Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Do you start a statin concurrently with icosapent ethyl for patients with moderate hypertriglyceridemia and high ASCVD risk, or do you prefer to start a statin alone and monitor triglyceride levels?
Statin therapy can lower TGs modestly (up to 20%) and are the first line therapy for ASCVD risk reduction. Therefore I usually initiate statin therapy first and reassess lipids prior to considering use of icosapent ethyl. Additionally IPE adds pill burden (need to take 4 g a day), so I prefer to wai...
When do you recommend screening patients with T2DM for heart failure?
Heart failure is increasingly being recognized as a complication of diabetes. Heart failure is classified in 4 stages. Stage A is “at risk” because of diabetes, stage B is asymptomatic for the patient but with detectable cardiac abnormalities and then stage C and D are symptomatic stages of heart fa...
How do you choose between finerenone and traditional steroidal MRAs for patients with heart failure and mildly reduced or preserved EF, considering recent results showing finerenone's efficacy in reducing heart failure events?
Not only is cost coverage important, with reduced rates for commercial, but not Medicare/Medicaid pts, but the expected reduced adverse drug effect profile of finerenone over spironolactone or eplerenone. That is relevant when treating men with borderline hyperkalemia.
In patients with moderate calcific mitral stenosis, possible HFpEF and dyspnea on exertion, how would you differentiate the etiology of the symptoms?
I would consider a dobutamine stress echocardiogram to evaluate the flow across the valve as well as diastolic parameters. If this does not answer the question, an exercise right heart catheterization could be helpful and could also look into concomitant pulmonary hypertension as a cause of dyspnea....
How soon after an elective, uncomplicated coronary intervention would you feel comfortable having a patient travel by air?
Usually, 3-5 days after uncomplicated PCI. But in the era of transradial and 5-fr sheaths, and in the absence of Sx, with preserved LV EF, this may be truncated to 48 hours.
Would you make any dialysis prescription modifications for an ESKD patient who develops tachycardia during a hemodialysis session?
Arrhythmias that initiate during dialysis treatment are almost always due to hypokalemia. Unfortunately, changing the potassium bath after an arrhythmia has already started will likely not help. The answer to the question depends on the circumstances of the patient. If unstable, would stop dialysis....
Is azilsartan superior to other angiotension receptor blockers in regard to cardiorenal outcome data?
In short, there are no data. There are very few head-to-head comparisons of ARBs on hard outcomes. Azilsartan was used in SPRINT (alongside losartan and valsartan), though the secondary analyses focused on class effect as opposed to specific med-to-med comparisons within a class (DeCarolis et al., P...
What clinical parameters or CV imaging considerations would prompt you to consider AV nodal ablation for patients with cardiac amyloidosis and symptomatic atrial fibrillation?
We do this quite often. Atrial fibrillation in amyloidosis often causes considerable clinical deterioration and the first approach should be to attempt to restore sinus rhythm. This can safely be done with electrical cardioversion after adequate anticoagulation. No pre Cardioversion transesophageal ...