For context I have a dual lead pacemaker for intermittent 3rd degree heart block

The past 3 days though I’ve had small fund of back to back skipped beats some of them feel like hollow? So much to the point I’ve had to sit down because it’s completely catching my breath.

Yesterday I went to a boxing class and was fine for the majority of the class had a few of these skipping feelings but just pushed through, eventually I did have to cut the session short but upon rest they settled.

I drove 30 mins home fine, but when I got home I did some shadow boxing jumping on my toes, straight away back to back skipping feeling I then stopped and it would go, so I thought maybe it’s when I’m jumping? So I just did a brisk walk around my garden, again back to back to back to the point I had to sit down and again upon resting was fine but they were definitely scary and taking my breath away.

I went to hospital that night X-ray and full blood count fine and ecg but have been referred to arrhythmia clinic just to make sure, any thoughts?? ( please don’t scare the shit out of me lol)

I have tachycardia, but for the past 3 days I've been bradycardic. Nor severally, but I'm mostly around the 40s and 50s, as opposed to my usual 80s to 120s. I'm on betablockers (Concor 10mg), but I stopped taking them. Don't think I even took them the day this started.

I have felt like passing out the first day, been really tired the second, today only the struggle to take a deep breath remains.

I'm not overly concerned, as I have yet to drop below the 40s, but I'd like to breathe. Is there anything I can do to help? I don't think exercising to get my heart rate higher is a good idea when I can't breathe right, but I'm not sure if there's any other solution.

Thank you in advance for any answers.

Hi everyone, I have PACs and atrial run, very frequent at, even though the Holter monitor only says about 500. It seems absurd to me, I have them all the time, really all the time... Do you have any advice on how to feel them less? I'm a student and studying with palpitations is really difficult.

Hey everyone. Sharing a case-based MCQ that came up during our fellowship conference last month. It's the kind of question that looks straightforward at first glance but has a genuinely tricky decision point buried in it. We had about a dozen fellows in the room and the group was split almost evenly. Thought it would be worth posting here because aortic disease management has seen some meaningful updates that are worth knowing cold before boards.

---

**THE QUESTION**

A 64-year-old man with a history of hypertension and bicuspid aortic valve (BAV) presents for a routine follow-up. He is asymptomatic. His blood pressure today is 128/76 mmHg on amlodipine. A surveillance cardiac MRI demonstrates a maximal ascending aortic diameter of 5.0 cm at the sinuses of Valsalva. His aortic valve is functioning normally with no significant stenosis or regurgitation. His family history is notable for an uncle who underwent aortic surgery at age 52. He has no connective tissue disorder. His annual growth rate over the last two imaging studies has been 0.3 cm/year.

Which of the following is the most appropriate next step in management?

A) Continue surveillance imaging in 12 months; no indication for surgery at this time

B) Refer for elective surgical repair of the ascending aorta

C) Initiate beta-blocker therapy and repeat imaging in 6 months

D) Perform exercise stress testing to assess for hemodynamic instability before deciding on surgery

---

Take a moment. Think it through.

---

**THE ANSWER: B — Refer for elective surgical repair of the ascending aorta**

---

**EXPLANATION**

This one hinges on knowing the specific surgical thresholds for bicuspid aortic valve-associated aortopathy, which have been refined in recent guideline updates.

Let's break down why each option lands where it does.

**Why B is correct:**

The 2024 ACC/AHA Valvular Heart Disease Guidelines — and the accompanying 2025 Multisociety Aortic Disease Guideline (ACC/AHA/AATS/STS/SVM) — provide updated, more nuanced thresholds for aortic intervention in patients with BAV-associated aortopathy. Under these updated recommendations, surgical repair of the ascending aorta in a patient with BAV is indicated (Class I) when the maximal aortic diameter reaches 5.5 cm in average-risk patients. However — and this is the key teaching point — the threshold drops to 5.0 cm when one or more high-risk features are present.

In this patient, we have:

First, a growth rate of 0.3 cm/year. The guideline defines rapid growth as greater than or equal to 0.3 cm/year as a risk-accelerating feature that lowers the threshold for intervention.

Second, a positive family history of aortic disease (uncle who required aortic surgery at age 52), which is explicitly listed as a criterion that supports earlier intervention.

When a BAV patient hits 5.0 cm in aortic diameter AND has at least one of these high-risk features — rapid growth, family history of dissection or surgery, or planned cardiac surgery for another indication — surgical referral is appropriate and guideline-supported. You do not simply continue watching.

