Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In patients presenting with ACS and multivessel disease, when do you favor immediate versus delayed complete revascularization?
My approach is to defer the PCI to a few weeks (as outpatient) as long as the patient is asymptomatic and does not have a critical lesion (i.e. greater than 90% stenosis in the proximal LAD, LCX or RCA). I have been very consistent with this approach and I recall one patient who came back with unst...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...
What would be a reasonable next-step approach to the evaluation of mild LV systolic dysfunction with regional wall motion abnormalities on TTE in a patient receiving carboplatin/paclitaxel for ovarian cancer without any cardiac symptoms?
Given the regional abnormalities observed, I would obtain stress testing to determine if an ischemic component may be contributing. If stress testing is negative, I would start low-dose GDMT for presumed non-ischemic cardiomyopathy.
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
What is the minimum duration of weeks on anticoagulation in which you would consider performing a DCCV without the need for TEE, provided the patient is an excellent historian and otherwise reliable?
If this were a board question, I agree with the guideline-listed answers here - it's 3 weeks. The most recent 2023 ACC AHA hours Atrial Fibrillation Guidelines by Joglar et al., PMID 38033089 are consistent: In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic an...
What parameters would you use to decide whether to stop hydroxychloroquine in a patient whose lupus is well controlled but is found to have a prolonged QT interval on routine EKG?
This is an excellent question for which there is no one-size-fits-all answer. The first question is how prolonged the QT is, and if there is another drug they are on that is contributing to the prolonged QT. Obviously, it is important to avoid prescribing other medications that prolong the QT. It is...
Is there a role for aspirin 81 mg daily in patients with nonischemic dilated cardiomyopathy with reduced EF?
When there are other indications for antiplatelet therapy such as history of stroke, PVD, etc., Aspirin has a role in pharmacological therapy of patients with non-ischemic dilated cardiomyopathy and a reduced left ventricular ejection fraction. However, in the absence of coexisting indications, ther...
Do you recommend checking urine sodium 2 hours after loop diuretic administration to determine the need for dose adjustment in a patient with acute decompensated heart failure?
I know that is maybe a more physiologic way, but I can tell if it is working just by the urine output. The urine output is not going to increase following a loop diuretic without a natriuresis. And what good id an increased urine Na if the volume of urine is insufficient? If I am diuresing in decom...