Dr. Usman's Cardiology Notes

  Ambulatory Blood Pressure Monitoring (ABPM) Device Ambulatory Blood Pressure Monitoring (ABPM) offers several benefits over traditional office-based blood pressure measurements: Benefits & Indications: 1. More Accurate Diagnosis: ABPM provides a comprehensive picture of blood pressure patterns over 24 hours, reducing the risk of misdiagnosis. 2. Identification of Masked Hypertension: ABPM can detect masked hypertension, where blood pressure is normal in the office but elevated at home. 3. Assessment of Blood Pressure Variability: ABPM measures blood pressure variability, which is a predictor of cardiovascular risk. 4. Detection of Nocturnal Hypertension: ABPM can identify nocturnal hypertension, which is associated with increased cardiovascular risk. 5. Monitoring of Treatment Efficacy: ABPM helps assess the effectiveness of antihypertensive therapy and guides treatment adjustments. 6. Reduced White Coat Hypertension: ABPM minimizes the impact of white coat hypertensio...

  This tracing shows over-sensing of T wave during exercise when heart rate exceeded 100bpm. Alternating 320 and 260ms intervals produces the train track appearance of the sensed activity. Raise the sensitivity threshold to make signals less likely to be detected with exercise. Other Differential Diagnosis of Train Track Pattern: The “train track” appearance on cardiac CEID (Cardiac Electronic Implantable Device) tracings, such as those from pacemakers or defibrillators, can be attributed to several causes. Here are the key causes: Electromagnetic Interference (EMI) : External electrical sources can cause interference, leading to a regular, repetitive pattern on the device tracings that resembles train tracks. Lead Fracture : A break or fracture in the lead wire can cause intermittent or repetitive signals, creating a characteristic “train track” pattern on the tracing. Lead Insulation Breach : Damage to the insulation of the le...

Measurement of TDI is integral part of every echocardiogram being performed. Following clip shows how to measure it correctly: Normal values for septal and lateral mitral annular tissue Doppler imaging (TDI): Septal Mitral Annular Velocity: - Peak early diastolic velocity (E'): 8-12 cm/s - Peak late diastolic velocity (A'): 5-8 cm/s - Peak systolic velocity (S'): 5-8 cm/s Lateral Mitral Annular Velocity: - Peak early diastolic velocity (E'): 10-15 cm/s - Peak late diastolic velocity (A'): 6-10 cm/s - Peak systolic velocity (S'): 6-10 cm/s Please note that these values can vary depending on age, sex, and other factors. Additionally, these values are based on average values reported in literature and may not reflect the specific normal values for your institution or laboratory. It's also important to remember that TDI velocities should be interpreted in the context of other echocardiographic parameters and clinical findings.

A 68 year old female with atrial fibrillation and dementia presented to the hospital with sudden onset of dyspnea that had begun 1 hour earlier. Before admission, he had not been taking anticoagulation therapy on the basis of discussions of his preferences with his primary care physician. Physical examination was notable for tachypnea and tachycardia. On chest radiography, the pulmonary vasculature was not visible in the right lung fields. In addition, the right descending pulmonary artery was enlarged. These radiograph findings display Westermark’s sign, which indicates an area of oligemia distal to a pulmonary embolism, and Palla’s sign, an enlargement of the right descending pulmonary artery. Computed tomographic (CT) pulmonary angiography of the chest confirmed the presence of pulmonary emboli in both pulmonary arteries, predominantly on the right side. The CT scan also showed oligemia in the lung parenchyma on the right side. Source: NEJM

  Intracardiac Tracing 1 Intracardiac Tracing 2 In the first tracing, Surface ECG showing upright P waves in lead 1 , sinus rhythm, four complexes visible on the tracing, every p wave being followed by qrs, pre-excitation or delta wave is not evident Ablation catheter showing large negative unipolar deflection occuring before the onset of QRS. His catheter is likely more in the RV, His signal not visible, large V signals On CS earliest activation is at 7,8 and A and V signals are more close in CS 1,2 In the second tracing same findings but in the end of tracing atrial activation sequence is changed with 9,10 leading Conclusion: Likely diagnosis Left Sided concealed Pathway being ablated.

Example of MVP Mode of Pacemaker Case: A 68-year-old male received dual chamber pacemaker sinus node dysfunction with syncope. The pacemaker tracing shown below was obtained 4 weeks postimplant: Device settings: • Mode: AAIRóDDDR • Pacing rate: 60 to 130 bpm • Paced #AV delay: 200 ms • Sensed AV delay: 170 ms Why there variation in the AV delay? The programmed mode is indeed #MVP, in which the device switches between #AAIR to DDDR depending on the presence of intrinsic R waves. Managed Ventricular Pacing (MVP) is a pacing mode in some Medtronic pacemakers, ICDs, and CRT-D devices that reduces unnecessary right ventricular pacing. In this mode, when the device is in AAIR and believes an atrial paced event is not followed by a ventricular sensed event, the device allows for this loss of conduction to occur once, and then follows with an atrial paced/ventricular paced event with a shortened paced AV delay of 80 ms The device then stays in AAIR mode and allows for an atrial paced event ag...

  The U waves !  Generally Not seen or difficult to be seen on surface However Whenever seeable , the following needs to be known  In normality , the following will be its like morphological appearances !  a. small, rounded deflection just after the T!  b.low amplitude , less than one fourth of the height of the preceding T wave  c.Usually same polarity as the before T however Negative U can appear, even With upright T !!! d. usually they will be either a monophasic positive or negative deflection, however sometimes they can be diphasic (positive-negative & negative-positive).        Best surface ecg leads to visualise  a. frequently absent in the limb leads and mostly easily seeable in chest leads V2 and V3.  b. As U vector is aligned similarly to the T vector ! So the normal U wave will sometimes be negative in limb leads III , AVF and isoelectric in leads I, aVR, and aVL! . c. better visualized in the precordial/ che...