customer service department, and was politely informed that subscriptions were handled by Google, and there was nothing that BMJ could themselves do. As it turns out, subscribed content is entirely the responsibility of the BMJ, so when I pointed this out, and asked for a refund, I was met with a wall of silence that is currently ongoing.

Although it may be tempting to download this app, I strongly recommend that you do not; the content isn’t there, the app itself is buggy and the developer’s desire to help with problems is as present as the paid topics, in that both have yet to materialise. Judging by the user reviews left on Google Play, I am not the only user to have faced any of these problems, so it’s not as though the devs are unaware.

This app doesn’t do enough, regarding functionality, to warrant being this unfinished. It genuinely frightens me to think that someone was paid a wage to develop this, and even more frightening, is that the BMJ are charging for content, despite the numerous complaints of bugs and such. The app lists its last update as 2015, but lord knows what it addressed, or how much worse it was before, if this is considered sufficient.

This, dear reader, is how NOT to make a mobile app.

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Review: Acadoodle

Acadoodle.comonline

Price: $99/ £66 per annum (approx)

Authors: Dr John Ryan, Dr John Seery

Acadoodle is a subscription-based online resource for ECG training that boasts a large selection of video tutorials which can be viewed individually, or as part of a tested course. The ECG Teacher sections are the primary focus of this review, but other courses such as blood gas analysis are available, however.

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Produced by Drs John Seery and John Ryan, I found these courses to compliment my study, and even when I wasn’t watching them directly, I found myself letting them play in the background as I read a textbook, or went over my lecture notes.

The videos themselves are well produced and make understanding the ECG and its subsequent analysis much easier. The animations are slick and the narration is clear, concise and full of all the pertinent diagnostic information you will require.

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Each area of study is tailored to a specific area of electrocardiogram diagnostics, so each playlist/module flows from one video to the next. In addition, the flow of the modules themselves makes sense, and the learning curve increases in a logical order and as such, each section follows on from the one that precedes it in a manner that doesn’t overload you with information before you’re ready.

A small selection of the videos are available on YouTube, so if you wished to try before you buy, then searching for “Acadoodle” would throw up some of the more basic tutorials for you to have a look at. I noticed that these YouTube videos are also embedded in the Acadoodle site proper, giving rise to a sometimes noticeable drop in picture quality, on occasion.

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It’s nearly impossible to fault the content and structure, as these videos have helped me immeasurably throughout the last six or seven months, but it is an expensive purchase for anyone, let alone students, especially when you consider that almost all of the content is in some way available via lectures or found in other, similar video courses on YouTube. In that respect, despite the quality of the content, I find it hard to recommend Acadoodle to physiology students who are considering purchasing a personal subscription, but for lecturers or professional bodies and universities, it should prove to be a valuable asset when clarifying concepts to a class full of students.

That isn’t to say that a student purchasing a subscription wouldn’t get a lot out of Acadoodle; it’s certainly worth it, it’s just expensive at a time when disposeable income is generally spent on textbooks or… food and shelter. If splitting £66 is something that you and a few peers feel is possible, then I highly recommend it, as the website can be used from multiple PCs with little to no issue.

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Holiday-Only Arrhythmias

During the festive season, its easy to indulge in excess; too many sprouts, an increase in afternoon napping, festive drinks… You know the score. It isn’t all smiles and sunshine, though, as we shall see.

One particular result of all the festive excess relevant to cardiac professionals, has been reported across the globe, but particularly in Entirely Fictitious Primary Care Centres (EFPCCs); Bacardi Branch Blocks, or BacBBs

BacBBs are thought to affect the heart as a whole, but it can be seen that they have a particularly odd effect on the ventricles, and cause an odd, never-seen-in-real-life depolarisation wave on the ECG, that actually defies physics and medical science by going back in time!

Symptom sheets compared with the compiled ambulatory data have shown unanimously that BacBBs are present sporadically within sinus rhythms, but coincide with that one-drink-too-many during a family game of Monopoly (Mr Moneybags isn’t thought to be an underlying cause, so the activity isn’t seen as a risk factor).

Atrial activity stops altogether, presumably because the SA node just forgets what it’s doing, as it’s seen enough crepe paper hats and screwdriver sets fly from crackers to last it a lifetime.

After an episode of BacBB, sinus rhythm resumes, and the patient will return to whatever their festive-norm may be until the next instance.

This phenomenon seems to disappear entirely during the first couple of weeks of January, when normal working hours begin again, hence, I feel that it is triggered by the holidays themselves.

None of this is being researched, or is even disputed, because it is both totally false, and invented entirely by me.

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Bacardi Branch Block

  • Common holiday rhythm abnormality only found during the festive season, and even then, only in fictitious settings
  • HR between 80-120bpm
    • Depends entirely on board game leader-board position
  • No P waves
  • Abnormal ventricular action
    • Resembles upturned cocktail glass
  • Is thought to only contribute to familial tolerance levels during prolonged exposure to each other

 

HAPPY HOLIDAYS FROM EVERYONE AT THE STUDENT PHYSIOLOGIST!!

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