Cardiology Course FM

Our 100th episode! Long before the first symptom, silent risk factors in the blood build coronary disease — often in young South Asians. In this masterclass Dr. A M Thirugnanam covers the diagnosis and management of familial hypercholesterolaemia, dyslipidaemia, lipoprotein(a), homocysteine and fibrinogen, and the patient with premature coronary disease and no obvious cause. Topics include why LDL is causal and "lower and earlier is better"; ESC targets by risk and Lipid Association of India targets; lipid therapy during the ACS admission and early combination therapy (2025 ESC/EAS focused update); practical laboratory points (non-fasting samples, Friedewald versus direct LDL); FH — genetics, prevalence, clinical signs, Dutch Lipid Clinic Network and Simon Broome criteria, genetic testing, cascade and childhood screening; treatment with high-intensity statins, ezetimibe, PCSK9 antibodies (FOURIER, ODYSSEY OUTCOMES) and inclisiran; homozygous FH — evinacumab, lomitapide, apheresis; FH and pregnancy; non-HDL…

Through a vein in the groin, a small clip grasps the leaflets of a leaking valve and holds them together. Transcatheter edge-to-edge repair of the mitral and tricuspid valves is changing the lives of patients once told nothing could be done. In this masterclass Dr. A M Thirugnanam, author of "Transcatheter Edge-to-Edge Repair of the Mitral and Tricuspid Valves", covers: primary versus secondary (ventricular and atrial) mitral regurgitation; comprehensive and 3D severity assessment; M-TEER for primary MR in high-risk patients (EVEREST II); the secondary MR evidence — COAPT, MITRA-FR, proportionate versus disproportionate MR, RESHAPE-HF2, and the 2025 ESC/EACTS class I recommendation; optimising GDMT and CRT first; atrial secondary MR; anatomical suitability (valve area, gradient, leaflet length, calcification, flail gap and width); pre-procedure work-up; MitraClip and PASCAL; step-by-step M-TEER — transseptal height and position, steering, alignment, grasping, leaflet insertion, residual MR, gradient and…

A mass in the left atrium causing fainting, a stroke in a young adult from a tiny growth on a heart valve, a recurrent pericardial effusion that turns out to be cancer — cardiac tumours are rare, but they test every clinical skill. In this masterclass Dr. A M Thirugnanam explains how to classify cardiac masses (primary benign, primary malignant, metastatic, and pseudo-tumours — with thrombus the commonest mass of all); the three classic presentations — obstruction, embolism and constitutional symptoms — plus arrhythmias, effusion and caval obstruction; examination clues, ECG, chest X-ray and blood tests; myxoma — location, tumour plop, interleukin-6, the Carney complex (PRKAR1A), urgent surgery, no catheter biopsy, and what to do while waiting; papillary fibroelastoma versus Lambl's excrescences and vegetations, and when to operate; lipoma, lipomatous septum, haemangioma, paraganglioma and the cystic tumour of the AV node; rhabdomyoma, tuberous sclerosis and everolimus; fibroma, Gorlin syndrome and sudden…

Some vitamin and micronutrient deficiencies cause life-threatening heart disease that can be cured within hours — others are linked to heart disease in observational studies, yet supplements have failed trial after trial. In this masterclass Dr. A M Thirugnanam separates the deficiencies that must never be missed from the supplements that do not protect the heart. Topics include who is at risk (elderly, alcohol, bariatric surgery, malabsorption, dialysis, vegans, pregnancy, poverty, and drugs such as loop diuretics, proton pump inhibitors and metformin); thiamine deficiency — wet beriberi, shoshin beriberi and infantile beriberi, diagnosis, "thiamine before glucose", and thiamine in heart failure on diuretics; telling beriberi from alcoholic cardiomyopathy; a practical, cost-conscious testing plan; iron deficiency in heart failure and IV iron (IRONOUT HF, CONFIRM-HF, AFFIRM-AHF, IRONMAN); B12 and folate deficiency, severe anaemia and safe transfusion; homocysteine-lowering trials (HOPE-2, NORVIT, VISP) and…

More than a third of the world lives in the tropics, where heart disease is often caused by infections, parasites, venomous bites, poverty and malnutrition — diseases of the young that are frequently missed, yet often curable. In this masterclass Dr. A M Thirugnanam gives a practical framework for diagnosis — the four Ps (place, period, profession and exposures) and the whole-body examination (eschar, conjunctival suffusion, rash, throat membrane, bite marks) — and covers: rheumatic heart disease, penicillin prophylaxis (GOAL) and warfarin in rheumatic AF (INVICTUS); cardiac involvement in dengue (and the fluid dilemma between plasma leakage and myocarditis), scrub typhus, leptospirosis, malaria, typhoid, chikungunya and other viruses; the role of cardiac MRI and biopsy; diphtheria myocarditis and heart block; tuberculous pericarditis, adenosine deaminase, GeneXpert, steroids (IMPI) and pericardiectomy; purulent and amoebic pericarditis; endomyocardial fibrosis; Chagas cardiomyopathy and benznidazole…

