The electrocardiogram (ECG) remains a cornerstone of modern cardiology, providing rapid, non-invasive, and widely accessible diagnostic insights. While ECG interpretation is an essential skill for clinicians, certain patterns can be subtle or atypical, posing diagnostic challenges. In our previous review (doi.org/10.3390/jpm12111754), we explored several uncommon ECG syndromes with significant clinical implications. However, the spectrum of electrocardiographic abnormalities extends far beyond those initially discussed. In this second installment, we expand our discussion of rare and underrecognized ECG syndromes, including Long QT, Jervell and Lange-Nielsen, Romano–Ward, Andersen–Tawil, Timothy, Short QT, and Twiddler’s syndromes, as well as Noonan, Barlow’s, Bundgaard, BRASH, Carvajal, Naxos, and Danon disease. We highlight their clinical context, characteristic findings, and implications for diagnosis and management. These conditions range from acute, life-threatening emergencies requiring immediate intervention to chronic electrical disorders necessitating long-term monitoring and risk stratification. By broadening our focus, we aim to enhance awareness and recognition of these entities, ultimately improving patient outcomes through timely and accurate diagnosis.

Cardiogenic shock is an acute, complex, and multifactorial syndrome caused by severe cardiac dysfunction leading to low cardiac output and tissue hypoperfusion. Identified risk factors (RFs) include: age >75 years, female sex, anterior or extensive acute myocardial infarction (AMI), angina pectoris, peripheral vascular disease, ejection fraction (EF) less 30%, mitral regurgitation, and diabetes mellitus. Early diagnosis, advanced hemodynamic monitoring (HM) using PiCCO, identification of mortality-associated RFs, and guidance of fluid and vasopressor therapy are key points in CS management with a major impact on reducing mortality. The aim of our study was to assess mortality-associated RFs in CS and demonstrate the benefit of advanced HM via PiCCO in optimizing treatment and improving outcomes. Out of 86 analyzed parameters, we identified: 6 common RFs for both groups (PiCCO and ECHO): NT-proBNP >4N, acute pulmonary edema, cerebral edema, troponin >2N, total bilirubin >4N, creatinine >2N; 7 PiCCO-specific RFs: VO₂ less 100 ml/min, DO₂ less 250 ml/min, coma, right ventricular AMI, ERO₂ >60%, PaCO₂ >50 mmHg, hemoglobin less 9.0 g/dL; 9 ECHO-specific RFs: hepatomegaly, oliguria less 30 ml/h, pyelonephritis, transmural AMI, hepatic failure, stroke, inferior and anteroinferior AMI, lactate >2 mmol/L. All patients with ≥5 RFs (PiCCO group) and ≥7 RFs (ECHO group) died (100%). Male patients had a higher mortality rate (35.8% vs. 26.4%). PiCCO monitoring enabled individualized guidance of fluid and vasopressor therapy, early detection of cardiogenic pulmonary edema, and differentiation from non-cardiogenic forms. Mortality was significantly lower in the PiCCO group compared to the ECHO group (36.5% vs. 62.3%, p=0.0112).

Stress ("Tako-Tsubo") cardiomyopathy or Takotsubo syndrome (TTS), is characterized by acute but rapidly reversible LV systolic dysfunction in the absence of atherosclerotic coronary artery disease, triggered by strong psychological, physical or iatrogenic stress. Takotsubo syndrome is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodal imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. This article describes the clinical case of a 67-year-old woman who, after a strong emotional stress, presented with clinical manifestations of ACS. Following laboratory tests and investigations (ECG, Echocardiography, Chest X-ray, Coronary angiography, Ventriculography) the diagnosis of Takotsubo Syndrome was established. Based on treatment with beta-adrenoblockers, anticoagulants, dual antiplatelet therapy (Aspirin+Clopidogrel), nitrates, statins, metabolic drugs (Mildronate), the patient"s condition improved, with the recovery of left ventricular systolic function.