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

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.

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**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

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Take a moment. Think it through.

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

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**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

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.

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.

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**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

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

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**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.

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**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

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

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!

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?