Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For a patient with known CAD and low baseline HDL, would a PCSK9 inhibitor be a better option than a statin, given concerns for paradoxical lowering of HDL levels with statin therapy that we can encounter in the outpatient clinical setting?
Statin therapy would still be your first choice as we know that they reduce CVD related outcomes regardless of the HDL. In fact, studies show that patients with low HDL benefit even more from statin therapy.
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
Is there any indication/benefit for heparin in a patient with suspected type 2 myocardial infarction?
There is no guideline rule for treating a type 2 MI like a type 1 MI. However, approximately 50% of type 2 MI patients have significant CAD (data from the University of Edinburgh published a year ago or so, in I think Circulation. My recommendation for type 2 MI is to treat the underlying condition ...
How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?
Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).
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 the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?
For the majority of patients with atrial fibrillation, symptoms are generated by the elevated heart rates rather than the irregularity or the loss of the atrial contribution to ventricular filling. The exception to this is patients with heart failure with preserved ejection fraction (diastolic dysfu...
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
For patients presenting with suspected type 1 NSTEMI and atrial fibrillation on anticoagulation, do you favor triple therapy or SAPT with systemic anticoagulation instead while awaiting LHC?
Standard therapy for acute coronary syndrome is suggested including statin therapy, beta blocker therapy, ACE inhibitors with DOAC use while awaiting LHC/PCI. UFH with the addition of P2Y12 inhibition during hospitalization is suggested even with DOAC use. A radial approach should be taken to decrea...
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?
I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...