Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is it possible to have first and second degree AV block, either type 1 or 2, on the same EKG strip?
First, there is no such thing as first-degree AV block. A prolonged PR interval is caused by AV delay. In that context, it is more likely that a patient with a long AV nodal conduction time would develop decremental AV conduction or type 1 second-degree AV block. Type 2 second-degree AV block is usu...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
Would you favor additional work-up for abnormally elevated ABIs that suggest noncompressible vessels to confirm the presence of PAD?
Any ABI greater than 1.4 is due to calcification of the blood vessels. This is abnormal, and the risk of MI, Stroke, and CV death is increased in these individuals. Therefore, I would treat them as if they had peripheral artery disease and would go for an LDL below 55. I would not necessarily do fur...
What would be your second pressor of choice if patients with LVOT obstruction remain persistently hypotensive on phenylephrine?
In patients with LVOT obstruction who remain hypotensive despite treatment with phenylephrine, choosing an appropriate second pressor requires careful consideration of the hemodynamic goals and the specific pharmacologic properties of available agents. Here are a few points: While the specific liter...
What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?
For the parasternal windows, your enemies are ribs and lungs. Regarding ribs: Whenever an image gets dark, people tend to try and crank up the gain knob to compensate. In many cases, however, it's usually because one of the edges of the probe is abutting a rib. Try and slide the probe a few millimet...
When would you consider PPM implantation for intermittent episodes of high-degree AVB that persist following a successful PCI in a patient presenting with an inferior STEMI?
AV block that occurs with an inferior STEMI is not usually caused by interruption of the distal conduction system and is often reversible. The key term in the question is "persistent." How long after the MI has AV block been observed, what is the heart rate, and is the escape rhythm wide or narrow? ...
What is your approach to anticoagulation in cirrhotic patients with platelet count loss than 50 in the setting of atrial fibrillation and elevated CHADSVASC?
First of all, we have no high-quality data to address this question since patients with this profile were not well represented in the DOAC pivotal trials. Consequently, we need to individualize the decision-making, taking into account variables such as patient age and co-morbidities, vascular risk s...
How do you determine which patient may be a good candidate for the Aurora EV-ICD and its smart sense algorithm?
The Aurora Extra-Vascular ICD (EV-ICD) was approved by the FDA in October 2023. The system consists of a lead that is tunneled beneath the sternum, with the lead tip positioned around the level of the carina, and a generator that is placed in the axillary area. The lead is anchored through a small i...
What clinical features drive your decision to use prophylactic mechanical circulatory support in a patient with severe left ventricular dysfunction undergoing complex PCI following the CHIP-BCIS3 trial?
This is a great question for the interventional cardiology community. I have been very reserved in using prophylactic mechanical circulatory support in very high-risk PCI patients (particularly microaxial flow pump). It has been my observation that mechanical circulatory support is more and more wid...
What is your stepwise approach to the management of culprit STEMI lesions with very high thrombotic burden in spite of multiple runs of mechanical thrombectomy?
We would typically add a double bolus of Integrilin in such a case.