Ritika Tuli
@ritikagad
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🫀 Cardiology Fellow at Allegheny General @AHN_CVI | Interest in Imaging & Cardio-Oncology I Proud alum of @IMMWHC and @kmc_manipal l Tweets are my own |
Pittsburgh, PA
Joined July 2021
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Internal medicine residency ✅
Onwards to Cardiology fellowship 🫀
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🫀V7-V9 have lower STEMI cutoffs (≥0.5mm) because they're on the back, where more muscle and bone buffer the ECG signal.
V2-V3 are closer to the chest wall, needing higher cutoffs (≥2mm men, ≥1.5mm women) to detect a STEMI.
#CardioTwitter
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🫀
In VT, slower cell-to-cell conduction (vs. rapid Purkinje fiber conduction) causes a prolonged RS interval. The inefficient spread of electrical impulses through ventricular myocytes lengthens depolarization time, leading to a long RS acceleration.
#CardioTwitter
#EPeeps
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🫀The Velocity Time Integral (VTI) is a measure used in echo to estimate the distance a column of blood travels during one cardiac cycle i.e. per heartbeat.
VTI is often used in calculating stroke volume and CO.
#CardioTwitter
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🫀What is the origin of the PVCs?
Simple tools:
1.
RBBB: Left Ventricular (LV)
LBBB: Right Ventricular (RV)
2. Inferior leads (II, III, aVF)
Positive: Base/Superior
Negative: Apex/Inferior
3. Leads I, aVL
Positive: Right side.
Negative: Left side
#CardioTwitter
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🫀ScvO₂ reflects tissue O₂ extraction from only the upper extremities and brain. It is measured at the SVC and can be measured with a central line.
The MvO₂ is measured at the Pulmonary artery and measured using a PA catheter.
#CardioTwitter
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🫀 VT or SVT with aberrancy?
EKG signs suggesting VT:
- Absence of typical RBBB/LBBB morphology
- Extreme axis deviation (QRS + in aVR, - in I/aVF)
- Broad QRS >160 ms
- AV dissociation
- Capture beats
- Fusion beats
#CardioTwitter
#MedTwitter
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🫀Landmarks to identify aortic valve cusps on PSAX.
1. The right coronary cusp is closest to the right ventricular outflow tract (RVOT).
2. The left cusp is nearest to the left atrium (LA).
3. The non-coronary cusp is adjacent to inter-atrial septum.
#CardioTwitter
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🫀Ashman phenomenon
An ECG finding where a supraventricular beat follows a longer cycle, leading to aberrant conduction, often mimicking a right bundle branch block.
Common in AFib- key to recognize it to avoid confusion with ventricular arrhythmias.
#EPeeps
#CardioTwitter
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Cardiology at Allegheny General!! Soo grateful and excited!! 🫀
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🫀Key EKG Findings in Arrhythmogenic Right Ventricular Dysplasia (ARVD):
1. T-wave inversions in V1-V3
2. Epsilon wave in V1-V3 (small positive deflection after QRS)
3. QRS prolongation in the right precordial leads
#CardioTwitter
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🫀For interested residents and new fellows:
What is this mode of echocardiogram called and what is the finding seen here? Which condition is it associated with?
@ACCinTouch
#CardioTwitter
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🫀This schematic explains the importance of using multiple views for evaluation of wall motion abnormalities:
PLAX/5ch/3ch: Anteroseptal & Inferolateral walls
2ch: Anterior & Inferior walls
4ch: Anterolateral & Inferoseptal walls
PSAX at multiple levels
#CardioTwitter
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Few weeks into Cardiology fellowship! Any recommendations for great resources or hidden gems for first-year fellows? 📚💡
#CardioTwitter
@ACCinTouch
#MedEd
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🫀Exercise improves Mobitz Type I heart block by reducing vagal tone and enhancing AV node conduction, but it may worsen Mobitz Type II as it increases the demand on an already impaired conduction system.
#CardioTwitter
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🫀Coumadin ridge is a small, mobile ridge seen on echocardiography, located in the left atrium between the left atrial appendage and left upper pulmonary vein. It’s a normal anatomical variant, often confused with thrombus or tumor but harmless.
#CardioTwitter
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🫀One of the rare causes of T-wave inversions (TWI) in electrocardiogram (ECG) are memory T-waves, especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome.
