Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Does theophylline have a role in bradyarrhythmias, and if so, in what patient population(s) can this be considered?
I do not have a lot of experience with theophylline, but since there are no other answers will take a stab.I would only consider it if something acute was happening, such as in the hospital setting with an easily reversible issue. Otherwise, a pacer (either transvenous or leadless) would be better f...
How would you approach the duration and initiation of DAPT or SAPT for SCAD in a patient with Atrial Fibrillation on therapeutic anticoagulation?
Spontaneous coronary artery dissection is a rare cause for an acute coronary syndrome afflicting predominantly females in the 30-55 year old age group and typically occurs in the absence of underlying atherosclerosis. This is a completely different mechanism for an acute infarction than that caused ...
Would you pursue imaging to clear the left atrial appendage or have a risk/benefit discussion with a patient prior to semi-urgent cardioversion if there was concern for delayed administration or a single missed dose of anticoagulation?
This would probably depend on the CHA2DS2VASc score. If CHA2DS2VASc <=2 for men or <=3 for women, I would have a risk/benefit discussion with the patient and consider proceeding without preprocedural imaging after shared decision-making. If CHA2DS2VASc risk is higher, I would favor pre-procedural im...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
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...
Besides anticoagulation, how would you approach the management of a large LV thrombus newly seen on TTE in patients on VA-ECMO?
This is a highly morbid condition due to coexisting high bleeding and thromboembolic risk in acutely ill patients. No guidelines exist to direct the best strategies.In addition to optimizing or changing anticoagulation strategy and depending on the location of the thrombus and co-morbidities, the fo...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...