Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How would you treat an elderly patient with borderline cardiac dysfunction who has stage 3 HR+ HER2- breast cancer?
If she has an invasive lobular carcinoma and is a borderline candidate for chemotherapy, can possibly try using neoadjuvant letrazole for 3-6 months with close monitoring with breast MRI every 2 months to make sure there is no progression and assess response. If she is lucky and has CR/PR, then poss...
What is your approach to anticoagulation in patients with hypertrophic cardiomyopathy and an apical aneurysm?
Patients with hypertrophic cardiomyopathy and an apical aneurysm are at higher risk for sudden cardiac death (hence the 2a guideline recommendation for primary prevention ICD) and thromboembolism. Rowin et al., PMID 29122139 previously noted that non-anticoagulated HCM patients with apical aneurysms...
What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?
I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is...
Do you recommend patients with hypertensive kidney disease transition from wrist to upper-arm home blood pressure monitoring prior to making dose adjustments to their antihypertensive regimen?
Possibly, if I think the measurements are not accurate. Home BP monitoring is an important part of hypertension management. In my practice, I've noticed that positioning while taking the BP is more important than the specific device type. I advise patients to check their BP at home in a hard-backed ...
Are there standardized, discrete cut-off values in T1/T2 mapping and extracellular volume fraction to aid in the diagnosis of various cardiomyopathies, or are these values largely scanner/institution specific?
T1/T2 mapping and extracellular volume fraction (ECV) are advanced parametric mapping MRI techniques increasingly used in the diagnosis and tissue characterization of different cardiac pathologies. However, the standardization of cut-off values for these parameters remains a challenge. These values ...
With the rise in home monitoring devices, how should we approach asymptomatic NSVT detected in healthy individuals with no prior cardiac history and with low risk cardiac profile?
With home monitoring devices, we are finding a lot of arrhythmias that would have previously remained unidentified. If episodes of NSVT are being found on home monitoring devices, the patient should receive a formal monitor to confirm NSVT. The formal monitor should be a Holter monitor that is able ...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...