Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to anticoagulation in cirrhotic patients with platelet count loss than 50 in the setting of atrial fibrillation and elevated CHADSVASC?
First of all, we have no high-quality data to address this question since patients with this profile were not well represented in the DOAC pivotal trials. Consequently, we need to individualize the decision-making, taking into account variables such as patient age and co-morbidities, vascular risk s...
How do you determine which patient may be a good candidate for the Aurora EV-ICD and its smart sense algorithm?
The Aurora Extra-Vascular ICD (EV-ICD) was approved by the FDA in October 2023. The system consists of a lead that is tunneled beneath the sternum, with the lead tip positioned around the level of the carina, and a generator that is placed in the axillary area. The lead is anchored through a small i...
What clinical features drive your decision to use prophylactic mechanical circulatory support in a patient with severe left ventricular dysfunction undergoing complex PCI following the CHIP-BCIS3 trial?
This is a great question for the interventional cardiology community. I have been very reserved in using prophylactic mechanical circulatory support in very high-risk PCI patients (particularly microaxial flow pump). It has been my observation that mechanical circulatory support is more and more wid...
Is there a role for measuring plasma aldosterone to guide the treatment of heart failure in specific populations?
Typically, there is no role in measuring aldosterone to guide therapy. In patients with HFpEF, the use of Aldactone is to help with membrane stabilization and management of RAAS inhibition. There are some reports of prior research supporting LV remodeling and reduction in myocardial fibrosis.
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
What aspects of HF management do you think hospitalists should prioritize before discharge in order to optimize HF admission care if there are limited resources available for specialized HF care, both inpatient and outpatient?
This is straightforward - many patients have poor discharge education on fluid and salt management. Recommendations for 50 oz and 2 gm/day salt are given, but what is this truly like in practice? Our article (Sharma & Goswami, PMID 38486616) suggests that we may need to focus on the basics for salt ...
When would you consider endomyocardial biopsy for newly noted LVH with genetic testing significant for MYH7 mutation but also a TTR VUS also present?
This is an interesting question. However, it is important to know further information about the patient, such as age, sex, family, history, and the specific variant of unknown significance in the TTR gene (since some so called variants of unknown significance have descriptions in the literature that...
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
What patient factors do you consider when selecting between a small interfering RNA, like inclisiran, and PCSK9 inhibitors in patients with recent acute coronary syndrome?
Insurance coverage and out-of-pocket costs usually drive my choice. It is fairly easy to get approval for evolocumab for most of my patients. I have had a hard time getting approval for inclisiran with the exception of those with traditional Medicare + supplemental medication coverage. I usually sta...
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...