Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How would you counsel patients with type 1 or type 2 diabetes mellitus and heart failure on the use of SGLT-2 inhibitors when they have a history of DKA?
Making a recommendation to prescribe this class will really require a case-by-case clinical assessment. It is clear that SGLT-2 inhibitors are very effective in preventing hospitalization for heart failure, and so we will want to suggest their use whenever possible. But it is also clear that DKA (mo...
How frequently do you obtain lipoprotein (a) levels on asymptomatic patients without a prior history of CAD?
Recent recommendations are considering that the entire population ought to be tested at least once in their lifetime given the estimated prevalence in the general population of some degree of elevation in as many as 20% of the population. That said I certainly check in most people with a family hist...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
In an article by the Yale group, Gallegos et al., PMID 33997256 give a nice summary of the literature cited options for managing cardiac sarcoidosis (Non-steroidal treatment of cardiac sarcoidosis: A systematic review.Options cited here that have not been discussed include cyclophosphamide, cyclospo...
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...
What is a reasonable protocol for how long to hold warfarin and/or DOACs before cardiac catheterization?
Thanks for bringing up this question Dr. @Dr. First Last. This is one of the most common questions my nurses ask me when scheduling cardiac catheterizations and other procedures. Here is my answer based on experience and literature. As such, there is no formal study, but the risk of thromboembolism ...
What are your management strategies for malignant pericardial effusion with a high risk of spontaneous hemorrhage, particularly in patients requiring anticoagulation for chronic atrial fibrillation?
We have many patients with malignant pericardial effusion who tolerate anticoagulation for DVT/PE/afib. In those patients, when AC is restarted (for example after pericardiocentesis), close monitoring with serial echo in a few days would be performed to see if effusion reaccumulates faster. Also, th...
Do you require an ECG to assess the QTc interval before administering ondansetron to a hospitalized patient without a known cardiac history or QT-prolonging medications?
There is a nice "Things We Do For No Reason" article in Journal of Hospital Medicine on this: "Hospitalists need not order an initial and subsequent ECGs when administering standard doses of intravenous ondansetron for patients without significant risk factors for QTc prolongation. To assess risk fa...
What hemodynamic parameters or RHC numbers do you use to prompt venting the LV emergently with an Impella overnight for patients on VA-ECMO?
Put simply, the role of adjunctive mechanical left ventricular unloading in a patient supported by peripheral VA ECMO is to treat left ventricular failure refractory to medical therapy (e.g., inotropes and diuretics). There are multiple clinical, imaging, and invasive hemodynamic parameters which ca...
Under what circumstances would you consider withdrawing aspirin and continuing with potent P2Y12 inhibitor monotherapy after successful PCI in patients with acute coronary syndromes, based on the findings of the NEO-MINDSET trial?
The NEO-MINDSET trial suggests that aspirin may not be essential after STEMI treated with PCI in selected patients. Its findings indicate that early aspirin withdrawal, continued with potent P2Y12 inhibitor monotherapy, can be safe, particularly when bleeding risk is elevated and ischemic risk is ty...
How would you recommend using POCUS to evaluate jugular venous pressure?
I use it in essentially the exact same way I do with visualizing the JVP; put the patient at a 30-45 degree angle, and measure how far up the neck it goes. If you are able to easily visually estimate JVP, POCUS doesn't add much. However, in someone whose venous pulse is hard to see, POCUS has been h...