Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
How do you decide between stereotactic arrhythmia radiation (STAR) and repeat catheter ablation in patients with refractory ventricular tachycardia who have already failed one prior ablation?
This is a great question and something that the ongoing RADIATE-VT trial is working to answer (NCT05765175). In this phase III RCT trial, recurrent VT patients who have had at least one prior catheter ablation, are considered to be candidates for a repeat catheter ablation by their electrophysiologi...
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
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 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:...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question about an article that is still in press. The authors of the study attempted to optimize BP after mechanical thrombectomy for stroke by determining an optimal BP range for each patient and by determining optimal tissue oxygenation via near-infrared spectroscopy in respon...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
Do you transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.