Transcatheter aortic valve replacement has transformed the treatment of severe aortic stenosis — but every successful TAVR is won in the planning. In this masterclass Dr. A M Thirugnanam, author of "Transcatheter Aortic Valve Replacement: Tricks and Tips", walks through the whole pathway: defining severe AS and low-flow low-gradient disease (dobutamine stress echo, CT calcium score); asymptomatic severe AS and EARLY TAVR; TAVR versus SAVR and the Heart Team (PARTNER, Evolut, DEDICATE, and the 2025 ESC/EACTS age threshold of 70); what favours surgery; risk stratification with STS, EuroSCORE II, frailty and futility; ECG-gated CT for annulus sizing, calcium, coronary heights, sinuses, access and projection angles; coronary obstruction risk, valve-to-coronary distance, coronary protection and BASILICA; femoral and alternative access, intravascular lithotripsy; echocardiography; coronary CTA and PCI before TAVR (NOTION-3); balloon-expandable versus self-expanding valves (SMART); step-by-step implantation —…

Cardiac drugs save lives every day — but in the wrong dose, the wrong patient or the wrong combination, they can stop the heart. In this masterclass Dr. A M Thirugnanam covers acute overdose and chronic toxicity of cardiac drugs: the first-hour approach (ECG, glucose, electrolytes, drug history, sustained-release preparations and 24-hour observation); activated charcoal and whole bowel irrigation with a protected airway; children and the "one tablet" danger; beta-blocker poisoning (propranolol, sotalol) — atropine, calcium, glucagon, vasopressors, pacing and high-dose insulin with glucose, and why it works; calcium channel blocker poisoning (verapamil, diltiazem, amlodipine) — high blood sugar as a severity marker, methylene blue, lipid emulsion and VA-ECMO; digoxin toxicity in the elderly — triggers, interactions, ECG clues (atrial tachycardia with block, regularised AF, bidirectional VT), interpreting levels after six hours, potassium as a severity marker, digoxin-specific antibody fragments, and care when…

A patient dies or has a poor outcome, grief turns into anger, a crowd gathers in the corridor — and afterwards come complaints, legal notices and sleepless nights. In this honest masterclass Dr. A M Thirugnanam explains how to handle medical negligence allegations, chaotic situations with relatives, and the consequences of a death or poor outcome. Topics include what negligence really is (duty, breach, causation, damage) and why a complication or death is not negligence; the Bolam principle; the Jacob Mathew judgment (2005) on gross negligence and the need for a credible medical opinion before prosecution; BNS section 106 for registered medical practitioners; consumer commissions and medical councils; prevention through honest consent, expectation setting, daily family updates and documentation; telling the family about a complication during a procedure; the first hour after a death; breaking bad news with a SPIKES-style approach; what never to say; what juniors and nurses should do; warning signs of…

The swollen, breathless patient who is not responding to diuretics, whose kidneys are worsening and whose blood pressure is too low for the medicines we want to give — refractory decompensated heart failure carries a very high risk of death. In this masterclass Dr. A M Thirugnanam gives a structured approach: the four questions to ask first (is the diagnosis right, what is the haemodynamic profile, what was the trigger, is there a reversible cause); warm/cold and wet/dry profiles; precipitants and reversible causes (valve disease, ischaemia, tachycardia-mediated cardiomyopathy, constriction, amyloid); immediate relief with non-invasive ventilation and nitrates; adequate IV loop diuretic dosing (DOSE); early urine sodium and urine output to guide treatment (PUSH-AHF); sequential nephron blockade with acetazolamide (ADVOR), thiazides (CLOVER) and SGLT2 inhibitors (EMPULSE); albumin and diuretic response; daily monitoring, natriuretic peptides and lung ultrasound; the cardiorenal syndrome — why congestion, not…

Primary angioplasty has transformed survival after STEMI — yet the sickest patients still die in the first hours, often on the cath lab table. In this masterclass Dr. A M Thirugnanam answers the hard questions. Topics include why primary PCI is preferred, the 90- and 120-minute targets and the pharmaco-invasive strategy (STREAM); whether to stabilise first or go straight to the lab — "stabilise while you move": rhythm, airway, blood pressure, potassium, defibrillator pads and a bedside echo in the first 15 minutes; pre-lab drugs (aspirin, ticagrelor/prasugrel, heparin; morphine delaying absorption; no routine oxygen — DETO2X; no IV beta-blockers in heart failure — COMMIT); nitrates in RV infarction; consent and talking to the family; when not to go straight to the lab (aortic dissection, major bleeding, late stable presenters — OAT, futile arrest); post-arrest STEMI (COACT, TOMAHAWK); the causes of death on the table — shock, reperfusion VF, Bezold-Jarisch bradycardia, no-reflow, mechanical complications,…

Every doctor eventually meets the patient who does not fit — the case labelled anxiety, viral or "just age", or the condition you have never seen before. In this masterclass Dr. A M Thirugnanam shares a step-by-step method for finding the hidden diagnosis. Topics include why diagnoses are missed (anchoring, diagnosis momentum, premature closure, attribution to age or anxiety); the four kinds of difficult case; starting again from zero with your own history, timeline, three-generation family history, travel, occupation and drug history; whole-body examination (skin, eyes, joints, all four pulses, both-arm blood pressure); problem representation, the "pivot" finding and the "orphan" finding; Occam's razor versus Hickam's dictum; a systematic anatomical and causal framework; common diseases in unusual dress and the "worst case" question; quiet ECG and lab clues (epsilon wave, fever-unmasked Brugada, low voltage with thick walls, eosinophilia, raised calcium, CK in checkpoint-inhibitor myocarditis); MINOCA and…

