Cardiac Activity and Ventricular Tachycardia (VT) Waveform

Cardiac Activity and Ventricular Tachycardia (VT) Waveform Lachlan Donnet-Jones Sudden cardiac death (SCD) is one of the leading causes of mortality in Australia. One of the primary causes of SCD is cardiac dysrhythmias, such as, Ventricular Tachycardia (VT). The most effective treatment for life-threatening cardiac dysrhythmias is defibrillation. This essay will examine the relationship between cardiac activity and the Ventricular Tachycardia (VT) waveform, and discuss how defibrillation may terminate this dysrhythmia, allowing the heart to return to a normal rhythm. The typical healthy adult heart will have a resting heart rate of between 60 and 100 beats per minute (Saladin, 2011). When the heart beats abnormally fast, it pumps less effectively, which decreases the level of perfusion to the tissue of the body, including the heart itself. This rapid heart rate increases the hearts muscle tissues (myocardium) demand for oxygen, and without intervention, can lead to the death of myocardial cells, which is known as a Myocardial Infarction (MI) (Huazers, 20). Each year in Australia approximately 55,000 people suffer a heart attack, or an Acute Myocardial Infarction (AMI). This is equal to 150 heart attacks per day or one in every 10 minutes (Heart Foundation). The Australian Bureau of Statistics reported that over 350,000 Australians will suffer an AMI at some point in their lives (ABS, health survey). In Trappes’ 2012 research article, Trappe notes that there is no single factor that causes an AMI, it is a multifactorial problem, however, approximately ninety percent of AMI’s are caused by tachyarrhythmia’s (Trappe, 2012). Before one can gain a thorough understanding of dysthymias, it is necessary to develop a fundamental grasp of the heart’s electrical conduction system and the associated physiology and pathophysiology. The primary function of the electrical conduction system is to transmit electrical impulses from the sinoatrial node (SA node) (normal site of conception) down to the atria and ventricles, triggering a contraction of heart muscle (myocardium) and controlling the heart rate. In a normal sinus rhythm, originating from the SA node, there are three phases; atrial depolarisation, ventricular depolarisation and atrial and ventricular repolarisation. The SA node is found within the wall of the right atrium proximal to the entrance of the superior vena cava. Similar to all electrical nodes within the heart, the SA node is composed of pacemaker cells which generate automatic and regular electrical impulses. These electrical impulses travel through the walls of the right atrium, causing contraction of the heart muscle (myocardium), to the atrioventricular node (AV node) via internodal conduction tracts (anterior, middle, and posterior). A final SA node conduction pathway, known as Bachmann’s bundle (interatrial conduction tract), transmits electrical impulses across the heart to the left atrium. On an electrocardiogram (ECG) this atrial depolarisation is represented by the P wave. The fibrous annulus is a non-conductive layer of tissue which prevents the electrical impulse from travelling outside the perimeter of the atrium. The primary function of the AV node is to process the electrical impulses from the atria to the bundle of His in a way that slows the impulses arrival at the ventricles by approximately 0.12 seconds. This delay allows for the atria to empty and the ventricles to fill before the next contraction. After the bundle of His, the electrical impulse will travel down the right bundle branch and the left common bundle branch. These bundle branches continue to subdivide into smaller branches, the smallest of which connect to the Purkinje network, an elaborate mesh of minute Purkinje fibres which spread throughout the ventricles. In a normal functioning heart it will take an electrical impulse approximately 0.2 seconds to travel from the SA node to the Purkinje network in the ventricles. On an ECG, this is shown as the P-R interval. At this point the impulse causes the ventricles to contract, pumping the blood out of the ventricles and into the systemic circulation. This depolarisation of the ventricles is represented by the QRS complex. Immediately following a QRS complex, is a period of time in which there is no electrical activity in the myocardium. This is known as the S-T segment and is normally represented as a flat line, level with the isoelectric line of an ECG. The proceeding T wave represents the repolarisation of the ventricles to their resting state. If at any point in this process the electrical impulse is disturbed, it can create a cardiac dysrhythmia, such as if the SA node were to produce rapid electrical impulses, resulting in tachycardia (fast heart beat). Ventricular Tachycardia (VT) is a type of tachycardia that originates within the inferior chambers of the heart, called the ventricles. The ventricles are the primary pumps of the heart, therefore, when they are compromised it can quickly deteriorate into a life-threatening dysrhythmia, such as, ventricular fibrillation (VF) or asystole (Chou, 2008). The diagnosis of VT is made by examining the rhythm seen on a 12-lead electrocardiogram (ECG). Although numerous diagnostic criteria have been developed, such as the ‘Brugada Criteria’ (Brugada, 1991), the following are the most commonly accepted (Riley, 2008). The rate of VT is above 100 per minute, typically 150 to 200, with a regular rhythm. The R-S complex is absent in precordial leads, and there are three or more consecutive Premature Ventricular Contractions (PVCs) present (AV dissociation). The ectopic