Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
Since novel biomarkers are not yet clinically available in most practice settings, these are not yet routinely being checked though they certainly merit further investigation for diagnosis of ICI myocarditis. Currently, recommended biomarkers include indicators of cardiac injury (troponin, BNP or NT...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Patients with ICI myocarditis are treated with 1g solumedrol for 3-5 days and then transitioned to oral prednisone at 1mg/kg per day. In general, a slow prednisone taper is recommended (i.e. decrease by 10mg per day every 1-2 weeks). Prior to de-escalating steroid therapy at each stage, there should...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
Can bleeding risk when switching from VKA treatment to a NOAC in frail, elderly patients be accurately compared if individual times in therapeutic range while on VKA treatment are not captured?
It has been postulated that, among patients who do not have an INR within therapeutic range, about half have subtherapeutic values and half have supratherapeutic values. Therefore, the latter are at higher risk of bleeding complications. Time in therapeutic range (TTR) ranges around 60-70% in random...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.
Do you tailor your choice of beta-blocker to the specific arrhythmia mechanism, or do you default to a cardioselective agent regardless of clinical context?
Since we do not have good comparative data among beta-blockers, I tend to use the best tolerated. Cardioselective beta-blockers, particularly those with low central nervous system (CNS) penetration, certainly have an advantage in that regard. There are a few exceptions. Acebutolol, an infrequently u...
Do you still recommend daily fluid restriction to ambulatory patients with mild to moderate heart failure symptoms, given RCT data showing no improvement in health status compared to liberal fluid intake?
No, I don't recommend daily fluid restriction for outpatients with mild/moderate HF symptoms. The data do not support it, and some patients truly feel limited and frequently thirsty with this intervention.
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...