Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you prefer a loading dose of 300mg or 600mg plavix for patients presenting with NSTEMI or unstable angina about to undergo LHC?
Interesting question! As a rule of thumb, 600mg loads faster than 300mg. Therefore, it is more important when you anticipate your ballooning/stenting happening sooner rather than later (within minutes/hours). Per guidelines, Plavix is preferred over prasugrel/brilinta for stable angina (which was no...
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 ...
What criteria do you utilize in deciding when to treat or not treat frequent VPC’s?
Symptoms (burden and severity) PVC burden (>15-20% may lead to a cardiomyopathy) Presence of LV dysfunction Interference with bi-ventricular pacing PVCs triggering VT or VF
When would you consider AV nodal ablation in CRT-non-responders with persistent atrial fibrillation?
AV node ablation is the most definitive method for rate control. In this scenario where the patient already has CRT and is a nonresponder, what I do next depends on age of the patient, how symptomatic the patient is, whether the rates are elevated causing the CRT pacing percentage to be suboptimal a...
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...
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...
What strategies do you employ to minimize the risk of cardiovascular collapse when intubating a patient with severe pulmonary hypertension?
Intubating patients with pulmonary hypertension is a challenging medical and critical care situation. Generally, I try to apply principles of right ventricular optimization of care before I proceed with endotracheal intubation. Intubating patients with pulmonary hypertension is a challenging medical...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Would you consider adding metoprolol succinate to a medication regimen for a patient with paroxysmal Afib on sotalol, known CAD, HF with mildly reduced LVEF, assuming hemodynamics could tolerate it?
Yes, the mechanism of action does not overlap entirely and metoprolol succinate would be indicated for HFmrEF.
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...