Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Do you still recommend a low-sodium diet in a patient with heart failure given recent data and guideline changes supporting more liberal intake?
Thanks for the question. It is a difficult one, and there remains a lot of variability regarding sodium intake and HF management. There are a few trials and conflicting results. There is also significant variability amongst individual patients. For example, those patients requiring no or small loop ...
Are there any radiation dosimetric considerations for patients with lung cancer that have had a TAVR?
No, the new valve solves a mechanical problem. It will have some metal in it, so it would be visible whether it is a mechanical or biosynthetic type. I'd suggest not having a direct beam hit it, as that is the area of the coronary arteries' origins, and avoid dose spillage to reduce late toxicity. T...
Is it possible to have first and second degree AV block, either type 1 or 2, on the same EKG strip?
First, there is no such thing as first-degree AV block. A prolonged PR interval is caused by AV delay. In that context, it is more likely that a patient with a long AV nodal conduction time would develop decremental AV conduction or type 1 second-degree AV block. Type 2 second-degree AV block is usu...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Would you favor additional work-up for abnormally elevated ABIs that suggest noncompressible vessels to confirm the presence of PAD?
Any ABI greater than 1.4 is due to calcification of the blood vessels. This is abnormal, and the risk of MI, Stroke, and CV death is increased in these individuals. Therefore, I would treat them as if they had peripheral artery disease and would go for an LDL below 55. I would not necessarily do fur...
What would be your second pressor of choice if patients with LVOT obstruction remain persistently hypotensive on phenylephrine?
In patients with LVOT obstruction who remain hypotensive despite treatment with phenylephrine, choosing an appropriate second pressor requires careful consideration of the hemodynamic goals and the specific pharmacologic properties of available agents. Here are a few points: While the specific liter...
What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?
For the parasternal windows, your enemies are ribs and lungs. Regarding ribs: Whenever an image gets dark, people tend to try and crank up the gain knob to compensate. In many cases, however, it's usually because one of the edges of the probe is abutting a rib. Try and slide the probe a few millimet...