Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
What is your approach to outpatient antihypertensive therapy after ICH for secondary prevention?
My approach to secondary prevention of ICH depends on the cause.With hypertensive ICH for secondary prevention, the blood pressure goal is less than 130/80 (This is from using the results of the SPS III trial, given the pathological disease mechanisms for both ischemic and hypertensive hemorrhages a...
What advice would you give to patients who are concerned about statin use and its controversies around brain health and dementia risk, based on previous studies?
I cannot think of any class of medications in cardiology that has undergone such scrutiny and investigation to try to find a reason not to take such an effective medication. From the earliest days of its use, one concern after another has arisen; from muscle deterioration, to increasing the risk of ...
Do you favor ticagrelor or prasugrel first-line for the treatment of ACS with planned PCI, provided no contraindications to either agent?
The data suggest that ticagrelor and prasugrel are preferred over clopidogrel in ACS, albeit with increased hazard of bleeding complications. In one of the few head-to-head comparison trials in ACS, ISAR-REACT 5, prasugrel had increased efficacy over ticagrelor. Based on the best available data, it ...
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 is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?
Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a part...
Is there a potential role that hormonal replacement therapy can play in contributing to the development of SCAD?
Spontaneous coronary artery dissection (SCAD) is an infrequent if not rare cause of acute coronary syndrome (ACS). SCAD is estimated to occur in 0.7-1.1% of acute infarctions. In patients, especially female, who present with an ACS but have a low risk profile for coronary disease, SCAD should be con...
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
What would be your advice to providers who are wary of QTc prolongation after starting an amiodarone load and wish to discontinue it?
Amiodarone has been studied in patients with prior TDP patients and found to be safe (small paper from Mattioni et al., PMID 2774388 at Northwestern at the time of my EP fellowship). Amiodarone has been found to be more effective when it prolongs the QT, and the 500 mS limit does not apply to it as ...
Do you routinely condition the implantation of a microaxial flow pump upon echocardiographic exclusion of left ventricular thrombus?
This question highlights a disconnect in current evidence-based guidelines. There is broad consensus across multisociety guidelines and statements (Bernhardt et al., PMID 36805198; Rihal et al., PMID 25861963) that left ventricular thrombus constitutes a contraindication to implantation of a microax...