Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
If a pregnant patient with a mechanical heart valve takes warfarin throughout her pregnancy, what are the chances that the fetus will be harmed?
Warfarin is effective for thromboembolic prevention in pregnant patients with mechanical valves. There is however an overwhelming evidence that warfarin taken during pregnancy is deleterious to the fetus. Its use during the first 6–12 weeks of gestation can be associated with important fetal complic...
What is your approach to medical management and echocardiographic surveillance for pregnant patients with severe aortic stenosis during the first, second, and third trimesters?
There is no need for routine echocardiographic surveillance during pregnancy if the patient is asymptomatic and there is no change in the level of BNP. The echo can be helpful for the assessment of pulmonary pressure in patient who develops symptoms .Change in the BNPlevel and echocardiographic PA p...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
Is there any data to support the use of bivalirudin over heparin in patients on VA-ECMO without ongoing concerns for HIT?
Multiple recent meta-analyses and retrospective studies suggest that bivalirudin may reduce the risk of circuit thrombosis, major bleeding, and in-hospital mortality compared to heparin in VA-ECMO patients, even in the absence of HIT.[1][2][3][4][5][6][7][8] Some studies also report improved time in...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
How would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
If the patient is mildly hypovolemic without evidence of respiratory insufficiency, hyperkalemia, or significant acidosis, then proceeding to cath and following with dialysis is reasonable. The other question is to ask, is cardiac catheterization is necessary, and is this a type 1 MI versus chronic ...
How frequently do you obtain lipoprotein (a) levels on asymptomatic patients without a prior history of CAD?
Recent recommendations are considering that the entire population ought to be tested at least once in their lifetime given the estimated prevalence in the general population of some degree of elevation in as many as 20% of the population. That said I certainly check in most people with a family hist...
What is the best approach for single vessel mid-LAD CTO in patient with preserved EF and no anginal symptoms?
Unless there are symptoms or severe ischemia refractory to optimal medical therapy, a PCI is generally not considered indicated in this setting. The presence of collaterals, additional disease, regional viability and technical complexity would enter into the decision as well. Lloyd W Klein MDUCSF
For patients with hypertension who have normal filling pressures following right cardiac catheterization, can hypertension still be attributed to volume overload?
I do not think of chronic hypertension as a disease of volume overload. Loop diuretics are indeed very poor antihypertensive agents. I agree that cardiac loading conditions are dynamic, but in a patient with normal filling pressures and hypertension, I would think of inappropriately increased periph...