Expertise is built, not born. In this masterclass we explore what separates an expert cardiologist from an experienced one — and how they pursue perfection in everything within their control. Topics include an honest look at "100% success" (aiming for 100% effort, preparation and honesty rather than claiming perfect outcomes); a deep foundation in physiology and evidence, including knowing who trials such as ISCHEMIA excluded; combining fast pattern recognition with slow analytical reasoning; the cognitive traps — anchoring, premature closure, confirmation and availability bias, diagnosis momentum — and the questions "what else could this be?" and "what is the worst it could be?"; systematic ECG reading; history and examination as the most powerful diagnostic tools; purposeful use of investigations and pretest probability; expert procedural practice — patient selection, preparation, mental rehearsal, bail-out planning, intravascular imaging and physiology, knowing when to stop, and the expert's ten-point…

Which book should you read first — and how do you actually use it on the ward, in the cath lab, in the ICU and in the exam hall? In this special episode, the author takes us on a guided, level-by-level tour of the cardiologybooks.com library. We cover the philosophy behind the books (practical, reasoning-based, evidence-based and instantly downloadable) and why they use numbered notes, algorithms and cases; how they complement large textbooks and guidelines; foundations for students and juniors (ECG Quick Notes, Cardiology Pathophysiology Quick Notes 1500, Quick Cardiology Notes); books for non-cardiologists (Cardiology Quick Notes for Non-Cardiologist, Cardiology for Every Specialty, General Medicine Quick Notes 2000); board preparation (Complete Cardiology MCQ Guide, Think Like an Examiner, Pass the Cardiology Boards in 60 Days, The Differential Drill); case-based learning (Differential Diagnosis in Cardiology: 1800 Clinical Cases, Cardiology Cases That Teach, The World's Greatest Cardiology Cases);…

The ventilator is not just a breathing machine — it is a powerful haemodynamic tool. In this cardiac critical care masterclass we cover heart–lung interactions (positive pressure lowers preload and LV afterload but can raise RV afterload); noninvasive ventilation in acute cardiogenic pulmonary oedema — CPAP and BiPAP settings, the 3CPO trial, contraindications and high-flow nasal oxygen; why intubation is so dangerous in cardiac patients and how to make it safer (pre-induction vasopressors, preoxygenation, reduced-dose ketamine or etomidate, video laryngoscopy); initial ventilator settings — 6–8 mL/kg predicted body weight, plateau <30, driving pressure <15, titrated FiO2; avoiding excess oxygen (AVOID, DETO2X, BOX); PEEP titration for LV versus RV failure; volume versus pressure control and pressure support; monitoring with arterial lines, end-tidal CO2, echo, lung ultrasound and PA catheters; ventilating the failing right ventricle — normal CO2, low PEEP and lung volumes, inhaled nitric oxide or…

Every antibiotic prescription has two sides: it can save a life within hours, or it can harm the patient and breed resistance. In this masterclass we cover a practical, systematic approach to antibiotic selection: deciding whether an antibiotic is needed at all; the five questions — site, likely organisms, the patient, severity and the local antibiogram; tissue penetration and why source control (abscess drainage, device extraction, early surgery in endocarditis) is essential; timing in sepsis and septic shock (Surviving Sepsis Campaign) and "start smart, then focus"; risk factors for MRSA, ESBL and Pseudomonas; narrowing therapy once cultures return (flucloxacillin or cefazolin over vancomycin for MSSA); IV-to-oral switch, with the POET and OVIVA trials; PK/PD dosing — time- versus concentration-dependent killing, extended infusions, AUC-guided vancomycin, loading doses, renal and hepatic adjustment and augmented renal clearance; short-course evidence (STOP-IT and others) and procalcitonin; penicillin…

Often dismissed as a harmless variant, a myocardial bridge can cause recurrent angina, MINOCA, ventricular arrhythmias and even sudden death. In this masterclass we cover what a bridge is and how common it is on angiography, CT and autopsy; why it causes ischaemia — delayed diastolic relaxation worsened by tachycardia and contractility, endothelial dysfunction and vasospasm, proximal atherosclerosis, septal branch steal and microvascular dysfunction; clinical presentations and red flags, including worsening with nitrates; special groups — HCM, athletes and transplant recipients; counselling; the differential diagnosis of angina with "normal" coronaries; angiography (milking effect, intracoronary nitroglycerin), IVUS half-moon sign and OCT; why conventional FFR underestimates bridges and the role of dobutamine diastolic FFR (≤0.76), resting diastolic indices and acetylcholine testing; CT depth and length, stress echo septal buckling, perfusion imaging and cardiac MRI; medical therapy — beta blockers…

Not every lesion needs a stent, and not every patient can have surgery. In this cath-lab masterclass we cover the "leave nothing behind" strategy for inoperable patients and non-stentable lesions: who these patients are — no-option surgical candidates, small vessels, diffuse disease, in-stent restenosis, high bleeding risk and side branches; why small vessels do badly with stents; the evidence for drug-coated balloons — BASKET-SMALL 2, PICCOLETO II, RESTORE SVD, BELLO, and the limits shown by REC-CAGEFREE I; how DCBs work — paclitaxel versus sirolimus, excipients, vasomotion and late lumen enlargement; the paclitaxel safety question; lesion preparation to International DCB Consensus criteria (residual stenosis ≤30%, no flow-limiting dissection, TIMI 3) and pressure-wire support; non-compliant, scoring, cutting and super-high-pressure balloons; debulking in small vessels with rotational and orbital atherectomy, intravascular lithotripsy and excimer laser; calcium as a barrier to drug delivery; IVUS/OCT…

