Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
In a hospitalized patient with compensated cirrhosis or heavy alcohol use requiring analgesia, do you use acetaminophen and if so how do you approach dosing?
For compensated cirrhosis, acetaminophen could be used. It's a common practice to offer acetaminophen in these patients at max 2 g/day. Again, I would advise closely monitoring liver function. In patients with heavy alcohol use, acetaminophen could be used cautiously if the liver function is fine (w...
For transgender women patients wanting to address their voice tone, do you first refer to ENT (i.e., for consideration of tracheal shave) or to speech language pathology (i.e., for behavioral speech therapy)?
Our center for transgender medicine and surgery, one of the biggest in the country, recommends speech pathology with a person trained in feminizing voice.
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
Would you consider opting for beta blocker withdrawal to improve exercise capacity in patients with heart failure with preserved ejection fraction and chronotropic incompetence?
The short version of my answer is Yes, however, I will provide more insight into this: When considering beta-blocker withdrawal to improve exercise capacity in patients with HFpEF and chronotropic incompetence, the evidence and guidelines are nuanced. A prospective, randomized, controlled trial "Pre...
When would you consider switching to or adding on a PCSK9 inhibitor to lipid-lowering therapy following hospital discharge for acute coronary syndrome, in light of the results of the VICTORION-INCEPTION trial, provided LDL is still not at goal?
I don’t think the trial really changed my mind on this. I never really worried about not having ACS patients in the original phase 3 trials, so I had already been using inclisiran when I could in recent ACS patients. I would never switch from a statin to a PCSK9i. Statins are cheap, effective, and w...
Do you frequently recommend the HPV vaccination series to patients above 26 years old?
The FDA approved the use of the 9-valent HPV vaccine in adults aged 27-45 in October 2018. In June 2019, the ACIP recommended that men and women aged 27-45 discuss vaccination with their doctor in a shared decision-making model. Extending mass vaccination for all adults aged 27-45 would cost approxi...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...