Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your step-wise approach to differentiating SVT with aberrancy versus VT?
Good question, this is addressed with classic algorithms such as the Brugada criteria.They can be a little cumbersome so I use the best parts of that, which would be: The likelihood of VT is increased with: Age > 35 (positive predictive value of 85%) Structural heart disease Ischemic heart diseas...
Should testing for Lyme disease be a routine part of work-up for new-onset high-degree AV block prior to PPM implantation, regardless of patient age or exposure history?
Lyme testing cannot be relied upon in all clinical circumstances because there is an appreciable rate of false positive results. Not only is there cross-reactivity with other infections, but the antibody tests may remain positive for years after an infection has resolved. There can also be false neg...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
How long should patients with atrial fibrillation who are already on systemic anticoagulation and are status post TAVR and PCI 6 months ago remain on Plavix?
If PCI was done for a plaque rupture event I.e. ACS, then DOAC + plavix for a year is the current SOC. For non ACS PCI, DOAC + plavix for 6 months, followed by DOAC mono Rx is a reasonable option.
What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?
I typically do not discontinue oral anticoagulation in post-ablation patients with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of >2. Catheter ablation is not considered a "cure" for atrial fibrillation; therefore, there is always a risk of recurrent arrhythmia. The patient may be asympt...