Heart blocks methodic guidelines for the 5th year students Self-training on the practical study icon

Heart blocks methodic guidelines for the 5th year students Self-training on the practical study




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Donetsk National medical university named after M. Gorky


HEART BLOCKS


Methodic guidelines for the 5th year students

Self-training on the practical study

at the Internal medicine # 1 department


Donetsk – 2009

Authors:

V. V. Adarichev

N. V. Kalinkina, MD


Reviewers:

T.A. Parkhomenko, MD, PhD, Internal medicine #2 department

R.V. Basiy, MD, PhD, Anatomy department.


I. Introduction:


Heart blocks are common in clinical practice of physicians. Any heart and vessel disorder may result in diagnosing of heart bocks which could burden an ongoing disease and lead to serious and even fatal complications.

This is a basis for studying various aspects of blocks. Knowledge of pathologic physiology, and heart conductive system anatomy is required for better understanding of the topic. As conduction disorders are very common, they could be met in practice of any specialty doctors. That is why knowledge in the current topic might be very useful.


II. Aims of studying the topic

^ Common purpose: you need to know how to differentiate heart blocks, define main strategies of treatment and approach to the patient, give urgent help to patients with heart blocks in emergent conditions .

Purposes

Basic skills required:

  1. Define main syndromes of conduction disorders in connection with history of disease.




  1. Approach to the patient: complaints, physical examination of the patients with cardiovascular disorders.




  1. Compile an individual scheme of diagnostic search. Interpret all necessary data for diagnosing heart block. Obtain the severity and type of conduction disorder.




  1. Obtain and interpret X-ray, ECG, EchoCG, Holter monitoring data.




  1. Differentiate heart blocks according to diagnostic algorithms.







  1. Diagnose emergencies .




4.Know how to recognize syndromes which characterize urgent conditions due to Cardiovascular diseases.



5. Approaches to the treatment of the patients with heart blocks.

5. Use methods of pathogenic and symptomatic therapy in the patients with cardiovascular disorders.



Literature for material revise:

  1. О.В.Синяченко, Г.А.Игнатенко. Пропедевтика внутренних болезней: учебное пособие. Донецк; Донеччина. -2004. -548 с.

  2. Патофизиология заболеваний сердечно-сосудистой системы / Под ред. Л.Лилли. –Москва; Бином. -2003. –С.328-376.

  3. Струтынский А.В., Баранов А.П. Основы семиотики заболеваний внутренних органов. М.1997. –С.91-142.

  4. Комиссаров И.В., Абрамец И.И., Самойлович И.М., Харин Н.А. Фармакология: введение в фармако- и химиотерапию. Донецк., Донбасс. -1999. –С.145-150.


Tests of initial level

1. The patient D., 67 y.o. had ECG-changes (see below):




These changes are caused by:

A. Right His Bundle Block (RHBB).

B. Frederique syndrome.

C. 1st grade AV-block.

D. Mycardial infarction (MI).

E. Left His Bundle Block (LHBB).


2. The patient B., 56 y.o., has an 2nd degree AV-block type 2.

Which from the listed are NOT the etiologic factors for heart blocks:

A. hyperkaliemia.

B. cardiosclerosis.

C. digoxin treatment.

D. M-choline blockers treatment.

E. high vagus tone.


3. In the patient B., 56 y.o., who suffers fron IHD, and having 2nd degree AV-block 2 type syncope suddenly has developed. Heart rate 36 bpm, regular, of different filling. BP 70/40 mm Hg.

^ The patient is having:

A. Stokes-Adams syndrome.

B. WPW-syndrome.

C. Clerk-Levi-Critescou (CLC) syndrome.

D. vena cava superior syndrome.

E. coronary sinus syndrome.


4. Complete RHBB differs from incomplete RHBB by duration of:

A. PQ.

B. QT.

C. RR.

D. QRS.

E. PP.


5. Which are the leads to measure internal deviation time in when LHBB is suspected?

А. V5-6

B. V3-4

C. I, aVL, V5-6

D. V1-2

E. III, aVF


IV. Study plan


The following topic parts should be studied to archive aims listed above:

1. Heart blocks etiology and pathogenesis.

2. Classification of heart blocks.

3. Methods for clinical and instrumental heart blocks’ diagnosing.

4. Conduction disorders’ differential diagnostics.

5. Urgent conditions caused by heart blocks.

6. Treatment of conduction disorders and emergencies caused by heart blocks.


Literature for studying theoretical aspects of the topic:

