Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
Do you plan to incorporate fish-oil supplementation into the care of hemodialysis patients to reduce cardiovascular events in light of the PISCES trial results?
I showed the paper to an Internal Medicine friend of mine who is more statistically savvy than me. He wrote this: "So I read the study, and I’m still at a loss to understand it. I’m pretty Bayesian, but this study breaks my priors. Prior studies were basically negative, not to mention that nothing e...
What degree of aortic valve insufficiency is reasonable to tolerate for Impella supported PCI provided that the Impella will be removed at conclusion of case?
Mild or moderate AI would be tolerated for a short period of time, so long as the patient tolerates it from a hemodynamic standpoint. I do not think severe AI would be tolerated, even for a short duration, such as the time it takes to do a PCI.
What objective tools do you use to help determine if a patient is too high risk for anticoagulation to prevent stroke or DVT?
There are a number of risk scores, like HAS-BLED, that can be used, but I continue to use clinical judgment and shared decision-making. The excellent risk profile of NOACs and the availability of LAAO mean that I can usually come up with a solution for almost every patient that will protect them fro...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
What is the frequency in which patients should be taking pill in the pocket medication for paroxysmal atrial fibrillation before you begin to consider maintenance dosing medications instead?
This is very patient-specific; they need to have a good understanding of the process and good access to an EKG (even if it is a consumer device like Kardia). I find many patients either do not understand fully or respect the potential dangers of these medications. For example, they will take multipl...
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
What are some TTE findings that suggest worsening function of a bioprosthetic AVR that would require further surveillance or diagnostic imaging?
Doppler findings of an increasing transaortic gradient; 2D findings of decreased valve excursion and increased cusp calcification.
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?
Ankle-brachial index(ABI) relies on the compression of upper and lower extremity arteries with blood pressure cuffs and measuring the ratio of blood pressure between them. While I am not aware of specific studies in those with metallic rod fixation, ABI measurements should have similar utility as lo...