Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
Has the FAME 3 trial showing similar 5-year mortality between FFR-guided PCI and CABG changed your default revascularization recommendation in a patient with three-vessel coronary artery disease who is eligible for both procedures?
FAME 3 continues to show a lasting effect of CABG in terms of less MI and revascularization.The decision about revascularization in a patient with multi-vessel disease rests on three pillars. Complexity of the patient's coronary artery disease, their presentation, and patient preference. Patient fac...
Would you consider an ICD for secondary prevention in an otherwise previously healthy adult found to have severe LV systolic dysfunction admitted s/p VF/VT arrest due to profound hypokalemia and hypomagnesemia, or defer implantation given resolution of arrhythmias after correcting electrolyte abnormalities?
I would need to have much more information. For example, does this person have CAD and/or a definable etiology for the cardiomyopathy? Does he/she/they have a family history or genetic profile that might influence the decision. Importantly, I would not dismiss a secondary ICD in this person based on...
Do you routinely opt for continuing a DOAC post-cardiac transplant in a patient with a history of atrial fibrillation pre-transplant?
No, I do not. Pre-transplant atrial fibrillation is not an indication to continue anticoagulation after heart transplant. Anticoagulation is recommended in heart transplant recipients if there is atrial flutter or fibrillation in the cardiac allograft or other qualifying thromboembolic indication fo...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
Is it worth getting a calcium score on a patient who is already on statin therapy?
Plaque, usually TCFA (thin-capped fibroatheroma), benefits immensely from statin Rx. TCFAs are vulnerable plaques that are highly prone to rupture. The pleiotropic effects of statin Rx allow for plaque stabilization and reduce the vulnerability of the plaque to rupture. Calcification of plaque is a ...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
What is the best approach for single vessel mid-LAD CTO in patient with preserved EF and no anginal symptoms?
Unless there are symptoms or severe ischemia refractory to optimal medical therapy, a PCI is generally not considered indicated in this setting. The presence of collaterals, additional disease, regional viability and technical complexity would enter into the decision as well. Lloyd W Klein MDUCSF
Under what circumstances would you consider withdrawing aspirin and continuing with potent P2Y12 inhibitor monotherapy after successful PCI in patients with acute coronary syndromes, based on the findings of the NEO-MINDSET trial?
The NEO-MINDSET trial suggests that aspirin may not be essential after STEMI treated with PCI in selected patients. Its findings indicate that early aspirin withdrawal, continued with potent P2Y12 inhibitor monotherapy, can be safe, particularly when bleeding risk is elevated and ischemic risk is ty...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...