Can music help us understand cardiac arrhythmias? 🎵💓 In this special podcast episode, I explore how musical notation can be used to visualize and "hear" ECG rhythms, providing an intuitive and structured approach to learning atrial fibrillation, AV blocks, ventricular tachycardia, and more. By "hearing" arrhythmias and "reading" them in a musical framework, trainees can develop an alternative approach to ECG interpretation, reinforcing pattern recognition through both visual and auditory learning modalities.Musical score published in JACC Clinical Electrophysiology:
https://doi.org/10.1016/j.jacep.2025.02.022📖 Musical notation as a novel framework for ECG teaching:🎼 Atrial activity (P waves) = High-pitched chimes🥁 Ventricular beats (QRS complexes) = Low-pitched snare drumNote Durations Reflect Physiological Intervals:🔹 P wave = 32nd note → Approximates a normal PR interval (120-200 ms)🔹 PR prolongation (1° AV block) = 16th note → Reflects delay in AV node conduction🔹 Dropped beats (2° AV block) = Missing notes → Represent non-conducted impulses🔹 Rapid rhythms (VT, SVT) = Increased tempo → Matches clinical tachycardia rates🔹 Irregular rhythms (AFib, MAT) = Variable note spacing → Captures unpredictable R-R intervalsThis lecture is designed for medical students, cardiology fellows, electrophysiologists, and music lovers who want to experience a new way of learning cardiology! I have also provided this talk to JACC: Clinical Electrophysiology as a Supplemental Video. Please see the paper here.
Tweetorial: https://x.com/ruey_hu/status/1919074533354656101🔔 Subscribe for more cardiology and medical education content!📢 Leave a comment below: What other arrhythmias can be represented through classical music notation? Let’s discuss!#Cardiology #MedicalEducation #ECG #Arrhythmia #MusicAndMedicine #Electrophysiology #HeartRhythm
Should non-culprit lesions be revascularized in STEMI and NSTEMI? Should revascularization of non-culprit lesions occur in a simultaneous or staged manner? How do these recommendations differ when acute MI presents with cardiogenic shock? When DAPT is reduced to SAPT, which P2Y12 inhibitor is favored for monotherapy? When is de-escalation from ticagrelor/prasugrel to clopidogrel reasonable? In post-PCI patients requiring antithrombotic therapy, what should the duration of triple therapy be, and what is the P2Y12 inhibitor of choice? What is the role of Impella, IABP, and VA-ECMO in ACS with cardiogenic shock? Tune in for answers to these questions in this "deep dive" of the 2025 AHA/ACC Guideline for the Management of Patients with Acute Coronary Syndromes.
Difficulty Level: Intermediate
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In this episode, we review congenital single ventricle, including physiology, surgical repair, and long-term management. What are the different types of univentricular heart defects, and how do they affect the systemic and pulmonary circulations? What are the three steps of staged surgical repair for single ventricle, and what are the indications for each? What is the difference between classic (unidirectional) Glenn surgery and bidirectional Glenn surgery? What is the difference between classic Fontan surgery, direct RA-to-PA Fontan, lateral tunnel Fontan, and extracardiac Fontan? What are the common post-repair complications, including arrhythmias, Fontan-associated liver disease (FALD), and thrombosis, and how are these complications managed? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review transposition of the great arteries (TGA), including the physiology, imaging, repair strategies, and potential complications. What is the difference between D-TGA (complete TGA) and L-TGA (congenitally corrected TGA), and why are they named D- and L-? How does blood flow through the heart in D-TGA, and why is a shunt necessary for survival? What imaging features help identify what is serving as a right ventricle versus a left ventricle? What do the atrial switch (Mustard, Senning), arterial switch (Jatene), and Rastelli surgeries entail, and what are their complications? In what subset of D-TGA patients is the Rastelli surgery indicated? How can you distinguish truncus arteriosus from tetralogy of Fallot with pulmonary atresia on imaging? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review right side congenital abnormalities, including Ebstein’s anomaly, double-chambered right ventricle (DCRV), tricuspid hypoplasia, and pulmonic hypoplasia. Which condition is characterized by "atrialization" of the right ventricle? How does the apical displacement of the septal leaflet of the tricuspid valve in Ebstein anomaly compare with what occurs in atrioventricular septal defect? What is the significance of an accessory pathway in patients with Ebstein’s anomaly? What are the indications for surgical intervention in Ebstein’s anomaly? How can tricuspid valve dysplasia be distinguished from Ebstein’s anomaly? What is the role of right ventricle-to-pulmonary artery conduits, and when should they be replaced? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review Tetralogy of Fallot (TOF), including its pre-repair issues, surgical options, and post-repair complications. What are the four cardinal abnormalities seen in TOF, and how do they impact right-to-left shunting and systemic oxygenation? What are the differences between the Blalock-Taussig shunt, the Waterston or Potts shunts, and complete TOF repair? What surgical strategies are used today? When are temporizing procedures acceptable over complete repair? What are the long-term complications after TOF repair, including pulmonary regurgitation (PR), arrhythmias, and sudden cardiac death, and how are these managed? When is it acceptable to perform pulmonary valve replacement in post-TOF repair patients who have moderate or severe PR that is asymptomatic? