Cardiology online

30/08/2026

𝐖𝐢𝐥𝐤𝐢𝐧𝐬 𝐒𝐜𝐨𝐫𝐞


The Wilkins Echo score to predict the procedural success of Percutaneous Balloon Mitral Valvuloplasty (PBMV) in Rheumatic Mitral Stenosis (MS).
MV morphology is considered favourable
if the Wilkins score is ≤ 8.

Other important predictors of procedural success and long-term outcome include :-
◽️commissural calcification or fusion,
◽️pre-procedure mitral regurgitation >2+,
◽️post-procedure mitral regurgitation >3+,
◽️Age,
◽️Prior surgical commissurotomy,
◽️NYHA functional class IV, and
◽️higher post-procedure pulmonary artery pressure.

30/08/2026

𝘼𝙩𝙧𝙞𝙖𝙡 𝙁𝙞𝙗𝙧𝙞𝙡𝙡𝙖𝙩𝙞𝙤𝙣 ➕ (𝙒𝙋𝙒) 𝙎𝙮𝙣𝙙𝙧𝙤𝙢𝙚

============================
Atrial fibrillation is medical emergency when Rapid Antegrade Conduction over Accessory pathway occurs in Wolff-Parkinson-White Syndrome .

📍Patients with Manifest(WPW) syndrome,
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Antegrade Conduction occurs over Accessory pathway.
If Atrial Fibrillation (AF) develops,
Normal rate-limiting effects of
Atrioventricular (AV) node are bypassed, and
the resultant Excessive ventricular rates
(sometimes 200 to 240 beats/min) may lead to
Ventricular Fibrillation and Sudden Death.

📍Patients with Concealed WPW Syndrome
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Not at risk because in them, antegrade conduction
does Not occur over the accessory connection.

⏲ Direct-current cardioversion
~~~~~~~~~~~~~~~~~~~~~~~~
The Treatment of Choice for Wolff-Parkinson-White syndrome is Direct-Current Cardioversion.

The usual rate-slowing drugs used in atrial fibrillation are not effective, and digoxin and the nondihydropyridine calcium channel blockers (eg, verapamil, diltiazem) are contraindicated because they may increase the ventricular rate and cause ventricular fibrillation.

If Cardioversion is Impossible,
~~~~~~~~~~~~~~~~~~~~~
drugs that prolong the refractory period of
the accessory connection should be used.
• IV procainamide or amiodarone is preferred,
• any class Ia, class Ic, or class III antiarrhythmic
drug can be used.

