Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How would you approach the duration and initiation of DAPT or SAPT for SCAD in a patient with Atrial Fibrillation on therapeutic anticoagulation?
Spontaneous coronary artery dissection is a rare cause for an acute coronary syndrome afflicting predominantly females in the 30-55 year old age group and typically occurs in the absence of underlying atherosclerosis. This is a completely different mechanism for an acute infarction than that caused ...
Would you pursue imaging to clear the left atrial appendage or have a risk/benefit discussion with a patient prior to semi-urgent cardioversion if there was concern for delayed administration or a single missed dose of anticoagulation?
This would probably depend on the CHA2DS2VASc score. If CHA2DS2VASc <=2 for men or <=3 for women, I would have a risk/benefit discussion with the patient and consider proceeding without preprocedural imaging after shared decision-making. If CHA2DS2VASc risk is higher, I would favor pre-procedural im...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
Are there specific types/brands of drug-eluting stent you prefer that perform well in terms of lower ISR rates or ones that are better for patients with high bleeding risk?
That is a great question. All of the currently available drug-eluting stents are very safe, and you can now get away with just one month of dual antiplatelet therapy (DAPT) in a patient with high bleeding risk. There is more and more evidence of using clopidogrel only monotherapy instead of using DA...
What is the clinical significance of newly appreciated left atrial enlargement following atrial fibrillation ablation and approach to monitoring for atrial fibrillation recurrence post-ablation in that setting?
An enlarged left atrium is a risk factor for recurrent AF after ablation or during antiarrhythmic drug treatment. How much it increases risk is not completely understood. While LA size or volume can be used to help decide about post-treatment monitoring, the most important element is vascular risk, ...
What is your stepwise approach to managing no re-flow during PCI?
It’s not so much the vasodilator cocktail, as much as it is, getting the vasodilator cocktail into the capillary bed. This is best achieved by very distal injection via any thrombectomy catheter (which can also be used for thrombectomy if needed). Adenosine at 24 mcg/cc + nicardipine (or verapamil) ...
What are reasonable next steps in the work-up of suspected ATTR amyloidosis if the PYP scan is equivocal, in light of the potential risks of endomyocardial biopsy?
Before addressing the next move after an equivocal PYP scan, some comments on PYP scan reporting are in order. Unfortunately, despite the relative simplicity of obtaining a high quality PYP scam, around 10 -20% of the ones that we see done at outside institutions (including teaching institutions) ar...
How do you decide between stereotactic arrhythmia radiation (STAR) and repeat catheter ablation in patients with refractory ventricular tachycardia who have already failed one prior ablation?
This is a great question and something that the ongoing RADIATE-VT trial is working to answer (NCT05765175). In this phase III RCT trial, recurrent VT patients who have had at least one prior catheter ablation, are considered to be candidates for a repeat catheter ablation by their electrophysiologi...