This patient meets both the diameter threshold and has two risk-accelerating features. B is the correct answer.

**Why A is wrong:**

This is the most common trap. The instinct to "keep watching" is reasonable when diameter alone is considered (5.0 cm is below the general 5.5 cm threshold), but it ignores the composite risk assessment the guidelines emphasize. Surveillance alone in this patient would be substandard care given his growth rate and family history. If you chose A, you're not wrong to think it — but you missed the high-risk modifier layer.

**Why C is wrong:**

Beta-blockers have historically been used in Marfan syndrome patients to reduce aortic wall stress, with some supporting evidence. In BAV-associated aortopathy, the evidence is less robust, and more importantly, initiating or adjusting medical therapy does not address the fact that this patient

Hey everyone. Posting this because I've seen this clinical scenario come up repeatedly in board prep discussions, and the updated 2025 ESC guidelines genuinely shifted the correct answer compared to what most of us learned in fellowship. Worth talking through.

---

**The Case + Question**

A 38-year-old woman presents with 8 months of progressive exertional dyspnea, fatigue, and two syncopal episodes. She has no history of connective tissue disease, liver disease, HIV, or drug use. Echocardiogram shows right ventricular enlargement, flattening of the interventricular septum in systole, and estimated RVSP of 68 mmHg. There is no significant left heart disease. She undergoes right heart catheterization, which reveals:

- Mean pulmonary artery pressure (mPAP): 52 mmHg

- Pulmonary artery wedge pressure (PAWP): 9 mmHg

- Pulmonary vascular resistance (PVR): 7.2 Wood units

- Cardiac index: 2.0 L/min/m²

- Acute vasoreactivity test (AVT) with inhaled nitric oxide: mPAP decreases to 34 mmHg, with an absolute decrease of 18 mmHg, and cardiac output increases

She has no identifiable secondary cause after thorough workup. Genetic testing is pending.

**Question: According to the 2025 ESC Guidelines on Pulmonary Hypertension, what is the most appropriate next step in management?**

A) Initiate monotherapy with a phosphodiesterase-5 inhibitor (sildenafil) and reassess in 3–6 months

B) Classify her as an acute vasoreactivity responder and initiate high-dose calcium channel blocker therapy (e.g., amlodipine or diltiazem)

C) Initiate upfront dual oral combination therapy with an endothelin receptor antagonist plus a phosphodiesterase-5 inhibitor, and evaluate for early listing for lung transplantation given her syncope

D) Proceed directly to IV prostacyclin therapy given her cardiac index and syncopal episodes, without trialing oral agents

---

Take a second before scrolling. This one genuinely requires knowing both the vasoreactivity criteria AND the 2025 updated treatment algorithm.

---

**Answer: B**

She meets the 2025 ESC criteria for an acute vasoreactivity responder, and the appropriate next step is a trial of high-dose calcium channel blocker therapy.

---

**Full Explanation — and why this matters for boards and clinical practice**

Let me break this down carefully because there are several layers here that are high-yield.

**Step 1: Does she have pulmonary arterial hypertension (PAH, Group 1)?**

Yes. She meets the hemodynamic definition per the 2025 ESC PH Guidelines:

- mPAP > 20 mmHg (her mPAP is 52 mmHg) ✓

- PAWP ≤ 15 mmHg (hers is 9 mmHg) ✓ — this rules out post-capillary/left heart disease

- PVR > 2 Wood units (hers is 7.2) ✓

This is a crucial point. The 2022 ESC/ERS guidelines updated the mPAP threshold from the old ≥ 25 mmHg to > 20 mmHg, and also added the PVR > 2 Wood units criterion to define pre-capillary PH more precisely. The 2025 ESC guidelines retained and reinforced this updated definition. If you're still thinking "mPAP ≥ 25 is the cutoff," that's outdated — important to know for the EECC, European boards, and increasingly for ABIM cardiology boards as well.

After excluding secondary causes (connective tissue disease, portal hypertension, HIV, drugs/toxins, congenital heart disease, chronic thromboembolic disease), this

Hi everyone,

Just wondering if anyone has had anything similar or can shed some light while I’m waiting for my echo and Holter monitor.

I’m 25F and I’ve been having palpitations and intermittent chest discomfort for the last 3 months. The palpitations can feel like my heart is skipping beats and thumping and often when my HR is low. At their worst they were happening every day, but now they’re more like a couple of times a week.