#CardioTwitter
#EPeeps
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🫀Interpolated PVCs are unique premature beats that slip between normal heartbeats without causing a compensatory pause.
In contrast, typical PVCs cause more noticeable symptoms like palpitations, or a feeling of a skipped beat due to the compensatory pause.
#CardioTwitter
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🫀 Any guesses on what we are seeing?
Hint: It connects the conus branch of the RCA to the LAD.
#CardioTwitter
@ACCinTouch
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🫀 A positive aVR on EKG can be seen in both Dextrocardia and incorrect lead placement.
1. In dextrocardia, precordial leads (V1-V6) are flipped (V1 may resemble V6 and vice versa).
2. In limb lead reversal, precordial leads usually remain normal.
#CardioTwitter
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🫀During inspiration, the RV fills more, and due to ventricular interdependence, the LV fills less. In which condition(s) is this observed, and what is the typical clinical examination finding associated with this physiology?
#CardioTwitter
@ACCinTouch
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🫀Had the incredible opportunity to participate in a sheep heart dissection— such a valuable experience for my understanding of cardiac structures and correlating them with imaging, cath findings, and more!
#CardioTwitter
#medicaleducation
#AGHCVI
@CaliRClark
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🫀What is this pattern of strain commonly referred to as, and what is its clinical implication?
#CardioTwitter
#CardioPearls
#echofirst
@ACCinTouch
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ECMO cannulation simulation today at AGH! Grateful to be constantly learning new skills. 🫀
@AdnanKhalifMD
@AakashTuliMD
@CaliRClark
@battel_
#CardioTwitter
#ECPR
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🫀 Bradycardia + prolonged QTc = higher risk of Torsades de Pointes ⚡️
Slower heart rates prolong repolarization, increasing the chance of life-threatening arrhythmias.
IV Magnesium for acute Torsades de Pointes. Avoid QT-prolonging drugs like amiodarone!
#CardioTwitter
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🫀
Multifocal Atrial Tachycardia and wandering pacemaker are both atrial arrhythmias.
1. MAT presents with ≥3 different P-wave morphologies and rates >100 bpm, often in COPD patients.
2. Wandering pacemaker shows similar P-wave variability but with normal rates.
#CardioTwitter
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🫀🚨 Update: The ESC has removed gender from the
CHA2DS2-VASc score.
-Female sex is an age-dependent stroke risk modifier, not a standalone risk factor.
-Does not account for non-binary, transgender individuals, or those on sex hormone therapy.
#CardioTwitter
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🫀Pharmacological MPI is ideal for stress testing in LBBB:
1️⃣ MPI assesses blood flow, avoiding false positives from abnormal septal motion on echo.
2️⃣ Regadenoson doesn't raise HR, preventing worsened septal motion that could mimic ischemia during exercise.
#CardioTwitter
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I love AGH for making us feel so welcome! Everything here feels like a big warm hug 🫰🏻
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🫀Learning so much about personal financial savvy and business savvy from brilliant female cardiologists and entrepreneurs!
#WIC
#accwic
@ACCinTouch
@Cardiology
@WomenAs1
@gina_lundberg
@Swimcruiserun
@DrJenniferCo_Vu
@DrToniyaSingh
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Excited and grateful that I had the opportunity to present this very interesting case report at
#SLEEP2023
@pennsleep
#followingmydreams
💭💭
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Excited to share that our research letter is published in
#JACC
HF! 🚨 16% of at-risk patients admitted for cardiac complaints have T. Cruzi infection, increasing to 25% if EF < 50%!
@chagasdoc
@AjayKerai_MD
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Ecstatic that I could attend
#ACC2024
, and meet my future Co-fellows and attendings at Allegheny General Hospital! Such an amazing team and am more excited than ever to start!
@KhandelwalMD
@alwaysinscrubs
@anuu_puttur
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This Thursday Morning, finally presenting to you our podcast on Chronic Chagas Cardiomyopathy that we recorded with the one and only CardioNerds!
@chagasdoc
@tsionaberra
@MedaNamratha
@CardioNerds
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🫀Splenic shutoff occurs during nuclear stress images due to radiotracer redistribution from the spleen to the myocardium, caused by Regadenoson-induced vasodilation.
