Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
In residency, we had to get patient permission to videotape sessions and allow our supervisors to watch sessions from behind a one-way mirror. If I were to use a scribe, especially an AI scribe, or if I were audio or video taping the sessions, I would definitely want to get a patient’s approval. I d...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.
How do you approach the management of extremely low LDL levels in older adult patients receiving statin therapy for primary prevention of cardiovascular disease?
In the absence of side effects, I am not concerned about very low LDL levels (e.g., less than 20 mg/dL), as there is a fairly linear association between LDL and CV risk, and there is no convincing evidence that even extremely low LDL levels are associated with cognitive impairment, intracranial hemo...
Has the CLOSURE-AF trial changed your threshold for referring a patient with atrial fibrillation for left atrial appendage closure?
The totality of data from recent clinical trials affirms that LAAO implantation should be viewed as a useful alternative strategy for patients at high risk of stroke and systemic embolism. Although closure can be used as a first-line treatment in select patients, I continue to recommend a trial of a...
When would you consider starting lipid-lowering therapy for young adults < 30 years of age who have markedly elevated LP(a) and family history of elevated LP(a) and ischemic heart disease?
Years ago, there was a cartoon where two men were sitting eating dinner, and one said to the other, “My physician told me that worrying about your cholesterol was the leading cause of hypertension.” Our discussion question is appropriate given the recently released new guidelines for treating choles...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
I'm a pediatric oncologist who runs our childhood cancer survivorship program, so I generally don't take care of adults. We are a free-standing children's hospital, so we have no affiliation with an adult program. So, when I transition our pediatric oncology patients out of our program, I transition...
Do you plan to incorporate fish-oil supplementation into the care of hemodialysis patients to reduce cardiovascular events in light of the PISCES trial results?
I showed the paper to an Internal Medicine friend of mine who is more statistically savvy than me. He wrote this: "So I read the study, and I’m still at a loss to understand it. I’m pretty Bayesian, but this study breaks my priors. Prior studies were basically negative, not to mention that nothing e...