Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your stepwise approach to supporting the RV in the setting of RV failure from unrevascularized RCA disease in an unstable patient in the absence of RP impella availability?
Physiology RV infarct → preload dependent, afterload sensitive, rhythm/AV-synchrony dependent. Aim to optimize preload (not too little/not too much), reduce RV afterload, maintain perfusion pressure, preserve sinus/AV synchrony, and relieve ischemia where possible. 1) Immediate stabilization (fir...
What is your approach to checking preoperative cardiac biomarkers such as troponin and BNP?
While now recommended as a means of risk stratification for those over 65 years with cardiac risk factors across all three guidelines (AHA/ACC, CCS, ESC), we mostly reserve the use of biomarkers preoperatively for patients in whom we are on the fence for obtaining additional cardiac workup. We view ...
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...
Are you more likely to initiate a calcium channel blocker rather than a beta-blocker as first-line therapy in patients with symptomatic nonobstructive hypertrophic cardiomyopathy, in light of emerging randomized data suggesting potential physiologic advantages with verapamil?
Verapamil, in my experience, has a far greater incidence of side effects, especially at moderate to high doses.
How do you approach prescribing statins in patients with an ASCVD <7.5% but have a strong family history and/or elevated LDL (but <190)?
When considering statin therapy for patients with an ASCVD risk of less than 7.5%, but with a strong family history of cardiovascular disease or elevated LDL cholesterol levels, the decision is nuanced. Here’s how I approach this situation: Shared Decision-Making: Involve patients in the discussion...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
Does theophylline have a role in bradyarrhythmias, and if so, in what patient population(s) can this be considered?
I do not have a lot of experience with theophylline, but since there are no other answers will take a stab.I would only consider it if something acute was happening, such as in the hospital setting with an easily reversible issue. Otherwise, a pacer (either transvenous or leadless) would be better f...
How would you approach the duration and initiation of DAPT or SAPT for SCAD in a patient with Atrial Fibrillation on therapeutic anticoagulation?
Spontaneous coronary artery dissection is a rare cause for an acute coronary syndrome afflicting predominantly females in the 30-55 year old age group and typically occurs in the absence of underlying atherosclerosis. This is a completely different mechanism for an acute infarction than that caused ...
Would you pursue imaging to clear the left atrial appendage or have a risk/benefit discussion with a patient prior to semi-urgent cardioversion if there was concern for delayed administration or a single missed dose of anticoagulation?
This would probably depend on the CHA2DS2VASc score. If CHA2DS2VASc <=2 for men or <=3 for women, I would have a risk/benefit discussion with the patient and consider proceeding without preprocedural imaging after shared decision-making. If CHA2DS2VASc risk is higher, I would favor pre-procedural im...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.