Hi guys, I’m a student nurse and the other day my assessor told me to always switch the frequency to 40Hz instead of 150Hz that’s set by default. She generally couldn’t explain how it’d affect the trace and her only rationale was “some doctors prefer it at 40”. Looking at the same trace at 40 and 150 all I could see is that some extremely negligible artefact was not present on 40.

From my understanding 40 should be used when there is significant somatic interference seen on 150 rather than stick it in by default.

My biggest question is if it’s possible to miss something significant by always switching to 40 by default and if it’s the case then what? And if you have any preferences between those two frequencies when interpreting?

Thank you!

Hey everyone,

I’ll be starting my IM internship next month, and I’m interested in cardiology. I would love to hear any advice on how you think I should go about learning EKGs? I was thinking of getting Dubins, but I wanted to hear some other perspectives before making a purchase. Thanks so much for your time!

For those who have passed RPVI boards in the last several years, what study material did you use/recommend? Are review videos enough?

Hello US-based cards docs

I'm interested in learning more about typical work models in cards (gen vs IC vs EP), and google just isn't cutting it.

What are examples of some practice models + compensation? Such as how many days per week working, split between clinic vs inpatient vs procedures vs reads, PTO, overall compensation / average hourly?

I've been using anesthesia as my baseline in terms of hours worked and call vs PTO and trying to judge the comparisons

And as a bonus - how did you choose Cards, and would you do cards (or even IM) again?

Thanks everyone!

I need help on how to classify an aortic dissection that I observed at an autopsy. There is a tear in the intima about 0.5 cm above the aortic valve and the right coronary artery is dissected. Would that be considered retrograde because the coronary ostia is proximal to the tear, or is it considered antegrade because the tear is in the ascending aorta and the coronary ostia is also in the ascending aorta? I understand the Stanford and DeBakey classifications, but don't know if those are used to determine retrograde and antegrade. Thanks!

IM PGY1 here having career questions. My program has the option to do a research year between PGY2 and 3 (seems mostly tailored for those in hardcore academia) and I am not sure if I should take a year or apply straight after 2nd year.

At the end of the day I want to be a great clinician and prioritize that over research. Ideally I would like to match into a clinically rigorous place like Cedars/THI/CCF that has good research or a strong academic program with good clinical training.

I am ok having research be 1/4-1/3 of my practice long term, but I don’t want to run my own lab or spend most of my time writing grants. I also don’t wanna succumb to the low pay and politics of hardcore academia but would like opportunities to collaborate on research projects when possible. At the moment I do enjoy research but do not want to dedicate my career to it

I go to a T20 IM program, have solid board scores and a decent research profile (not a lot in cards yet) but am not sure if that will cut it for the competitive programs I mentioned.

Would a research year and the connections that come with it be worth it for my application for the programs I’m shooting for? (I have no interest in doing a chief year and have heard hospitalist years can hurt for top cards programs?)

Is prestige of fellowship program important for getting offers in PP (or just for academia)? Is a 70-30 clicinal/research position viable and is it obtained through academia or PP?

Sorry for the many questions- happy to provide more details. TIA cardiotrons

Good evening cardiology group. Does anyone have experience with a Samsung V8 for TTE? I tried one out on a few patients and I really liked it. I felt it had similar 2D quality to a Phillips Epiq and picked up color better and had better AI features. Samsung is obviously less commonly used when compared to GE/Phillips (which are the machines I trained on) so I'm a bit afraid of taking the leap. I was wondering if anyone had used the Samsung V8 over a more prolonged period and had any insights.

The GE Vivid series is not an option as I need the machine to be able to do fetal echo as well, and GE has a separate machine for general ultrasound / OB (the Voluson E10).

Thanks in advance!

Hello, I'm an internal medicine resident and something I've struggled with for a long time is the relation between QT interval and heart rate, and subsequent risk for TdP and was hoping to get some clarity from experts here.

