Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
For patients presenting with suspected type 1 NSTEMI and atrial fibrillation on anticoagulation, do you favor triple therapy or SAPT with systemic anticoagulation instead while awaiting LHC?
Standard therapy for acute coronary syndrome is suggested including statin therapy, beta blocker therapy, ACE inhibitors with DOAC use while awaiting LHC/PCI. UFH with the addition of P2Y12 inhibition during hospitalization is suggested even with DOAC use. A radial approach should be taken to decrea...
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?
I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
Unfractionated heparin, with its much shorter T 1/2, is preferred to enoxaparin (T 1/2 12 odd hours), even in the era of transradial procedures (as opposed to transfemoral cases with higher bleed risk).
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
What is your approach to using beta-blockers in patients with acute myocardial infarction with preserved LV ejection fraction who undergo early coronary angiography in light of the REDUCE-AMI trial findings?
I would not change practice based on the findings of this study alone. Treatment cross-over in both arms of the study may obscure the potential benefits of post-MI beta-blocker therapy in patients with preserved EF.
Should an ischemic evaluation be pursued in cases of unexplained complete heart block or high-degree AV block?
Not necessarily. There are many factors to consider including the site of block (AV nodal versus distal conduction system), the presence of previously diagnosed coronary artery disease, and symptoms at the time of the event.
What is your step-wise approach to differentiating SVT with aberrancy versus VT?
Good question, this is addressed with classic algorithms such as the Brugada criteria.They can be a little cumbersome so I use the best parts of that, which would be: The likelihood of VT is increased with: Age > 35 (positive predictive value of 85%) Structural heart disease Ischemic heart diseas...
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...
Knowing that there is going to be significant PR prolongation with RA pacing, should a LBBA pacing lead be recommended in patients with a PPM indication and a significant first degree AV block (>250msecs) especially if the patient has a borderline LVEF (~45-55%) to prevent diastolic MR-pacemaker syndrome ?
Yes, this would certainly be reasonable, but less likely required. There are other considerations with LBAP, such as extended procedure time and lack of specific reimbursement for this extra time. If the patient is already tolerating this significant PR, it may not be worth the LBAP if it turns out ...