Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach revascularization in patients over 75 years with NSTEMI, given recent evidence from the SENIOR-RITA trial that an invasive strategy does not significantly reduce cardiovascular events compared to a conservative strategy?
The Senior-Rita trial was a randomized trial of nstemi patients over the age of 75 randomized to conservative therapy versus an invasive strategy plus optimal medical therapy. Non-fatal MI was more common in the conservative strategy group but overall a primary outcome event occurred in 25-26% in bo...
In patients with resolved LV thrombus post-MI after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
A common and sometimes challenging scenario. If there is persistent LV dysfunction (EF <40%) with apical akinesis /aneurysm, I maintain anticoagulation regardless of thrombus resolution. Recurrence of thrombus, even after echo imaging evidence of resolution in this state has been observed. There is ...
What are your top takeaways from AHA 2025?
The signal across fields: cardiology is moving toward biology + behavior to prevent and treat disease earlier/better. POLY-HF: A single once-daily polypill (β-blocker + MRA + SGLT2i) in HFrEF improved LVEF, QOL, and cut HF events by ~60% vs usual care → major signal that adherence-first strategies ...
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...
Would you consider overdrive pacing for recurrent torsades des pointes in a patient without an obvious drug causing QTc prolongation or significant electrolyte abnormality?
Overdrive pacing is a guideline-recommended treatment for recurrent torsade de pointes in the setting of prolonged QT interval, particularly for patients with bradycardia exacerbating the QT prolongation. Isoproterenol infusion is another option to treat these patients. In these patients, the overdr...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How would you approach warfarin management in patients with mechanical aortic valve and atrial fibrillation, if they develop chemotherapy-related severe thrombocytopenia?
In general, anticoagulants are held once the platelet count drops to < 50K due to excessive bleeding risk. In patients at very high thrombotic risk (i.e, mechanical mitral valve, tilting disk valve), unfractionated heparin can be considered with close PTT monitoring, though most case reports still h...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?
This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary cal...