It is a tool to ensure Regadenoson’s effect isn’t inhibited, e.g., by caffeine intake.
#CardioTwitter
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🫀Subcutaneous ICDs (S-ICDs)
Benefits:
1. Reduced infection risk.
2. Preserved vascular access.
Cons:
1. They lack pacing capabilities
2. Can deliver more painful shocks because they rely on higher energy levels to achieve defibrillation.
#CardioTwitter
#EPeeps
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“There are more women in cardiology now than in the past but women are only 18% of cardiology fellows, 10-15% of practicing cardiologists”-ACC.
Grateful and excited for the opportunity to meet and learn from the other participants and mentors
#CardioTwitter
#womenincardiology
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So lucky that Dr. Marcus (she says we should call her Rachel but I never can!) mentored us on this prospective research project on Chagas cardiomyopathy and attended the presentation too!! I have learnt so much from you and hope to continue doing so!
@chagasdoc
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So grateful and so inspired by all the conversation this morning at
@ACCinTouch
WIC seminar. “Create the option you want and create that before someone asks you a yes/no question” - Dr. Bozkurt
@noshreza
@JeomiOkwara
@BiykemB
@drmalissawood
@KTamirisaMD
#ACCWIC
#ACCinTouch
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Absolutely thrilled that I had the opportunity to speak in front of so many people who love cardiology!
@chagasdoc
@vbluml
#ACC2023
#ACCinTouch
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What a wonderful talk on MCS, combined with a much-needed pep talk!
@Babar_Basir
. Understanding the various MCS devices more and more every single day.
#CardioTwitter
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🫀CFR, IMR, and FFR are key measures of coronary physiology. CFR assesses overall coronary blood flow, IMR evaluates microvascular function, and FFR gauges the significance of coronary artery blockages.
#CardioTwitter
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The MvO₂ is lower than the ScvO₂ and reflects the average O₂ extraction for the entire body. It is called “mixed” because the venous return from the SVC, IVC, and coronary sinus is mixed by the RV.
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Had a super cool moment where another physician and I were able to provide medical care to a passenger on board!
It was such an experience and the best feeling ever, and the miles were the cherry on top!
Thankyou!
@AirFranceKLM
@airfrance
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Enjoyed presenting these interesting cases of catamenial pneumothorax, and Paxlovid-Tacrolimus interactions at
#SHMConverge2023
!!
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So excited about this publication!
Tremendous effort by the entire team and we couldn’t have don’t it without the guidance of Dr. Pristoop, Dr. Chai and Dr. Ammar!
@ACCinTouch
@accwic
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🫀Can the DI ever be more than 1?
🫀The Dimensionless Index compares blood flow velocities in the LVOT and across the aortic valve.
It can never exceed 1, as aortic stenosis causes higher velocity across the valve compared to the LVOT.
More in comments ⬇️
#CardioTwitter
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Glad I could meet
@RyanMeyerMPP
@HFnursemaghee
at
#ACC2023
Thankyou for everything that you do to further inclusion and diversity!!
#womenincardiology
@ACCinTouch
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Amazing session on ACS in the ED and cath lab and post-MI in the CICU by Dr. Ann Gage this Saturday morning
@anna_bortnick
@AnnGageMD
@SrihariNaiduMD
Great advice for new fellows!
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Clinical Features Suggestive of VT
Age > 35 (positive predictive value of 85%)
Structural heart disease
Ischaemic heart disease
Previous MI
Congestive heart failure
Cardiomyopathy
Family history of sudden cardiac death
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Such an eye-opening and inspiring experience. We have laughed and cried and learned SO MUCH about patient safety 🩺🥼
#AELPS
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Learning about the role of legislation, advocacy and politics in the world of Cardiology from the brilliant
@mikeallen
@JimVandeHei
Such an enriching experience for any fellow in training!
#heartPAC
@Cardiology
@ACCinTouch
#ACCLegislative
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Correct! It is Vieussens' ring. Here is the reference:
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♥️Honored to have Dr.
@EdwardFryMD
, past president of the ACC, speak to us about the importance of addressing Social Determinants of Health (SDOH) in preventing ASCVD events.
Just in time for the ACC legislative conference too!
#CardioTwitter
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🧵🫀✨
1/ Before you start writing your PS, ask yourself some key questions:
- Why Cardiology?