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review coarctation of the aorta (CoA), including its epidemiology, presentation, imaging, and management. Which type of VSD is commonly seen in patients with CoA? What proportion of CoA patients have bicuspid aortic valve, and what proportion of bicuspid aortic valve patients have CoA? What key physical exam findings suggest CoA, and how does it present in young patients versus adults? What pattern should you see on PW Doppler of the descending aorta and CW Doppler of the coarctation? What is considered a significant peak-to-peak gradient across a coarctation? What are the criteria for surgical or transcatheter intervention? What are the long-term complications after repair? When should you suspect re-coarctation after CoA repair? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review the physiology, imaging, and management of patent ductus arteriosus (PDA). What is the classic murmur of PDA, and how does it change with shunt reversal? Why do patients with PDA get left heart enlargement instead of right heart enlargement? How does the differential cyanosis seen in PDA with Eisenmenger syndrome present? How do you calculate pulmonary artery systolic pressure using PDA velocity? How do you distinguish the Doppler CW profile of PDA from pulmonary valve regurgitation? What are the indications for PDA closure, and why are Qp ratios not used as they are for ASD and VSD? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we explore anomalous pulmonary venous return (APVR), including its types, associated conditions, and management. What is the difference between total anomalous pulmonary venous return (TAPVR) and partial anomalous pulmonary venous return (PAPVR)? How do supracardiac, cardiac, infracardiac, and mixed types of TAPVR differ? Which ASD type is most commonly associated with PAPVR? What are the physiologic consequences of right heart overload caused by APVR, and what are the criteria for surgical intervention? How is Scimitar syndrome diagnosed and managed, and when should surgery be considered for this rare condition? Lastly, we will touch upon persistent superior vena cava syndrome. Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we explore atrioventricular septal defects (AVSD), covering its types, physiology, and when to intervene. How do complete, partial, transitional, and intermediate AV septal defects differ in structure and physiology? What are the anatomic and functional consequences of a primum ASD with cleft mitral valve, and how does this affect the mitral valve's position relative to the tricuspid valve? What challenges do patients with AVSD face post-surgery, including risks of mitral regurgitation, left ventricular outflow tract obstruction, and arrhythmias? When is surgery recommended for AVSD, and what are the key considerations for long-term follow-up? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review ventricular septal defects (VSDs), including their types, physiology, and management. What are the differences between inlet, outlet, membranous, and trabecular VSDs? How do these defects vary in terms of location, association with other cardiac conditions, and suitability for percutaneous closure? Which VSD types tend to have aortic cusp prolapse, leading to aortic regurgitation? If you see a color jet from a VSD in parasternal short axis view, what is the significance of the color jet being adjacent to the tricuspid valve versus being adjacent to the pulmonary valve? What are the physiologic consequences of left-to-right shunting in VSDs, and how does this lead to left heart dilation, pulmonary overcirculation, and potential progression to Eisenmenger syndrome? What are the criteria for VSD closure? Which is the only VSD type that is amenable to percutaneous closure? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review patent foramen ovale (PFO), including its types, physiology, presentation, and when to intervene. How does a PFO differ from an atrial septal defect (ASD), and why does PFO not cause the right heart enlargement and pulmonary hypertension seen in ASD? What is platypnea-orthodeoxia syndrome? What can cause platypnea-orthodeoxia syndrome other than PFO? What features on brain MRI suggest that the etiology of an ischemic stroke is cardioembolic? What features on echocardiography distinguish between PFOs and ASDs? How can PFOs contribute to cryptogenic stroke, and what high-risk features indicate the need for closure? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review atrial septal defects (ASDs), including their types, imaging, and management. What is the difference between secundum defect, primum defect, sinus venosus defect, and coronary sinus defect? Which is the only ASD defect out of the four that can be percutaneously closed (in addition to surgically closed)? Which ASD type is accompanied by anomalous pulmonary venous return? What are the physiologic consequences of left-to-right shunting in ASDs, and how can these lead to pulmonary hypertension and RV failure? What is Holt-Oram syndrome? What are the criteria for ASD closure? Tune in for answers to these questions.
