Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
What are your preferred femoral vascular closure devices for severely calcified femoral artery vessels following PCI, especially with higher sticks, and why?
One should not have high sticks. The femoral access should be methodical. One should make sure to mark the inferior border of the inguinal ligament and stay below the ligament. I always use a micropuncture needle and obtain fluoroscopy to assess the position of the needle in relation to the femoral ...
Would you favor culprit-only PCI, complete revascularization via percutaneous approach, or urgent CABG evaluation for a young diabetic patient with newly reduced LVEF < 35% presenting with an anterior STEMI and multivessel disease?
This is an uncommon scenario. Everything depends on the severity of the disease and the complexities of the lesions. I will favor multi-vessel PCI (after STEMI has been taken care of with primary PCI) if anatomy is suitable. I would favor CABG if there are long lesions, involvement of LM (particular...
Do you prefer the routine use of bivalirudin over UFH during PCI cases in patients presenting with ACS?
The antiplatelet strategy is the key, in terms of pre-treatment, or post-treatment, maintenance therapy, or loading therapy, and choice of DAPT therapy. This antiplatelet regimen, in terms of timing of load and choice of non-ASA antiplatelet therapy, is a major factor in maximizing PCI outcomes. Int...
Do you still recommend a low-sodium diet in a patient with heart failure given recent data and guideline changes supporting more liberal intake?
Thanks for the question. It is a difficult one, and there remains a lot of variability regarding sodium intake and HF management. There are a few trials and conflicting results. There is also significant variability amongst individual patients. For example, those patients requiring no or small loop ...
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...