Pearls & Pitfalls
~~~~~~~~~~~
Do not give digoxin or nondihydropyridine calcium channel blockers (eg, verapamil, diltiazem) to patients with atrial fibrillation and WPW because these drugs may trigger ventricular fibrillation.

*************************************************
👨‍⚖️By m

30/08/2026

𝙑𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 𝙎𝙚𝙥𝙩𝙖𝙡 𝘿𝙚𝙛𝙚𝙘𝙩 - 𝘾𝙖𝙨𝙚 𝘿𝙞𝙨𝙘𝙪𝙨𝙨𝙞𝙤𝙣


A 31-year old man was referred to cardiologist
by a general physician, for evaluation of a heart murmur.

The man was normally very active and denied complaints of chest pain, breathlessness, palpitations or syncope.

There was no history of cyanotic spells, joint pains or repeated chest infections during childhood and he regularly played cricket and football in school.

On Examination,

• Average built and height and looked healthy.
• Pulse = 84 b/min. regular ,no special character.
• BP = 134/76 mm Hg in the right arm while sitting.
• No anemia, cyanosis or sign of congestive HF
• Apex beat was ill-sustained, heaving in nature and
slightly displaced towards the axilla.
• Pansystolic murmur over middle Lt sternal border
Not radiate towards the axilla.
No parasternal heave and
• Lower border of Liver was not palpable.
• S3 sound in early diastole.
• Lung fields were clear.

CLINICAL DISCUSSION

From the history and physical examination,
this asymptomatic young man had a parasternal pansystolic murmur.

Typical causes of a pansystolic murmur are
——————————————————————
• Ventricular septal defect and

• Mitral regurgitation,
(Radiates towards the axilla)

• Tricuspid regurgitation
(Engorged neck veins and enlarged pulsatile liver)

• Sometimes, tight coarctation of aorta or
Patent ductus arteriosus with pulmonary HTN
(usually located at the upper left sternal edge)

ECG showed :-
biphasic RS complexes in the mid-precordial leads.

Chest X-ray showed :- mild cardiomegaly
with minimal signs of pulmonary congestion.

On ECHO,
• Left ventricle was normal in size with normal EF.
• Signal drop-out in mid-portion of IVS
• No abnormality of the cardiac valves
• Pulmonary artery pressure was normal.
• Abnormal flow map extending from the LV to RV
• High velocity jet on continuous wave Doppler.

Therefore, the definite diagnosis in this ca

30/08/2026

🔵 𝐒𝐩𝐢𝐤𝐞𝐝 𝐇𝐞𝐥𝐦𝐞𝐭” 𝐒𝐢𝐠𝐧:🛎
New ECG Marker of
Critical Illness and High Risk of Death
=================================
Spiked Helmet Sign (SHS) is
ECG marker associated with increased risk of
lethal ventricular tachyarrhythmias and
sudden cardiac death.

SHS formation is attributed to sympathetic hyperactivity, which mediates increased dispersion of ventricular repolarization, leading to marked QT prolongation and macroscopic T-wave alternans.

This pattern can be observed in critically ill patients with cardiac or noncardiac conditions. In particular, immediate identification of this ECG abnormality is crucial in recognizing and treating noncardiac conditions in older male patients.

𝙏𝙝𝙞𝙨 𝙥𝙖𝙩𝙩𝙚𝙧𝙣 𝙞𝙨 𝙘𝙝𝙖𝙧𝙖𝙘𝙩𝙚𝙧𝙞𝙯𝙚𝙙 𝙗𝙮 🛎
• slurring or notching J-point elevation,
• subsequent downsloping ST-segment elevation,
• wide T(U)-wave inversion in the inferior leads,
• suggesting a combination of J-point,
elevated ST segment, and T-wave.

ECG showed Dome-and-Spike Pattern,
Giving the appearance of Pickelhaube,
German military spiked helmet
introduced in 1842 by Friedrich Wilhelm IV,
King of Prussia (Figure).

𝙈𝙚𝙘𝙝𝙖𝙣𝙞𝙨𝙢

Certain pathological conditions can rarely result in Repetitive contraction of the diaphragm
that is in concert with the cardiac cycle.

Such diaphragmatic contractions may result in Alteration of the ST segment,
which is best seen in the inferior leads.

💮 𝙋𝙪𝙡𝙨𝙖𝙩𝙞𝙡𝙚 𝘿𝙞𝙖𝙥𝙝𝙧𝙖𝙜𝙢𝙖𝙩𝙞𝙘 𝙢𝙤𝙩𝙞𝙤𝙣 𝙈𝙚𝙘𝙝𝙖𝙣𝙞𝙨𝙢
——————————————————————
• Direct stimulation of the diaphragm
by the inferior wall of the left ventricle or