pacemaker is below the Atrioventricular node (AV node), therefore, the PR interval is irrelevant. In addition, different ambulance services will have their own specific diagnostic criteria for VT, for example, Ambulance Tasmania (AT) Clinical Practice Guidelines (CPG’s) state that the rhythm must present with QRS complexes of over 0.12 seconds, and be sustained for a period of over 30 seconds (sustained VT). VT can be classified using three methods; morphology, episode duration, and symptoms. In regards to morphology, there are two primary categories of VT; monomorphic and polymorphic. Monomorphic VT has numerous causes, but is determined by consistent appearance across all leads of an ECG. A common reason that the beats from each lead appear the same, is because the impulse is being generated from an increased rate of automaticity in a single point from the left or right ventricles. This means that the pacemaker cells, such as the Purkinje fibres in the left and right ventricles, that are able to reach an action potential on their own accord (automaticity), have increased the rate at which they fire impulses (intrinsic rate). Another reason for monomorphic VT is due to the presence of a re-entry circuit within the ventricle. A re-entry circuit occurs when an electrical impulse constantly travels in a constricted circle within the heart, as opposed to moving from one end of the heart to the other, like a normal electrical impulse circuit. Although monomorphic VT has many causes and contributing factors, the most common cause is scarring of the myocardial tissue from a previous MI episode. The scarred tissue left behind does not conduct electrical impulses, and therefore, the potential for a circuit around the scar can result in tachycardia. This is similar to the aforementioned re-entrant circuit, and is a common cause of other dysrhythmias, such as, atrial flutter (Af) and supraventricular tachycardia (SVT). Scar-related monomorphic VT is predominantly prevalent in patients who have a previously survived a MI, particularly in those who have damaged myocardium as a result (John, reference). Unlike the cons istent rhythm seen is monomorphic VT, polymorphic VT is an irregular rhythm that has constant variations in its morphology. A second method to define VT is studying the duration of the episode. Three or more consistent contractions on an ECG, originating from within a ventricle at over 100 beats per minute, is determined as VT. If the tachycardia rhythm terminates itself in under 30 seconds, it is considered non-sustained VT. If the rhythm continues beyond 30 seconds, it is considered sustained VT. The final method to classify VT is reviewing symptoms. When a patient is in VT, the loss of co-ordinated atrial contraction and high heart rate can impair cardiac output (CO), and therefore, they will not have a palpable pulse. This is known as Pulseless VT. Pulseless VT is concomitant with an absence of cardiac output (CO), and therefore, according to AT clinical practice guidelines, is to be treated as worst case scenario, which is ventricular fibrillation (VF), a shockable rhythm (CPG Reference). In a report from the American College of Cardiology, Zipes et. al note that VT can occasionally be accompanied by reasonable cardiac output and may even present as asymptomatic, however, the heart will not tolerate this rhythm for a sustained period of time, and will eventually deteriorate to pulseless VT or VF. Supraventricular Tachycardia (SVT) with a bundle branch block (BBB) or Wolff-Parkinson-White syndrome is commonly misdiagnosed as VT (Trappe). This is due to the similar diagnostic characteristics, such as, wide QRS complexes and high heart rates, which are mutual in all wide complex tachycardia (litfl). It is important to differentiate the two because certain medications used to treat SVT could potentially worsen the patient’s condition. As Trappe notes in his research article ‘Treating critical supraventricular and ventricular arrhythmias’, it is always beneficial to treat for the worst case scenario, in this case, VT (Trappe, 2010). This opinion is mutual in regards to Ambulance Tasmania CPG’s, where it recommends treating for worst case scenario. Once a shockable dysrhythmia has been recognised, it is necessary to intervene with an external source of electrical activity to correct the hearts rhythm. Defibrillation is the standard and most effective treatment for cardiac dysrhythmias, such as VT and VF (Reference). Defibrillation is the process of using a device called a defibrillator to deliver a therapeutic measure or ‘shock’ of electrical current through the heart. The current delivered, aims to depolarise a critical mass (Critical mass theory**) of the heart muscle (myocardium), interrupting the dysrhythmia and allowing the heart’s natural pacemaker, the SA node, to return to a normal sinus rhythm. Defibrillators are becoming widely available in the form of transvenous, implanted (implantable cardioverter-defibrillator), or external (automated external defibrillators) devices. Despite the different forms a defibrillation device may present in, they all operate on the same principle. There are two different methods of delivering an electrical shock from a defibrillation device; monophasic and biphasic waveforms. Monophasic is the ‘old’ method in which the electrical current travelled in one direction through a patient’s chest. The second method is using a biphasic waveform, meaning the current is delivered to the heart in two vectors (two directions). Due to the use of two vectors, the peak electrical current needed to revert a dysrhythmia is decreased to 200 joules, as opposed to 360 joules of a monophasic waveform. Due to the high voltage (360 joules) used in monophasic waveform it can cause superficial burns to the patients skin. Additionally, _____ found the use of a biphasic waveform to be more effective at returning the heart to a sinus rhythm and resulted in less damage to myocardium, leading to better patient outcomes (Reference) . ____ notes that for the aforementioned reasons, monophasic waveform defibrillation is quickly being replaced with biphasic (Reference). Page 1 of 5