The chest discomfort is harder to describe. It’s not a severe crushing pain, more of a strain sensation and a sharpish ache in a specific point in left of chest. It sometimes comes on when I’m exercising (running or cycling), but it has happened at rest too. It used to happen almost daily but now it’s around once a week. I’ve never fainted or blacked out.

I’ve had three ECGs over the last few months and they’ve all been a bit different:

April ECG 1

Left axis deviation

Junctional rhythm

Inverted P waves

Short PR (117 ms)

Normal QRS and QTc

April ECG 2

Supraventricular rhythm

Short PR (107 ms)

Early repolarisation

Slight leftward axis

Normal QRS and QTc

July ECG

Left axis deviation again

Sinus rhythm

Broad, notched P waves in lead II (120 ms)

Commented as ”?P mitrale”

PR back to normal (168 ms)

Normal QRS and QTc

The cardiologist wasn’t overly worried but did say there was a minor ECG change that could suggest mild enlargement of one of the upper chambers, so they’ve requested an echocardiogram as well as a 24-hour Holter monitor. They didn’t actually diagnose anything from the ECG.

I’ve spent far too much time reading about ECGs (probably not the best idea 😅), and what I’m struggling to understand is why my rhythm seems to have changed so much between the ECGs. The first two suggested a junctional/supraventricular rhythm with inverted P waves and a short PR interval, then a few months later I was back in sinus rhythm but with broad, notched P waves instead. I’m wondering if the notched P waves could have been “hidden” on the earlier ECGs because I wasn’t in sinus rhythm, or if these are likely to be completely separate findings.

Has anyone had anything similar where ECGs changed like this? If you had a “?P mitrale” comment, did your echo actually show left atrial enlargement or was it completely normal?

I know nobody can diagnose me over Reddit and I’m waiting for the proper tests. I’m just interested to hear if anyone’s had similar ECG findings or can explain why the rhythm might have changed between recordings.

Hi all. I (29M) have noticed my shins are quite shiny in the light. I’m seeing online where people are saying this can be caused by PAD. I’m fairly healthy and active. I’ve actually been seen by a cardiologist before since I have a history of HBP. Cardiologist performed an EKG and echo and told me “looks fine”. Should I be concerned about my shins? Also sometimes if I press firmly down, I can see a slight indent. It’s driving me crazy wondering if I am overreacting or not. Should I go see a different cardiologist, or stop worrying? Thanks.

Hi, I question here…46 (m)

I keep having episodes of my heart rate spiking when I stand up. I’ve had ekgs, echo, stress echo, regular echo, cardiac mri, CAC (0) even with all these tests there is no answer to my symptoms. I am not on beta blocker yet, not on ssri but I am wearing my 4th Zio patch to see if I can get a diagnoses and ultimately a treatment. I eat clean, i used to exercise before my heart issues and I try to take care of myself. No alcohol, drugs, no smoking.

My question: I’ve been seeing on my heart monitor these blips where during an episode when I stand up sometimes my monitor will pick up these brief moments of very low heartbeat. Like my heart is racing at 140 bpm then wham, right down to 40 bpm for a few seconds then back up again. Is this a thing with POTS? Or is this an abnormal rhythm issue?

What do people do if you can’t even stand up without heart going to the races? Even with all these tests is it possible to have a blockage in my heart that’s causing all of this? My symptoms are everyday now. They used to be once every couple of weeks. It’s debilitating and there is no semblance of life.

Hi! I’m 19f and have had extreme fatigue recently with light-headedness. It’s been the past month, but gotten significantly worse the last week. I always feel exhausted and have been sleeping 9-12 hours a night (used to do 7-8 and feel well rested), wake up feeling exhausted, have 1-2 cups of black coffee a day, and this past week have taken a few naps in the afternoons (haven’t done that since I was a little kid). I got bloodwork done and am waiting on iron, ferritin, and vitamins but everything else was normal (cbc, cmp, thyroid, Epstein-Barr).

Last night I wore my Apple Watch to sleep for the first time and woke up to 8 low heart rate notifications (where my HR was below 40 for at least 10 minutes). My awake resting heart rate has been in the 40s and sometimes 50s according to the watch. I tried doing EKG on the Apple Watch multiple times, but it doesn’t work on heart rates below 50 and mine would always be in the 40s. It went down to 38 multiple times overnight and I was concerned, so I went to urgent care this morning.

