Dr. Usman's Cardiology Notes

Rheumatic Mitral Stenosis – Key Echocardiographic Assessment Points 1) Morphologic Features (2D Echo – Parasternal & Apical Views) • Thickened mitral leaflets (especially leaflet tips) • Diastolic doming of anterior leaflet (“hockey stick” appearance) • Commissural fusion (best seen in parasternal short axis) • Reduced leaflet mobility • Subvalvular involvement: chordal thickening, fusion, shortening • Calcification (late disease) Rheumatic MS typically shows leaflet tip restriction with relatively preserved basal leaflet mobility (early disease). --- 2) Mitral Valve Area (MVA) – Severity Assessment • Planimetry (PSAX at leaflet tips in mid-diastole) – Gold standard if image quality good • Pressure Half-Time (PHT method): MVA = 220 / PHT • Continuity equation (if significant MR absent) Severity grading: • Mild: MVA > 1.5 cm² • Moderate: 1.0–1.5 cm² • Severe: < 1.0 cm² • Very severe: ≤ 0.8 cm² Always prefer planimetry when feasible. --- 3) Transmitral Doppler Assessment • Mean...

Mitral Inflow E/A Ratio by Pulsed Wave Doppler A Practical, Guideline-Based Approach --- 1. Introduction Mitral inflow assessment using pulsed wave (PW) Doppler is a fundamental component of diastolic function evaluation. The E/A ratio reflects the relationship between early passive LV filling (E wave) and late filling due to atrial contraction (A wave). It is simple to measure but frequently misinterpreted if age, heart rate, and complementary parameters are not considered. Guidelines reference: ASE/EACVI Recommendations for the Evaluation of LV Diastolic Function (2016 update). --- 2. Physiology Behind E and A Waves During diastole: • Early rapid filling → E wave • Diastasis → minimal flow • Atrial contraction → A wave Normal physiology: Young adults: E > A (E/A > 1) With aging: relaxation slows → E decreases, A increases --- 3. Correct Method of Measuring E/A Ratio A. Image Acquisition View: Apical 4-chamber Doppler type: Pulsed Wave (PW) Sample volume size: 1–3 mm B. Correct ...

Major Echocardiographic Views and Normal Dimensions of the Right Ventricle (RV) and Right Atrium (RA) Right heart assessment is essential in pulmonary hypertension, congenital heart disease, RV infarction, cardiomyopathy, and advanced left-sided heart disease. Accurate chamber quantification should follow the recommendations of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI). Right heart measurements are ideally obtained at end-diastole (for RV size) and end-systole (for RA area), using RV-focused views whenever possible. ━━━━━━━━━━━━━━━━━━ 1. Apical 4-Chamber View (RV-Focused View) This is the most important view for quantitative RV and RA assessment. Technique: • Optimize by centering and enlarging the RV • Avoid LV foreshortening • Measure RV at end-diastole • Measure RA at end-systole Right Ventricle – Normal Dimensions (End-Diastole) • RV Basal Diameter (RVD1): 25–41 mm • RV Mid Cavity Diameter (RVD2): 19–35 mm • RV Lon...

  How to diagnose Dextrocardia on ECG? DEXTROCARDIA – ECG SUMMARY (High-Yield) Classic ECG Findings Limb Leads Lead I: inverted P, QRS, T (often QS) aVR: upright P, QRS, T Inferior leads (II, III, aVF): usually positive Precordial Leads (Left-sided placement) Absent R-wave progression Dominant S waves V1–V6 All QRS predominantly negative Key Concept Electrical forces directed rightward because heart is located on right side. --- Confirmation 1. Apex beat on right side 2. Chest X-ray → right-sided cardiac shadow 3. Repeat ECG with right-sided leads (V1R–V6R) → normal R progression appears --- Differential Diagnosis 1) RA–LA Limb Lead Reversal (Most common mimic) Lead I negative aVR positive BUT normal R-wave progression in chest leads → Chest leads differentiate it --- 2) Extreme Right Axis Deviation Lead I negative Inferior leads may vary Normal precordial progression → Does NOT give global negative V1–V6 --- 3) Severe COPD / Vertical heart Low voltage Delayed R progression Not glo...

 

The most dangerous ECGs don’t always have the biggest ST elevation. If you’re staring at V2–V3 trying to decide between Early Repolarization and a subtle LAD occlusion, stop looking at the ST segment and look at the Terminal QRS. What is Terminal QRS Distortion? It’s a binary finding. In V2 or V3, ask yourself: Is the S-wave gone? Is the J-wave gone? If the answer to both is YES, you are looking at Grade III ischemia. The Stats: Specificity: ~100% vs. Early Repolarization. BER simply doesn’t do this. Sensitivity: ~20–35%. It won’t catch every STEMI, but when it’s there, it’s a “rule-in” sign. Risk: Associated with larger infarct size (CMR-proven) and higher rates of heart failure. The Logic: This is depolarization failing in real-time. Severe ischemia slows conduction so much that the end of the QRS gets “swallowed” by the repolarization phase. Takeaway: Millimeters can lie. Morphology rarely does. If the S-wave is missing in the anterior leads, call the lab.

Assessment of Pulmonary Embolism (PE) Pulmonary embolism (PE) is a potentially life-threatening condition requiring rapid, structured, and guideline-directed evaluation. Early risk stratification determines urgency of imaging, need for thrombolysis, and level of care. This post summarizes a practical, ESC-aligned approach to assessment of PE. 1. Clinical Suspicion Always think of PE in patients with: Acute unexplained dyspnea Pleuritic chest pain Hemoptysis Syncope Unexplained tachycardia New hypoxia Risk Factors Recent surgery or immobilization Active cancer Previous VTE Pregnancy/postpartum OCP use Thrombophilia Obesity 2. Hemodynamic Assessment (First Step) Immediately determine if the patient is: A. Hemodynamically Unstable (High-Risk PE) SBP <90 mmHg Drop in SBP ≥40 mmHg Shock or cardiac arrest → Urgent bedside echocardiography → If RV dysfunction present → treat as high-risk PE (consider thrombolysis) 3. Clinical Probability Assessment Use ...