Internal And External Factors Effect The Levels Of Management Essay

How Internal And External Factors Effect The Levels Of Management For a company to be successful in the long term today, they must be diverse. The company needs to be able to adapt to changes. The need for these changes can present themselves from many angles. Some would include changes in the economy, marketing, or even a change in the target audience. A company has to look at more than just the four levels of management. Organizations must look at how internal and external factors can affect the four levels of management, and adjust accordingly for these changes to be successful in today’s world. Diversity  There are many types of diversity, racial, ethnic, cultural, age, gender, and geographic. But diversity can also include experience and skills. A company’s ability to survive depends on their ability to adapt to current changes. The diversity within a company must be taken into consideration during the four functions of management. The most successful companies will be those that recognize the power of diversity in their workforce and in the product mix, and effectively create products and services that appeal to their increasingly diverse customer base. By including diversity in the planning stage, Amazon. om would reflect diversity in their business. This would results in better products and a wider range of consumers giving them an advantage over competitors. The company must understand its’ organizational structure, and the social and cultural perspectives of its’ employees in order to be effective, efficient, and promote an environment suitable for progress. Employees who are diverse in skills, experience, and background help to builds a strong organizational foundation. Increasing globalization requires companies to have more interaction with diverse cultures and backgrounds. Organizations must be prepared to teach themselves and their employees to value multicultural differences. Management must motivate their employees to attend diversity training in order to be educated on different cultures and traditions and to respect these differences. Diversity is critical to a company’s success. We are part of a worldwide economy with global competition. Diversity can increase productivity, marketing opportunities, recruitment, and the organization’s image which, in turn, can increase profits (Leading With Diversity, nd). Globalization Globalization has changed the face of business. In today’s business market, international business is necessary in order to gain an advantage. Amazon. com understands this requirement. With the formation of the Internet and Internet marketing, globalization was a beneficial perk which changed the business market, providing a way for companies to reach businesses and customers from around the globe at the click of a mouse. Amazon. com was created to work in the global business environment through the Internet. The company handles B2B and B2C relations and transactions. Amazon. com uses an online customer data base to keep up with the demands of customers. The company created an Internet e-business model, and built up from these based on information obtained from customers. â€Å"The company’s strong infrastructure supports its mission to be the leader in e-commerce,† (â€Å"A Conceptual Analysis f the Key success of Business in â€Å"terms of Internet Marketing, 2012). Customers are always looking for convenience in today’s global economy. Amazon. com uses technological innovation to drive growth and deliver convenience to its customers. An online business, such as Amazon. com, bases goals for â€Å"Planning† on these factors. In order to deliver strategic value, a company such as Amazon. com works to extend globally to reach customers and retailers internationally. Amazon. com began with a B2C platform, but management saw the potential to be an online global leader by handling B2B relations as well. When Organizing, management adds software, e-commerce capabilities, and access for businesses to use the online company’s resources. Amazon. com has created a global online business through proper planning and organizing that delivers strategic value. Management Leading can mobilize and motivate employees. Amazon. com has extended its sales and products through extended branches in different parts of the world to provide services anytime and anywhere through the Internet and globalization. Through the Controlling process of management, online companies such as Amazon. com have continuously improved and expanded services to all over the world. As a result of success through correctly utilizing the four functions of management, Amazon. com is a leading fortune 500 company who uses globalization through the World Wide Web to deliver fast, successful services to customers and retailers. Without the possibility of globalization through technology, e-commerce would not be enough for the company to stay on top. Technology Technology is constantly changing and considerably hard to keep up with. Because of these changes, managing at Amazon. com would definitely be a challenge. Managers must start with the planning phase