Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
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...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
What is your preferred follow-up imaging modality for an incidentally found thoracic aortic aneurysm measuring 4.4 cm detected on CT?
It depends on the location. If proximal, I would use echo. If more distal, I would prefer MRA.
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...