Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
I advocate for the use of LMWH. I see a surprising number of patients on unfractionated heparin with PTTs indicating either homeopathic (<35s) or supratherapeutic (>120s) levels of anticoagulation. The 2025 ACC/AHA Guideline for the Management of Patients With Acute Coronary Syndromes summarizes cli...
What is your approach to inpatient work-up for suspected long QT syndrome in a young adult with otherwise normal labs and no medications causing prolonged QTc?
I would emphasize the basics when I approach this clinical scenario. The first step is to carefully analyze the ECG that raised the question. Though measuring the QT interval should be easy, we all appreciate that this is not always the case. Carefully examine the index ECG, look at all the leads b...
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
Would you consider amiodarone for the treatment of atrial fibrillation with RVR in patients who cannot tolerate beta blockers but have a high CHA2DS2-VASc score and are not on anticoagulation?
We typically do not due to risk of chemical cardioversion and precipitating an embolism.
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
How do you decide if a patient should get follow-up perfusion imaging after acute PE when they are minimally symptomatic?
I practice essentially as reflected in the most recent AHA/ACC/ACCP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Diagnosis and Management of Acute Pulmonary Embolism in Adults.Figure 8. Evaluating Ongoing Symptoms Following Acute PE - concisely outlines the workup of patients with ongoing symptoms f...
Are there mechanisms in place to distinguish SVT with aberrant conduction from VT on external cardiac monitoring devices?
Unfortunately, there is no easy answer to this question. Differentiation of aberrancy from ventricular tachycardia can be very difficult, even with high quality 12-lead ECGs. Standard rules can be applied but many features of VT such as precordial R-wave concordance, is not possible. The best idea i...
When do you add a thiazide-type diuretic to IV furosemide for a patient with acute decompensated heart failure who has had an inadequate diuretic response after 48 hours?
I think you hit the nail on the head - I start it after inadequate diuretic response for 48 hours to a high dose of IV furosemide (e.g., 80 mg IV TID dosing), and I want to avoid going to a furosemide drip, as this has implications for level of care in my hospital. If I suspect that the furosemide i...
How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?
The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.