by evaluating and determining consumer’s needs for buying, selling, using, and shipping which can show both internal and external growth. Personal data is shared online and is protected to ensure safe transactions. Amazon. com ensures that identity theft is never an option through their technology. Organizing all the data gathered from technology can also help management keep track of trends, sales, and possible returns. Once this information is shared among management, they are then able to lead employees with training on how to implement new technology like software, security protection on servers. Amazon. com also ensures employees are adhering to company policy with the use and access of services online. The controlling phase of management is completed by watching over the progress of smart phone applications, Internet home use, and shipping sales. By watching progress and being sure initial goals and challenges are being met, the security of consumer information and products are not being put to risk, and if a problem arises, management can catch it early enough to take care of the situation. With technology making access to Amazon. com so much easier for consumers, the management of this constant changing technology can be a huge challenge with so many options for access and keeping the information protected with encryptions. Innovation With an ever changing market, a great business has to be able to become what the consumer needs at any given moment. This requires innovation. Innovation involves any new idea, product, process, technology or service that a business introduces to its consumer. When it comes to innovation and the planning process, a business needs to be aware that factors such as the market, the customer’s current needs, and even what products competitors have released, can affect the current business plan. There needs to be flexibility in the business plan to account for these changes. A business needs to have leaders who are able to understand how their business is being currently run and how it can be run in the future. This allows them to see ow changes in the business plan might affect all aspects of the business. A business manager needs to be open-minded and encourage its employees to share their ideas on new business models, new ways to make a profit and even ways to improve existing business methods so that the current business plan is both innovative and effective. When it comes to innovation and the organizing process, a company needs to be aware of the current business plan at all times. The need for a business to be innovative and adapt to the changes in the market can cause all four functions of management to need adjusting frequently. If the business plan is changed, the company needs to re-gather and assign all its resources, employees and finances to ensure that the new plan can be implemented fully and in an organized manner. Innovation affects this function of management in a more indirect way; by changing the planning process, the directing process changes. When a company decides to change their business plan, they have to re-direct the staff. When evaluating the staff, the manager needs to be sure that they are on track to meet the goals outlined in the planning process. Innovation can cause the goals to change, thus causing managers to re-evaluate the employees to be sure they are still on track. Ethics Every business is run by a set code of ethics. Ethics are different for every person, as they are an individual’s personal take on what is right and what is wrong. A business uses a code of ethics to ensure that every employee abides by the same set of standards and upholds the values of the organization with which they work. When it comes to the planning process, ethics play a key role. The company needs to know how they want their business to appear to the public and develop their plan around that. If a company wants to appear ethical and trustworthy to its customers it has to provide great customer service at all times. This meant that Amazon. com had to create a safe site, a quality product, and be sure to deliver the product promptly. When it comes to organizing and ethics, Amazon. com had to be sure to keep all resources, employees, and finances in order to keep their word on the quality of both their product and their delivery times. For the customer to believe that Amazon. com is an ethical and trustworthy site requires employees and resources to be organized at all times. When it comes to leading their employees, it is important to be sure that they are not only on task but also following the company’s code of ethics. If having a safe site, a quality product, and prompt delivery is important to Amazon. com; it needs to be important to all their employees as well. When analyzing the progress being made, the manager needs to also be sure that the staff is remaining diligent in their efforts to ensure quality customer service. Ethics are found in every facet of a company and therefore they need to be monitored regularly. Conclusion There is so much more that goes into maintaining a successful business in today’s competitive marketplace than just the four levels of management. The company must always be aware of and be able to adapt to many changing factors. These factors come from many places in the marketplace. Some are external and the company will have little to no control over these and must simply adapt. However the internal factors can be controlled by the company through monitoring and policy changes. The company that can notice the changing factors and integrate and adapt to these changes will be successful in today’s competitive marketplace.

