Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach the risk/benefit ratio of pericardiocentesis as opposed to close observation with serial TTEs in a hemodynamically stable elderly patient on anticoagulation with a large circumferential pericardial effusion?
Core principle: balance the diagnostic and therapeutic benefits of drainage against procedural risks heightened by anticoagulation and patient frailty. Key Considerations: Indication for pericardial drainage: Diagnostic: uncertainty regarding malignancy, infection, or hemopericardium. Therapeutic:...
When would you consider switching to or adding on a PCSK9 inhibitor to lipid-lowering therapy following hospital discharge for acute coronary syndrome, in light of the results of the VICTORION-INCEPTION trial, provided LDL is still not at goal?
The VICTORION-INCEPTION trial looked at LDL-lowering with inclisiran following AMI. I don't know that it enhanced my knowledge or toolkit - as I would have assumed this to be the case - inclisiran offers further LDL-lowering (~40% reduction) compared with usual care. Practically, it is hard to get c...
Do you prefer CTA or MRA for further imaging in patients with ascending aortic dilatation detected on TTE?
The first question you need to ask yourself is whether or not any further evaluation of the aorta is needed at all. Depending on why the echo was ordered in the first place, the finding of the dilated aorta may be a serendipitous finding unrelated to the indication for the echo, and easily explainab...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
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 is a reasonable length of time to pass before considering TEE guided DCCV for atrial fibrillation in a patient with a suspected acute cardioembolic stroke and concerns for tachycardia-mediated cardiomyopathy?
There are many issues to consider before proceeding with DCCV. We need to make sure the patient is neurologically stable following the stroke and can be anticoagulated. We seek the opinion of a knowledgeable stroke neurologist in that regard. As soon as anticoagulation can be initiated with a DOAC t...
Would you recommend holding anticoagulation in a patient with persistent atrial fibrillation presenting with a mechanical fall and found to have a scalp hematoma in the absence of intracranial bleeding?
I would not hold anticoagulation in this situation, particularly if the patient has high vascular risk. However, there are a few caveats. First, I would seek an expert opinion about the strength of evidence that an intracranial bleed had not occurred and that it was unlikely to occur later. I would ...
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...