References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Attaran RR, Edwards ML, Arena FJ, et al. 2025 SCAI Clinical Practice Guidelines for the Management of Chronic Venous Disease: This statement was endorsed by the Society for Vascular Medicine (SVM). J Soc Cardiovasc Angiogr Interv. 2025;4(8):103729. Published 2025 Jun 30. doi:10.1016/j.jscai.2025.103729 O'Malley PG, Fukaya E, Kolluri R. Nonsurgical Management of Chronic Venous Insufficiency. N Engl J Med. 2024;390:727-735. DOI: 10.1056/NEJMcP2310224 The 2020 update of the CEAP classification system and reporting standards. Lurie, Fedor et al. Journal of Vascular Surgery: Venous and Lymphatic Disorders, Volume 8, Issue 3, 342 - 352

*]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" dir="auto" data-turn-id= "request-69209691-f368-832a-9fca-8c5d6a87f659-9" data-turn-id-container= "request-69209691-f368-832a-9fca-8c5d6a87f659-9" data-testid= "conversation-turn-242" data-scroll-anchor="false" data-turn= "assistant"> In this episode, we review hypotension, a clinical state of abnormally low blood pressure that can lead to inadequate tissue perfusion and organ dysfunction. We discuss the major underlying mechanisms, including hypovolemia, distributive shock, cardiogenic causes, and obstructive physiology, along with common risk factors such as dehydration, hemorrhage, sepsis, medications, endocrine disorders, and cardiac disease. The episode highlights classic signs and symptoms including dizziness, syncope, weakness, altered mental status, tachycardia, and signs of shock, emphasizing the importance of identifying the underlying cause rather than treating the blood pressure value alone. We also review key components of the diagnostic evaluation, including orthostatic vitals, laboratory studies, EKG, and bedside assessment of perfusion, as well as initial management with fluid resuscitation, vasopressors when indicated, and rapid treatment of the underlying etiology. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Wieling W, Kaufmann H, Claydon V et al. Diagnosis and treatment of orthostatic hypotension. The Lancet Neurology, 21, 735-746 Goldberger, Z, Petek, B, Brignole, M. et al. ACC/AHA/HRS Versus ESC Guidelines for the Diagnosis and Management of Syncope: JACC Guideline Comparison. JACC. 2019 Nov, 74 (19) 2410–2423. https://doi.org/10.1016/j.jacc.2019.09.012 VanWijnen VK, Finucane C, Harms MPM, Nolan H, Freeman RL, Westerhof BE, Kenny RA, terMaaten JC, Wieling W (University Medical Center Groningen, University of Groningen, The Netherlands; St James's Hospital; Lincoln Gate, Trinity College, Dublin, Ireland; Harvard Medical School, Boston, MA, USA; VU University Medical Center; Academic Medical Center, Amsterdam, The Netherlands). Noninvasive beat-to-beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages (Review). J Intern Med2017; 282: 468–483 Kim, M. J., & Farrell, J. (2022). Orthostatic Hypotension: A Practical Approach. American family physician, 105(1), 39–49. 

In this episode, we review hypertensive emergency, a life-threatening condition defined by severely elevated blood pressure accompanied by acute end-organ damage. We discuss the underlying pathophysiology of vascular endothelial injury and impaired autoregulation, along with common risk factors such as chronic uncontrolled hypertension, medication nonadherence, kidney disease, stimulant use, and endocrine disorders. The episode highlights classic clinical presentations including neurologic deficits, chest pain, pulmonary edema, acute kidney injury, and retinal changes, emphasizing the importance of identifying organ dysfunction rather than focusing on the blood pressure number alone. We also cover diagnostic evaluation, including laboratory testing, EKG, imaging, and fundoscopy, as well as evidence-based treatment with carefully titrated IV antihypertensive therapy to avoid overly rapid blood pressure reduction. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Peixoto AJ. Acute severe hypertension. N Engl J Med. 2019;381(19):1843-1852. doi:10.1056/NEJMcp1901117 Bress AP, Anderson TS, Flack JM, et al. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension. 2024;81(8):e94-e106. doi:10.1161/HYP.0000000000000238 Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2025;86(18):1567-1678. doi:10.1016/j.jacc.2025.05.007 

