Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you consider 10MV beams safe in a patient with an implantable cardiac device?
I follow the AAPM TG-203 which considers beams up to 10 MV photons to be non-neutron producing. For example, in a lung, abdominal, or pelvis tumor, I find the reduction in total body dose worthwhile to use 10 MV.
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
What are the alternatives to anticoagulation in an individual with an atrial thrombus and absolute contraindications to anticoagulation?
This is not an easily answered question in this sort of a forum. This clinical situation requires multidisciplinary input and individualized approach. Factors to consider include but not limited to, 1) estimated risk of systemic arterial embolism (note, current tools/calculators provide the annual r...
At what heart dose would you prospectively refer a patient to cardiology due to anticipated long term risks?
If a patient had prior BCT and now inflammatory, I would refer given the most likely plan for additional chemotherapy and RT. In general, I refer for cardiac oncology based on a combination of cardiac risk factors (HTN, DM, HLP), family cardiac history, anthracycline receipt, and cardiac dose (ex. I...
Are there situations where you would start treatment for cardiac amyloid in a patient with amyloid seen on biopsy, but still pending mass spectrometry results?
I do not think of treating cardiac amyloid without the results of mass spec. You really need to know what type of amyloid you are dealing with.
Do you consider the use of bevacizumab in patients with HHT who have high output cardiac failure related to liver AVMs who also have cerebral AVMs?
Liver and cerebral AVMs are common manifestations in patients with HHT. Treatment of these manifestations should be considered and managed independently. Guideline recommendations to effectively eliminate the future risk of cerebral hemorrhage in patients with cerebral AVMs is consultation with HHT ...
Do you change management in patients that are taking bisphosphonates and develop atrial fibrillation?
I allow bisphosphonates in patients with afib. In both the alendronate and zolendronic acid trials subanalysis revealed a minimal increase of afib but FDA review suggested both conditions occur often in the elderly and there was no causality. Our group has given several thousand infusions with no af...
What is your approach to volume resuscitation in patients with obvious septic shock but also with a component of suspected cardiogenic shock?
I think it comes down to clinical decision-making at bedside with the help of a combination of modalities. POCUS to evaluate the IVC size and collapsibility is one option we commonly use and is quick and easy to obtain. Additionally, in situations of unclear shock state, our practice is to float a P...
How do you counsel high-risk women with congenital heart disease who are looking to conceive?
Most women with CHD do well during pregnancy; however, some are very high risk and should not get pregnant. These include women with mWHO classification IV for example pulmonary arterial hypertension, severe systemic ventricular dysfunction, or severe mitral stenosis (see ECS 2018 guidelines for com...