Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When do you use anticoagulation over antiplatelet therapy for secondary stroke prevention in patients with LV injury or dysfunction?
First, I will observe that the recent work is a cohort study, not an RCT< and I would be careful about concluding that anticoagulation is the best approach. We have had prior trials, e.g., WARCEF and the related ESUS trials (NAVIGATE and RESPECT), and others that have looked at possible cardioemboli...
Do you use DOAC in patients with mild or moderate rheumatic mitral stenosis?
Although using DOACs in this population may be safe, these patients were excluded from the large DOAC trials. In addition, MS progresses, so what may be moderate disease today will progress rapidly in some patients. Thus, if anticoagulation is necessary and a VKA is a major issue for the patient, a ...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
Would you consider an ICD for secondary prevention in an otherwise previously healthy adult found to have severe LV systolic dysfunction admitted s/p VF/VT arrest due to profound hypokalemia and hypomagnesemia, or defer implantation given resolution of arrhythmias after correcting electrolyte abnormalities?
I would need to have much more information. For example, does this person have CAD and/or a definable etiology for the cardiomyopathy? Does he/she/they have a family history or genetic profile that might influence the decision. Importantly, I would not dismiss a secondary ICD in this person based on...
Do you routinely opt for continuing a DOAC post-cardiac transplant in a patient with a history of atrial fibrillation pre-transplant?
No, I do not. Pre-transplant atrial fibrillation is not an indication to continue anticoagulation after heart transplant. Anticoagulation is recommended in heart transplant recipients if there is atrial flutter or fibrillation in the cardiac allograft or other qualifying thromboembolic indication fo...
What is the best approach for single vessel mid-LAD CTO in patient with preserved EF and no anginal symptoms?
Unless there are symptoms or severe ischemia refractory to optimal medical therapy, a PCI is generally not considered indicated in this setting. The presence of collaterals, additional disease, regional viability and technical complexity would enter into the decision as well. Lloyd W Klein MDUCSF
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?
This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary cal...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...