Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to inpatient work-up for suspected long QT syndrome in a young adult with otherwise normal labs and no medications causing prolonged QTc?
I would emphasize the basics when I approach this clinical scenario. The first step is to carefully analyze the ECG that raised the question. Though measuring the QT interval should be easy, we all appreciate that this is not always the case. Carefully examine the index ECG, look at all the leads b...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
When is a reasonable amount of time for patients to be on 90 mg BID of ticagrelor before transitioning to 60 mg BID following PCI?
That depends on the type of PCI.Generally speaking, I do not continue Ticagrelor beyond six months for stable angina PCI and one year for PCI in the setting of acute coronary syndrome.If the patient has had recurrent ACS or complex bifurcation PCI, I would consider long term dual anti-platelet thera...
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
What is your approach to anticoagulation in cirrhotic patients with platelet count loss than 50 in the setting of atrial fibrillation and elevated CHADSVASC?
First of all, we have no high-quality data to address this question since patients with this profile were not well represented in the DOAC pivotal trials. Consequently, we need to individualize the decision-making, taking into account variables such as patient age and co-morbidities, vascular risk s...
Should CCTA be considered the diagnostic test of choice in the outpatient evaluation of chest pain?
CCTA can not likely stand as a way of perfectly excluding ischemic heart disease, but neither can any test, such as ETT, SET, MRA, etc. As such, it seems attractive to individualize screening tests and even employ a complementary array of techniques.
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
When pursuing complex PCI of the RCA (especially when lesion preparation is required), when do you consider placing a transvenous pacemaker in anticipation of conduction abnormalities?
There are a few options when using roto for the RCA or a dominant LCX. Upfront TVP if you want to play it safe. Pretreatment with aminophylline 100-250 mg 10 minutes. Test run without pre-treatment and having atropine and/or TVP nearby at the ready. Which you choose depends on gut instinct and how...
What is the clinical significance of newly appreciated left atrial enlargement following atrial fibrillation ablation and approach to monitoring for atrial fibrillation recurrence post-ablation in that setting?
An enlarged left atrium is a risk factor for recurrent AF after ablation or during antiarrhythmic drug treatment. How much it increases risk is not completely understood. While LA size or volume can be used to help decide about post-treatment monitoring, the most important element is vascular risk, ...
Is it possible to have first and second degree AV block, either type 1 or 2, on the same EKG strip?
First, there is no such thing as first-degree AV block. A prolonged PR interval is caused by AV delay. In that context, it is more likely that a patient with a long AV nodal conduction time would develop decremental AV conduction or type 1 second-degree AV block. Type 2 second-degree AV block is usu...