  1. H. Ross Cardiology. MCCQE , 2000. p. 18-19.

  2. Tinsley Harrison. Internal diseases. Book 4. –М., Практика. -2005. –p.1536-1544.

  3. Clinical Electrocardiography / F. Zimmerman, М.: Binome. – 1997. – Chapters I-VI.

  4. Lectures in hospital therapy.



Short methodic guidelines for the classes on the topic “Heart blocks”


First the teacher checks students’ initial knowledge level using initial level tests and corrects it if necessary. Then students examine patients on the topic of the lesson and start detailed discussion of the patients with the teacher. The discussion is followed by the end-level tests. In the end of the lesson the teacher summarizes students’ work on the topic.

Appendix 1

^

Heart blocks





Main symptoms





Hypotonia

Bradycardia






Syncope






Clinical features



Additional studies (ECG, EchoCG, Lab)



Lab studies





  • Potassium, calcium

  • Myocardial necrosis markers (Troponins, CPK-МВ)

  • Endocrine system function (TTH, Т4)









Differential diagnosis:

Diseases and pathologic conditions which result in heart blocks development: IHD, hypothyroidism, multiple myeloma, potassium-saving diuretics or potassium medications overdose








Heart blocks classification

(appendix 3)



Treatment (according to ethiology)

Appendix 2 Conduction system of Heart





^ HEART BLOCKS CLASSIFICATION

  • Blocks that occur within the sinoatrial node (SA node) are described as SA nodal blocks.

  • Blocks that occur within the atrioventricular node (AV node) are described as AV nodal blocks.

  • Blocks that occur below the AV node are known as infra-Hisian blocks (named after the bundle of His).

  • Blocks that occur within the left or right bundle branches are known as bundle branch blocks.

  • Blocks that occur within the fascicles of the left bundle branch are known as hemiblocks.
^

Types of SA nodal blocks


  • SA node Wenckebach (Mobitz I)

  • SA node Mobitz II

  • SA node exit block

Types of AV nodal blocks


  • First degree AV block

  • Second degree AV block

    • Type 1 second degree AV block (Mobitz I) (also known as Wenckebach phenomenon)

  • Third degree AV block (Complete heart block)
^

Types of infra-Hisian block


Infrahisian block describes block of the distal conduction system. Types of infrahisian block include:

  • Type 2 second degree heart block (Mobitz II)

  • Left bundle branch block

    • Left anterior fascicular block

    • Left posterior fascicular block

  • Right bundle branch block


Appendix 4

Summary Test Control


1. The Patient Y, male, 52 y.o. suddenly felt an intensive burning pain in heart area during 30 min. He took nitroglycerine 4 times during period of pain without any effect. ECG: sinus rhythm, regular, HR 92 bpm, PQ 0.18, QRS 0.15. No previous ECGs available.

What should be done to exclude MI?

А. blood test for troponin T, CPK-MB;

B. alkaline phosphatase;

C. ESR;

D. stress-EchoCG;

E. treadmill.


2. The patient D. is suffering from Essential hypertension of the 2nd stage after taking some drugs an AV-block of the 2nd grade was registered on ECG.

^ What should be excluded from the list of administered to the patient medications?

А. enalapril;

B. hypothiazide;

C. atenolol;

D. mildronat;

E. phenazepam.


3. The patient W., 67 y.o., suffering from IHD, complains on feeling of irregular heart rhythm, “sinking” heart. On the ECG: irregular rhythm, progressing PQ increase with following QRS drop out.

^ ECG changes are specific for:

А. 1st grade AV block;

B. 2nd grade AV block (Mobitz 1);

C. 2nd degree AV block type 2 (Mobitz 2);

D. 2nd degree AV block type 3;

E. 3rd degree AV block (complete).


4. In the patient J, 65 y.o., suffering from multiple myeloma 2nd stage during ECG-recording the doctor has noticed following changes: PQ 0,24 s, QT – 0,30, HR 69 bpm.

What resulted in these ECG-changes?

A. hyperproteinemia;

B. hypouricemia;

C. hypercalciemia;

D. hyponatriemia;

E. hypoproteinemia.


5. Complete AV-block has developed in the patient who underwent coronary angiography.

Which medication is contraindicated to the patient?

А. atropine;

B. dophamine;

C. adrenalin;

D. labetalol;

E. euphylline.





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