• Triggering of the left leaf of the diaphragm
by the left phrenic nerve.

• Repetitive Epidermal stretch in association
with Nearby pulsatile flow or due to
Acute rise in Intrathoracic or Intra-abdominal pressure.

𝘾𝙤𝙣𝙘𝙡𝙪𝙨𝙞𝙤𝙣

The spiked helmet sign is a potential novel ECG marker of a very h

30/08/2026

𝐀𝐂𝐄 𝐈𝐧𝐡𝐢𝐛𝐢𝐭𝐨𝐫𝐬 𝐈𝐧𝐢𝐭𝐢𝐚𝐭𝐢𝐨𝐧 𝐚𝐧𝐝 𝐔𝐩-𝐓𝐢𝐭𝐫𝐚𝐭𝐢𝐨𝐧
𝐟𝐨𝐫 𝐇𝐞𝐚𝐫𝐭 𝐅𝐚𝐢𝐥𝐮𝐫𝐞 𝐏𝐚𝐭𝐢𝐞𝐧𝐭


𝙄𝙛 𝙞𝙣𝙞𝙩𝙞𝙖𝙩𝙞𝙣𝙜 𝘼𝘾𝙀 𝙞𝙣𝙝𝙞𝙗𝙞𝙩𝙤𝙧 𝘾𝙤𝙣𝙨𝙞𝙙𝙚𝙧 ...
========================
1️⃣ Start with a low dose

2️⃣ Start only if:

🔸 Blood pressure at least 100mmHg systolic

🔸 Potassium no higher than 5.5mmol/L

🔸 Creatinine less than 250micromol/L or

🔸eGFR at least 50 (or seek specialist advice)

3️⃣ Arrange to check potassium and creatinine
One week after first dose

4️⃣ Ask them to arrange another GP appointment
at least two weeks after first dose

5️⃣ Provide a Heart Failure Action Plan

𝙒𝙝𝙚𝙣 𝙪𝙥-𝙩𝙞𝙩𝙧𝙖𝙩𝙞𝙣𝙜 𝙙𝙤𝙨𝙚...
**********************
1️⃣ Double dose at not less than two weekly intervals

2️⃣ Aim for target dose or highest tolerated dose

3️⃣ Make sure they have a biochemistry form
to check electrolytes before next dose titration
———————————————————————
𝘼𝙨𝙠 𝙖𝙗𝙤𝙪𝙩:
***********
➰ Cough – if troubling consider
Angiotensin receptor blocker (ARB)

➰ Hypotensive symptoms – consider
reducing other BP lowering medicines
(eg diuretics), or dosing at night

➰ Angioedema – STOP ACE inhibitor
(consider ARB)

➰ Symptoms that may be exacerbated
by a drug interaction eg NSAID
———————————————————————
𝙐𝙥-𝙩𝙞𝙩𝙧𝙖𝙩𝙚 𝙊𝙉𝙇𝙔 𝙞𝙛:
*******************
🎴Blood pressure at least 95 mmHg systolic

🀄️Potassium is no higher than 5.5mmol/L

• If Potassium is between 5 – 5.9mmol/L –
consider adjustments of potassium sparing
or high potassium food and repeat electrolytes

• If Potassium is above 5.9mmol/L –
STOP ACE inhibitor and seek specialist advice

• Creatinine is no more than 25% above baseline
(or seek specialist opinion)

Note: During initiation of treatment an increase in creatinine up to 30% above baseline is acceptable (provided creatinine is no greater than 250micromol/L) and should stabilise within t

30/08/2026

𝐌𝐚𝐧𝐚𝐠𝐞𝐦𝐞𝐧𝐭 𝐨𝐟 𝐇𝐢𝐠𝐡 𝐈𝐍𝐑


An INR greater than or equal to 5 significantly increases the risk of bleeding.

Refer to the Table 👇 for recommended actions
for high INR results.

Consider whether or not a patient with a high INR result requires admission to hospital for access to specialised treatment (e.g. blood products) and monitoring.

Source: adapted from Tran et al. 201:

# Not for intramuscular injection; Konakion MM®,
the intravenous preparation of vitamin K (phytomenadione), may be given orally

*Major bleed in previous four weeks,
major surgery in previous two weeks,
thrombocytopaenia with platelets < 50 x 10/L,
known liver disease or
concurrent antiplatelet therapy.

Note: For patients that have been treated for warfarin reversal, reassess the patient for suitability of warfarin therapy.

25/08/2026

DOAC & Stage 5 CKD/Dialysis:
Apixaban: 2.5 or 5 mg twice daily
Rivaroxaban: 15 mg once daily
Edoxaban & Dabigatran: Both are Contraindicated.

𝙎𝗼𝘂𝙧𝗰𝙚: 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis & Management of AF
𝙎𝙖𝙫𝙚 𝗶𝘁 ➠ 𝙎𝙝𝙖𝙧𝙚 ➠ 𝙡𝙞𝙠𝙚 & 𝙛𝙤𝙡𝙡𝙤𝙬 🔁

25/08/2026

Crochetage Sign

● Notch near the apex of the R wave in the inferior leads on ECG.
● The notch resembles a “crochet hook”, which is why it is called crochetage
● Often associated with incomplete RBBB.

》Diagnostic Value & Clinical Pearls
● Crochetage sign + incomplete RBBB ➠ think ASD.
● Highly suggestive of secundum ASD.
● Specificity increases when present in all three inferior leads.
● The sign may disappear after ASD closure (surgical or device closure).
● Persistence of the sign may indicate residual shunt after closure.

𝙎𝙖𝙫𝙚 𝗶𝘁 ➠ 𝙎𝙝𝙖𝙧𝙚 ➠ 𝙡𝙞𝙠𝙚 & 𝙛𝙤𝙡𝙡𝙤𝙬 🔁

18/07/2026

Mitral Regurgitation

19/06/2026