Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
In a patient with known chronic LV thrombus and atrial fibrillation, is rhythm control still an option?
I am not sure why it wouldn’t be. The decision to anticoagulate for a chronic thrombus is separate from an AF indication. As long as a left atrial (LA) clot is not present, one could argue that chronic anticoagulation will be a necessity whether the patient is converted to sinus rhythm or remains in...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
When would you consider starting lipid-lowering therapy for young adults < 30 years of age who have markedly elevated LP(a) and family history of elevated LP(a) and ischemic heart disease?
Years ago, there was a cartoon where two men were sitting eating dinner, and one said to the other, “My physician told me that worrying about your cholesterol was the leading cause of hypertension.” Our discussion question is appropriate given the recently released new guidelines for treating choles...
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...