December 18th, 2014 · Leave a Comment

Enhancing Provider Communication and End-of-Life Planning Competencies

By Dr. Shannon Dunlay

Lack of Provider Confidence Yields 8-part CME Series

As an Advanced Heart Failure cardiologist, I find it alarming that most patients with heart failure have never spoken with their doctors about their wishes for end-of-life care.  Most don’t have an advance directive or living will either.

My colleagues and I noticed that patients with heart failure were often readmitted to the hospital with advanced, stage D symptoms, and faced making difficult end-of-life decisions with very little preparation or planning.  In an effort to improve our practice, we set out to learn more about our own patients and clinicians.  We discovered that only 42 percent of our local heart failure patients had an advance directive.  Furthermore, we found that Mayo clinicians caring for these patients hesitated to discuss prognosis and end-of-life care because they were uncomfortable having the discussion or didn’t have enough time.  Many clinicians also lacked confidence in discussing these issues or providing high-quality end-of-life care to their patients.

In order for clinicians to feel competent and comfortable in approaching these issues, we realized it would be necessary to equip them with the appropriate tools and specific knowledge.  To address this need, we partnered with our experts in Palliative Medicine to develop an 8-part tutorial series that is now available for review and CME credit.  Examples of topics covered include basics of advance care planning, how to approach goals of care discussions, the role of palliative care, and tips for managing symptoms at end-of-life.  This series has been tremendously helpful to me in caring for my patients, and I hope that it is helpful to you in your practice.

Below is an excerpt from the fourth part of the palliative care self-study video series, Starting the Palliative Care Conversation.


For more information, or to purchase self study materials, visit:

View full entry · Comment on this

Tags: End-of-Life Planning Competencies, Enhancing Provider Communication, palliative care

December 16th, 2014 · Leave a Comment

Test Your Knowledge Tuesday #31

By Amy Beeman

This week’s question from Dr. Iftikhar Kullo covers diseases of the aorta and peripheral arteries.

Question: Choose the one best answer

A 45-year-old man with history of familial hypercholesterolemia presents with a six month history of back and flank pain. He has smoked one to two packs daily since his teens and has a history of hypertension.

Over the last few weeks, the pain has increased in severity but he denies any fever, chills or hematuria. The pain does not go into his legs. Upon examination, his blood pressure is 140/80, heart rate of 84, jugular venous pressure not elevated, a left carotid bruit, lungs clear at auscultation. A grade 3/6 mid-peaking ejection systolic murmur was present at the base and his abdomen revealed mild mid-line tenderness and a prominent aortic impulse. The remainder of the examination was normal.

Labs revealed an erythrocyte sedimentation rate (ESR) of 45 mm/hour, C-reactive protein of 8 mg/L, and creatinine of 0.9 mg/dl. An echocardiogram showed mild aortic stenosis with a mean gradient of 10 mm across the valve. An ultrasound of the abdomen showed a 4.7 cm infrarenal abdominal aortic aneurysm with wall thickening. A CT angiogram was done and this showed a 4.8 cm infrarenal abdominal aortic aneurysm with an 8 mm thick wall. Renal arteries were patent. No additional fibrosis was noted in the abdomen.

The diagnosis is:

A. Takayasu’s disease
B. Retroperitoneal fibrosis
C. Inflammatory abdominal aortic aneurysm
D. Giant cell arteritis
E. Intra abdominal lymphoma

Read the rest of this entry »

View full entry · Comment on this

Tags: aorta and peripheral arteries, Dr Iftikhar Kullo, familial hypercholesterolemia

December 12th, 2014 · Leave a Comment

Cardiovascular Device Infections: Grand Rounds Video

By Amy Beeman

Mayo Clinic Center for Translational Science Activities presents Grand Rounds on Cardiovascular Device Infections: State-of-the-Heart. In this Mayo Clinic CV ME video Dr. M. Rizwan Sohail covers the following topics in relation to cardiac device infections:

• Trends in epidemiology
• Financial cost
• Risk factors
• Contemporary approach to management
• New diagnostic methods
• Novel prevention strategies

For more Grand Rounds videos, visit the Mayo Clinic Medical Professional Video Center.

View full entry · Comment on this

December 9th, 2014 · Leave a Comment

Test Your Knowledge Tuesday #30

By Amy Beeman

Dr. Joseph Murphy challenges us with a question regarding patient factors for treating myocardial infarction.


Patients presenting with acute ST elevation myocardial infarction (MI) at hospitals not capable of percutaneous coronary intervention (PCI) are generally treated with local in situ thrombolysis or are transported to a PCI-capable hospital for emergency PCI.

The point at which PCI-related time delay loses its advantage over in situ immediate thrombolysis is called the equipoise time.

Which of the following patient factors reduces the equipoise time for PCI-related treatment delay in acute ST elevation MI:

A. Age greater than 65 years
B. Anterior wall MI
C. Pre-hospital delay greater than two hours before initial healthcare presentation
D. Prior history of stroke
E. Concomitant dabigatran use for non-valvular atrial fibrillation

Read the rest of this entry »

View full entry · Comment on this

Tags: Dr Joseph Murphy, myocardial infarction

December 4th, 2014 · Leave a Comment

Leadless Pacing Available for Selected Patients

By Amy Beeman

The following is an excerpt from a recently published article in the Mayo Clinic Cardiovascular Update Newsletter:

Over the past 60 years, pacemakers have become a highly effective therapy for life-threatening conduction system disease.

The “weak link” in device therapy has been the leads. While transvenous leads typically have lower thresholds and better longevity than epicardial leads, they are associated with increased morbidity and mortality. Complications at implant include bleeding, vascular damage, cardiac perforation, pneumothorax, and dislodgment. Potential long-term concerns include lead fracture, malfunction, venous obstruction, tricuspid valve regurgitation, and the risks associated with lead extraction. Transvenous leads are contraindicated in the presence of right-to-left shunt and in some patients with congenital heart disease.

Recently, two leadless devices have become available: the Nanostim leadless pacemaker (St. Jude Medical, St. Paul, Minn.) and the Micra transcatheter pacing system (Medtronic, Minneapolis, Minn.).


          Nanostim (St. Jude Medical)                                                                  Micra (Medtronic)











The Nanostim uses active fixation, while the Micra has a tined fixation mechanism to secure the device to the right ventricular endocardial surface. Both devices are capable of VVIR pacing and have estimated battery longevity between 7 and 10 years. When the battery is depleted, a new device can be implanted and the existing device left in place.

These devices are contraindicated in individuals who require dual-chamber pacing or who have demonstrable pacemaker syndrome. Anticoagulation is not required after implant placement. Current devices are not MRI compatible. Leadless pacemakers are contraindicated in patients with implantable cardioverter-defibrillators, as high-voltage shocks could damage the pacemaker, and the effect of the pacemaker on shock effectiveness is unknown. Leadless devices should be avoided in individuals with elevated right ventricular pressures because of higher theoretical risk of embolization. The presence of mechanical tricuspid valves or inferior vena cava filters also precludes the use of leadless pacemakers. Successful device retrieval has been accomplished in animal studies.

For more information or to refer a potential candidate for leadless pacing, please contact Paul A. Friedman, MD, director of the Heart Rhythm Device Clinic, at 507-255-4244.

To access the current issue as well as past issues of the CV newsletter, visit the Mayo Clinic Cardiovascular Update page.

View full entry · Comment on this

Tags: leadless devices, leads, Micra, Nanostim, pacemakers