Causes of Parallel Economy in India Essay

There are several factors responsible for the emergence – of parallel economy. It would be relevant to discuss those factors so that a correct understanding about the genesis, growth and expansion of black money can be made. The principal factors are: 1.Rigid and Complicated tax & high tax rates implemented by the government- High tax rates and defective tax structure have also been responsible for the existence of black money to a large extent. Take for instance direct taxation. Till recently the tax on income and on wealth was very high to invite evasion. The marginal rate of income tax was as high as 75 per cent. And when it was combined with the tax on wealth, it was still higher. The corporate tax rate too was very high. In these circumstances the temptation / gain from tax evasion was substantial. 2.Quantitative and qualitative Controls and licensing system- The system of controls, permits, quotas and licenses which are associated with misdistributions of the commodities in short supply results in the generation of black money. Since considerable discretionary powers lay in the hands of those who administered controls. This provided them with a scope for corruption – ‘speed money’ for turning a blind eye to the violation of controls. All this gave rise to trading in permits, quotas and licenses, malpractices in distribution and in the process; it generated sizeable sums of black money. 3.Price and distribution controls- Price and distribution controls have in the past led to the generation of black money on a significant scale. Any price control without any adequate machinery of distribution and speedy arrangement for increasing supplies is potentially a source of black money generation. 4.Hawala market as the main cause of black money generation- It is very well known that the international smugglers or the traders in other illicit trade cannot complete their monetary transactions through any nationalized or other private legal banks in India. Also, the amount of money in which the drugs and other weapons are imported or exported is quite large, usually in billions. 5.Transactions is real estate property- Since the sale of property on lease hold is permitted by the government only at a payment of certain amount of premium to it, the lessee generally completes this transaction through the power of attorney so that they escape from paying the premium which is fixed on the basis of the difference between the current market price and the price fixed by the government. 6.Inflation – Both a Cause and Consequence of Black Money- During inflation there is a general rise in the consumer price index or simply the cost of living of the people. As such, the workers and the various labors in the production process demand a rise in their wages to meet the rise in expenditure. This lead to increase in the cost of production of the products. They try to meet this increased cost of production by increasing the profits margin through sales price. 7.Deterioration of the Quality and Morality of the General Masses- The objective of the business is generally profit maximization and that of government is social justice and quality that goes against each other. But it seems that both have joined hands to maximize their own profits at the stake of the common people. Bribing the government officials and letting them earn some commissions on the foreign export and import by urging them to reduce the customs duties and simplify the procedure of documentation are some of the common phenomenon in our daily life. 8.Donation to Political Parties- Ever since the Government decided to ban donations to political parties in 1968; it prompted businessmen to fund political parties, especially the ruling party, with the help of black money. Ostensibly, this decision was taken to reduce the influence of big business on the electoral process, but in practice what happened was precisely the opposite. Businessmen everywhere have by now learnt that they should pay a certain charge out of the black money to the coffers of political parties, resulting, relaxation of various controls, permitting business houses to enter areas reserved for the public sector, putting a large number of banned items on the Open General License list etc. 9.The Political Instability Witnessed in the Country- In various states widespread horse-trading of the MLAs at the state levels and MPs at the Central level. In this process of buying political support, black money plays a crucial role. Consequently the determination of the ruling political party to curb black money has become very weak. As a consequence, businessmen feel they have an unfettered license to spin black money, pay a small part to the political parties as donations and then enjoy the rest the way they like. Unless the link between black money and political power is broken, there is no hope of controlling the generation of black money or its link with crime. 10.Ineffective Enforcement of Tax Laws- Whereas the Government has an armory of tax laws pertaining to income tax, sales tax, stamp duties, excise duty etc., their enforcement is very weak due to widespread corruption in these departments. . The high rates of these taxes induce businessmen to avoid recording of these transactions. This evasion largely goes unchecked and thus sets in a chain reaction for the generation of black money at the wholesale, retail as well as production levels. 11.Generation of Black Money in the Public Sector- Every successive five-year plan is planned for a larger size of investment in the public sector. The projects undertaken by the public sector have to be monitored by the bureaucrats in Government departments and public sector undertakings. Tenders are invited for the various works and these tenders are awarded by the bureaucracy in consultation with the political bosses. 