Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...
Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?
Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramin...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
For CLL patients with high-risk cytogenetics on ibrutinib who develop a cardiac event such as an MI, would you continue ibrutinib?
It depends on the cardiac event (and the CLL status). After any serious event, if the CLL is under good control (clinical CR), I think it is very acceptable to stop the ibrutinib and wait until clinical progression occurs - which can be a while for some patients (median 2 years from the E1912 study)...
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you decide between opting for semi-elective outpatient versus inpatient TAVR for patients with severe critical AS?
Most patients undergo semi-elective procedures, which are more favorable for hospital reimbursement and reduce the risk of acute kidney injury. However, in a small subset of patients (<20%) with critical aortic stenosis (AS) and severe symptoms, particularly syncope, inpatient management is required...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
What factors should be prioritized when deciding the timing of CIED extraction in patients with high surgical risk or multiple comorbidities?
I'll do my best to respond, though the question isn’t entirely clear to me. If the intent is to determine which patients should be prioritized for CIED extraction, the key consideration is whether the benefits outweigh the risks. The most straightforward case is persistent bacteremia, especially in ...