Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach exercise recommendations in a frail patient with chronic heart failure who has low baseline functional capacity?
Generally, the frail chronic heart failure patient will potentially benefit from a multicomponent and progressive approach to exercise. This should include balance training and flexibility in addition to resistance and endurance training. Studies have supported the benefit of exercise training in th...
How do you decide in older adults with newly diagnosed stage 2 hypertension when to start with two antihypertensive agents versus taking a more cautious approach due to concerns about potential orthostasis, frailty, or polypharmacy?
Starting Dual Therapy vs. a Staged Approach in Older Adults with Newly Diagnosed Stage 2 HypertensionThe core question isn't just how high blood pressure is; it's how much treatment this patient can safely absorb.In geriatric cardiology, cardiovascular risk reduction and treatment-related harm are t...
How do you approach the management and surveillance of mixed aortic valvular disease with moderate AS and AR, and threshold to refer for surgical intervention?
There are three parameters to consider for surgical management in moderate AS/AR: symptoms LVSF LV dilation Progressive pulmonary hypertension may also make surgery the appropriate decision.
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
When you identify new atrial fibrillation in a hospitalized patient that spontaneously converts to sinus rhythm within 24–48 hours, and the patient has a CHA₂DS₂-VASc score of 2–3, how do you decide whether to initiate anticoagulation and/or discharge with a wearable cardiac monitor?
This is a tough one. I think the easier part is who should get a wearable cardiac monitor? I think the answer is pretty much everyone since the recurrence rate is around 30% in one year - and if it recurs, it predisposes to strokes, and I'd likely provide anticoagulation per AHA/ACC based on CHA₂DS₂...
What is your diagnostic and therapeutic approach to hospitalized patients with persistent hypotension (MAP <65) of uncertain etiology, but no evidence of hypoperfusion or shock physiology?
Clinical concern for MAPs <65 mmHg has become ingrained due to extensive literature on septic shock, but there is little evidence to support intervening solely at this threshold in patients without evidence of hypoperfusion. My initial approach to hypotension is therefore diagnostic: confirm it is r...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
How do you decide between obtaining routine, outpatient ETT versus stress TTE when screening for CAD, especially given insurance company preference on ETTs?
Before getting into the opinion on the above question, it has to be said that the practice of utilizing any stress test to "screen" for coronary artery disease is currently frowned upon, and it is recommended that proceeding with a diagnostic workup should be based on the patient being both at risk ...
What is a reasonable minimal duration of DAPT following drug coated balloon angioplasty for ISR lesions?
A reasonable duration of dual antiplatelet therapy (DAPT) following drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) is at least one month. A JAMA Cardiology review (2025) suggests a minimum of 30 days of DAPT. A JACC review (2022) recommends the following durations: stable corona...
In what scenario could brachytherapy be favored over CABG for recurrent ISR lesions with two layers of stent refractory to cutting balloon or laser, provided the patient is a good surgical candidate?
This is a very interesting question that is nuanced by the specific situation. Knowing the specific anatomy is important. Whether this is single- or multivessel disease, and whether it is focal or diffuse, will influence the decision, as will patient preference.I approach this using the information ...