Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
I agree with Dr. @Dr. First Last. I have had patients with APS and recurrent thromboembolic events although not necessarily strokes to whom I have added aspirin and HCQ to the treatment regimen. I did this because she continued to have recurrent events. However, there is at least one article that ne...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
When should we consider screening patients with systemic sarcoidosis for cardiac involvement using cardiac MRI or PET given their high risk for sudden cardiac death and discrepancies between reported cardiac symptoms (2-5%) and evidence of cardiac inflammation on advanced imaging and autopsy findings (>25% of cases)?
The current guideline recommendations are only to pursue advanced imaging in patients who have symptoms, EKG abnormalities or abnormal echocardiogram. In our experience, we have been able to capture patients with strict assessment of these criteria. However, it certainly can be challenging in patien...
Is there a validated risk prediction model you favor to risk stratify patients for cardiotoxicity prior to initiation of chemotherapy?
I would recommend the HFA-ICOS risk calculator as recommended by the 2022 ESC/ICOS Cardio-Oncology guidelines. There is a great discussion here:Strategies for risk stratification and cardiovascular toxicity prevention in patients with cancerAnd there is an easy-to-use version online and on the ESC P...
Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?
If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to ru...
Would you empirically elective to anticoagulate patients with a remote (i.e. >10 year) history of paroxysmal atrial fibrillation presenting with newly diagnosed CVA, presumed cardioembolic in etiology, without any documented recurrence of AF?
Yes, I would, especially if the etiology is suspicious for being cardio-embolic. As per the ACC/AHA/HRS 2019 Updated Guidelines for AF management, patients with non-sex-related CHA2DS2-VASc score of >/=1 should be offered oral anticoagulation. For this particular patient, that score would be 2.
When is an appropriate time to consider endomyocardial biopsy for non-ischemic cardiomyopathy?
Endomyocardial biopsy is mostly indicated when there is a suspicion for acute myocarditis specially if related with arrhythmias at presentation to r/o giant cell myocarditis, chemotherapy agents related cardiomyopathy specially a tracy clones and immune checkpoint inhibitors, restrictive disease of ...
What is your approach to initiating and titrating midodrine for both inpatient and ambulatory settings?
It depends on the indication: Orthostatic Hypotension: 2.5 mg TID CC Inpatient - Check orthostatics SEATED 5', then Standing 1' 3' 5' about one hour after dosing. Increase by 2.5 mg every other dose until patient clinically not orthostatic or 10mg TID CC is achieved or seated hypertension or other s...
Should vasodilatory therapies be considered first-line in the management of hypertension in patients with severe aortic regurgitation?
Yes, ACEi or ARB or dihydropyridine Calcium channel blockers would be the preferred anti-hypertension medication classes in patients with HTN and significant aortic regurgitation. There is no role, however, for using these agents in patients with severe AR without HTN.
Should we have a lower threshold to consider revascularization of coronary lesions in athletes, compared to non-athletes?
Broad question, that may be best asked slightly differently; does CABG or PCI reduce cardiac events in asymptomatic athletes? My approach would be to treadmill stress (preferably MPI) and assess the arrhythmic, ischemic, symptomatic, and hemodynamic burden of disease with exercise stress. And, decid...