Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What clinical features during a heart failure hospitalization make you defer SGLT-2 inhibitor initiation to outpatient follow-up rather than starting in-hospital?
I have witnessed clinical practice evolve considerably over the past few years on this topic, and there is now increasing emphasis and consensus around initiating SGLT-2 inhibitors during a heart failure hospitalization rather than waiting until after discharge. Evidence suggests that benefits begin...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
What is your preferred next step when you do not achieve daily diuresis goals with spot doses of IV furosemide in patients with decompensated heart failure?
When faced with a situation where the congested heart failure patient is not responding to initial spot (bolus) IV loop diuretic (typically furosemide), my initial step would be assurance that the appropriate dose is being used. We learned from the DOSE-AHF trial (Felker et al., PMID 21366472) that ...
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
What could cause a sudden rise in LDL cholesterol in young adults who have not changed their lifestyle or started any new medications?
Depending on the degree of the rise in LDL-C noted, there are a number of reasons. Despite the person reporting that they have "not changed their lifestyle," one must consider either reduced activity or a diet with more saturated fat, due to being less diet-conscious, or due to a low-carbohydrate or...
What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?
ALONE-AF is another recent trial to challenge the current dogma. The 2023 ACC/AHA/HRS guidelines for AF recommend "In patients who have undergone catheter ablation of AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (e.g., CHA2DS2-VASc sc...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
How do you monitor for cardiac toxicity in patients taking osimertinib?
There are multiple studies that have explored the issue of cardiotoxicity from osimertinib. A large single-center retrospective observational cohort series from Taiwan, (n=401) compared a matched cohort of patients treated with osimertinib (n=253) to those treated with other EGFR TKIs (n=195) and fo...
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...