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Arjun Khadilkar, MD Profile picture
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Jan 26 • 9 tweets • 4 min read
One of the most important diagnostic tests in Cardiology to interpret is the EKG.

Here are my thoughts and notes. Will continue to this thread. Let me know what you think!

#arjuncardiology #medtwitter #CardioTwitter #MedEd #IMG
Conduction System:
- SA node (pacemaker cells) have specialized conduction tissue
- SA node is located in the RA near the opening of the SVC
- Stimulation occurs from right atrium to left atrium
- Simultaneous atrial contractions allows for blood filling into LV and RV
Conduction:
- AV Junction: Located at the base of the inter-atrial septum and extends into the inter-ventricular septum; the proximal portion is the AV node and distal portion is bundle of His
- Left & Right Bundle branches depolarize the myocardium via Purkinje fibers
Conduction:
- Electromechanical coupling: release of calcium ions inside atrial and ventricular heart muscles
- Fastest conduction in Purkinje fibers; slowest in the AV node
- Failure of SA node to stimulate atria can lead to sick sinus syndrome or sinus node dysfunction
Benefits of EKG:
- Electrical disturbances (at AV junction, bundle branch block)
- Mechanical & Metabolic problems (myocardial infarction, electrolyte disorders, drug toxicity)
- Preventable catastrophes (prolonged QTc)
Baseline Resing Potential:

- Normal ‘resting’ myocardial cells (atrial and ventricular cells) are polarized (outside positive and inside net negative of -90 mV)

- Depolarization: Occurs from. Endocardium to epicardium

- Repolarization: Epicardium to the endocardium
Definitions:
- P-wave: Atrial Depolarization
- QRS: Ventricular Depolarization
- ST, T-wave, and U-wave: Ventricular Repolarization
-U-wave: Small deflection after T-wave, final phase of ventricular depolarization
- PR Interval: Time for stimulus through atrium & through AV
Definitions:
- Q-wave: Initial downward deflection
- R-wave: First positive deflection
-S-wave: First negative deflection after R-wave
-QS: Completely negative deflection
- QRS Width: Time to pass through the ventricles, should be < 0.10 seconds
Stay tuned for more threads. Let me know what you think!

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More from @akhadilkarMD

Arjun Khadilkar, MD Profile picture
Jan 8
As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 4: Clinical Consequences of Hypertensive Urgency/Emergency

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd
1) Hypertensive Encephalopathy
- Cerebral edema is induced by markedly elevated blood pressures
- Dysregulation of auto-regulatory capabilities of the brain
- Characterized by headache, irritability, and altered mental status
- Treatment of choice: Nitroprusside/Labetalol
2) Reversible Posterior Leukoencephalopathy Syndrome (PRES)
- MRI may reveal white matter edema in the parito-occipital regions
Read 9 tweets
Arjun Khadilkar, MD Profile picture
Jan 3
As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 3B: Therapy

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd
Fenoldopam:
- Used mainly by anesthesiologists to control BP intra-operatively
- Selective peripheral dopamine-1 receptor agonist approved for the management of severe HTN
- Arterial vasodilator w/ relatively short half-life
- Contraindicated w/ glaucoma b/c can raise ICP
Nicardipine:
- Dihydropyridine calcium channel blocker that inhibits vascular smooth muscle contraction
- Little to no activity on the AV or sinus node
- Does not raise ICP and reduces cerebral ischemia
- Contraindicated w/ advanced HF, acute MI, and renal failure
Read 8 tweets
Arjun Khadilkar, MD Profile picture
Jan 3
As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 3A: Therapy

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd
Therapy:
- The presence of acute/rapidly progressive end-organ damage and not the absolute BP determines whether the situation is an emergency
- Goals should be based on mean arterial pressure (MAP) with close monitoring in ICU setting with arterial line
Therapy:
- In general, should reduce no more than 25% of MAP in the first 24 hours; after this time will be more gradual and allow auto-regulatory mechanisms to reset
- Exceptions: more aggressive BP reduction in aortic dissection, post-operative bleeding, and pulmonary edema
Read 11 tweets
Arjun Khadilkar, MD Profile picture
Dec 31, 2022
As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 2: Etiology, Presentation, Diagnosis

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd
Etiology:
- 30-40% with hypertensive crisis have an identifiable underlying cause
- Should evaluate for secondary causes
- Common scenario: Inadequate treatment/medication non-compliance
- Risk factors: Male, low socioeconomic, tobacco use, oral OCP use
Underlying Contributing Pathology:
- Renal parenchymal disease
- Renovascular HTN
- Collagen vascular disease
- Scleroderma
- Vasculitis
- Pre-eclampsia
- Untreated OSA
Read 12 tweets
Arjun Khadilkar, MD Profile picture
Dec 30, 2022
As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 1: Background & Pathophysiology

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd
Background:
- More than 50 million in the US are diagnosed with systemic hypertension, many of whom are inadequately controlled
- Unless acute hypertensive crisis is properly recognized and treated, can lead to acute CNS, renal, cardiovascular dysfunction & death
Background:
- Normal blood pressure: defined as < 130/80
- Severe hypertension: systolic > 180 mm Hg and/or diastolic > 120 mm Hg
Read 11 tweets
Arjun Khadilkar, MD Profile picture
Dec 7, 2022
As a Cardiology fellow, we get a lot of consults for HFpEF.

Part 1: Background & Presentation

*Not to use as medical advice, just tips, and always discuss with your fellow/attending*

-thread 🧵-

#MedTwitter #MedEd #Cardiotwitter #IMG
Background:
- Heart Failure with Preserved Ejection Fraction composes nearly 50% of heart failure with overall similar survival rates to HFrEF
- Patients tend to be older, more likely to be female
- Associated with HTN, DM, Obesity, and CKD
Definition:
- LV ejection fraction > 50%
- Patients have signs and symptoms of heart failure
- Evidence of diastolic dysfunction (seen on doppler echo, catheterization, and natriuretic peptide measurement)
Read 10 tweets

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