Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
Would you consider a short duration of dual antiplatelet therapy following plain old balloon angioplasty (POBA) to a femoropopliteal bypass graft
Aspirin alone is sufficient after plain old balloon angioplasty, particularly in a high bleeding risk patient.
Do you prefer the routine use of bivalirudin over UFH during PCI cases in patients presenting with ACS?
The antiplatelet strategy is the key, in terms of pre-treatment, or post-treatment, maintenance therapy, or loading therapy, and choice of DAPT therapy. This antiplatelet regimen, in terms of timing of load and choice of non-ASA antiplatelet therapy, is a major factor in maximizing PCI outcomes. Int...
Following completion of antiplatelet monotherapy (i.e., Plavix) plus oral anticoagulation in patients with AFib post-PCI, would you favor continuing antiplatelet therapy + OAC, switching from Plavix to aspirin and continuing OAC, or stopping antiplatelet therapy and continuing OAC?
My practice has always been to continue ASA in addition to anticoagulation but I'm starting to change this practice and remove antiplatelet therapy and continue OAC alone, especially in higher bleeding risk patients. There have been a couple of studies (AFIRE and OAC-ALONE) that would seem to suppor...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
With the FDA recently approving acoramidis for ATTR cardiac amyloidosis, how should we decide on optimal drug therapy and options for our patients?
Both tafamidis and acoramidis are stabilizers of transthyretin (TTR) and both have been shown in clinical trials to lessen hospital admissions for CHF and to reduce death in TTR cardiomyopathy compared to placebo. Although acoramidis is said to produce "near complete stabilization" of TTR, and is re...
What are high-risk clinical and echocardiographic features in pregnant patients with congenital heart disease?
The most commonly used risk stratification tool available has been the mWHO maternal cardiovascular risk classification which places women into different categories (I-IV) based on diagnosis/ residual lesions. Class IV patients are considered very high risk for cardiovascular events (bleeding, throm...
What are your first-line vasopressors of choice for the management of acute severe aortic regurgitation and persistent hypotension/shock?
Clinically, it's a surgical emergency, but I would reach for norepinephrine in the acute setting for hypotension, keeping a lower MAP target to manage after load as best as possible.
How do you decide between ordering coronary calcium scoring versus coronary CTA in asymptomatic patients with low to moderate risk for CAD?
Arteries try to “heal” atherosclerotic plaques by calcifying them. Consequently, the presence of coronary artery calcium (CAC) indicates that there is at least some coronary atherosclerotic plaque. The amount of coronary calcium is quantified using the “Agatston” CAC score. The higher the score, the...