The calcified left main bifurcation combines the three hardest challenges in PCI — the left main, a bifurcation and calcium. In this cath-lab masterclass we cover the Heart Team decision (SYNTAX score, EXCEL, NOBLE and the SYNTAX left main subgroup); pre-procedure planning — angiographic analysis, LV function, access, contrast and kidney protection, and planned mechanical support; why calcium causes stent under-expansion and why lesion preparation comes before stenting; IVUS and OCT assessment — calcium arc, thickness and length, the OCT calcium score, left main MLA thresholds, and evidence for imaging guidance (RENOVATE-COMPLEX-PCI, OCTOBER); the calcium toolbox — non-compliant, scoring, cutting and super-high-pressure balloons, rotational and orbital atherectomy, intravascular lithotripsy (Disrupt CAD III), "Rota-tripsy" and excimer laser; safe rotational atherectomy technique and lithotripsy technique at the left main; one-stent versus two-stent strategy (DEFINITION II, DKCRUSH-V, EBC MAIN); step-by-step…

A normal ECG, a normal echo, a normal treadmill test and even a normal angiogram — yet the heart stopped. In this masterclass we explore sudden cardiac death with normal cardiac tests: why routine tests miss the cause, and how to find it. Topics include sudden arrhythmic death syndrome (SADS) and idiopathic VF; why intermittent and concealed diseases escape detection; the channelopathies — long QT (borderline QT, failure to shorten in exercise recovery, T wave morphology), Brugada (high right precordial leads, fever, ajmaline or flecainide challenge), CPVT, short QT and early repolarisation syndrome; subtle ECG clues — intermittent pre-excitation, epsilon waves, right precordial T inversion, low voltage and short-coupled ectopy; how to measure the QT manually (tangent method, Bazett versus Fridericia); concealed cardiomyopathies — arrhythmogenic, genetic DCM (lamin A/C, filamin C, desmoplakin, RBM20), mild or apical HCM, myocarditis and sarcoidosis — and the role of cardiac MRI and FDG-PET; coronary causes…

A normal angiogram does not mean a normal heart — and many sudden deaths strike people who never had a warning. In this masterclass we cover microvascular angina and the causes, prevention and management of sudden cardiac death. Topics include INOCA and ANOCA; impaired vasodilation versus microvascular and epicardial spasm; risk factors and why women are more affected; invasive coronary function testing — FFR, coronary flow reserve, index of microcirculatory resistance and acetylcholine provocation — and the CorMicA trial; non-invasive PET, perfusion MRI and Doppler; mechanism-based treatment — beta blockers, calcium channel blockers, nitrates, ranolazine, ivabradine, nicorandil, trimetazidine, low-dose tricyclics, rehabilitation and the coronary sinus reducer; prognosis (WISE) and the link with HFpEF; the definition and burden of sudden cardiac death; causes by age — coronary disease and cardiomyopathy in older adults, inherited cardiomyopathies and channelopathies (long QT, Brugada, CPVT, WPW) in the…

An acute myocardial infarction in the middle of chemotherapy — with low platelets, a tumour that could bleed, surgery planned next week, and a cancer drug that may have caused the event. In this masterclass we cover how to diagnose and treat MI during cancer treatment while keeping cancer therapy on track. Topics include why cancer and its treatment raise MI risk (shared risk factors, the pro-thrombotic state, radiotherapy, demand ischaemia); culprit drugs — 5-FU and capecitabine, cisplatin, VEGF inhibitors, ponatinib and nilotinib, immune checkpoint inhibitors, androgen deprivation (HERO), thalidomide and lenalidomide; mimics — vasospasm, checkpoint inhibitor myocarditis, PE, Takotsubo, tamponade, type 2 MI; why a cancer diagnosis should not prevent primary PCI, and why thrombolysis is often contraindicated; SCAI platelet thresholds for angiography, aspirin, clopidogrel and avoiding prasugrel/ticagrelor, with reduced heparin; radial access, intravascular imaging and radiation-related coronary disease; short…

A young mother in labour develops crushing chest pain, a fall in blood pressure, or collapses — an acute myocardial infarction in the labour ward, with two lives at stake. In this masterclass we cover how the cardiologist, obstetrician, anaesthetist and neonatologist recognise and manage it together. Topics include how common pregnancy-associated MI is and who is at risk; the enormous haemodynamic stress of labour and the postpartum surge; why spontaneous coronary artery dissection (SCAD) — not atherosclerosis — is the commonest cause, plus thrombosis, vasospasm and MINOCA; recognising MI in labour with the ECG, troponin and echo; the mimics — pulmonary embolism, aortic dissection, peripartum cardiomyopathy, amniotic fluid embolism, Takotsubo and Kounis syndrome; first steps — the mother comes first, left lateral tilt, aspirin; primary PCI versus thrombolysis, fetal radiation, and deciding whether to deliver first or go to the cath lab first; conservative management of SCAD versus intervention;…

The monitor shows ST elevation in the middle of a laparotomy, the blood pressure falls, and every heart-attack treatment carries a risk of surgical bleeding. In this masterclass we cover acute myocardial infarction during and after non-cardiac surgery, and how the surgeon, anaesthetist and cardiologist handle it effectively as one team. Topics include how common perioperative cardiac events are and why most are silent (VISION); type 1 plaque rupture versus type 2 supply–demand infarction; the first minutes in theatre — confirming ST changes with a 12-lead ECG and TEE, and correcting low blood pressure, bleeding, tachycardia and low oxygen; mimics in theatre — massive PE, anaphylaxis and Kounis syndrome, Takotsubo, vasospasm and bone cement implantation syndrome; damage-control surgery and why thrombolysis is contraindicated after major surgery; primary PCI with aspirin, clopidogrel, radial access, minimal unfractionated heparin, no GP IIb/IIIa, and short DAPT with modern stents (LEADERS FREE, ONYX ONE,…

