Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
There still is a role for TTM in post-cardiac arrest patients. The Targeted Temperature Management After Cardiac Arrest: A Systematic Review was a systematic review of six randomized clinical trials with a total of 3870 participants that were examined. Of these, 2,767 participants were treated with ...
How is your experience with point-of-care INR systems for home monitoring of vitamin K antagonists?
Point of care (POC) INRs are reliable and can be used to monitor patients once their INRs have been stabilized on warfarin. In fact, there is data on better time in the therapeutic range for self-testing and also self-management of dosing. However, this needs to be done in conjunction with a warfari...
What are your recommendations for the long-term management of patients who have experienced Takotsubo cardiomyopathy, particularly regarding ongoing medication management and follow-up imaging?
The management of Takotsubo cardiomyopathy (TTC) focuses on both the acute phase and long-term care. While specific guidelines for TTC are still evolving, a tailored approach based on individual patient profiles and clinical circumstances is recommended. In regards to the long-term medication strate...
How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?
Assuming that the apixaban dose was 5 mg bid, I would switch to warfarin and aim for INR 2.5-3.5.
How do you approach mitral valve endocarditis associated with a large vegetation size and severe mitral regurgitation, but without any heart failure, hemodynamic instability or valve destruction?
This is a great question and it poses the risk-benefit of the situation nicely. This stems off the 2012 NEJM (Kang et al., PMID 22738096) paper linked in the question, comparing Early (<48 hr) vs Conventional/Abx treatment for large vegetation (>10 mm) without major stroke yet. Summary: this was pre...
When would you consider using Ibutilide for rapid pharmacologic cardioversion of atrial fibrillation?
Someone already on anti-coagulation for paroxysmal or persistent atrial fibrillation. As well as someone with very recent onset atrial fibrillation/flutter in less than 24 hours. (Some may like less than 12 hours others less than 48 hours) Someone I planned on electrical cardioversion that day, how...
How do you approach inpatient DVT prophylaxis in patients already on low dose rivaroxaban 2.5 mg BID for PAD?
I suspect that the approach to this situation may vary by provider given the lack of definitive evidence. ASH 2018 guidelines provide recommendations for inpatient thromboprophylaxis in acutely or critically ill patients. Generally, prophylactic LMWH is recommended over DOACs, but guidelines acknowl...
How would you decide between conservative management vs. ILR or pacemaker for asymptomatic nocturnal bradycardia/pauses (as an example rates in the 30s, pauses ranging 4-12 seconds) in the absence of bradyarrhythmias during the day and ECG with normal intervals, and not otherwise on medications to slow down HR?
The guidelines are clear in stating that patients with symptomatic bradycardia or higher degree heart block during waking hours would benefit from pacing, but determining symptom-rhythm correlation is not always easy. In sinus node dysfunction, there is no established minimal HR or length of pause t...
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
What are your top takeaways from ACC 2024?
In the field of critical care cardiology, DanGer Shock stands out as a key trial presented at ACC 2024 and simultaneously published in NEJM (Møller et al., PMID 38587239). The “splash” of DanGer Shock comes as it is the first randomized controlled trial to demonstrate a mortality benefit from a temp...