Throughout my medical training, I've heard internists and cardiologists tell me that bradycardia increases risk for TdP and tachycardia is relatively protective for TdP. We learned early on about how QT prolongs at lower heart rates and shortens at higher heart rates and thus we need to use corrective formulas to find QTc. My understanding has always been that a prolonged QTc is what increases risk for TdP, not QT perse. This has always left me confused; why would bradycardia then be a predisposing risk factor for TdP if we're correcting for the degree of QT prolongation it causes. Does bradycardia also prolong QTc on top of whatever effect it has on QT? As in, for a particular patient, assuming medications and electrolytes and sympathetic tone were stable, would their QTc be longer at 40 bpm vs 80 bpm (I assume no just based on what we're trying to accomplish with the corrective formulas, though big assumption of the formulas actually working well).

This questioning led me down somewhat of a rabbit hole of case reports and review articles about bradycardia and QT/risk for TdP and I came upon this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974330/ . It claims that there is additional "torsadogenicity" (what an amazing word) implicated by bradycardia besides the rate-dependent QT prolongation. The third paragraph mentions that faster heart rates protect against EAD while the reverse is true with bradycardia; is this maybe what these internists/cardiologists were referencing when they said that high heart rates are protective?

I think overall my question is as follows: for a particular patient that I'm admitting with all the typical risk factors for TdP (hypoK/hypoMg, got a dose or two of Zofran in the ED, their baseline QTc was 480ms, etc.), with a QTc of 470 should I be even more concerned if their HR is 40? Should I be somewhat reassured if their HR is 120? Thank you so much for any clarification! Please let me know if the question wasn't clear or if I'm missing something obvious.

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Fellow here, I am planning to take nuclear boards this year. For planning purposes, how many months ahead do people typically start to prepare? How much dedicated time is needed towards the time close to exam? What was your strategy?

Hi all. This probably will be more geared towards cardiology docs and cardiac sonographers in Europe, but I’m sitting the ESC TTE exam in June and was wondering what books, resources you all used to study and pass the exam ?

Also any tips for the exam/ day of exam would be greatly appreciated!

Current second year fellow (PGY5) applying soon to noninvasive cardiology jobs in a desired, HCOL/VHCOL area. One institution I did research on requires 3 letters of recommendation. I know most other places just need references or points of contact if they have any questions.

The 3 attendings I am thinking to ask to write a strong LOR are:

• the PD who has a lot of connections and is academically oriented (regular publications, involved in social media and giving presentations nationally, goes to ACC and AHA regularly) and word-of-mouth is that they write amazing LORs for the fellows, has been an attending for 20+ years

• my clinic mentor who is personable but is early career (about 3-4 years as an attending), I staff my clinic patients with them almost every week and have worked with them in CCU and in echo lab

• former clinic mentor and especially former chief of cardiology who also has a lot of connections nationally, knows graduates who may know other cardiologists in the area I want to find jobs in, and has been in the field for almost 60 years

There are other people I was thinking of to write me a LOR but don't think they know me that well or would not be able to describe my character and work ethic as well as the ones above. These include the current chief of cardiology (who has many connections but very busy person) and my research mentor.

Initially I was gung-ho about going into academics, but given I want to pay off my med school debt ASAP (aka have a reasonable salary) and am not interested in research anymore, I am also open to private practice or semi-private practice as long as the job fits within my goals. These goals are being able to focus on clinical practice, using my skills so that they don't go to waste (reading echos, nuclear, doing TEEs; not sure about CT since don't have that experience yet), and mainly doing outpatient since I prefer that. I do enjoy teaching but that is not a requirement for now (perhaps many years down the road when I am more established). Location is the most important for me since my SO's job is not as flexible as mine, then lifestyle and finally salary is lowest on priorities (though aiming for $400k+). Side note: plan on cohabiting and travelling for a bit before getting married and having kids. I am a female in cardiology.

1. What should I ask my letter writers to include?

2. Does it matter if I should ask my writers to have 2 separate LORs ready in case I want to apply to academics and private practice? For instance, the academic letter would include my work ethic in research but the latter would not need that?

3. Anything else I should know about what employers are looking for to increase my chances of getting an interview?

Thanks in advance! I'm hoping the general cardiology market being in high demand works in my favor as well.

