Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Besides anticoagulation, how would you approach the management of a large LV thrombus newly seen on TTE in patients on VA-ECMO?
This is a highly morbid condition due to coexisting high bleeding and thromboembolic risk in acutely ill patients. No guidelines exist to direct the best strategies.In addition to optimizing or changing anticoagulation strategy and depending on the location of the thrombus and co-morbidities, the fo...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
Are there specific types/brands of drug-eluting stent you prefer that perform well in terms of lower ISR rates or ones that are better for patients with high bleeding risk?
That is a great question. All of the currently available drug-eluting stents are very safe, and you can now get away with just one month of dual antiplatelet therapy (DAPT) in a patient with high bleeding risk. There is more and more evidence of using clopidogrel only monotherapy instead of using DA...
What is the clinical significance of newly appreciated left atrial enlargement following atrial fibrillation ablation and approach to monitoring for atrial fibrillation recurrence post-ablation in that setting?
An enlarged left atrium is a risk factor for recurrent AF after ablation or during antiarrhythmic drug treatment. How much it increases risk is not completely understood. While LA size or volume can be used to help decide about post-treatment monitoring, the most important element is vascular risk, ...
What is your stepwise approach to managing no re-flow during PCI?
It’s not so much the vasodilator cocktail, as much as it is, getting the vasodilator cocktail into the capillary bed. This is best achieved by very distal injection via any thrombectomy catheter (which can also be used for thrombectomy if needed). Adenosine at 24 mcg/cc + nicardipine (or verapamil) ...
When telemetry or ECG shows a newly prolonged QTc (e.g., >500 ms) in an otherwise stable hospitalized patient, how aggressively do you modify medications, electrolytes, or monitoring?
A newly prolonged QT can be easy to overlook amid the complexity of inpatient hospitalization, and when identified, I generally add it to the problem list so it remains visible during the admission and in future care. Although prolonged QT is associated with torsades de pointes, sudden cardiac death...
Do you require an ECG to assess the QTc interval before administering ondansetron to a hospitalized patient without a known cardiac history or QT-prolonging medications?
There is a nice "Things We Do For No Reason" article in Journal of Hospital Medicine on this: "Hospitalists need not order an initial and subsequent ECGs when administering standard doses of intravenous ondansetron for patients without significant risk factors for QTc prolongation. To assess risk fa...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...