Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you favor CT AV calcium score or dobutamine stress echo for a patient with symptomatic AS and an aortic valve with normal SV/SV index, Vmax 3.4m/s, AVA < 1.0 cm2, and mean gradient < 40 mmHg?
This scenario appears to be one of normal flow, low gradient severe aortic stenosis(NF-LG AS). This is one of the least understood variants of low gradient aortic stenosis. The most important focus should be on avoiding measurement errors during echocardiography, which may lead to underestimation of...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
What is your preferred anticoagulation/antiplatelet regimen for younger patients presenting with ACS, found to have an acute thrombotic event requiring aspiration thrombectomy without need for stent deployment?
Spontaneous in situ thrombosis of a coronary is rare, especially in the absence of a plaque rupture event. Malignancy-related coronary thrombotic occlusion, even with DOAC semi-compliance, is pathophysiologically difficult to understand, because coronary arteries are relatively high-flow areas, fili...
Are there instances where TAVR should be considered for patients with moderate AS and HFrEF?
Perhaps this is better asked provocatively; did AS (with less than severely elevated gradients) result in a decline in LVEF, or did moderate AS cause HFrEF? In the absence of an alternate cause of LV dysfunction, AS may be the only causative elephant in the room. Other subtle markers of AS severity,...
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...
What is your approach to statin and/or PCSK9i initiation and counseling in a patient who has an HDL above 100, LDL within normal range, but markedly elevated calcium score exceeding 1000?
First, I'd like to know how high is the HDL. They could have a SCARB1 mutation that confers increased atherogenic risk alongside very high HDL levels, likely because of decreased hepatic clearance. I would also like to know their Lipoprotein (a) level and their ApoB level. The LDL can be low while e...
Are there robust clinical data on the safety of IV amiodarone for atrial fibrillation of unclear duration and very difficult to control HR in the current era of widespread DOAC use, as opposed to older data with warfarin?
In the current DOAC era, there are no prospective or randomized data specifically evaluating IV amiodarone administered for rate control in atrial fibrillation of uncertain duration. The principal safety concern is not the agent itself but the possibility of unintended pharmacologic cardioversion, w...
What has been your approach to percutaneous intervention for calcified nodules and threshold for intervention?
Very high threshold for intervention in these cases. Generally, there is severe calcification all around and sometimes multiple calcified nodules. There has to be a strong indication for me to consider such cases. I generally start with rotational atherectomy (multiple runs) followed by angioplasty ...
How long do you continue aspirin and clopidogrel after and uncomplicated transfemoral carotid stent?
Typically one month, but many of our carotid patients have concomitant disease in other vascular beds and are often treated with prolonged anti-platelet therapy.
How do you decide the duration of DAPT following TAVR, especially for patients already on a DOAC?
ASA mono Rx usually suffices after TAVR. If PCI + TAVR is performed, then triple Rx for 2-4 weeks, followed by Clopidogrel + DOAC therefore.