Patients on dialysis carry an extraordinary cardiovascular risk — yet they were left out of almost every major trial. In this masterclass we cover how to diagnose and treat acute myocardial infarction in patients with kidney failure on dialysis, and how to manage the many complications. Topics include why coronary disease is so aggressive in kidney failure (medial calcification, mineral bone disorder, inflammation, anaemia, LV thickening); atypical presentations — breathlessness, falls in blood pressure during dialysis, arrhythmias; interpreting the ECG with LV strain, LBBB and potassium changes; chronically raised troponin and the importance of the rise and fall; primary PCI without delay for contrast, protecting residual renal function; thrombolysis with unfractionated heparin when PCI is unavailable; protecting the fistula arm and future access, ultrasound-guided femoral access; severe calcium — IVUS/OCT, cutting and scoring balloons, rotational and orbital atherectomy, intravascular lithotripsy;…

A bleeding brain, a blocked coronary artery, and a blood pressure through the roof — every treatment that helps the heart seems to harm the brain. In this masterclass we cover how to handle acute intracerebral haemorrhage with accelerated hypertension together with an acute myocardial infarction. Topics include why the two strike together; the first and most important question — true coronary occlusion or neurogenic stunned myocardium (brain–heart syndrome); subarachnoid haemorrhage mimicking anterior STEMI; how this differs from ischaemic stroke with MI and the danger of aortic dissection; why thrombolysis is absolutely contraindicated; when and how to perform primary PCI — team decision, radial access, minimal heparin, no GP IIb/IIIa or cangrelor, balloon-only and staged stenting; antiplatelet timing and short DAPT with high-bleeding-risk stents (LEADERS FREE, ONYX ONE, MASTER DAPT), avoiding ticagrelor and prasugrel; anticoagulation and VTE prevention; aligning blood pressure targets (INTERACT2,…

A bleed in the brain, a blood pressure of 240/140, and every minute counting. In this masterclass we cover acute intracerebral haemorrhage with accelerated hypertension — and why it is very much the cardiologist's problem. Topics include why hypertension causes deep (putaminal, thalamic, pontine, cerebellar) haemorrhages, and when to suspect amyloid angiopathy, malformations or drugs; hypertensive emergency and malignant hypertension with multi-organ damage; the first minutes — airway, GCS, glucose and non-contrast CT before any antithrombotic; haematoma volume, intraventricular blood, CT angiography and the spot sign; how fast and how far to lower blood pressure (INTERACT2, ATACH-2) and the INTERACT3 care bundle; handling pressures above 220; drug choice — nicardipine, clevidipine, labetalol, esmolol, urapidil — and why to avoid sublingual nifedipine and nitroprusside; immediate reversal of warfarin (4F-PCC, vitamin K), dabigatran (idarucizumab) and factor Xa inhibitors (andexanet, ANNEXA-I, or PCC); why…

Most heart attack patients first reach a hospital without a cath lab. In this masterclass for doctors in district, rural and secondary hospitals, we cover how to manage acute myocardial infarction with cardiogenic shock when primary angioplasty is not in the building. Topics include the scale and mortality of infarct-related shock and the lesson of the SHOCK trial; the first ten minutes — 12-lead ECG, defibrillator pads, aspirin, oxygen only when needed (DETO2X); identifying LV failure, right ventricular infarction (V4R) and mechanical complications, with bedside echo; STEMI equivalents (posterior MI, new LBBB, aVR elevation), shock without ST elevation and mimics such as massive PE; the 120-minute rule — when to transfer and when to thrombolyse, and the pharmaco-invasive strategy (STREAM); tenecteplase dosing including half dose at 75 and over, enoxaparin and clopidogrel, and why streptokinase is a problem in shock; contraindications and excluding aortic dissection; fibrinolysis after cardiac arrest and in…

A patient with dilated cardiomyopathy develops sepsis — then shock after shock from ventricular tachycardia and fibrillation that won't stop. In this masterclass we cover how to tame an electrical storm while treating the infection and supporting a failing pump. Topics include the definition and prognosis of electrical storm; why a dilated, scarred ventricle is electrically unstable (mid-wall and epicardial scar, lamin A/C, filamin C, desmoplakin, sarcoid, myocarditis, Chagas); how sepsis triggers storm — catecholamines, fever, electrolytes, acidosis, low oxygen, QT-prolonging drugs, septic cardiomyopathy and line tips; immediate cardioversion and defibrillation; monomorphic versus polymorphic VT; torsades — magnesium, potassium, stopping culprit drugs and raising the heart rate; the trigger checklist and immediate device interrogation for inappropriate shocks; amiodarone, lignocaine and mexiletine; beta blockade in storm (MANIA) and short-acting esmolol or landiolol in shock; reducing pro-arrhythmic…

Atrial fibrillation, flutter or atrial tachycardia that won't settle — in a patient with a normal left ventricle, and in one whose ventricle has already failed. In this masterclass we cover how the state of the LV changes almost every decision. Topics include whether an arrhythmia is truly refractory (wrong diagnosis, drug or dose, and untreated triggers — thyroid, alcohol, sleep apnoea, obesity, electrolytes); failure of rate control versus failure of rhythm control; recognising flutter and focal atrial tachycardia; risk factor management (LEGACY) and the updated CHA2DS2-VA score; rate and rhythm drugs in the normal heart — beta blockers, diltiazem, verapamil, flecainide, propafenone ("pill in the pocket"), sotalol, dronedarone; first-line ablation (EARLY-AF, STOP AF First, Cryo-FIRST) and pulsed field ablation (ADVENT); ablation complications including tamponade, phrenic palsy and atrio-oesophageal fistula; the AF–heart failure vicious circle and reversible tachycardia-induced cardiomyopathy; safe rate…

