Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you calculate QTc intervals in patients being admitted for AAD drug loading who remain in atrial fibrillation or atrial flutter?
We measure 10 R-R intervals and the corresponding 10 QT intervals, average each of them, and then calculate the QTc. Bazett’s formula is commonly used, but is probably less accurate than other correcting formulae, particularly for patients actively in atrial fibrillation. We often use the Framingham...
What is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?
Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a part...
Is there a potential role that hormonal replacement therapy can play in contributing to the development of SCAD?
Spontaneous coronary artery dissection (SCAD) is an infrequent if not rare cause of acute coronary syndrome (ACS). SCAD is estimated to occur in 0.7-1.1% of acute infarctions. In patients, especially female, who present with an ACS but have a low risk profile for coronary disease, SCAD should be con...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
What would be your advice to providers who are wary of QTc prolongation after starting an amiodarone load and wish to discontinue it?
Amiodarone has been studied in patients with prior TDP patients and found to be safe (small paper from Mattioni et al., PMID 2774388 at Northwestern at the time of my EP fellowship). Amiodarone has been found to be more effective when it prolongs the QT, and the 500 mS limit does not apply to it as ...
Do you routinely condition the implantation of a microaxial flow pump upon echocardiographic exclusion of left ventricular thrombus?
This question highlights a disconnect in current evidence-based guidelines. There is broad consensus across multisociety guidelines and statements (Bernhardt et al., PMID 36805198; Rihal et al., PMID 25861963) that left ventricular thrombus constitutes a contraindication to implantation of a microax...
Is there any utility in starting quinidine for non-ischemic VT storm refractory to amiodarone, lidocaine?
Unfortunately, there are no data regarding this strategy. In addition, IV quinidine is generally not available in the US. In this clinical scenario, in addition to beta-blockade, my choice might be to try mexiletine, although again, it is only available orally and there are scant data in this regard...
How should a CAC score of 350 influence risk stratification in an asymptomatic primary‑prevention patient with borderline‑to‑intermediate ASCVD risk?
I really appreciate this question because it occurs often in real-life clinical practice. Let's establish some basic grounds here: [1] Elevated coronary artery calcium (CAC) scores are predictive of high atherosclerotic cardiovascular disease (ASCVD) outcomes and major adverse cardiovascular events ...
How would you counsel patients with type 1 or type 2 diabetes mellitus and heart failure on the use of SGLT-2 inhibitors when they have a history of DKA?
Making a recommendation to prescribe this class will really require a case-by-case clinical assessment. It is clear that SGLT-2 inhibitors are very effective in preventing hospitalization for heart failure, and so we will want to suggest their use whenever possible. But it is also clear that DKA (mo...