Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I do not think that anticoagulation is contraindicated in patients with these Alzheimer's disease antibodies, but I would want to check APOE status. I would not initiate the AD treatment if the patient is E4E4, and even one E4 would make me hesitant to have a patient on anticoagulation and an Alzhei...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How would you approach the management of a patient who develops an accelerated junctional rhythm who exhibits no symptoms and has no prior history of cardiac issues, aside from consulting a cardiologist?
There would be many clinical factors to consider before making a decision to treat to suppress such an arrhythmia including the age of the patient, presence of associated structural heart disease, symptoms associated with the arrhythmia, its rate and putative mechanism, and its pattern and persisten...
What is your preferred duration for triple therapy post-PCI in patients on systemic anticoagulation?
Most practitioners extrapolate data from the AUGUSTUS and PIONEER-AF trials to answer this question.These trial used apixaban and rivaroxaban, respectively, along with use of DAPT with clopidogrel 75mg qd and ASA 81mg qd. From these 2 trial, Augustus demonstrated lower bleeding risk compared to trip...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
What are some TTE findings that suggest worsening function of a bioprosthetic AVR that would require further surveillance or diagnostic imaging?
Doppler findings of an increasing transaortic gradient; 2D findings of decreased valve excursion and increased cusp calcification.
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...