Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
Would you consider starting with 12 mg of adenosine rather than 6 mg in a hemodynamically stable patient with SVT?
I know of no data to support higher dose adenosine for SVT termination for any particular clinical scenario. There is a rationale for administering 12 mg if an initial 6 mg doesn't work. In any case, it hardly matters because adenosine is safe at either dose. Any changes in blood pressure or proarrh...
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
CCB edema (also hydralazine edema) are so underappreciated by non-nephrologists. Rarely does a clinic go by without me seeing some form of it. It is from vasodilation that allows gravity to increase capillary hydrostatic pressure, fluid moves out of vascular space to interstitial space and in that r...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...