Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
What patient factors do you consider when selecting between a small interfering RNA, like inclisiran, and PCSK9 inhibitors in patients with recent acute coronary syndrome?
Insurance coverage and out-of-pocket costs usually drive my choice. It is fairly easy to get approval for evolocumab for most of my patients. I have had a hard time getting approval for inclisiran with the exception of those with traditional Medicare + supplemental medication coverage. I usually sta...
In a patient with decompensated heart failure requiring urgent non-cardiac surgery, how much volume optimization do you pursue preoperatively, and at what point does the risk of further surgical delay outweigh the benefit of continued diuresis?
I would recommend preoperative placement of a Swan-Ganz catheter in this situation to guide perioperative management, including intensity of diuresis and use of intravenous inotropic agents and/or vasodilators.
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...
Would you favor CT AV calcium score or dobutamine stress echo for a patient with symptomatic AS and an aortic valve with normal SV/SV index, Vmax 3.4m/s, AVA < 1.0 cm2, and mean gradient < 40 mmHg?
This scenario appears to be one of normal flow, low gradient severe aortic stenosis(NF-LG AS). This is one of the least understood variants of low gradient aortic stenosis. The most important focus should be on avoiding measurement errors during echocardiography, which may lead to underestimation of...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
Similar to the HFA-ICOS risk stratification tool for patients on chemotherapy, are there cardiac risk calculators available for use in patients starting immunotherapy?
No, there are no cardiac risk calculators for patients starting on immune checkpoint inhibitors (ICI). This is primarily because, aside from the use of dual immune checkpoint inhibitor therapy, we have not identified risk factors for ICI-induced myocarditis (Mahmood et al., PMID 29567210). Prior to ...
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...