Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How frequently and how soon after starting a patient on flecainide should they undergo exercise treadmill testing to look for QRS widening due to use-dependence?
Following initiation of flecainide or after a dose escalation, exercise treadmill testing is typically performed once, early in therapy, generally within 1–2 weeks, after steady-state drug levels are achieved. The purpose is to evaluate for rate-dependent QRS widening related to use-dependent sodium...
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...
What would be your transfusion strategy for a patient with decompensated cirrhosis presenting with concomitant acute upper GI bleed and acute MI?
I would be guided by the patient's vital signs, response to crystalloids, and clinical findings for red cell transfusion decisions, more so than any hemoglobin/hematocrit determination. I would avoid plasma transfusion for INR/prothrombin time abnormalities unless the viscoelastic testing demonstrat...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
When should you suspect TR related to pacemaker lead placement as a cause of RV dysfunction rather than pulmonary HTN or other etiologies for RV failure associated with tricuspid regurgitation?
It would be patient-specific but would need to include RHC to rule out pHTN (of any group). That should point you in the right direction. I suspect this would be pretty rare and would have to have very severe TR. We know there is a magic amount of slack to put in the RV lead to minimize TR, but this...
What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?
This would be a case-by-case evaluation with additional history, examination and imaging features. I would take a multidisciplinary approach and also consult with hematology and cardiology. I am assuming all other workups are negative. I would probably repeat APLS labs in 6 weeks with lupus anticoa...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
What is your go-to non-invasive test for the evaluation of angina in the primary care setting?
Great question, but not a simple answer! In my experience, there is no "go-to" noninvasive test for the evaluation of angina in the primary care setting. That is because each noninvasive test has its own strengths and pitfalls, which must be judiciously applied in the selection process for the indiv...
What would be your approach to percutaneous intervention for acute plaque rupture and cardiogenic shock for a patient with cirrhosis and severe thrombocytopenia?
This is a risk benefit ratio question and the benefits of PCI far outweigh the bleeding (and paradoxically, thrombotic) risk. ASA and ADP antagonists last the lifespan of the platelet for the most part, so after the early stage of DAPT with ASA and a potent P2Y12 inhibitor, d/c’ing ASA may reduce ov...
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...