Since I have seen discussions about future of AI and future of cardiology, I was curious to see what people here think about the future of healthcare in general, or simply does the future even exist? I am talking about the economics of healthcare in the western hemisphere. Every time I look at the amount of wasted products worth tens of thousands of dollars from a single PCI or any medical procedure, I cannot help but think who is going to pay for that? The median income in the US is around 35-40k. This can barely cover a “simple” admission for an MI. Assuming no fancy pumps or devices used. Think how many people we see in ICU spending days or weeks with endless amounts of procedures. We know that most patients are not going to be able to pay for it in their lifetime. Hospitals and big pharma and device companies are obviously making shit loads of money, otherwise they would cease to exist. So can someone help me understand where this money comes from? And is this really sustainable? Is there going to be a future in 10 years or even 5 years? If/when things start to collapse, how will our careers be affected?

Just wondering how people here think various AI technologies will change the way we practice cardiology in the next 2, 5, 10 years?

Hi there,

I'm recently cared for an elderly patient who was diagnosed with an aortic dissection. It was the largest dissection I've ever seen, starting in bilateral carotids and extending down into the common iliac. Non-surgical candidate due to age and comorbids. Plan was to send them home hospice, but they ended up passing away in the hospital a few days after admission due to the inability to keep their blood pressure under control for long enough.

The treatment plan consisted of very little, with obvious emphasis on maintaining a systolic blood pressure of under 110. At my facility, esmolol is the go-to infusion for patients with aortic dissections. I gave several push-doses of hydralazine alongside several oral doses of the same.

They were maxed on esmolol and quite a fair amount of IVP hydralazine, and I asked the docs (I'm a nurse) if more drugs could be started because at the time I left to go home, their systolics were in the high 130s to 140s and rising quickly. The team kind of brushed me off and said no, esmolol. I was like we're already maxed on it!! The patient's pain was also increasing and mental status was deteriorating in front of my eyes. I think, at the very least, something else could have been started for long enough to call family and have them come to bedside before the dissection turned into a rupture.

My question is, why aren't Ca+ channel blockers or ACE inhibitors be used in this setting? I know things are different in different facilities, but the cards team I was talking to seemed to only want esmolol and hydralazine. I even asked if another beta blocker could be added because clearly the esmolol wasn't doing enough. From the little research I've done on the topic, I understand B-blockers are the front-line treatment for dissection, and that makes sense.

Why aren't other classes of vasodilators as effective?

Thanks

What subspecialties do you think will have a recession in 10-20 years? Which would have a boom?

My limited thoughts are below. What would you add, subtract, or change about these impressions?

• IC: coronary event rates continue declining; still new innovations in PCI technology but probably plateauing and progressing towards diminishing benefits with each iteration of technology; lot of new work in complex PCI but this is very limited to major centers and relatively small number of operators; always will have a need for people to fill STEMI call but otherwise seems the field is past its prime for good; older field with more older docs set to retire

• Structural: the hot new kid on the block; currently too few spots and not enough new job openings to keep up with the number of new grads; TAVR numbers expected to only continue going up, MitraClip numbers probably too; new work in tricuspid interventions perhaps not as optimistic a future; perhaps a lot of room for innovation and entrepreneurship

• EP: in somewhat of a bubble currently, reimbursements will likely continue falling; that being said, ablation data recent and ongoing seem more likely to favor higher ablation rates especially for new onset arrhythmias; may have among the most positive 10-20 year outlooks; lot of room for innovation; young field with less people set to retire

• Imaging: certainly a boom in structural imaging needs, increased CT and to a lesser degree CMR needs; lot of work in AI especially related to reading echo; personally don't see a risk of imagers being replaced in our lifetime but recent AI technology becoming very good at reading TTE; perhaps some above average room for innovation

• HF: transplant need and numbers likely to continue increasing for the foreseeable future; not much new advances in terms of on-market HF technology though we have recently seen after a long hiatus some newer HF medications and there are newer technologies under research such as non-blood contact LVAD devices though it's unclear how these will pan out; seems the need for HF docs will be similar to slightly more than current demand

• ACHD: largely a black box to me but for many reasons the field seems to be more or less slowly progressing and there probably isn't necessarily a major boom or decline looming

​

Arterial circle of Vieussens

RCA / conus branch to distal occluded LAD

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I work cardiac rehab. A common perception among patients that do not participate in rehab is that their cardiac disease is cured or significantly decreased by a stent/graft intervention. I'm fairly sure that they reach that conclusion mostly on their own. I've worked in Healthcare long enough to know patients will endless overestimate how healthy they are and underestimate how much of it can be affected with lifestyle changes. How do you all discuss this issue with your patients? And how do you balance the value of assuring them that the procedure was successful with the possibility/likelihood of negative outcomes, especially without significant change in lifestyle post intervention?

