Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
How long do you continue aspirin and clopidogrel after and uncomplicated transfemoral carotid stent?
Typically one month, but many of our carotid patients have concomitant disease in other vascular beds and are often treated with prolonged anti-platelet therapy.
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...
How do you decide the duration of DAPT following TAVR, especially for patients already on a DOAC?
ASA mono Rx usually suffices after TAVR. If PCI + TAVR is performed, then triple Rx for 2-4 weeks, followed by Clopidogrel + DOAC therefore.
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
At what cumulative anthracycline dose is it recommended to use dexrazoxane for cardioprotection?
Typically considered in patients with anticipated >300 mg/m2 doxorubicin, as has been mentioned, which is most commonly seen in patients with sarcoma or recurrent lymphomas. Great discussion re: evidence and considerations in this piece in JACC Cardio-Oncology Upshaw et al., PMID 38773999.In practic...
Do you prefer TTE, CMR, or cardiac CT for the evaluation of PFOs?
In my experience, CMR does not have the spatial resolutions required to assess for a PFO, and cardiac CT (CCTA), while it has the spatial resolution, cannot reliably be performed with provocative maneuvers to increase RA pressure and induce right-to-left shunting as needed to visualize most PFOs. So...
Do you always give 325 mg aspirin if not already loaded with antiplatelets prior to the start of every LHC, even just for diagnostics in the absence of ACS?
Yes. I favor loading almost all patients prior to a LHC even if only diagnostic. That includes those on a DOAC as well. The reason I favor this is in case there was a complication and need for PCI that the patient at least has one anti-platelet in their system.
Would you continue SAPT beyond 12 months after left main stenting in an elderly patient on DOAC for paroxysmal atrial fibrillation?
Many clinical decisions like this one require tailoring the pharmacologic regimen to the individual patient. Obviously, elderly patients on a DOAC are inherently at risk for bleeding, but the risk of a left main stent thrombosis must also be considered. Clinical trials and retrospective data help us...
Do you prescribe hydroxychloroquine to patients who are on other medications that can prolong the QT interval?
First, I'll remind everyone that before COVID-19, case reports of QT-prolongation-associated arrhythmias were rare. It wasn't until COVID that we all at once saw cases with the caveats that these were in patients treated with higher doses of HCQ, commonly loading doses of 800 mg daily, plus COVID-1...