Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Are there any indications for valve intervention in asymptomatic patients with moderate AS?
There are a few indications for this: These are Class Ila recommendations. If undergoing concomitant cardiac surgery (e.g., CABG, surgery for AA or other valves). If there is LV dysfunction (EF<50%) Rapid progression or high-risk features (e.g., high pulmonary pressure) exist.
How do you approach agitation management, especially the use of neuroleptics in hospitalized patients with a prolonged QTc?
First, I'd wonder how long the QTc actually is. Especially in tachycardic and bradycardic situations (let alone non-sinus rhythms), hand calculation (e.g. via the hodges formula) is advised since the electronic reading is often off. Also, textbook-prolonged and prolongation that would indicate conce...
What is a reasonable timeline for a left heart catheterization in a patient with newly diagnosed severe LV systolic dysfunction of unclear etiology and without an ACS presentation?
Like most problems facing cardiologists, making absolutes about any patient can be misleading. In patients with newly discovered left ventricular dysfunction, symptomatic or asymptomatic, it is important to put the entire clinical picture together to decide what would be the next diagnostic step. Pr...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
For optimal GDMT for patients with HFrEF and co-existing ESRD, is there evidence to support the use of SGLT2 inhibitors and/or ARB/ARNI?
For patients with heart failure with reduced ejection fraction (HFrEF) and co-existing end-stage renal disease (ESRD), the use of sodium-glucose co-transporter-2 inhibitors SGLT2i and angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor ARB/ARNI therapies requires careful considera...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
Do you routinely recommend IVIG for viral myocarditis?
I do not routinely recommend IVIG for viral myocarditis. If there is a case of immune-mediated myocarditis) - It may be recommended. In cases of severe COVID myocarditis in the past, use has been reported. However, it is not something that I routinely recommend.
What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?
ALONE-AF is another recent trial to challenge the current dogma. The 2023 ACC/AHA/HRS guidelines for AF recommend "In patients who have undergone catheter ablation of AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (e.g., CHA2DS2-VASc sc...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
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 ...