Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
What patient factors do you consider when selecting between a small interfering RNA, like inclisiran, and PCSK9 inhibitors in patients with recent acute coronary syndrome?
Insurance coverage and out-of-pocket costs usually drive my choice. It is fairly easy to get approval for evolocumab for most of my patients. I have had a hard time getting approval for inclisiran with the exception of those with traditional Medicare + supplemental medication coverage. I usually sta...
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...
Would you favor CT AV calcium score or dobutamine stress echo for a patient with symptomatic AS and an aortic valve with normal SV/SV index, Vmax 3.4m/s, AVA < 1.0 cm2, and mean gradient < 40 mmHg?
This scenario appears to be one of normal flow, low gradient severe aortic stenosis(NF-LG AS). This is one of the least understood variants of low gradient aortic stenosis. The most important focus should be on avoiding measurement errors during echocardiography, which may lead to underestimation of...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
When would you consider switching to or adding on a PCSK9 inhibitor to lipid-lowering therapy following hospital discharge for acute coronary syndrome, in light of the results of the VICTORION-INCEPTION trial, provided LDL is still not at goal?
I don’t think the trial really changed my mind on this. I never really worried about not having ACS patients in the original phase 3 trials, so I had already been using inclisiran when I could in recent ACS patients. I would never switch from a statin to a PCSK9i. Statins are cheap, effective, and w...
What is your preferred anticoagulation/antiplatelet regimen for younger patients presenting with ACS, found to have an acute thrombotic event requiring aspiration thrombectomy without need for stent deployment?
Spontaneous in situ thrombosis of a coronary is rare, especially in the absence of a plaque rupture event. Malignancy-related coronary thrombotic occlusion, even with DOAC semi-compliance, is pathophysiologically difficult to understand, because coronary arteries are relatively high-flow areas, fili...
Are there instances where TAVR should be considered for patients with moderate AS and HFrEF?
Perhaps this is better asked provocatively; did AS (with less than severely elevated gradients) result in a decline in LVEF, or did moderate AS cause HFrEF? In the absence of an alternate cause of LV dysfunction, AS may be the only causative elephant in the room. Other subtle markers of AS severity,...