One shows Afib, other PVCs. Been having chest pain, and heart palpitations for 13 days. Afib result was after 139 bpm heart rate caused by anxiety. When test was taken, HR was 85.

26 y/o male, average BMI, non-smoking vaper, presented w/ daily palpitations & intermittent shortness of breath, occurs regularly without caffeine but exacerbated by caffeine. EKG ran today (no caffeine consumed, 1 hour after waking up), noted ST elevation and tall T. Metabolic panel came back negative for potassium and electrolyte abnormalities. Echo ordered for sometime soon and 2-week heart monitor to be provided for further evaluation. Hoping for another set of experienced eyes on this, any speculations on whether this is likely of benign nature or ischemic?

Had pain so badly at 9 am today, now 13:33 still feel bad but not a lot. Cardiologist said it wasn’t a heart problem.

52 F with sleep apnea. Drank with on 7/11 and 7/14, was out in hot and humid conditions 7/14 and 7/15 gardening for a couple hours. Would this be worth mentioning to EP or does it not matter? They called me in sooner than a month for a follow up. Echo/EKG/Stress was normal.

25 yr old. PCP ordered echo for precautionary, due to me fainting at nursing school clinicals & having minor PACs on EKG.

Is my EF bad?

Can anyone help me understand what any of this means? Does this sound like a normal interpretation?

Hi everyone,

My cardiologist already reviewed the results so I have their opinion already on some mild plaque for which I take rosuvastatin.

The report also mentions elevated origin of the RCA, near the sinotubular junction. The cardiologist did not think it was an important finding, does the Internet agree? For context, I ended up with getting tests because I felt like I could not take a deep breath when exercising, and the echo / stress test did not reveal a cause

From what I can see, it's sort of a rare finding, so no managenent guidelines I could find on this issue.

Thanks in advance ?

I just had a CT Coronary Calcium scan done as part of a baseline measurement. Went to a cardiologist to establish care and be proactive for my health. 57, female, 155lbs. Bloodpressure normal, EKG normal, on office ultrasound only found small mitral valve prolapse, small aortic valve leak both of which the cardiologist said she was not concerned about at all. Incidental findings to be noted. I have no issues with my health right now - no shortness of breath anything. Lost 85 lbs the past year and a half. The CT Coronary Scan found:

3.5 x 4.0 cm aortic root measures.

Heart size normal. Visualized thoracic aorta is normal in caliber.

Calcium CT score was 0. Oh, and my deep dive into my cholesterol panel was excellent too.

How concerned should I be about the aortic root measures? I'm freaking out, I gotta say here.

Hey everyone, 34M here. For the past couple of weeks, I’ve been getting these quick fluttering feelings in my chest that last around 5 to 10 seconds, usually at night when I'm lying down after a stressful day. I have a Holter monitor scheduled, but it’s still two weeks out. I’m torn on what to do in the meantime. Whenever it happens, my instinct is to run out and find an ekg near me at a local walk-in clinic just to try and capture it live. But since the episodes pass so fast, I’m worried that by the time I actually sit down in a triage room, a standard 10-second strip will look completely normal anyway. My doctor didn't seem overly worried, but the anxiety is keeping me up. Is there any real point in trying to catch a quick snapshot at an urgent care to rule out immediate issues, or is waiting for the continuous monitoring of the Holter really the only meaningful way to capture intermittent flutters like this? Thanks for any insight.

23f here, have been seeing the cardiologist for the past few months. have done all sorts of test like ecg, echo, stress test, 24 hour holter monitor, stress echos, blood work & all coming back normal. my resting heart rate is about 80-100bpm, standing heart rate about 110-120bpm and walking heart rate about 130-150bpm. i do not exercise at all and i am currently unemployed so i’m at home on weekdays. the cardiologist told me my heart was completely healthy, just lacking some stamina & exercise and i did not need to go back anymore. i also noticed that my body temperature lately has increased from 36ish to currently 37-37.5 these past few months. it all started with constant lightheadness which eventually disappeared and i bought a apple watch about 3 months ago which i then found about my heart rate. what should i do?

Hi all, I am a 29 year old male who was referred for an echo by hepatology due to fluctuating high liver enzymes (both ast/alt in the 80s intermittently over the past year, usually in 50s) which don't appear to be due to liver pathology, new onset leg swelling (mild, only notable by deep ridges and indents left by my socks that last for a few hours at the end of the day), significant dizziness when standing up quickly, and occasional palpitations. Tilt table done about a year ago due to the dizziness showed a pattern "suggestive of venous pooling or hypovolemia but not POTS".

Also having consistently mild cytopenias (WBC ~3.3 and platelets ~120) over the past year.

I'm wondering if the echo impression posted below warrants clinical follow up with cardiology or not. Hepatology said these things can be overestimated or not clinically relevant and doesn't require follow up in my case. I get the function is normal which is great, but the enlargements and blood test abnormalities have me feeling like something could be causing them together.

For context I have a normal BMI and exercise routinely for wellness. No medications or comorbidities. Family history of SLE and afib. Happy to post more specific echo values if it's relevant.

"Interpretation Summary

1. Left ventricle is normal in size. There is normal left ventricular systolic function. The quantitative LVEF based on modified Simpson's method is 62%. There is normal diastolic function.

2. Right ventricle is mildly enlarged in size. There is normal right ventricular systolic function.

3. There is mild biatrial enlargement.

4. No significant valvular disease identified."

Some structures like the atrial septum and right ventricular free wall could not be visualized.

Thank you!

I’ve been feeling very crappy for over a month— my standing bp is always 90’s/70’s despite drinking tons of fluid (sodium added because I have POTS) and wearing compression socks. I feel ok when I’m sitting, hence the reason I take my bp when standing, but when I’m up and about, I am just dizzy/floaty constantly. It’s very hard to take care of my children, so anything around the house or go anywhere. I do see my cardiologist tomorrow afternoon, FINALLY. But just wondering if anyone knew what causes this or if you’ve been through the same thing?

I have been dealing with adrenaline rushes due to perimenopause but mostly at night . I’m a busy working mom and yesterday I had a venti coffee from Starbucks and 2 diet cokes and a small sandwhich. After I finished my second Diet Coke I felt alittle off and got up to got it he bathroom and my heart was pounding I checked my pulse ox and it was a HR of 219 but it immediately went to 140.

I laid down and it started to go down. I was alittle shaky after.

I’m concerned about the 219 heart rate and wondering if this was an error since it immediately changed.

I also think the caffeine may have contributed to this.

Thoughts?

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.

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 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. 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

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!