Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is there any indication/benefit for heparin in a patient with suspected type 2 myocardial infarction?
There is no guideline rule for treating a type 2 MI like a type 1 MI. However, approximately 50% of type 2 MI patients have significant CAD (data from the University of Edinburgh published a year ago or so, in I think Circulation. My recommendation for type 2 MI is to treat the underlying condition ...
How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?
Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
For patients presenting with suspected type 1 NSTEMI and atrial fibrillation on anticoagulation, do you favor triple therapy or SAPT with systemic anticoagulation instead while awaiting LHC?
Standard therapy for acute coronary syndrome is suggested including statin therapy, beta blocker therapy, ACE inhibitors with DOAC use while awaiting LHC/PCI. UFH with the addition of P2Y12 inhibition during hospitalization is suggested even with DOAC use. A radial approach should be taken to decrea...
What is your approach to using beta-blockers in patients with acute myocardial infarction with preserved LV ejection fraction who undergo early coronary angiography in light of the REDUCE-AMI trial findings?
I would not change practice based on the findings of this study alone. Treatment cross-over in both arms of the study may obscure the potential benefits of post-MI beta-blocker therapy in patients with preserved EF.
What is your step-wise approach to differentiating SVT with aberrancy versus VT?
Good question, this is addressed with classic algorithms such as the Brugada criteria.They can be a little cumbersome so I use the best parts of that, which would be: The likelihood of VT is increased with: Age > 35 (positive predictive value of 85%) Structural heart disease Ischemic heart diseas...
Knowing that there is going to be significant PR prolongation with RA pacing, should a LBBA pacing lead be recommended in patients with a PPM indication and a significant first degree AV block (>250msecs) especially if the patient has a borderline LVEF (~45-55%) to prevent diastolic MR-pacemaker syndrome ?
Yes, this would certainly be reasonable, but less likely required. There are other considerations with LBAP, such as extended procedure time and lack of specific reimbursement for this extra time. If the patient is already tolerating this significant PR, it may not be worth the LBAP if it turns out ...
When and should you consider Watchmans for patients with high bleed risk/recurrent GI bleeds and valvular atrial fibrillation with moderate-severe mitral stenosis?
I am not aware of any studies that include those patients.In terms of watchmen in general, the debate still rages on. The most recent trial (non-industry funded) is the CLOSURE-AF Trial, which found that standard medical therapy (anticoagulation) was superior to catheter-based left atrial appendage ...
Could you describe the variables that influence your decision against or advocating for performing atrial fibrillation/flutter ablations in morbidly obese patients, versus opting for medical therapy and if so, choice of antiarrhythmic agent?
The short answer is yes. We know extreme obesity will increase procedural complications, including but not limited to anesthesia issues, groin access issues, etc. We also know the chances of meaningful long-term success in very obese patients are lower than what would be in the trials. Different EPs...
Which anticoagulant (DOAC or Warfarin) would you recommend in the case of a 70-year-old male with persistent atrial fibrillation and history of rheumatic mitral stenosis now status post bioprosthetic MVR?
There won't be perfect data on this, per the 2023 guidelines:The distinction between “valvular” and “nonvalvular “AF remains a matter of debate. Their definitions may be confusing. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants in AF were performed am...