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 transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.
What ECG features for ST depression would prompt you to report these ST changes if a patient exercised well and did not have any questions during their stress test?
During an exercise treadmill test many components are used to help decide the prognosis and risk of the patient. First is the amount of time the patient exercises on the treadmill. Traditionally doing greater than 10 METS has been shown to have a good prognosis. I say that in patients who are your a...
Under what clinical circumstances, if any, would you prescribe fenofibrate along with statin therapy?
Yes, I do sometimes combine fibrates and statins. Usually, it’s in the setting of needing to treat severe hypertriglyceridemia with the fibrate in a patient who also has hypercholesterolemia and an indication for a statin. If a patient is on a statin and still has mild to moderate hypertriglyceridem...
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
Should there be a role for sacubitril-valsartan in the management of patients with heart failure with preserved ejection fraction?
When it comes to HFpEF, we don't have a lot of effective therapies in our armamentarium. SGLT2 inhibitors have known cardiovascular benefits and were shown primarily to reduce hospitalization in EMPEROR-Preserved and DELIVER. Arguably, spironolactone can be included here despite a trial (TOPCAT) tha...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
How often do you have worsening hypoxia with patients started on sotatercept?
I have not observed hypoxia with sotatercept. I have seen in a proportion of patients on IV Remodulin as they are titrated in the ICU, usually those with borderline wedge pressures and diastolic dysfunction.
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 ...
What is your approach to the management of incidentally elevated HDL levels in isolation and is there any utility for further ASCVD risk stratification and/or genetic testing for lipid disorders?
Although the U-shaped curve for HDLC and ASCVD was a surprise (probably missed until huge population cohorts were studied), the data have been reasonably confirmed in many studies now, with some heterogeneity regarding gender as well as CVD vs total mortality. If I see a patient now with an HDL over...