In this episode, we review giant cell arteritis (GCA), an autoimmune large-vessel vasculitis that most commonly affects the temporal arteries and can lead to devastating ischemic complications if not recognized early. We discuss the underlying inflammatory pathophysiology, major risk factors including advanced age and polymyalgia rheumatica, and the hallmark presentation of temporal headache, jaw claudication, scalp tenderness, and transient vision loss. The episode also covers key diagnostic findings such as elevated ESR and CRP, the classic "halo sign" on Doppler ultrasound, and why temporal artery biopsy remains the gold standard for diagnosis. Treatment focuses on the urgent initiation of high-dose glucocorticoids to prevent permanent vision loss and other vascular complications. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Weyand, C. M., & Goronzy, J. J. (2023). Immunology of Giant Cell Arteritis. Circulation research, 132(2), 238–250. https://doi.org/10.1161/CIRCRESAHA.122.322128 Samson, M., Corbera-Bellalta, M., Audia, S., Planas-Rigol, E., Martin, L., Cid, M. C., & Bonnotte, B. (2017). Recent advances in our understanding of giant cell arteritis pathogenesis. Autoimmunity reviews, 16(8), 833–844. https://doi.org/10.1016/j.autrev.2017.05.014 Cacoub, P., Vieira, M., Langford, C. A., Tazi Mezalek, Z., & Saadoun, D. (2025). Large-vessel vasculitis. Lancet (London, England), 406(10514), 2017–2032. https://doi.org/10.1016/S0140-6736(25)01436-9   

In this episode, we review atrial flutter, a supraventricular tachyarrhythmia caused by a reentrant electrical circuit within the atria that produces the classic "sawtooth" flutter waves on EKG. We discuss the underlying pathophysiology, major risk factors including heart failure, COPD, coronary artery disease, hypertension, hyperthyroidism, and obstructive sleep apnea, and the typical presentation of palpitations, dyspnea, fatigue, and chest pain. Diagnostic evaluation focuses on recognizing the characteristic 2:1 AV conduction pattern with atrial rates near 300 bpm and ventricular rates around 150 bpm. We also cover acute management with rate control, rhythm control, and cardioversion, as well as long-term treatment strategies including catheter ablation and anticoagulation guided by the CHA₂DS₂-VASc score. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Writing Committee Members, Joglar JA, Chung MK, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(1):109-279. doi:10.1016/j.jacc.2023.08.017 Wolfes, J, Ellermann, C, Frommeyer, G. et al. Comparison of the Latest ESC, ACC/AHA/ACCP/HRS, and CCS Guidelines on the Management of Atrial Fibrillation. J Am Coll Cardiol EP. 2025 Apr, 11 (4) 836–849.  January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):e199-e267. doi:10.1161/CIR.0000000000000041 

In this episode, we review rheumatic heart disease, a chronic valvular complication that develops after acute rheumatic fever following untreated Group A Streptococcal pharyngitis. We discuss the autoimmune pathophysiology driven by molecular mimicry, leading to inflammatory damage of the heart valves, particularly the mitral valve. Clinical manifestations including migratory polyarthritis, carditis, murmurs, Sydenham chorea, erythema marginatum, and subcutaneous nodules are reviewed along with the classic Jones criteria used for diagnosis. We also cover characteristic echocardiographic findings, long-term complications such as mitral stenosis, atrial fibrillation, heart failure, and embolic stroke, and treatment strategies including antibiotics, anti-inflammatory therapy, and secondary prophylaxis with penicillin. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nature Reviews Disease Primers. 2016;2(1). doi:10.1038/nrdp.2015.84 Dougherty S, Okello E, Mwangi J, Kumar RK. Rheumatic heart disease. Journal of the American College of Cardiology. 2023;81(1):81-94. doi:10.1016/j.jacc.2022.09.050 Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. The Lancet. 2012;379(9819):953-964. doi:10.1016/s0140-6736(11)61171-9

In this episode, we review cardiac tamponade, a life-threatening condition caused by rapid accumulation of fluid within the pericardial sac leading to impaired ventricular filling and hemodynamic collapse. We discuss the underlying pathophysiology of rising intrapericardial pressure, common causes including malignancy, infection, autoimmune disease, uremia, trauma, and post-MI complications, and why the rate of fluid accumulation is often more important than the total volume. Clinical presentation, including dyspnea, chest pain, tachycardia, hypotension, and shock, is reviewed alongside classic exam findings such as Beck's triad and pulsus paradoxus. We also cover high-yield diagnostic findings on echocardiography, EKG, and chest imaging, as well as emergent management with pericardiocentesis and definitive treatment of the underlying cause. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Adler Y, Ristić AD, Imazio M, et al. Cardiac tamponade. Nature Reviews Disease Primers. 2023;9(1). doi:10.1038/s41572-023-00446-1 Spodick DH. Acute cardiac tamponade. New England Journal of Medicine. 2003;349(7):684-690. doi:10.1056/nejmra022643 Wang TK, Klein AL, Cremer PC, et al. 2025 concise clinical guidance: An ACC expert consensus statement on the diagnosis and management of pericarditis. JACC. 2025;86(25):2691-2719. doi:10.1016/j.jacc.2025.05.023

