Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How would you balance the risk of intracranial hemorrhage with thrombosis of mechanical valves in patients with infective endocarditis?
I'm not sure that there is a good answer to this question. If you look at it segmentally, clearly, patients with mechanical valves require anticoagulation, especially in the mitral position. In patients with endocarditis and native valves, whether or not to anticoagulate the patient after or before ...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
Are there robust clinical data on the safety of IV amiodarone for atrial fibrillation of unclear duration and very difficult to control HR in the current era of widespread DOAC use, as opposed to older data with warfarin?
In the current DOAC era, there are no prospective or randomized data specifically evaluating IV amiodarone administered for rate control in atrial fibrillation of uncertain duration. The principal safety concern is not the agent itself but the possibility of unintended pharmacologic cardioversion, w...
What has been your approach to percutaneous intervention for calcified nodules and threshold for intervention?
Very high threshold for intervention in these cases. Generally, there is severe calcification all around and sometimes multiple calcified nodules. There has to be a strong indication for me to consider such cases. I generally start with rotational atherectomy (multiple runs) followed by angioplasty ...
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 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 long do you continue aspirin and clopidogrel after and uncomplicated transfemoral carotid stent?
Typically one month, but many of our carotid patients have concomitant disease in other vascular beds and are often treated with prolonged anti-platelet therapy.
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...