Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How would you approach warfarin management in patients with mechanical aortic valve and atrial fibrillation, if they develop chemotherapy-related severe thrombocytopenia?
In general, anticoagulants are held once the platelet count drops to < 50K due to excessive bleeding risk. In patients at very high thrombotic risk (i.e, mechanical mitral valve, tilting disk valve), unfractionated heparin can be considered with close PTT monitoring, though most case reports still h...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
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...
How do you monitor for cardiac toxicity in patients taking osimertinib?
There are multiple studies that have explored the issue of cardiotoxicity from osimertinib. A large single-center retrospective observational cohort series from Taiwan, (n=401) compared a matched cohort of patients treated with osimertinib (n=253) to those treated with other EGFR TKIs (n=195) and fo...
What are your thoughts on the results from the AQUATIC trial which showed that the addition of aspirin daily + oral anticoagulation in patients > 6 months from PCI and with high atherothrombotic risk was associated with a higher risk of death, MI, stroke, coronary revascularization and acute limb ischemia, compared to oral anticoagulation alone?
I think AQUATIC is a well-designed definitive trial. It shows that in patients with chronic CAD (at least 6 mo. out from stent) who are also receiving anticoagulation (typically for AFib), the use of anticoag monotherapy is safer (statistically lower risk in terms of a composite endpoint as well as ...
Should we be more cautious with the use of GLP 1 R agonist therapy in patients with Type 1 diabetes mellitus and obesity given the increased risk of cardiovascular disease with high body weight variability?
There doesn't seem to be any evidence that GLP-1 RA would increase the risk of CV disease. Biologically, the benefits that have been shown in patients without Diabetes (the SELECT trial) should still be applicable for patients with Diabetes Type 1.The trials that didn't show much efficacy in glucose...
During a coronary intervention, if the activated clotting time (ACT) is not within the therapeutic range despite administering weight-based unfractionated heparin, what alternative options do you consider?
I would consider additional boluses of 2000–5000 units of heparin and recheck ACT. If the ACT continues to be below the therapeutic range, consider alternate anticoagulation such as bivalrudin, 2b3a inhibition, and low molecular weight heparin. I also assume we have checked the ACT device. In additi...
How do you advise patients on cardiotoxicity when they are expected to receive a low mean heart dose and low cardiac substructure doses with their radiation plan?
I would say something along the lines of: "Radiation therapy is an effective tool for treating your cancer. However, whenever we give radiation therapy, there is always some incidental dose delivered to the adjacent normal tissues. We cannot make the dose zero to all of the normal tissues. Thus, we ...