Atrial fibrillation extras

As discussed in the podcast, here is the stroke risk calculator and an ECG example

CHADS2 Scoring Scheme

Condition Points
C Congestive heart failure 1
H Hypertension 1
A Age > 75 years 1
D Diabetes Mellitus 1
S2 Prior Strokeor TIA 2

Annual Stroke Risk with Respect to CHADS 2 Score (1)

CHADS2 Score Stroke Risk % 95% confidence interval
0 1.9 1.2-3.0
1 2.8 2.0-3.8
2 4.0 3.1-5.1
3 5.9 4.6-7.3
4 8.5 6.3-11.1
5 12.5 8.2-17.5
6 18.2 10.5-27.4

AF rapid ventricular response



Complete heart block


Complete Heart Block

Complete heart block (or third-degree AV heart block)

A colleague showed me an unusual looking ECG on a patient with no cardiac symptoms. We asked a cardiologist for advice and he diagnosed Complete Heart Block (CHB). As the patient was well he was referred to cardiology clinic the following day for a pacemaker.

Complete heart block is the most serious type of AV heart block.  This is an abnormal heart rhythm (arrhythmia) that happens when there is a complete absence of electrical impulses (AV conduction) between the atria and ventricles.

Normally a back-up system keeps ventricles beating (junctional or ventricular escape rhythm), but the ventricles beat much slower than normal. This can affect the flow of blood to the body and brain and will cause symptoms of confusion, collapse, dizziness, breathlessness and tiredness.

Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).

What causes complete heart block?

Most people with complete heart block have an underlying heart condition like coronary heart disease, cardiomyopathy or congenital heart disease.

It can also be caused by ageing of the electrical pathways in your heart (meaning you’re more likely to get it if you’re older), electrolyte imbalances, and some medicines (e.g. calcium-channel blockers, beta-blockers, digoxin)


The patient will have severe bradycardia (slow heartbeat) with independent atrial and ventricular rates, i.e. AV dissociation on ECG-see below.

Example of complete heart block

The atrial rate is approximately 100 bpm.

The ventricular rate is approximately 40 bpm.

The two rates are independent; there is no evidence that any of the atrial impulses are conducted to the ventricles.


Patients require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker.





I hope you have had a very happy Christmas. Now  we can look forward to 2018 and how we can make virtual doctors even better and relevant to you. The cases you send us are interesting and often very educational for us in the U.K. too.

The idea of the blog, the cases from the field, that I write, is to give a flavour of the work that you ,the clinical officers, do. I hope to put it in some context for those interested in reading about the virtual doctors work. It is put on the Virtual Doctors website.  I am aware that I probably don’t get all the facts right! So please let me know about your homeland- the highlights, the challenges and where I’ve got muddled up geographically! My aim is make the blog as authentic as possible so I need your help!

If you can, please leave me a comment here- short or long.

many thanks for your help



Benign paroxysmal positional vertigo and Epley

BPPV Benign paroxysmal positional vertigo

BPPV is the commonest cause of vertigo. It is Benign as although it can be quite disabling, it is not due to serious disease; Paroxysmal because it occurs in short bursts of up to one minute; Positional as it is provoked specifically by movement to or from certain positions; Vertigo – dizziness defined as an illusion of movement.

Who is affected by BPPV?

BPPV is estimated to affect roughly 50% of all people at some time in their lives and becomes progressively more common with age.

Symptoms of BPPV

The vertigo is generally rotational (like getting off a roundabout) but sometimes sufferers, on lying down, will feel that they are falling through the bottom of the bed or, on getting up, that they are being thrown back onto it. The classic provoking movements to induce BPPV are: lying flat, sitting up from lying flat; turning over in bed; looking up (e.g. hanging washing) or bending down, especially if also looking to the side. The duration of the vertigo is brief; usually five to 30 seconds but very occasionally lasts up to two minutes.

What causes BPPV?

BPPV is caused when loose chalk crystals get into the wrong part of the inner ear. These microscopic crystals should be embedded in a lump of jelly. The crystals weigh the jelly down and make that part of the ear sensitive to gravity. The crystals are constantly being re-absorbed and re-formed and over time fragments come loose. Lying flat can then occasionally cause some of the loose debris to fall into one of the semi-circular canals; the parts of the ear responsible for sensing rotation. Movement in the plane of the affected canal causes the crystals to move along the canal, stimulating it and giving the sensation of rotation.

How is BPPV diagnosed?

During periods when attacks are not occurring, the diagnosis is made from the characteristic history and by the exclusion of other disorders that can cause similar dizzy symptoms. When attacks are occurring, the Hallpike positional test is diagnostic. In the commonest form of BPPV the Hallpike test is positive (i.e. induces vertigo and nystagmus) when the affected ear is down most. Up to 10% of cases may involve both ears.

How is BPPV treated?

At least a half of all cases will get better without treatment though this may take months. As BPPV is basically a mechanical disorder, drugs have no effect and should be avoided. Most cases that do not resolve rapidly can now be relieved by the appropriate Particle Repositioning Manoeuvre; of which the most commonly performed is the Epley manoeuvre which offers instant relief of symptoms in nine out of 10 patients.


Assessing the Unconscious Patient

A recent case sent to the volunteers  involved an unconscious patient.  A great acronym was given to help assess such a patient:


AEIOU TIPS is used to assess patients with an altered mental status (AMS) or an altered level of consciousness (ALOC).
A    Alcohol
E     Epilepsy
I     Insulin
O    Overdose
U    Underdose

T   Trauma
I    Infection
P    Psychosis
S    Stroke



There are some other useful tips on this website too.



Contraception guidelines

Guidance on contraception changes frequently, and I find the attached UKMEC guidelines really helpful to assess the risk of each contraceptive.

My take home messages are

  1. start contraception as soon as possible to prevent pregnancies. Please don’t wait until the patient’s next menstruation (which was previous advice). None of the hormonal contraceptives will adversely affect a pregnancy but delaying starting contraception places a woman at risk of an unwanted pregnancy.
  2. any type of migraine is now a potential contraindication to COCP. Previously only migraine with aura was felt to be high risk.UKMEC