Going to ACC this weekend. PGY-3, re-applying to match. Everyone says “excited to network and meet new people”. As someone wanting to show my face to PDs, what can or should I be doing? There’s a state chapter ACC event I will attend though I think it’s obviously geared towards FITs and cardiologists.

Thanks for any help 🙂

Hi fellow heart enthusiasts.

I'm a rising first year cardiology fellow. I have a career/job question.

I find cardiac MRI fascinating. The first cine MRI I saw of a moving heart felt like love at first sight. But I am also passionate about procedures, I'm certain I want to pursue a career in Intervention, likely structural interventional (SI). Can thes 2 sub sub specialties co-exist in a real job? More importantly, could I find a job where I could split time as a SI + reading cMRI?

Thanks in advance.

This is a situation I have been confronted with not once and I am curious about the way you approach the issue.

Say you have a patient that for some weird reason has a coronary CT scan that is abnormal so he ends up having a coronary angiogogram which shows severe 3 vessel disease with no left main lesion, elevated Syntax score.

He is completely asymptomatic.

What is your approach?

I'm well aware of the results of Ischemia and Courage but I want to to know how others judge the situation in day to day clinical practice.

PGY-3. Didn’t match. I interviewed with a new program and didn’t match again. USDO with an average application, or so I thought. I feel pretty dejected seeing colleagues match into their chosen sub-specialties and to be the only one still not to have matched out of my cohort is deflating. I matched at my #1 residency program thinking the in-house fellowship and other “perks” would help, but it never really materialized. They decided to pick other candidates. I had to go see a therapist at one point because I was riddled with so much self-doubt, anxiety, and melancholy as the fellowship cycle was a giant dud (3 interviews). I think emotionally and mentally, I am much better than where I was 6 months ago, but it is still difficult.

I had folks tell me my app was good. That if I applied broadly I’d be fine. For the time being, I have an external PGY-4 Chief Resident position lined up which I am somewhat excited about. I feel like I owe it to myself to try one more time and perhaps the Chief status will make a difference. I am also thinking of dual-applying to Cards and PCCM perhaps this upcoming year because I think if I it were to be trying to match into something versus not matching again and maybe going to do a HF year or some other CV builder I don’t think I could stomach it. I’m 31, about to get married, and want to at least start making money for my future family.

Thanks for reading and sorry if this is full of self-pity. The world is indifferent at the end of the day. My mentors can only do so much.

Can I get some good cardiology fellowship programme recommendations that take imgs in Pennsylvania??

Thanks in advance 🙏

Hello heart ppl,♥️🧡🩷💚💜,

I am an ED nurse trying to clarify something I heard and hoping you can help. Had a pt present the other day who was at first thought to be a cardiac issue but ultimately was something else. During workup he had a RBBB and a (very) mildly elevated trop. One of the other girls said, "oh well his trops are probably chronically elevated with that BBB." My understanding of BBBs is that they're basically just an aberrant electrical pathway, so I don't gather why someone should have elevated trops with same. Pt was not bradycardic. The dude also had lots of other reasons why his trop might be slightly up, but I'm more interested in this comment as I've never heard that BBBs should be associated with chronic "troponitis"- is this true and if so can someone explain to me why that would be the case? Thanks

This is a common question I often receive overnight concerning patients experiencing acute atrial fibrillation (AF) with rapid ventricular response (RVR) and either soft pressures or heart failure (HF), where the physician calling cannot administer beta-blockers (BB) or other AV node-blocking agents.

How do you generally approach the question of using amiodarone and the risk of inadvertent cardioversion/stroke (disregarding digoxin) in these scenarios?

For instance, if a patient arrives at the hospital in new decompensated HF with new AF with RVR and the HR is persistently > 130s and the BP is 90/60s.

Hi everyone,

I just matched IM, and I love cardiology. I was wondering if anyone fellows or attendings out are willing to answer a few questions I have. Im motivated to work as hard as I can to secure a fellowship, and I feel like some guidance would really help. Thank you!