Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
Is dexrazoxane recommended for cardioprotection in AYA patients with Hodgkin lymphoma who are receiving anthracyclines as part of their upfront therapy?
This is a good question that reflects the growing body of evidence in favor of dexrazoxane cardioprotection being safe and beneficial (Chow et al., PMID 26014292; Getz et al., PMID 32343641). For AYAs with Hodgkin lymphoma, doxorubicin remains a key component of therapy even for lower stage disease ...
How do you approach the management and surveillance of mixed aortic valvular disease with moderate AS and AR, and threshold to refer for surgical intervention?
There are three parameters to consider for surgical management in moderate AS/AR: symptoms LVSF LV dilation Progressive pulmonary hypertension may also make surgery the appropriate decision.
How do you approach the management of extremely low LDL levels in older adult patients receiving statin therapy for primary prevention of cardiovascular disease?
In the absence of side effects, I am not concerned about very low LDL levels (e.g., less than 20 mg/dL), as there is a fairly linear association between LDL and CV risk, and there is no convincing evidence that even extremely low LDL levels are associated with cognitive impairment, intracranial hemo...
What are your top takeaways from AHA 2026?
The Lp(a) HORIZON trial is certainly thought-provoking. While pelacarsen produced substantial Lp(a) lowering, the HORIZON trial did not demonstrate a reduction in major cardiovascular outcomes. At the same time, the study reinforces something we already know works: aggressive control of established ...
How do you think about using contraction alkalosis as a mark of achieving goal diuresis?
Thank you for your insightful question. Residual congestion at discharge for patients treated for decompensated heart failure is associated with increased rates of readmission and mortality. While I do occasionally use the development of metabolic alkalosis as a marker of decongestion, a review of t...
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...
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
How do you counsel a masters endurance athlete with a high coronary artery calcium score and no symptoms about continued training?
While I very infrequently order coronary calcium scoring in athletes in the absence of contrast-enhanced CT, this is indeed a common clinical scenario. I begin by assessing for the presence and severity of traditional determinants of atherosclerotic risk (i.e., hypertension, dyslipidemia, etc.) and ...