Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach the risk/benefit ratio of pericardiocentesis as opposed to close observation with serial TTEs in a hemodynamically stable elderly patient on anticoagulation with a large circumferential pericardial effusion?
Core principle: balance the diagnostic and therapeutic benefits of drainage against procedural risks heightened by anticoagulation and patient frailty. Key Considerations: Indication for pericardial drainage: Diagnostic: uncertainty regarding malignancy, infection, or hemopericardium. Therapeutic:...
Do you prefer CTA or MRA for further imaging in patients with ascending aortic dilatation detected on TTE?
The first question you need to ask yourself is whether or not any further evaluation of the aorta is needed at all. Depending on why the echo was ordered in the first place, the finding of the dilated aorta may be a serendipitous finding unrelated to the indication for the echo, and easily explainab...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
What is a reasonable length of time to pass before considering TEE guided DCCV for atrial fibrillation in a patient with a suspected acute cardioembolic stroke and concerns for tachycardia-mediated cardiomyopathy?
There are many issues to consider before proceeding with DCCV. We need to make sure the patient is neurologically stable following the stroke and can be anticoagulated. We seek the opinion of a knowledgeable stroke neurologist in that regard. As soon as anticoagulation can be initiated with a DOAC t...
Would you recommend holding anticoagulation in a patient with persistent atrial fibrillation presenting with a mechanical fall and found to have a scalp hematoma in the absence of intracranial bleeding?
I would not hold anticoagulation in this situation, particularly if the patient has high vascular risk. However, there are a few caveats. First, I would seek an expert opinion about the strength of evidence that an intracranial bleed had not occurred and that it was unlikely to occur later. I would ...
In a patient with IABP set on 1:1, do you always maintain them on systemic heparin, and if so, is there a goal ACT range?
No, never been a problem.
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Would it be reasonable to refer an otherwise healthy patient in their 40s for LHC after CCTA findings note significant proximal RCA stenosis, which was obtained following a transient episode of resting substernal chest pain but without subsequent reproducible symptoms with exercise?
I would favor a nuclear stress test to see if the lesion was associated with myocardial ischemia during exercise. If there was substantial evidence of ischemia, then I would proceed to LHC. If minimal or no myocardial ischemia, I would proceed with aggressive medical and lifestyle therapy.
Can mavacamten be considered for patients with HCM and ongoing dyspnea in setting of an elevated LVEDP but without significant LV outflow obstruction on imaging?
Yes, mavacamten may be a viable option for patients with HCM who have persistent dyspnea and elevated LVEDP, even without significant LVOT obstruction. While most of the evidence for mavacamten focuses on obstructive HCM, emerging data suggest it may have a role in non-obstructive HCM as well.The MA...