A patient with an acute myocardial infarction survives a cardiac arrest — and the heart is mechanically broken: a ruptured ventricular septum, a torn papillary muscle, or a rupture of the free wall. In this masterclass we cover how to recognise, stabilise and repair these patients while protecting the brain after the arrest. Topics include who is at risk (late presenters, unreperfused infarcts, older women, first MI) and the timing of rupture; how each mechanical complication causes or complicates an arrest; PEA, tamponade and ultrasound during resuscitation; parallel post-ROSC priorities for heart, circulation, lungs and brain; when to go to the cath lab (TOMAHAWK, COACT) and the value of angiography before surgery; ventricular septal rupture — diagnosis, oxygen step-up, IABP, the timing debate, and surgical or transcatheter closure; papillary muscle rupture — the soft or absent murmur, flash pulmonary oedema, emergency mitral surgery and rescue TEER; acute and subacute free wall rupture; true versus false…

CABG and surgical aortic valve replacement are among the most effective operations in medicine — but the hours, days and weeks after surgery bring their own complications. In this masterclass we follow the post-operative timeline and show how to recognise and manage each one effectively: telling apart low cardiac output, vasoplegia, bleeding and tamponade in the first hours; epicardial pacing to optimise rate and rhythm; inotropes, IABP and mechanical support; refractory vasoplegia, vasopressin and methylene blue; bleeding thresholds, protamine, viscoelastic testing and early re-exploration; localised post-operative tamponade, blocked drains and the value of TEE; right ventricular failure and inhaled pulmonary vasodilators; cardiac arrest after cardiac surgery (CALS) — three stacked shocks, epicardial pacing and emergency resternotomy; type 5 (CABG-related) MI and early angiography for graft failure; post-operative atrial fibrillation, prevention with posterior pericardiotomy (PALACS) and LAA occlusion…

Every interventional cardiologist fears it: a death on the cath lab table, or a patient who was talking in the morning and gone by evening. In this masterclass we examine why table deaths and in-hospital sudden deaths happen — and how many are predictable, preventable or survivable with preparation. Topics include the true risk of procedural death and the patients who carry it; the five families of table death (coronary catastrophes, arrhythmias, collapse in patients with no reserve, systemic events, and bleeding); heart-team planning, mechanical support on standby, bail-out equipment and the team time-out; reading the pressure tracing — damping and ventricularisation; flow-limiting and iatrogenic left main dissection; no-reflow and intracoronary vasodilators; coronary perforation (Ellis classification), balloon tamponade, dual-guide covered stents, coils and pericardiocentesis; ventricular fibrillation on the table, pre-applied pads, mechanical CPR (LUCAS) and ECPR (ARREST); bradycardia, vagal reactions and…

A patient recovering from a myocardial infarction develops sepsis, then multiple organ failure, then disseminated intravascular coagulation — with a fresh stent that needs antiplatelets and a blood that is clotting and bleeding at once. In this masterclass we cover how to handle it safely and effectively: why post-MI patients become septic (lines, pacing wires, access sites, ventilation, aspiration, urine, C. difficile); separating post-infarction fever from true sepsis, and using procalcitonin wisely; Sepsis-3 and septic shock; the first hour — antibiotics within one hour, small reassessed fluid boluses in the infarcted heart, early norepinephrine, vasopressin and hydrocortisone; holding and later restarting post-MI medicines; aggressive source control and Staphylococcus aureus bacteraemia; the pathophysiology and phenotypes of DIC, the ISTH overt DIC score and the sepsis-induced coagulopathy (SIC) score; excluding HIT (4T score), TTP and drug-induced thrombocytopenia with a blood film; treating the cause,…

When the heart fails, it rarely fails alone. In this masterclass we cover the patient with heart disease and multiple organ failure — kidneys, lungs, liver, brain and blood — and how to break the vicious circle with a clear plan. Topics include the SOFA score and why mortality climbs with each failing organ; the first hour: ABC, shock type, reversible cause, organ support, lactate trends and point-of-care ultrasound; SCAI shock stages A–E; perfusion targets, norepinephrine first (SOAP II), dobutamine, milrinone and vasopressin; fluid as a test, congestion as an organ injury, and VExUS; pulmonary artery catheter, cardiac power output and PAPi; mechanical circulatory support after IABP-SHOCK II, DanGer Shock and ECLS-SHOCK, LV unloading and the shock team; cardiorenal syndrome, urine sodium–guided diuretics, ADVOR and CLOROTIC, and CRRT; non-invasive ventilation, safe intubation in shock and protecting the right ventricle; congestive hepatopathy versus shock liver, drug dosing and viscoelastic testing;…

More patients than ever survive cancer — and many have heart disease before treatment or develop it during therapy. In this masterclass we cover cardiac care during cancer treatment, with one goal: keeping life-saving cancer therapy possible. Topics include the 2022 ESC cardio-oncology guideline and the HFA-ICOS baseline risk tool; ECG, echocardiography with global longitudinal strain, troponin and NT-proBNP at baseline; grading cancer therapy-related cardiac dysfunction (CTRCD); anthracycline cardiotoxicity, dexrazoxane, and cardioprotection with ACE inhibitors, carvedilol and statins (PRADA, CECCY, STOP-CA, SUCCOUR); HER2-targeted therapy and "permissive cardiotoxicity" (SAFE-HEaRt); immune checkpoint inhibitor myocarditis, the myositis–myasthenia overlap, and high-dose methylprednisolone; VEGF inhibitor and TKI hypertension and why to avoid diltiazem and verapamil; CYP3A4 and P-gp drug interactions; QTc monitoring with Fridericia; ibrutinib-related atrial fibrillation (ELEVATE-RR) and anticoagulation;…

