Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
Is it reasonable to start de-escalating GDMT for patients with recovered LVEF following PCI for anterior STEMI, and if so, what class of medication would you consider stopping first?
This depends upon what is defined as "recovered" (TTE vs cardiac MRI), but I would be hesitant to de-escalate - wary of second "hits" and the natural history of LV trajectories (Lupon et al., PMID 30071987 - albeit the IHD cohort is not included here).Age and co-morbidities (younger - more "life yea...
Is the newly approved oral PCSK9 Inhibitor, Lipfendra, as clinically efficacious as injectable versions of the drug such as Repatha?
While this new cholesterol-lowering agent, enlicitdie, has been shown to be very effective, we cannot say it is "as efficacious" as PCSK9 monoclonal antibodies. The studies were done in different populations, with different baseline LDL levels, different potential concomitant medications, etc. The o...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...
Would you routinely initiate a high-intensity statin before discharge in an elderly patient presenting with a STEMI s/p revascularization who has an LDL below 70 mg/dL on no prior lipid-lowering therapy?
Yes. High dose stain therapy’s pleiotropic effects after a ‘plaque rupture’ event cannot be overlooked. Also, LDL-C in plaque rupture events (ACS, STEMI, NSTEMI) can be transiently lower due to the acute-phase response/inflammation. Starting high-intensity therapy ensures the ≥50% drop and addresses...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.