Dr. Usman's Cardiology Notes

  SUMMARY 👉  Bempedoic Acid  Class ATP-citrate lyase inhibitor Mechanism of Action Bempedoic acid inhibits hepatic cholesterol synthesis upstream of statins, leading to reduced LDL-cholesterol (LDL-C). The drug is activated only in the liver, not in skeletal muscle. Importance of Bempedoic Acid  Both patients with Type 2 Diabetes and non-diabetic patients with ASCVD or very high cardiovascular risk share the same therapeutic goal: 👉 Aggressive LDL-C reduction to lower cardiovascular events While statins remain first-line therapy, real-world challenges include:  • True statin intolerance  • Failure to achieve LDL targets despite maximally tolerated statins ± ezetimibe For these patients, bempedoic acid provides an effective non-statin option. Indications (Applies to Both Diabetic & Non-Diabetic Patients) Bempedoic acid should be considered in patients who: ✔️ Have established ASCVD ✔️ OR have very high ASCVD risk ✔️ AND either:  • True statin into...

Tall R Wave in V1: ECG Interpretation and Clinical Significance A tall R wave in lead V1 is an important ECG finding that often reflects altered ventricular depolarization. Normally, V1 shows a small R wave and a deep S wave because left ventricular forces dominate. When the R wave in V1 becomes tall (R/S ratio >1 or R ≥7 mm), it suggests either increased right ventricular forces, altered cardiac position, conduction abnormalities, or mirror-image changes from infarction. Common Causes of Tall R Wave in V1 1. Right Ventricular Hypertrophy (RVH) RVH produces increased right-sided electrical forces, resulting in a dominant R wave in V1–V2. Associated findings include right axis deviation, right atrial enlargement, and strain pattern in right precordial leads. Common etiologies include pulmonary hypertension, chronic lung disease, and congenital heart disease. 2. Duchenne Muscular Dystrophy Patients with Duchenne muscular dystrophy often demonstrate tall R waves in V1–V2 due to selecti...

  Chest Pain Evaluation Algorithm – Detailed, Stepwise Clinical Approach Chest pain is a common yet high-stakes presentation. The primary goal is rapid identification of life-threatening causes while avoiding unnecessary testing in low-risk patients. A structured algorithm improves safety, accuracy, and efficiency. 1. Immediate Triage and Stabilization (First 5–10 Minutes) Assess ABCs and vital signs immediately. • Airway, breathing, circulation • Pulse oximetry • Blood pressure in both arms if dissection suspected • Cardiac monitor • IV access Red flags requiring immediate resuscitation: • Hypotension or shock • Hypoxia • Altered mental status • Ongoing severe chest pain • Ventricular arrhythmias • ST-elevation on monitor Give early supportive therapy if unstable: • Oxygen if SpO₂ < 90% • Aspirin 150–325 mg (unless contraindicated) • Nitroglycerin if ischemic pain and no hypotension • Morphine only if pain refractory and diagnosis reasonably clear 2. Rapid Identification of Lif...

  Anticoagulation for AF with intracranial bleed Anticoagulation for Atrial Fibrillation with Intracranial Bleed Atrial fibrillation (AF) significantly increases the risk of ischemic stroke. Anticoagulation markedly reduces this risk, but in patients who have experienced an intracranial hemorrhage (ICH), the decision about anticoagulant therapy is particularly complex because of the competing risks of recurrent bleeding and thromboembolism. Background AF is associated with a five-fold increase in the risk of ischemic stroke, and oral anticoagulants (OACs) — including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) — are the mainstay for stroke prevention in patients with elevated thromboembolic risk as assessed by scores like CHA₂DS₂-VASc. However, anticoagulation carries a risk of major bleeding including ICH, which has high mortality and morbidity. Initial Management After Intracranial Hemorrhage When an ICH occurs in a patient on anticoagulation, immediate ce...

Definition Coronary cameral fistula is an abnormal direct communication between a coronary artery and a cardiac chamber (atrium or ventricle), bypassing the myocardial capillary bed. It represents a subset of coronary artery fistulas where the drainage is specifically into a heart chamber rather than into a great vessel or other structure. Epidemiology • Rare congenital anomaly, incidence ~0.1–0.2% in patients undergoing coronary angiography • Accounts for the majority of coronary artery fistulas • Most are congenital; acquired forms are uncommon • Often detected incidentally in adulthood Embryology and Pathogenesis During normal cardiac development, primitive coronary sinusoids regress and form a mature capillary network. Failure of regression or persistence of these sinusoids leads to abnormal communications between coronary arteries and cardiac chambers. Types Based on Origin and Drainage Origin • Right coronary artery (most common) • Left anterior descending artery • Left circumfle...

The Hidden ECG Pattern That Saves Lives — but Most Doctors Miss It A silent ECG abnormality can sit unnoticed on an otherwise “normal-looking” tracing, yet carry a powerful association with malignant ventricular arrhythmias and sudden cardiac death. These patterns often present subtly, blend with baseline ECG variability, and require intentional recognition. Missing them delays lifesaving interventions, risk stratification, and preventive therapy. Key Hidden ECG Patterns with High-Risk Implications 1. Wellens Syndrome: The STEMI That Doesn’t Elevate A critical LAD occlusion presenting during a pain-free interval with no ST elevation. ECG clues: • Deeply inverted or biphasic T waves in V2–V3 • Minimal ST-segment changes • Normal or slightly elevated enzymes early Why it matters: Progresses to massive anterior MI within hours to days if not urgently catheterized. Thrombolysis and stress testing are contraindicated; immediate invasive evaluation is required. 2. De Winter’s Pattern: The ST...

    Signs on ECG Which Must Not Be Missed: STEMI Equivalents Acute coronary occlusion (ACO) does not always produce classic ST-segment elevation. Several high-risk ECG patterns represent the same emergency as STEMI and require immediate reperfusion therapy. Missing these patterns leads to delayed diagnosis, larger infarct size, cardiogenic shock, and increased mortality. Below is a comprehensive, clean, blogger-ready article on the STEMI-equivalent signs that must never be overlooked. --- 🚨 Introduction STEMI equivalents are ECG patterns indicating acute coronary occlusion without meeting traditional ST-elevation criteria. Emergency physicians, cardiologists, and ECG interpreters must learn these patterns because many are subtle and frequently misdiagnosed as “NSTEMI.” --- 1. Posterior Myocardial Infarction (Isolated Posterior MI – LCx/RCA Occlusion) Often presents with ST-depression in V1–V3, which is actually reciprocal to posterior ST elevation. Key ECG clues • Horizontal ...