Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
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...
How long do you recommend waiting before competitive sports athletes resume sports activities following inpatient management for an NSTEMI?
Dear Dr. @Dr. First Last - thank you for your question. We address this issue in the new ACC/AHA Scientific Statement by Kim et al., PMID 39976316.Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Hea...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
What is your stepwise approach to managing no re-flow during PCI?
It’s not so much the vasodilator cocktail, as much as it is, getting the vasodilator cocktail into the capillary bed. This is best achieved by very distal injection via any thrombectomy catheter (which can also be used for thrombectomy if needed). Adenosine at 24 mcg/cc + nicardipine (or verapamil) ...
What are your preferred femoral vascular closure devices for severely calcified femoral artery vessels following PCI, especially with higher sticks, and why?
One should not have high sticks. The femoral access should be methodical. One should make sure to mark the inferior border of the inguinal ligament and stay below the ligament. I always use a micropuncture needle and obtain fluoroscopy to assess the position of the needle in relation to the femoral ...
Would you favor culprit-only PCI, complete revascularization via percutaneous approach, or urgent CABG evaluation for a young diabetic patient with newly reduced LVEF < 35% presenting with an anterior STEMI and multivessel disease?
This is an uncommon scenario. Everything depends on the severity of the disease and the complexities of the lesions. I will favor multi-vessel PCI (after STEMI has been taken care of with primary PCI) if anatomy is suitable. I would favor CABG if there are long lesions, involvement of LM (particular...
During a coronary intervention, if the activated clotting time (ACT) is not within the therapeutic range despite administering weight-based unfractionated heparin, what alternative options do you consider?
I would consider additional boluses of 2000–5000 units of heparin and recheck ACT. If the ACT continues to be below the therapeutic range, consider alternate anticoagulation such as bivalrudin, 2b3a inhibition, and low molecular weight heparin. I also assume we have checked the ACT device. In additi...
Do you prefer the routine use of bivalirudin over UFH during PCI cases in patients presenting with ACS?
The antiplatelet strategy is the key, in terms of pre-treatment, or post-treatment, maintenance therapy, or loading therapy, and choice of DAPT therapy. This antiplatelet regimen, in terms of timing of load and choice of non-ASA antiplatelet therapy, is a major factor in maximizing PCI outcomes. Int...