Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What advice would you give to patients who are concerned about statin use and its controversies around brain health and dementia risk, based on previous studies?
I cannot think of any class of medications in cardiology that has undergone such scrutiny and investigation to try to find a reason not to take such an effective medication. From the earliest days of its use, one concern after another has arisen; from muscle deterioration, to increasing the risk of ...
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...
What is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?
Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a part...
Are there specific types/brands of drug-eluting stent you prefer that perform well in terms of lower ISR rates or ones that are better for patients with high bleeding risk?
That is a great question. All of the currently available drug-eluting stents are very safe, and you can now get away with just one month of dual antiplatelet therapy (DAPT) in a patient with high bleeding risk. There is more and more evidence of using clopidogrel only monotherapy instead of using DA...
Does theophylline have a role in bradyarrhythmias, and if so, in what patient population(s) can this be considered?
The only time I have ever used theophylline is in the post-transplant setting and really only as a bridge until a permanent pacemaker could be installed. I have rarely seen a case where theophylline works reliably long term to consider a permanent solution. The procedural risk of inserting a pacemak...
When should you suspect TR related to pacemaker lead placement as a cause of RV dysfunction rather than pulmonary HTN or other etiologies for RV failure associated with tricuspid regurgitation?
It would be patient-specific but would need to include RHC to rule out pHTN (of any group). That should point you in the right direction. I suspect this would be pretty rare and would have to have very severe TR. We know there is a magic amount of slack to put in the RV lead to minimize TR, but this...
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...
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...
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...
When would you consider endomyocardial biopsy for newly noted LVH with genetic testing significant for MYH7 mutation but also a TTR VUS also present?
This is an interesting question. However, it is important to know further information about the patient, such as age, sex, family, history, and the specific variant of unknown significance in the TTR gene (since some so called variants of unknown significance have descriptions in the literature that...