n this episode, we review atrioventricular (AV) blocks, focusing on the mechanisms, EKG findings, clinical presentation, and management of first-, second-, and third-degree heart block. We discuss how conduction delays through the AV node can range from benign prolongation of the PR interval to complete electrical dissociation between the atria and ventricles. Key distinctions between Mobitz type I (Wenckebach) and Mobitz type II are emphasized, along with the life-threatening implications of complete heart block. Clinical symptoms such as bradycardia, dizziness, syncope, fatigue, and hypotension are reviewed, as well as important causes including ischemic heart disease, medications, fibrosis, and increased vagal tone. We also cover hallmark EKG patterns, indications for pacing, and high-yield clinical pearls to help listeners confidently recognize and manage AV conduction abnormalities in both exams and clinical practice. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Ahmed I. Atrioventricular Block. StatPearls [Internet]. February 12, 2024. Accessed March 15, 2026. https://www.ncbi.nlm.nih.gov/books/NBK459147/. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Journal of the American College of Cardiology. 2019;74(7). doi:10.1016/j.jacc.2018.10.044 Wung S-F. Bradyarrhythmias. Critical Care Nursing Clinics of North America. 2016;28(3):297-308. doi:10.1016/j.cnc.2016.04.003

In this episode, we review atrial septal defects (ASDs), one of the most common congenital heart defects characterized by persistent communication between the atria resulting in a left-to-right shunt. We discuss the major ASD subtypes, including secundum, primum, sinus venosus defects, and patent foramen ovale, along with the pathophysiology behind right heart enlargement and pulmonary overcirculation. Clinical presentation ranges from asymptomatic childhood disease to adult symptoms such as fatigue, dyspnea, palpitations, syncope, and exercise intolerance. Key physical exam findings including fixed splitting of S2 and systolic flow murmurs are highlighted, as well as classic diagnostic findings on echocardiography and EKG. We also cover indications for surgical versus transcatheter closure, long-term complications such as pulmonary hypertension and atrial arrhythmias, and important clinical pearls for recognizing and managing ASD in both pediatric and adult patients. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Geva T, Martins JD, Wald RM. Atrial septal defects. The Lancet. 2014;383(9932):1921-1932. doi:10.1016/s0140-6736(13)62145-5 Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. Journal of the American College of Cardiology. 2008;52(23). doi:10.1016/j.jacc.2008.10.001 Turner ME, Bouhout I, Petit CJ, Kalfa D. Transcatheter closure of atrial and ventricular septal defects. Journal of the American College of Cardiology. 2022;79(22):2247-2258. doi:10.1016/j.jacc.2021.08.082

In this episode, we review atrial fibrillation (AF), the most common sustained cardiac arrhythmia, and discuss the underlying mechanisms driving its characteristic "irregularly irregular" rhythm. We cover the pathophysiology of chaotic atrial electrical activity, major risk factors including advanced age, hypertension, obesity, heart failure, and sleep apnea, and the growing prevalence of AF in the aging population. Clinically, patients may present with palpitations, fatigue, dyspnea, dizziness, chest pain, or exercise intolerance, while some remain asymptomatic. We break down the diagnostic approach with emphasis on classic EKG findings including absent P waves, fibrillatory baseline activity, and variable R-R intervals. Management focuses on the modern AF-CARE approach, including stroke prevention with anticoagulation, rate and rhythm control strategies, and aggressive risk factor modification. References Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817 Bizhanov KA, Аbzaliyev KB, Baimbetov AK, Sarsenbayeva AB, Lyan E. Atrial fibrillation: Epidemiology, pathophysiology, and clinical complications (literature review). Journal of Cardiovascular Electrophysiology. 2022;34(1):153-165. doi:https://doi.org/10.1111/jce.15759 Gawałko M, Linz D. Atrial fibrillation detection and management in hypertension. Hypertension. 2023;80(3):523-533. doi:10.1161/hypertensionaha.122.19459 Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (eacts). European Heart Journal. 2024;45(36):3314-3414. doi:10.1093/eurheartj/ehae176