Every doctor sees patients worth writing about — but few are ever taught how to write. In this masterclass for undergraduates, postgraduate residents and cardiology fellows, we cover the complete path from a bedside observation to a published paper: what to aim for at each stage of training; finding a research question and testing it with FINER and PICO; a systematic literature search (PubMed, MeSH, Boolean operators) and reference managers; choosing the right study design; involving the statistician early and calculating sample size; ethics committee approval, informed consent, the Declaration of Helsinki, ICMR guidelines and trial registration (CTRI, ClinicalTrials.gov); planning a postgraduate thesis — timeline, protocol, chapters, data management with a codebook, working with your guide, and the commonest examiner criticisms; reporting effect sizes with confidence intervals; writing an original article in IMRAD format and the best order to write it; the reporting guidelines on the EQUATOR Network…

More patients now live beyond 100 — and most of our guidelines stop at 75 or 80. In this masterclass we cover cardiac care for centenarians and the very old: the physiology of the ageing heart (arterial stiffness, diastolic dysfunction, conduction disease, blunted reserve) and the high prevalence of wild-type ATTR amyloid; comprehensive geriatric assessment, the Clinical Frailty Scale and goals of care; avoiding both ageism and over-treatment; deprescribing with STOPP/START and Beers criteria and dosing by Cockcroft-Gault; individualised blood pressure targets and orthostatic hypotension (HYVET, SPRINT); anticoagulation for atrial fibrillation with appropriately dosed DOACs, falls, and very-low-dose edoxaban (ELDERCARE-AF); HFpEF and gentle diuresis, SGLT2 inhibitors (EMPEROR-Preserved, DELIVER); TAVR in nonagenarians and centenarians and the risk of futile procedures; mitral and tricuspid TEER (COAPT, TRILUMINATE); acute coronary syndromes in the very old (After Eighty, SENIOR, MOSCA-FRAIL, POPular AGE),…

We cannot always cure, but we can always care. In this masterclass we cover tertiary cardiac care for the critically ill patient in the final days of life: recognising the dying cardiac patient (refractory shock, progressive multi-organ failure, repeated arrests, mechanical support with no exit strategy), the surprise question and SPICT; excluding reversible causes and using time-limited trials; communicating serious news and leading family meetings with a SPIKES-based approach and substituted judgement; cultural, religious and legal considerations, including India's Common Cause judgment and advance directives; DNACPR decisions and ceilings of treatment; neuroprognostication after cardiac arrest; managing disagreement; withholding versus withdrawing life support and how to withdraw inotropes, mechanical ventilation, IABP, ECMO and dialysis; ICD shock deactivation and LVAD deactivation; expert symptom control for breathlessness, pain, anxiety, delirium and terminal secretions (opioids adjusted for renal…

Every readmission for heart failure is a signal that something has not been fixed. In this masterclass we cover recurrent and worsening heart failure from end to end: the definition of a worsening HF event and the HFrEF, HFmrEF, HFpEF and HFimpEF categories; a systematic search for precipitants (non-adherence, ischaemia, arrhythmia, hypertension, infection, renal dysfunction, harmful drugs, valve disease and under-treatment); diagnosis with clinical congestion and perfusion profiles, NT-proBNP trends, echocardiography, lung ultrasound, VExUS and cardiac MRI, including when to suspect ATTR amyloid; complete decongestion with adequately dosed IV loop diuretics, natriuresis-guided therapy and sequential nephron blockade (DOSE, PUSH-AHF, ADVOR, CLOROTIC); why a modest creatinine rise should not stop decongestion; the four pillars for HFrEF started in hospital and rapidly up-titrated (PARADIGM-HF, PIONEER-HF, DAPA-HF, EMPEROR-Reduced, EMPULSE, SOLOIST-WHF, STRONG-HF); vericiguat, ivabradine, digoxin and…

ECMO buys time — but only if we choose the right patient, the right configuration and a clear destination. In this masterclass we cover the ECMO circuit, choosing veno-venous versus veno-arterial support (and hybrid V-A-V configurations), indications and contraindications, the SAVE and RESP scores, ultrasound-guided cannulation and the distal perfusion cannula, daily circuit management (flows, pressures, pre- and post-oxygenator gases, right radial monitoring and Harlequin syndrome), left ventricular distension and unloading with IABP or Impella (ECPELLA), anticoagulation with unfractionated heparin guided by anti-Xa levels, bivalirudin for HIT, DAPT in freshly stented patients, transfusion and haemolysis monitoring, sedation and antibiotic pharmacokinetics on the circuit, vasopressors and inotropes, weaning (flow-reduction trials with echo criteria for VA-ECMO and sweep-off trials for VV-ECMO), bridge to LVAD or transplant, palliative care, and care after decannulation — illustrated with a fulminant…

