Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
How often do you have worsening hypoxia with patients started on sotatercept?
I have not observed hypoxia with sotatercept. I have seen in a proportion of patients on IV Remodulin as they are titrated in the ICU, usually those with borderline wedge pressures and diastolic dysfunction.
What clinical parameters or CV imaging considerations would prompt you to consider AV nodal ablation for patients with cardiac amyloidosis and symptomatic atrial fibrillation?
We do this quite often. Atrial fibrillation in amyloidosis often causes considerable clinical deterioration and the first approach should be to attempt to restore sinus rhythm. This can safely be done with electrical cardioversion after adequate anticoagulation. No pre Cardioversion transesophageal ...
Are there any radiation dosimetric considerations for patients with lung cancer that have had a TAVR?
No, the new valve solves a mechanical problem. It will have some metal in it, so it would be visible whether it is a mechanical or biosynthetic type. I'd suggest not having a direct beam hit it, as that is the area of the coronary arteries' origins, and avoid dose spillage to reduce late toxicity. T...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
What is your approach to the management of incidentally elevated HDL levels in isolation and is there any utility for further ASCVD risk stratification and/or genetic testing for lipid disorders?
Although the U-shaped curve for HDLC and ASCVD was a surprise (probably missed until huge population cohorts were studied), the data have been reasonably confirmed in many studies now, with some heterogeneity regarding gender as well as CVD vs total mortality. If I see a patient now with an HDL over...
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?
I typically do not discontinue oral anticoagulation in post-ablation patients with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of >2. Catheter ablation is not considered a "cure" for atrial fibrillation; therefore, there is always a risk of recurrent arrhythmia. The patient may be asympt...