Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?
For the parasternal windows, your enemies are ribs and lungs. Regarding ribs: Whenever an image gets dark, people tend to try and crank up the gain knob to compensate. In many cases, however, it's usually because one of the edges of the probe is abutting a rib. Try and slide the probe a few millimet...
How would you lead a goals of care discussion in terms of prognosis/survival likelihood for patients with inotropic dependent HFrEF with CRT-D on maximally tolerated GDMT?
I usually start by reviewing the prognosis with inotrope-dependent HF, quote data from DT VAD trials (REMATCH). I assess the eligibility for DT VAD and transplantation and review the shared decision-making pathways (IDECIDE LVAD) if the patient is eligible for DT VAD. If the patient is not a candida...
How soon following pacemaker implantation can patients safely undergo elective cardioversion?
That is a good question. From a technical standpoint, a cardioversion can be done at any time after a pacemaker implantation. In the past, we often did defibrillation threshold testing on patients on the EP lab table after implanting an ICD and sometimes they would require a shock externally. This w...
For asymptomatic, incidentally found Lambl's excrescence, should long-term surveillance imaging be considered and if so, how often should repeat imaging be ordered?
For small Lambl's excrescence (often characterized as less than 10mm) and found incidentally in asymptomatic individuals, there is no data to support repeat imaging or surveillance. For large/giant growths, or those in the setting of cryptogenic or embolic stroke, further imaging with TEE may be nee...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
What is your preferred diagnostic approach to suspected immune checkpoint inhibitor cardiotoxicity in patients who are otherwise not clinically stable enough for cMRI?
The initial diagnostic imaging for a patient with suspected ICI myocarditis/myositis that is not clinically stable enough for a cardiac MRI should be transthoracic echocardiography. However, if the patient is clinically unstable to the degree that they are unable to have a cardiac MRI performed, the...
Similar to the HFA-ICOS risk stratification tool for patients on chemotherapy, are there cardiac risk calculators available for use in patients starting immunotherapy?
Currently, there are no validated risk calculators available for predicting ICI-induced cardiovascular immune-related adverse events (irAEs). Several risk factors have been reported to be associated with a higher risk of experiencing cardiac irAEs. These risk factors include a history of preexisting...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
What is your approach to evaluating a patient with a suspected myocardial contusion?
Echocardiogram and troponin levels...
Should systemic anticoagulation be considered for patients with a less than 1% atrial fibrillation burden on outpatient monitoring with an elevated CHADSVASc score and acceptable bleeding risk?
This is a recurrent question. My policy is to anticoagulate such patients. The cutoff for anticoagulation is still controversial though. I believe that any episodes lasting longer than 5 min deserve anticoagulation. Not so sure what to do with shorter episodes but my philosophy is that prevention of...