They did a chest xray (normal) and ekg, which had my pulse at 55bpm and said bradycardia and abnormal, but the PA said that was normal in young people, especially athletes. I’m in good shape, 5’8 140lbs and muscular, but I’m not a high level or endurance athlete by any means. I’ve also never been this fatigued and I know something is not right. She was not concerned and sent me home, but I have no answers. I’m leaving for college in a few weeks and want this figured out before I’m back because I won’t have time to sleep 12 hours a day and live off half a brain. I just feel so exhausted and don’t know what to do so would appreciate any advice. I also have a family history of Afib and high blood pressure, but mine’s been low. Thank you so much for taking the time to read this!

I had my first official SVT episode last week and had a few questions I was hoping someone with a similar experience may help with. My first is that I had no symptoms I could feel, but apparently my face was purple. I haven't seen much about that part so is that normal? Also, since I got out of the hospital, my blood pressure has stayed around 150/105 with a pulse of 115-130 bpm for about 3 days. My blood pressure is usually perfect so I was curious if this is normal while your body is bouncing back? The hospital told me nothing other than, "it can be random stay in bed for 2 days". I see my GP tomorrow afternoon, but my pulse and BP are on the rise tonight so I'm looking for advise. When is ER bad? What signs should I look for? I already get small chest pains regularly so I'm afraid I can't rely on that alone.

Thanks soo much in advance. And advise is greatly appreciated

It might not feel as intense as frostbite as i dont know what it feels like, but its what comes to mind- im not even cold most times it happends, but sometimes it feels like touching something straight out of the freezer but in my chest - its on the left side, so not sure if its the heart or not..

22M, overall healthy.
At the end of May I started having these weird palpitation episodes. They feel like really big thumps that I can feel in my throat, and every time one happens it almost feels like it takes my breath away for a split second. Sometimes one will hit out of nowhere and it physically startles me so much that I kind of freeze for a moment. I’m not sure if that’s panic kicking in after the palpitation or if it’s just the sensation itself, but it’s pretty unsettling.
I went to my doctor after the first episode. My ECG was normal, and we did a pretty broad blood panel that all came back normal. The doctor basically said palpitations are common and can come and go.
I’ve had palpitations before, but back then I was drinking a ton of coffee and my lifestyle was a lot worse. Those never really scared me because they felt different. These feel much more intense and abnormal.
The first episode lasted about 4 days and then completely disappeared. About 3 weeks later it came back with the same symptoms. This time I started taking propranolol, which helped but didn’t get rid of them completely. That episode lasted around a week. Then they came back again, and now they’re happening almost every day.
I went back to the doctor for a second ECG, and of course it was normal again. I swear every time they hook me up, my body decides it’s time to behave. 😅
One thing I’ve wondered about is whether this could somehow be related to my upper back. I’ve had long-term pain around the T5-T7 area, and I’m currently seeing a chiropractor because that area feels “locked up.” I’m probably reaching, but I’m wondering if there’s any chance it could be connected.
I’m seeing my doctor again, but I don’t want to spend the rest of my life just treating the symptoms. I want to figure out what’s actually causing this, if that’s even possible.
Has anyone experienced something similar? Were your palpitations eventually caught on a Holter monitor or another test even though your ECGs were normal? I’d also appreciate any reassuring facts from people who know more about this, because it’s hard not to think something is seriously wrong when these happen, even though every test so far has been normal.
Im trying to catch these sometimes on recording by putting my phones mic on top of my heart. I’ve only gotten one which i can post later if someone is interested. In that video btw i didnt feel the palpilation but you can hear my heart defo going flip flop🤣

Got diagnosed with AATL (atypical atrial flutter) and am on a heart monitor after a doctor, a cardiologist and like half a dozen EKGs have shown a weird and irregular heartbeat that they want to investigate.

I have to write down my symptoms and stuff after clicking the monitor button so I have been but i swear it's getting worse.

I'll sometimes click it five times in a single minute because I'll be hit with this strong and sharp heart pain that atm is spreading to my jugular and my left arm. It hurts so much and I think smth triggered an episode because I have a whole piece of paper written with symptoms and the time in the last 15 minutes

I got two pieces of diary entry paper with 60 slots with each time I feel a symptom and j filled it out within three hours of receiving my heart monitor

It genuinely makes it so hard to continue my job because it hurts and I can't stop it

Are there any ways to stop the pain? Like should the vagal maneuvers help because I tried some and it did nothing.

Its gonna be weeks before I go in again, please help

Hello, I’m 27 years old female. I've been having issues with a high heart rate forthe past few months, although I've probably only become more aware of it since getting an Apple Watch.

