Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Should we routinely incorporate iron studies into admissions for acute decompensated heart failure?
Low serum Iron level in ADHF patients is an independent predictor of poor prognosis. Iron is an essential element in oxygen transportation, delivery, and utilization. I would check the Iron panel in patients with ADHF. However, the frequency of follow-up has not been well defined. Iron deficiency is...
Which clinical and echocardiographic parameters (i.e. LVEF, AVA) do you use when determining patient candidacy for LV device-assisted percutaneous balloon aortic valvuloplasty in patients with cardiogenic shock and severe AS?
This is a tough one and there is no one best answer. The entire clinical picture must be taken into account. Typically, use of an RHC can help guide a patient in cardiogenic shock the best. Historically, patients with mean gradients over 40 mmHg with AVA < 1.0 cm sq by echo or by invasive testing wi...
Is there a preferred heart rate range for patients with moderate to severe paravalvular leak post-TAVR?
There is no optimal heart rate in managing moderate to severe paravalvular regurgitation after TAVR. I generally begin at 70 BPM. Depending on associated conditions such as CAD or mitral stenosis the rate can be increased with echo guidance for optimal rate
What would be a reasonable means of mechanical circulatory support as a bridge to AVR for patients with severe aortic regurgitation complicated by cardiogenic shock?
Options are limited when dealing with severe aortic regurgitation. LAVA-ECMO should be considered to provide needed support. This can reduce the increased left-sided filling pressures and urgent surgery is warranted. Tandem heart can also be considered to help provide needed support without increase...
Should all pregnant patients with newly reduced LVEF <45% be referred as soon as possible to advanced heart failure given high risk for maternal morbidity/mortality in setting of suspected peripartum cardiomyopathy?
The ESC EURObservational Research Programme demonstrated that at six months, in women with peripartum cardiomyopathy: Left ventricular function recovery occurred in 46% of women, whereas 23% continued to have persisting and severe left ventricular dysfunction Re-hospitalization rate was one in 10, a...
What is your approach to weaning IABPs?
The weaning of IABP has varied tremendously across facilities and even providers. To my knowledge, there is no evidence-based method for weaning an IABP. However, there was a beautiful expert-consensus paper released recently that provides excellent scaffolding. Use Table 4 from the article below as...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...
Which hemodynamic parameters can be used to titrate positive pressure ventilation in preload dependent settings such as RV failure, cardiac tamponade, HOCM or hemodynamically significant PE?
As this question alludes, the application of positive pressure ventilation influences cardiac hemodynamics. Key principles of these cardiopulmonary interactions are outlined nicely by Alviar and colleagues (1) in a well-done review. In contemplating this question, it is important to consider the sep...
How would you approach a patient incidentally found to have PET avid large vessel vasculitis on CT angiogram during pre CABG workup?
Observational data from cohorts of patients with Takayasu arteritis has shown that patients with active vasculitis undergoing surgical intervention are more likely to require re-operation (e.g. Fields et al., PMID 16414389).Based on such data, the ACR/VF guidelines for the management of large vessel...
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...