Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you recommend transitioning elderly patients from thiazide diuretics to alternative agents when managing hypertension given the increased concern for hyponatremia in this patient population?
In short, no.If hyponatremia from a thiazide occurs, which is rare (~2% among individuals in the intensive treatment arm of SPRINT), it is more likely to be in the first month after thiazide initiation. Hyponatremia occurring in an individual with chronic thiazide use very likely represents the pres...
When and should you consider Watchmans for patients with high bleed risk/recurrent GI bleeds and valvular atrial fibrillation with moderate-severe mitral stenosis?
I am not aware of any studies that include those patients.In terms of watchmen in general, the debate still rages on. The most recent trial (non-industry funded) is the CLOSURE-AF Trial, which found that standard medical therapy (anticoagulation) was superior to catheter-based left atrial appendage ...
Could you describe the variables that influence your decision against or advocating for performing atrial fibrillation/flutter ablations in morbidly obese patients, versus opting for medical therapy and if so, choice of antiarrhythmic agent?
The short answer is yes. We know extreme obesity will increase procedural complications, including but not limited to anesthesia issues, groin access issues, etc. We also know the chances of meaningful long-term success in very obese patients are lower than what would be in the trials. Different EPs...
Which anticoagulant (DOAC or Warfarin) would you recommend in the case of a 70-year-old male with persistent atrial fibrillation and history of rheumatic mitral stenosis now status post bioprosthetic MVR?
There won't be perfect data on this, per the 2023 guidelines:The distinction between “valvular” and “nonvalvular “AF remains a matter of debate. Their definitions may be confusing. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants in AF were performed am...
Should presence of coronary artery calcifications on CT/CTA be considered as presence of vascular disease on CHA2DS2-VASc score?
This is a great question, not only for this aspect but also even defining as what counts as secondary prevention vs primary prevention, etc. The short answer is that it is not clarified in CHADSVASC, but at that time, they were more using the definition of "clinical CAD," so I generally do not count...
For a platelet-transfusion-dependent elderly patient with recurrent bacteremia and a dual chamber pacemaker, and TEE with fibrin vs. possible vegetation, would you consider device removal or favoring treatment with suppressive antibiotics?
Depends on clinical situation and the patient, lead dwell time, and complexity of the extraction procedure.
Do you transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...
What is your approach for de-escalation of antiarrhythmics for patients with a history of ventricular arrhythmias?
This is an important question. The answer depends on several factors including the type of arrhythmia being treated, the patient's underlying condition, drug intolerance and expense, and patients' expectations. Unfortunately, there is very little published information on this topic but as a general ...
How frequently and how soon after starting a patient on flecainide should they undergo exercise treadmill testing to look for QRS widening due to use-dependence?
Following initiation of flecainide or after a dose escalation, exercise treadmill testing is typically performed once, early in therapy, generally within 1–2 weeks, after steady-state drug levels are achieved. The purpose is to evaluate for rate-dependent QRS widening related to use-dependent sodium...