Over 58 episodes we have studied diseases. Today we study how an expert thinks. How do you approach the complex, challenging case that does not fit the textbook — the patient with a heart attack, kidney failure and a bleeding history all at once? We cover the four types of complexity, stabilising before thinking, applying trials wisely (is my patient the trial patient?), the Heart Team, cognitive traps such as anchoring and the oculostenotic reflex, risk scores, physiology and intravascular imaging, managing complications, shared decision-making and practice in resource-limited settings — with worked cases drawing on SYNTAX, EXCEL, ISCHEMIA, REVIVED, CULPRIT-SHOCK, DanGer Shock, AUGUSTUS, PIONEER AF-PCI, PARTNER, COAPT and STREAM. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart.…

The Basic Skills That Master Complex and Challenging Cases in Cardiology In our last episode we explored how an expert thinks. Today we go to the foundation underneath: the basic skills that win complex and challenging cases. We cover the investigative history (tempo, trigger, trajectory, background and every medicine), the purposeful examination, a systematic ECG read with the dangerous patterns, focused bedside echo, haemodynamics (pump, pipes, volume or rate), safe radial and ultrasound-guided femoral access, temporary pacing, pericardiocentesis, resuscitation and cardioversion, guide and wire handling, physiology and intravascular imaging, antithrombotic pharmacology and reversal, interpreting labs as trends, procedure planning with bail-out options, closed-loop communication, handover and documentation — drawing on RIVAL, MATRIX, FAME, DEFINE-FLAIR, iFR-SWEDEHEART, ULTIMATE, RENOVATE-COMPLEX-PCI, OCTOBER, EBC MAIN and DKCRUSH. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional…

In our last episode we covered hypertension and the current guidelines. Today we go deeper into the two most challenging forms: resistant hypertension, where blood pressure stays high despite multiple medicines, and malignant hypertension, a true medical emergency in which severely raised blood pressure damages the eyes, kidneys, brain and heart, sometimes within days. We'll cover definitions, how to uncover hidden causes, the step-by-step treatment of resistant hypertension including renal denervation and new drugs, and the emergency management of malignant hypertension. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology…

Today's topic is the single most important modifiable risk factor for death worldwide: hypertension, or high blood pressure. It affects over a billion people, causes strokes, heart attacks, heart failure, kidney disease and dementia — and yet most people with it are either undiagnosed, untreated or poorly controlled. In the last two years, new European and American guidelines have changed how we define, measure and treat blood pressure, and exciting new treatments are arriving. We'll cover diagnosis, the current guidelines, treatment and long-term management. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology courses:…

In our recent episodes we've explored conduction disease, pacemaker modes and cardiac resynchronisation. Today we focus on one of the most remarkable innovations in device therapy: the leadless pacemaker. Imagine a complete pacemaker — battery, electronics and electrode — about the size of a large vitamin capsule, delivered through a vein in the leg and fixed directly inside the heart, with no wires and no surgical pocket. We'll cover how these devices work, who should receive them, how they are implanted, their complications, and how patients should be managed in the long term. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online…

In our last episode we discussed conduction defects and pacemaker modes. Today we focus on one of the most important device therapies for heart failure: cardiac resynchronisation therapy, or CRT. For the right patient, it can transform breathlessness into an active life, shrink a dilated heart and reduce the risk of death. But around a third of patients don't respond as hoped. So who should receive CRT, how is it implanted, how do we make sure it works, and what are the new alternatives, such as conduction system pacing? Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology courses: https://cardiologycourse.com • World Elite…

Today we're exploring the heart's wiring — the conduction system — and what happens when it fails. Sinus node disease, heart block and bundle branch block can cause dizziness, fainting, heart failure and even sudden death. And the pacemaker, one of the greatest inventions in medicine, can restore a normal life. But which patients need a pacemaker, and which mode should we choose — single chamber, dual chamber, biventricular, conduction system pacing, or the new leadless devices? We'll cover diagnosis, temporary and permanent pacing, mode selection and long-term management. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology…

In our last episode we explored the atrial arrhythmias. Today we move down to the ventricles, where arrhythmias can be the difference between life and death. Ventricular arrhythmias range from harmless extra beats to ventricular tachycardia, ventricular fibrillation and sudden cardiac death, which claims millions of lives worldwide every year. We'll cover the mechanisms, how to interpret the ECG, how to investigate the underlying heart, and how to treat — from the emergency department to the cath lab and the electrophysiology suite. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology courses: https://cardiologycourse.com •…

Today we're focusing on the atrial arrhythmias — the rhythm disturbances that arise in the upper chambers of the heart. They range from harmless atrial ectopic beats to atrial tachycardia, atrial flutter and, most importantly, atrial fibrillation, the commonest sustained arrhythmia in the world and a major cause of stroke and heart failure. We'll cover how to recognise them on the ECG, how to investigate them, and how to treat and manage them using the latest guidelines and trials. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology courses: https://cardiologycourse.com • World Elite Doctors: https://worldelitedoctors.com For…

Today's topic is one that every doctor prescribes, every examiner asks about, and many of us find confusing: the antiarrhythmic drugs. How are they classified? How do they work at the level of the ion channels? When do we use them — and, just as importantly, when can they harm or even kill? From amiodarone and flecainide to beta-blockers, digoxin and adenosine, we'll cover classification, mechanisms, clinical effects and side effects. Guest: Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist, author, educator and founder of the Academy of Elite Doctors. Host: Alexander Wood Cardiology Course FM is the station for doctors, students, nurses and everyone who looks after the heart. Learn more: • Cardiology books: https://cardiologybooks.com • Mentorship with the Academy of Elite Doctors: https://academyofelitedoctors.com • Online cardiology courses: https://cardiologycourse.com • World Elite Doctors: https://worldelitedoctors.com For medical education only. This episode is not a…