Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
What are your top 5 reasons to choose between a TAVI valve Edwards SAPIEN 3 (Edwards Lifesciences) vs an Evolut FX (Medtronic) and what favors one over the other?
Considering the SMART trial, for patients with a small annulus I favor Medtronic. However, evaluating other studies comparing hemodynamics and EOA, I favor Medtronic for most patients (FAVORS MEDTRONIC). If patients have lower coronaries, especially with the history of coronary artery disease, prev...
What is your approach to determining the safety, appropriateness, and timing of SPECT or PET MPI in patients admitted with NSTEMI and who remain chest pain-free and hemodynamically stable?
Patients with NSTEMI who are stable should have a coronary angiogram as soon as possible. If an angiogram is not available or may be higher risk due to renal failure then a stress test is reasonable but it should be also be done as soon as possible. The goal is to revascularize a vulnerable plaque b...
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
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) ...
How frequently do you opt to use IVUS as opposed to OCT or invasive hemodynamic assessment when evaluating coronary lesions?
For questions of lesion significance, I rely on FFR. But I use IVUS on nearly all PCI's for vessel sizing, plaque characteristics, and then stent results. Tend to favor IVUS over OCT because will often do 2-3 IVUS runs (or more) for stent optimization and want to avoid multiple contrast boluses. Are...
What is the clinical significance of a paradoxical decrease in HDL cholesterol after starting statin therapy?
Whether HDL goes up, goes down or stay stable on statin therapy is honestly not of much concern to me. I do not think it is of any clinical significance since we know that statin therapy improves outcomes. In fact, studies show that the clinical benefit of statins is even stronger in individuals wit...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Do you avoid high-potency P2Y12 inhibitors in favor of clopidogrel in patients with atrial fibrillation on a DOAC who undergo PCI?
Not in all cases, favor high potency P2Y12 in high-risk coronary/complex anatomy, clopidogrel in high-risk bleeding patients.