Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you start a statin concurrently with icosapent ethyl for patients with moderate hypertriglyceridemia and high ASCVD risk, or do you prefer to start a statin alone and monitor triglyceride levels?
Statin therapy can lower TGs modestly (up to 20%) and are the first line therapy for ASCVD risk reduction. Therefore I usually initiate statin therapy first and reassess lipids prior to considering use of icosapent ethyl. Additionally IPE adds pill burden (need to take 4 g a day), so I prefer to wai...
When do you recommend screening patients with T2DM for heart failure?
Heart failure is increasingly being recognized as a complication of diabetes. Heart failure is classified in 4 stages. Stage A is “at risk” because of diabetes, stage B is asymptomatic for the patient but with detectable cardiac abnormalities and then stage C and D are symptomatic stages of heart fa...
How do you choose between finerenone and traditional steroidal MRAs for patients with heart failure and mildly reduced or preserved EF, considering recent results showing finerenone's efficacy in reducing heart failure events?
Not only is cost coverage important, with reduced rates for commercial, but not Medicare/Medicaid pts, but the expected reduced adverse drug effect profile of finerenone over spironolactone or eplerenone. That is relevant when treating men with borderline hyperkalemia.
In patients with moderate calcific mitral stenosis, possible HFpEF and dyspnea on exertion, how would you differentiate the etiology of the symptoms?
I would consider a dobutamine stress echocardiogram to evaluate the flow across the valve as well as diastolic parameters. If this does not answer the question, an exercise right heart catheterization could be helpful and could also look into concomitant pulmonary hypertension as a cause of dyspnea....
How soon after an elective, uncomplicated coronary intervention would you feel comfortable having a patient travel by air?
Usually, 3-5 days after uncomplicated PCI. But in the era of transradial and 5-fr sheaths, and in the absence of Sx, with preserved LV EF, this may be truncated to 48 hours.
Would you make any dialysis prescription modifications for an ESKD patient who develops tachycardia during a hemodialysis session?
Arrhythmias that initiate during dialysis treatment are almost always due to hypokalemia. Unfortunately, changing the potassium bath after an arrhythmia has already started will likely not help. The answer to the question depends on the circumstances of the patient. If unstable, would stop dialysis....
Is azilsartan superior to other angiotension receptor blockers in regard to cardiorenal outcome data?
In short, there are no data. There are very few head-to-head comparisons of ARBs on hard outcomes. Azilsartan was used in SPRINT (alongside losartan and valsartan), though the secondary analyses focused on class effect as opposed to specific med-to-med comparisons within a class (DeCarolis et al., P...
What clinical parameters or CV imaging considerations would prompt you to consider AV nodal ablation for patients with cardiac amyloidosis and symptomatic atrial fibrillation?
We do this quite often. Atrial fibrillation in amyloidosis often causes considerable clinical deterioration and the first approach should be to attempt to restore sinus rhythm. This can safely be done with electrical cardioversion after adequate anticoagulation. No pre Cardioversion transesophageal ...
What is your loading dose goal and typical loading regimen for PO amiodarone in patients with atrial fibrillation?
I generally aim for a loading dose of 10 grams. This is a combination of both IV and PO amiodarone administered. For an outpatient, I utilize one of the original dosing schedules consisting of 200 mg TID x 3 weeks, followed by 200 mg daily (although this is a little more than 10 grams). For an inpat...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...