Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
What neurologic and hemodynamic parameters do you use to determine candidacy for emergent cath lab activation following out of hospital cardiac arrest from VT/VF in patients with NSTEMI after ROSC has been achieved?
Neurologic Futility: Immediate coronary angiography is not recommended if the patient is comatose with clinical signs of severe, irreversible brain damage or brain death. Viability Assessment: If the patient presents with refractory cardiogenic shock or ongoing ischemia, emergency catheterization is...
When you identify new atrial fibrillation in a hospitalized patient that spontaneously converts to sinus rhythm within 24–48 hours, and the patient has a CHA₂DS₂-VASc score of 2–3, how do you decide whether to initiate anticoagulation and/or discharge with a wearable cardiac monitor?
This is a tough one. I think the easier part is who should get a wearable cardiac monitor? I think the answer is pretty much everyone since the recurrence rate is around 30% in one year - and if it recurs, it predisposes to strokes, and I'd likely provide anticoagulation per AHA/ACC based on CHA₂DS₂...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
Will TRYNGOLZA (olezarsen), recently approved for familial chylomicronemia syndrome, also lower triglycerides due to other genetic causes of hypertriglyceridemia?
Yes, olezarsen does lower triglycerides due to other causes of hypertriglyceridemia. It is currently in trials in patients with severe hypertriglyceridemia without Familial Chylomicronemia Syndrome (FCS).
How do you decide between manual pressure versus opting for a specific vascular closure device at the conclusion of a femoral access case?
Manual vs closure devices depend on the following: cathlab turnover- if fast turnover needed, manual pressure with sheath pull in PACU speeds up stuff, as long as the “puller” is not the provider cath’ing evidence for closure device vs manual pressure is only good for hospital LOS and early deambul...