Difficulty Level: Advanced
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In this episode, we review the epidemiology of congenital heart diseases and develop a framework for categorizing them by cyanotic and non-cyanotic disorders, and go over physiologic concepts across congenital conditions. What are the 5 'T' disorders that are characterized by cyanosis? What are the non-T disorders that can develop cyanosis? What is the tipping point for Eisenmenger syndrome to occur? What are the non-cardiac manifestations of Eisenmenger syndrome? Is phlebotomy appropriate in Eisenmenger syndrome? What is the role of bosentan and sildenafil/tadalafil in Eisenmenger syndrome? What Qp/Qs ratio indicates a large left-to-right shunt that requires repair? What Qp/Qs ratio indicates a a small left-to-right shunt? What Qp/Qs ratio indicates net right-to-left shunting? What is the Flamm formula for calculating mixed venous saturation proximal to a transatrial shunt? What should you suspect if pulmonary oxygen saturation exceeds 80%, or is 8% higher than the superior vena cava's oxygen saturation? What is the difference between physiologic shunting and anatomic shunting? What conditions comprise ACHD physiologic stages A, B, C, and D? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review highlights of cardiovascular considerations in pregnancy. How does pregnancy affect blood volume, systemic vascular resistance, pulmonary vascular resistance, heart rate, and cardiac output? What routine physical exam findings in pregnancy that can mimic heart disease, and what physical exam findings are abnormal in pregnancy? How do LV mass, chamber size, and LV outflow tract velocity time integral (VTI) change in pregnancy? What is the effect of labor and delivery on cardiac output, blood volume, and venous return? What conditions comprise WHO risk class IV pregnancy patients? If a patient with peripartum cardiomyopathy has recovery of LV ejection fraction to >=50%, which WHO pregnancy class does that place them in? Are aspirin, clopidogrel, and heparin safe in pregnancy? What is the difference between gestational hypertension, pre-eclampsia, and eclampsia? What severe features comprise the diagnosis of pre-eclampsia with severe features? What is the target blood pressure in pregnancy? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review cardiac masses, including primary benign, primary malignant, and secondary (metastatic) cardiac tumors. Are malignant tumors much more likely to occur in the ventricles or the atria? If you see a myxoma in any cardiac chamber other than the left atrium, what syndromic complex should you suspect? What echocardiographic features distinguish benign and malignant cardiac masses? Which type of sarcoma is the most common primary cardiac tumor? What are the most common sources of metastatic cancer to the heart? Which cardiac chamber or junction would you find the moderator band, eustachian valve, crista terminalis, and Chiari network, which may be mistaken as cardiac masses? In what situation is resection of a papillary fibroelastoma indicated? How can you differentiate between Lambl's excrescences, fenestrated aortic valve, and nonbacterial thrombotic endocarditis? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review orthostatic hypotension (OH). What criteria define OH? What is a simple way to distinguish neurogenic OH from volume depletion-related OH? What criteria define postural orthostatic tachycardia syndrome (POTS)? What non-pharmacologic measures should be undertaken as first-line measures for OH? How do fludrocortisone, midodrine, droxidopa, and atomoxetine work, and what are their side effects? How is supine hypertension managed? Tune in for answers to these questions.
Difficulty Level: Easy
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In this episode, we explore the diagnosis and management of three important causes of secondary hypertension: renovascular hypertension, primary aldosteronism, and pheochromocytoma. Which segments of the renal artery are preferentially affected by atherosclerotic renovascular hypertension versus fibromuscular dysplasia, and which is more likely to be accompanied by disease in other arterial beds? What characteristics suggest that a patient may benefit from renal artery revascularization? What next steps do you pursue if a plasma aldosterone to renin ratio exceeds 20? How do you differentiate between unilateral adenoma and bilateral adrenal hyperplasia? When would you pursue a MIBG scan in pheochromocytoma? Tune in for answers to these questions.
Difficulty Level: Easy
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In this episode, we review hypertensive urgency and emergency. What counts as "end-organ" damage in hypertensive emergency? What neurological signs are consistent with hypertensive encephalopathy? Which acute conditions require bringing systolic blood pressure (SBP) down to ≤160 mmHg in the first hour, and which require bringing SBP down to ≤140 mmHg in the first hour? Which acute conditions require bringing SBP down to ≤120 mmHg in the first 5 minutes? How does the BP threshold change in acute ischemic stroke depending on whether you plan to give tissue plasminogen activator (tPA) or not? What is permitted hypertension? Tune in for answers to these questions.
Difficulty Level: Intermediate
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In this episode, we review chronic hypertension. How did the the definitions of stage 1 and stage 2 hypertension change in the most recent AHA/ACC/ASH guidelines? What happened to "prehypertension"? Which chronic condition needs control of systolic blood pressure (SBP) to <120/80; which conditions need control of SBP to <130/80? What is the natural variation in BP with sleep and with age? What are the most common causes of secondary hypertension? Which outpatient antihypertensives cause reflex tachycardia, and which cause salt and water retention? Tune in for answers to these questions.
Difficulty Level: Easy
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