Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
Is it worth getting a calcium score on a patient who is already on statin therapy?
Plaque, usually TCFA (thin-capped fibroatheroma), benefits immensely from statin Rx. TCFAs are vulnerable plaques that are highly prone to rupture. The pleiotropic effects of statin Rx allow for plaque stabilization and reduce the vulnerability of the plaque to rupture. Calcification of plaque is a ...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
Can a dihydropyridine calcium channel blocker (CCB) like amlodipine be prescribed in addition to a non-dihydropyridine CCB such as diltiazem or verapamil for treating hypertension?
Yes, with extreme caution. Diltiazem and Verapamil are CYP450 inhibitors, which can interfere with the metabolism of many medications (commonly statins and calcineurin inhibitors), but also can increase levels of nifedipine and presumably other dihydropyridine CCBs, like amlodipine. Diltiazem or ver...
Could plasmapheresis be reasonably considered in pregnant patients for primary prevention in asymptomatic familial hypercholesterolemia, and if so, is there an LDL cutoff that would prompt consideration to proceed?
Plasmapheresis/LDL apheresis is considered a safe and effective option for maternal LDL-C lowering in pregnancy, especially in women with homozygous FH, where it is considered standard of care. In heterozygous FH, the use of plasmapheresis for primary prevention is reasonable in patients with a true...
In an asymptomatic patient who has had a routine TTE for non-cardiac reasons, would you order further work-up if there are any WMA or mild LVEF reduction?
Yes, I will follow up with Echo again if he develops symptoms. Yes, I will do a stress test.
How do you calculate QTc intervals in patients being admitted for AAD drug loading who remain in atrial fibrillation or atrial flutter?
We measure 10 R-R intervals and the corresponding 10 QT intervals, average each of them, and then calculate the QTc. Bazett’s formula is commonly used, but is probably less accurate than other correcting formulae, particularly for patients actively in atrial fibrillation. We often use the Framingham...
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
What is your approach to inpatient work-up for suspected long QT syndrome in a young adult with otherwise normal labs and no medications causing prolonged QTc?
I would emphasize the basics when I approach this clinical scenario. The first step is to carefully analyze the ECG that raised the question. Though measuring the QT interval should be easy, we all appreciate that this is not always the case. Carefully examine the index ECG, look at all the leads b...
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...