Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?
Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a part...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Is there a potential role that hormonal replacement therapy can play in contributing to the development of SCAD?
Spontaneous coronary artery dissection (SCAD) is an infrequent if not rare cause of acute coronary syndrome (ACS). SCAD is estimated to occur in 0.7-1.1% of acute infarctions. In patients, especially female, who present with an ACS but have a low risk profile for coronary disease, SCAD should be con...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
How frequently have you seen hypokalemia play a role in ventricular arrhythmias, and is there a baseline goal K level to aim for in these patients to lower the risk of arrhythmia recurrence?
I was very impressed with the results of the POTCAST study, which showed that, in patients who had an ICD and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels led to a significantly lower risk of appropriate ICD therapy, unplanned hospitalization...
What is a reasonable minimal duration of DAPT following drug coated balloon angioplasty for ISR lesions?
A reasonable duration of dual antiplatelet therapy (DAPT) following drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) is at least one month. A JAMA Cardiology review (2025) suggests a minimum of 30 days of DAPT. A JACC review (2022) recommends the following durations: stable corona...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...
Do you use DOAC in patients with mild or moderate rheumatic mitral stenosis?
Although using DOACs in this population may be safe, these patients were excluded from the large DOAC trials. In addition, MS progresses, so what may be moderate disease today will progress rapidly in some patients. Thus, if anticoagulation is necessary and a VKA is a major issue for the patient, a ...
Would you consider amiodarone for the treatment of atrial fibrillation with RVR in patients who cannot tolerate beta blockers but have a high CHA2DS2-VASc score and are not on anticoagulation?
We typically do not due to risk of chemical cardioversion and precipitating an embolism.
In post-AFib ablation patients with a retroperitoneal bleed requiring transfusion, when should oral anticoagulation be restarted?
There is no easy answer. Much of the decision will depend on the cause of the bleed (e.g., spontaneous versus iatrogenic), the patient's comorbidities and bleeding risk scores, the indication for oral anticoagulation (OAC), and the availability of alternatives such as left atrial appendage occlusion...