12.A Symbiotic Relationship Develops between the Contractors, Bureaucracy and the Politicians- A symbiotic relationship develops between the contractors, bureaucracy and the politicians and by a large number of devices costs ‘are artificially escalated and black money is generated by underhand deals. Instability of the political system has given a further momentum to this process. Since the ministers are not sure of their tenure and in a majority of cases, the tenure is very short, the principle ‘Make hey while the sun shines’ is adopted by most of them. The larger numbers of scandals that are unearthed by the Opposition only support the contention that huge investment in the public sector is a big potential source for black money generation. In this process, bureaucrats act as brokers for political leaders and thus the nexus between business, bureaucracy and politicians promotes the generation of black money. 13.Ceiling on Depreciation and Other Business Expenses- Government has imposed restriction. It has also circumscribed expenses on advertisement, entertainment, guest houses, and payment of perquisites to directors. The purpose of these restrictions is to protect the shareholders and consumers from the unscrupulous action of businessmen. But businessmen feel that these restrictions are unjustified. They take the maximum advantage of these provisions but do not like to part with the remaining part of by various clandestine devices; they convert it into black money and use it either for conspicuous production to satisfy the wants of the rich and elite sections of society. 14.Capitation Fees- Capitation fees are a very common term used in the context of admissions in big educational institutes and universities. Capitation fees if another term used for the donations given to these universities for the purpose of seeking admissions when the students fails to secure the minimum cut off percentage required. Generally, the money rose by these colleges and institutes through these methods are not revealed to the income tax departments. They are also called the hidden income of these educational temples. Moreover, the amount of capitation fees for big in Small Scale institutes ranges in lakh and not just in thousands. 15.Unawareness of the Consumers’ Rights and Duties- Unawareness of the consumer’s rights and duties is also another cause for the generation of black money. For example, the consumers fail to take a proper invoice from the shopkeepers so as to evade the tax to be paid on the purchase of those goods. There are more of such instances where the shopkeeper too fools the consumers. Sometimes, they charge more that mentioned as MRP on the packet. They even paste false stickers on the packets to hide the real value of the good. The extra money charged above the MRP is kept by them as black money. They do not pay taxes in such income. 16.Donations to Charitable and Temple’s Trusts- Donations to charitable and temples trusts are another source of black income. There are various issues related to the income of these trusts. It is generally the ignorance of devotees that prompt such a large amount of donations to these temples. 17.Paying Bribes- Paying bribes to the government officials for various purposes has become very common in modern times. Paying bribes for obtaining legal sanctions for the illegal immovable property, paying bribes to the traffic constables and others on the violation of the rules and norms etc. are some of the examples of our malicious acts. It is we that prompt and encourage these public servants to accept bribes from the public and exploit them.

Essay On Buying Your First Home - 1308 Words

So you’ve gone through four different apartments in five years. You’re sick of moving, you’re sick of paying rent, and you’re sick of having landlords who can’t even be bothered to fix a leaky faucet until your lease is almost up. You’re making good money with a great job, and you’re thinking about settling down. The thought of taking out a mortgage and buying a home of your own has been sitting in the forefront of your mind for a while. But how do you know when it’s time to buy your first home? True, the Canadian mortgage industry is going through some significant changes this year that effects all home owners (one of which involves a mortgage stress test for those putting less than a 20% down payment), making the fiscal responsibility†¦show more content†¦Your credit score should also be a consideration – the better your credit the easier it will be to obtain a loan from your lender but every lender will have different requirements. If you’re credit score is low or non-existent it could be worth saving for a few more years in order to raise your score and secure a better long-term rate on your mortgage. You’ve Saved Enough Cash To Put Down A Beefy Down Payment Down payments are a huge part of real estate. We won’t go into the math here, but putting down a large, 20% down payment can save you literally tens of thousands of dollars when buying a house, as compared to a 10% or lower down payment. The recent changes to the Canadian mortgage industry now include a â€Å"stress test† for any buyer putting down less then 20% of the home up front. This is to determine if the borrower can afford to pay back the loan against a five year fixed 4.64% loan. Despite the changes buyer still need to consider additional costs such as mortgage insurance, closing costs, taxes, repairs, furnishings and more when purchasing a new home. Can you really handle all that if you can’t handle a large down payment? 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