Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is the newly approved oral PCSK9 Inhibitor, Lipfendra, as clinically efficacious as injectable versions of the drug such as Repatha?
While this new cholesterol-lowering agent, enlicitdie, has been shown to be very effective, we cannot say it is "as efficacious" as PCSK9 monoclonal antibodies. The studies were done in different populations, with different baseline LDL levels, different potential concomitant medications, etc. The o...
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
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...
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...
Would you routinely initiate a high-intensity statin before discharge in an elderly patient presenting with a STEMI s/p revascularization who has an LDL below 70 mg/dL on no prior lipid-lowering therapy?
Yes. High dose stain therapy’s pleiotropic effects after a ‘plaque rupture’ event cannot be overlooked. Also, LDL-C in plaque rupture events (ACS, STEMI, NSTEMI) can be transiently lower due to the acute-phase response/inflammation. Starting high-intensity therapy ensures the ≥50% drop and addresses...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...