Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
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 ...
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...
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...