Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
When would you consider PPM implantation for intermittent episodes of high-degree AVB that persist following a successful PCI in a patient presenting with an inferior STEMI?
AV block that occurs with an inferior STEMI is not usually caused by interruption of the distal conduction system and is often reversible. The key term in the question is "persistent." How long after the MI has AV block been observed, what is the heart rate, and is the escape rhythm wide or narrow? ...
What is your approach to anticoagulation in cirrhotic patients with platelet count loss than 50 in the setting of atrial fibrillation and elevated CHADSVASC?
First of all, we have no high-quality data to address this question since patients with this profile were not well represented in the DOAC pivotal trials. Consequently, we need to individualize the decision-making, taking into account variables such as patient age and co-morbidities, vascular risk s...
How do you determine which patient may be a good candidate for the Aurora EV-ICD and its smart sense algorithm?
The Aurora Extra-Vascular ICD (EV-ICD) was approved by the FDA in October 2023. The system consists of a lead that is tunneled beneath the sternum, with the lead tip positioned around the level of the carina, and a generator that is placed in the axillary area. The lead is anchored through a small i...
What clinical features drive your decision to use prophylactic mechanical circulatory support in a patient with severe left ventricular dysfunction undergoing complex PCI following the CHIP-BCIS3 trial?
This is a great question for the interventional cardiology community. I have been very reserved in using prophylactic mechanical circulatory support in very high-risk PCI patients (particularly microaxial flow pump). It has been my observation that mechanical circulatory support is more and more wid...
What is your stepwise approach to the management of culprit STEMI lesions with very high thrombotic burden in spite of multiple runs of mechanical thrombectomy?
We would typically add a double bolus of Integrilin in such a case.
Is there a role for measuring plasma aldosterone to guide the treatment of heart failure in specific populations?
Typically, there is no role in measuring aldosterone to guide therapy. In patients with HFpEF, the use of Aldactone is to help with membrane stabilization and management of RAAS inhibition. There are some reports of prior research supporting LV remodeling and reduction in myocardial fibrosis.
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
What aspects of HF management do you think hospitalists should prioritize before discharge in order to optimize HF admission care if there are limited resources available for specialized HF care, both inpatient and outpatient?
This is straightforward - many patients have poor discharge education on fluid and salt management. Recommendations for 50 oz and 2 gm/day salt are given, but what is this truly like in practice? Our article (Sharma & Goswami, PMID 38486616) suggests that we may need to focus on the basics for salt ...