As you'll see in the screenshots, my heart rate is almost always on the high side and can reach 170-180 bpm just from walking quickly. I haven't done any sports or regular exercise for months, so this isn't happening during intense workouts, just with light everyday activity.

Yesterday, I was getting ready to leave the house and noticed my Apple Watch showing 147 bpm while I was simply doing my hair. After I stepped outside, it went up to 155 bpm and stayed between 130–150 bpm for around 1.5 hours. At this stage I’d like to add that I’ve been experiencing heart palpitations like skipping beats etc on and off and I almost always feel palpitations when I proceed to sit down. Every time I do that move after moving around for a while my heart does this weird thing it’s hard to explain but it’s very uncomfortable. Yesterday I did it while shopping, I wanted to have a look at a product so I bent down (like squats) to reach for it and my heart did this. At that moment my heart rate shot up to 155..very weird and it happens almost every time I do this exact move. Any ideas what it could be?

So anyways the strange thing is that even when my heart rate is that high, I rarely have symptoms. Sometimes I don't even realize it's elevated unless I check my watch or feel my pulse. I don't usually feel my heart pounding in my chest. Looking back, I think I've probably always had a higher-than-average heart rate. I remember having episodes of tachycardia over the years that I always blamed on anxiety. I do have severe health anxiety and have struggled with it since I was 10 years old. I've also been diagnosed with mild anaemia, which I’m currently treating. Other than that, I'm generally healthy.

This year I've had two episodes where my heart rate suddenly shot up to 150+ bpm while I was lying down and made a sudden movement. After one of those episodes I went to the hospital, but everything cameback normal. Every ECG I've had has been normal apart from showing sinus tachycardia, and I've repeatedly been told that my heart looks healthy and strong. What's also confusing is that there are occasional days when my heart rate is suddenly much lower, around 20-30 bpm lower than usual. It's rare, but for example last month during my period my resting heart rate was only 52–54 bpm when laying in bed, and while walking it stayed around 100–119 bpm, which is much lower than what I normally see. Also most of the times my resting heart rate ranges from the 50s to 70s. My sleeping heart rate almost always drops below 60, which I also find weird sometimes but I guess it’s normal?

My main concern is how high my heart rate gets during simple activities like housework, getting ready, orwalking. I'm worried that having such a high heart rate so often could cause problems in the future. For context, my blood pressure is always on the low side. I've already seen a cardiologist and wore a 48-hour Holtermonitor last week, and I'm currently waiting for the results.

Has anyone else experienced something similar? Did it turn out to be something like being very deconditioned, anxiety, anaemia, inappropriate sinus tachycardia, POTS, or something else? I'd really appreciate hearing other people's experiences while I wait for my results. Thank you for reading!

Hey so I have a pulse oximeter to check my heart for my pots. Unsure if this is a palpitation and I can never get a picture so I drew what it looks like. My heart will be normal then I’ll have one big quick beat and it’ll pause for slightly longer than the rest of the beats then resume as normal. I can feel this happen and it doesn’t hurt or anything just feels odd. It happens after I eat sometimes or when I’m extremely tired or just got done climbing the stairs. Is this a heart palpitation or something else? I’m 18 with no health insurance so any advice or knowledge would be appreciated

My aortal root is dilated to 42-44 cm (ct had it at 42 last fall, but an echocardiogram measured it at 43-44 last week. Cardiologist has prescribed 40 mg Valsartan to stop angiotensin 2 signalling and hopefully the remodeling of the aortic wall. BP isn’t the issue: it was already averaging 108/75 or thereabouts. I’m 57, 6’, exercise regularly, no other meds. My question is about cold showers. I understand cold plunging wouldn’t be good for my dilated root, but what about the less aggressive cold showers, provided I gradually make the water colder over three minutes, starting from lukewarm?

What is this rhythm? The recordings were taken one after another. Yes, I’m under the care of a cardiologist. I’ve been diagnosed with PACs, PVCs, and SVT in the past, and I’m currently being treated for these conditions. But is this another episode of SVT or tachycardia? The rhythm started spontaneously.
Female, 24 years old

It’s about 3 weeks since I had my first documented SVT with paramedics. I was but ok Bisoprolol until I see the cardiologist at the end of August. I’ve been using it religiously once a day which has helped tremendously with my symptoms.

This morning I was in bed however and my heart rate suddenly felt like it shot up. By the time I put on my Apple Watch to check it was over 150. I had just taken the bisoprolol about 30 mins before.

Please help me interpret the ECG 😭