Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is it worth getting a calcium score on a patient who is already on statin therapy?
Plaque, usually TCFA (thin-capped fibroatheroma), benefits immensely from statin Rx. TCFAs are vulnerable plaques that are highly prone to rupture. The pleiotropic effects of statin Rx allow for plaque stabilization and reduce the vulnerability of the plaque to rupture. Calcification of plaque is a ...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
Could plasmapheresis be reasonably considered in pregnant patients for primary prevention in asymptomatic familial hypercholesterolemia, and if so, is there an LDL cutoff that would prompt consideration to proceed?
Plasmapheresis/LDL apheresis is considered a safe and effective option for maternal LDL-C lowering in pregnancy, especially in women with homozygous FH, where it is considered standard of care. In heterozygous FH, the use of plasmapheresis for primary prevention is reasonable in patients with a true...
In an asymptomatic patient who has had a routine TTE for non-cardiac reasons, would you order further work-up if there are any WMA or mild LVEF reduction?
Yes, I will follow up with Echo again if he develops symptoms. Yes, I will do a stress test.
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
What is your approach to inpatient work-up for suspected long QT syndrome in a young adult with otherwise normal labs and no medications causing prolonged QTc?
I would emphasize the basics when I approach this clinical scenario. The first step is to carefully analyze the ECG that raised the question. Though measuring the QT interval should be easy, we all appreciate that this is not always the case. Carefully examine the index ECG, look at all the leads b...
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
Should CCTA be considered the diagnostic test of choice in the outpatient evaluation of chest pain?
CCTA can not likely stand as a way of perfectly excluding ischemic heart disease, but neither can any test, such as ETT, SET, MRA, etc. As such, it seems attractive to individualize screening tests and even employ a complementary array of techniques.
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
When pursuing complex PCI of the RCA (especially when lesion preparation is required), when do you consider placing a transvenous pacemaker in anticipation of conduction abnormalities?
There are a few options when using roto for the RCA or a dominant LCX. Upfront TVP if you want to play it safe. Pretreatment with aminophylline 100-250 mg 10 minutes. Test run without pre-treatment and having atropine and/or TVP nearby at the ready. Which you choose depends on gut instinct and how...