Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your outpatient approach to patients with new-onset paroxysmal atrial fibrillation in the setting of acute illness but who are otherwise asymptomatic with normal sinus rhythm post-hospital discharge?
I tend to individualize my approach. In general, I consider any significant episode of atrial fibrillation with a chadsvasc 2 score =/>2 to warrant long-term anticoagulation provided no bleeding contraindications. An acute illness involving infection, trauma or surgery would not likely steer me awa...
When would you consider PPM implantation for intermittent episodes of high-degree AVB that persist following a successful PCI in a patient presenting with an inferior STEMI?
AV block that occurs with an inferior STEMI is not usually caused by interruption of the distal conduction system and is often reversible. The key term in the question is "persistent." How long after the MI has AV block been observed, what is the heart rate, and is the escape rhythm wide or narrow? ...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...
What factors influence your choice between low-dose DOAC therapy and dual antiplatelet therapy for the first 3 months after percutaneous left atrial appendage occlusion?
Using the ADALA study and previous observational studies, the use of apixaban 2.5 mg BID appears to be at least as safe if not safer than the use of DAPT. As a result, in patients who are unable to tolerate full-dose anticoagulation, low-dose DOAC is my first line. However, if patients have cerebra...
Do you recommend the use of bempedoic acid (Nexletol) for treatment of hyperlipidemia in patients with elevated baseline uric acid levels?
I would still use bempedoic acid in patients with asymptomatic hyperuricemia if they have no previous history of gout, and will clearly benefit from lipid lowering (high risk ASCVD and statin intolerance). Would monitor uric acid levels in such individuals. However if they have had recurrent gout, I...
When do you consider revascularizing chronic total occlusions after failing medical management?
CTO revascularization is recommended for refractory symptoms despite optimal medical management with anti-anginals and after treating non-CTO lesions (grade 2b recommendation- 2021 AHA/ACC/SCAI revascularization guidelines).
For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?
Elective left atrial appendage occlusion with both Watchman and Amulet systems most often utilizes continuous uninterrupted oral anticoagulant administration (including the day of procedure) along with intra-procedural heparin to ACT 250-400 during implant. Procedural heparin is reversed immediately...
Given findings from the LIFE trial, are there any benefits in using Entresto over valsartan alone in HFrEF patients?
Thank you for your question. The LIFE trial studied more advanced heart failure patients. In this patient population, there was no apparent difference in overall outcomes between the two groups in the primary and secondary endpoints but a rise in non-life threatening potassium levels in the Entresto...
What patient characteristics prompt you to prescribe vericiguat for patients with heart failure with reduced ejection fraction who are already on standard therapy?
When considering the addition of vericiguat for patients with HFrEF who are already on standard therapy, several patient characteristics guide my decision-making process: Recent Decompensation: I particularly consider vericiguat for patients who have experienced a recent episode of heart failure de...