- What makes you unique and a great fit for Cardiology?
- What struggles have you faced and how have they shaped you? 💪
- What research have you done and how has it impacted you? 🔬
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The term "Coumadin ridge" originates from early observations where this anatomical feature was often mistaken for a thrombus or other mass, leading to unnecessary anticoagulation with warfarin in some cases. Over time, it became colloquially known as the "Coumadin ridge".
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Coumadin ridge can be seen in both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), though it is often more clearly visualized with TEE due to its proximity to the left atrium.
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Just completed an incredible medical educator course with the amazing Dr. Christy Kaiser and Dr. Tara Coles! Their mentorship was absolutely fantastic, and I can't express how grateful I am for their guidance. This course was such a worthwhile investment of my time!
@DrTaraColes
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@ACCinTouch
During inspiration, increased filling of the right heart shifts the septum, reducing left heart filling and mitral inflow velocity. This causes a significant drop in systolic BP in conditions like cardiac tamponade, which is the physiological mechanism behind pulsus paradoxus.
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Oh my god it makes me so happy to see an
#AASM
booth at
#ACC
🥹
There’s more of a relation between sleep disorders and cardiovascular health than we realise!
#sleeppeeps
#ACC2023
#choosesleep
#womenincardiology
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With regards to the RG Kar rape and murder case of a 31 year old resident INSIDE the hospital.
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ScvO₂ reflects tissue O₂ extraction from only the upper extremities and brain, missing what the visceral organs (including the coronary sinus, which empties into the RA) and lower extremities are doing.
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Valid anger! Such last-minute delays to the NEET PG exam amplify stress and anxiety, and undermine the dedication and hardwork of physicians in India. Better planning and communication are essential.
#PhysicianWellBeing
#NEETPG2024
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Committed to advancing awareness and research in Chagas disease and cardiomyopathy. It's crucial we enhance our understanding and treatment options to improve patient care.
@medpagetoday
@JACCJournals
#Cardiotwitter
#ChagasDisease
#Cardiomyopathy
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AHA updates - sleep is now a part of life’s essential 8! Because “it is much easier to change to your cars oil when you’re not driving it”
@michaelgrandner
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Amazing session on ‘Mx of complex older adults undergoing TAVR’. Love listening to new perspectives!
@DrDamluji
@DrAROrkaby
@cardskrish
@Gwen_Bernacki
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As the aortic valve becomes narrowed (stenotic), the velocity of blood flow across the valve increases to maintain the same flow through the LVOT. In this case, the aortic valve VTI becomes larger than the LVOT VTI, causing the dimensionless index to drop below 1.
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Thanks for sharing
@Sydneycheryl1
. Always appreciate platforms that make learning accessible.
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Gained more insight into healthcare costs in America from this episode than from my 3 years of internal medicine training. There is a real need for trainees to understand costs in medicine from a practical point of view.
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@ACCinTouch
Absolutely! The normal myocardium shows a uniform pattern of strain throughout the heart. In cardiac amyloidosis, there is a characteristic pattern where the apical segments (the "cherry") retain relatively preserved strain.
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I found this seminar so helpful last year! Must attend for cardiology applicants
As part of the ACC FIT Council, we are delighted to invite all residents to ACC's Cardiology Applicant Mentorship Program! 🫀
PD Insights Webinar: May 30, 8-9.30 PM
Register:
Mock Interview Program Application Deadline: May 31
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CFR: Coronary Flow Reserve
IMR: Index of Microcirculatory Resistance
FFR: Fractional Flow Reserve
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And I cannot thank you enough!
@chagasdoc
. Your mentorship and the opportunities you gave us meant everything to me.
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@HarshShahMD
@SrihariNaiduMD
@DrSiyabMD
@SCAI
Very interesting! Is the blister formation a localized allergic reaction to the anesthetic, or maybe caused by barotrauma from the TR band?
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Thankyou for your authenticity and vulnerability!
@DrBillLombardi
Many of us in the world of Cardiology can improve in aspects of diversity, inclusion and wellness.
Here’s to starting with self-awareness!
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@BilalIbraiz
Hi
@BilalIbraiz
You are right in physiological conditions. However in critically ill patients, MVO2 is lower than Svco2. Mixed venous includes blood coming from the heart, which extracts significant oxygen.
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