Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In a patient with decompensated heart failure requiring urgent non-cardiac surgery, how much volume optimization do you pursue preoperatively, and at what point does the risk of further surgical delay outweigh the benefit of continued diuresis?
This is an interesting question and a challenging situation for a patient. I think that the ideal scenario would be for the patient to be euvolemic clinically prior to surgery. I am very aggressive with intravenous diuretics. I think that a discussion with the patient, with the surgeon, and with ane...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose / extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose response. Therefore, one could argue that even though DOACs were not studied at low dose, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply ...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis pts do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thus effi...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...
Would you favor CT AV calcium score or dobutamine stress echo for a patient with symptomatic AS and an aortic valve with normal SV/SV index, Vmax 3.4m/s, AVA < 1.0 cm2, and mean gradient < 40 mmHg?
This scenario appears to be one of normal flow, low gradient severe aortic stenosis(NF-LG AS). This is one of the least understood variants of low gradient aortic stenosis. The most important focus should be on avoiding measurement errors during echocardiography, which may lead to underestimation of...