Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How does LV non-compaction on TTE change your secondary stroke prevention management?
Left ventricular non-compaction is a rare condition where the L atrial wall is thick and irregular and can contain areas of clot. I would favor anticoagulation in this situation, rather than antiplatelet therapy, but of course there are no clinical trials regarding this uncommon finding.
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
How do you decide if a patient should get follow-up perfusion imaging after acute PE when they are minimally symptomatic?
I practice essentially as reflected in the most recent AHA/ACC/ACCP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Diagnosis and Management of Acute Pulmonary Embolism in Adults.Figure 8. Evaluating Ongoing Symptoms Following Acute PE - concisely outlines the workup of patients with ongoing symptoms f...
How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
Are there mechanisms in place to distinguish SVT with aberrant conduction from VT on external cardiac monitoring devices?
Unfortunately, there is no easy answer to this question. Differentiation of aberrancy from ventricular tachycardia can be very difficult, even with high quality 12-lead ECGs. Standard rules can be applied but many features of VT such as precordial R-wave concordance, is not possible. The best idea i...
When do you add a thiazide-type diuretic to IV furosemide for a patient with acute decompensated heart failure who has had an inadequate diuretic response after 48 hours?
I think you hit the nail on the head - I start it after inadequate diuretic response for 48 hours to a high dose of IV furosemide (e.g., 80 mg IV TID dosing), and I want to avoid going to a furosemide drip, as this has implications for level of care in my hospital. If I suspect that the furosemide i...
How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?
The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...
What would be your approach to percutaneous intervention for acute plaque rupture and cardiogenic shock for a patient with cirrhosis and severe thrombocytopenia?
Thrombocytopenia is not an absolute contraindication to indicated percutaneous coronary intervention (PCI) and the antiplatelet therapy which it obligates. In a scenario such as this one -- cardiogenic shock complicating an acute myocardial infarction -- PCI is indicated as a life-saving procedure. ...
What is your preferred next step when you do not achieve daily diuresis goals with spot doses of IV furosemide in patients with decompensated heart failure?
When faced with a situation where the congested heart failure patient is not responding to initial spot (bolus) IV loop diuretic (typically furosemide), my initial step would be assurance that the appropriate dose is being used. We learned from the DOSE-AHF trial (Felker et al., PMID 21366472) that ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...