Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What degree of aortic valve insufficiency is reasonable to tolerate for Impella supported PCI provided that the Impella will be removed at conclusion of case?
Mild or moderate AI would be tolerated for a short period of time, so long as the patient tolerates it from a hemodynamic standpoint. I do not think severe AI would be tolerated, even for a short duration, such as the time it takes to do a PCI.
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...
What objective tools do you use to help determine if a patient is too high risk for anticoagulation to prevent stroke or DVT?
There are a number of risk scores, like HAS-BLED, that can be used, but I continue to use clinical judgment and shared decision-making. The excellent risk profile of NOACs and the availability of LAAO mean that I can usually come up with a solution for almost every patient that will protect them fro...
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 the frequency in which patients should be taking pill in the pocket medication for paroxysmal atrial fibrillation before you begin to consider maintenance dosing medications instead?
This is very patient-specific; they need to have a good understanding of the process and good access to an EKG (even if it is a consumer device like Kardia). I find many patients either do not understand fully or respect the potential dangers of these medications. For example, they will take multipl...
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...
What is/are your preferred technique(s) for obtaining LV-Ao pressure gradients in the cath lab?
Two other ways to do this I learned while the Langston Cather was on back order to use a 6F 75 or 85 cm R2P sheath parked in the ascending aorta and a 4F pigtail in the LV. With two transducers (on off the side of R2P and one on pigtail) and a 2F difference in size of catheters, you get nice fidelit...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
What are some TTE findings that suggest worsening function of a bioprosthetic AVR that would require further surveillance or diagnostic imaging?
Doppler findings of an increasing transaortic gradient; 2D findings of decreased valve excursion and increased cusp calcification.