Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Do you tailor your choice of beta-blocker to the specific arrhythmia mechanism, or do you default to a cardioselective agent regardless of clinical context?
Since we do not have good comparative data among beta-blockers, I tend to use the best tolerated. Cardioselective beta-blockers, particularly those with low central nervous system (CNS) penetration, certainly have an advantage in that regard. There are a few exceptions. Acebutolol, an infrequently u...
Do you still recommend daily fluid restriction to ambulatory patients with mild to moderate heart failure symptoms, given RCT data showing no improvement in health status compared to liberal fluid intake?
No, I don't recommend daily fluid restriction for outpatients with mild/moderate HF symptoms. The data do not support it, and some patients truly feel limited and frequently thirsty with this intervention.
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.
Is there evidence to support the use of automated blood pressure checks during exercise stress testing, or does manual BP remain superior in terms of accuracy and consistency?
While there are certainly some advantages with automated blood pressure monitors, there are some limitations that require a manual backup or check. Exercise peak BPs should be verified with manual cuffs as well as measurements during arrhythmias, which can affect the accuracy of automated devices. A...
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...
In patients with resolved LV thrombus post-MI after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
A common and sometimes challenging scenario. If there is persistent LV dysfunction (EF <40%) with apical akinesis /aneurysm, I maintain anticoagulation regardless of thrombus resolution. Recurrence of thrombus, even after echo imaging evidence of resolution in this state has been observed. There is ...
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...
When is a reasonable amount of time for patients to be on 90 mg BID of ticagrelor before transitioning to 60 mg BID following PCI?
That depends on the type of PCI.Generally speaking, I do not continue Ticagrelor beyond six months for stable angina PCI and one year for PCI in the setting of acute coronary syndrome.If the patient has had recurrent ACS or complex bifurcation PCI, I would consider long term dual anti-platelet thera...
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...