Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
What is your outpatient approach to monitoring paroxysmal atrial fibrillation (i.e. mobile cardiac telemetry, decision to anticoagulate if high likelihood of recurrence) in young adults with CHADsVASC score of 0, in light of potential remodeling and increased Afib burden as they age?
This is an important question, especially in light of the most recent data suggesting that early maintenance of sinus rhythm is beneficial in patients. If the patient truly has a CHADsVASC score of zero, they have lone atrial fibrillation, low stroke risk, and our major concern is prevention of remo...
How do you determine the feasibility of doing a valve-in-valve for patients requiring AVR with index surgical aortic valve replacement?
The feasibility of doing a valve-in-valve TAVR for patients with preexisting SAVR all rests on a high-quality CT pre-planning analysis. a good high-quality study will reveal important information regarding the primary access approach for the TAVR, coronary heights, sinus widths, valve-to-coronary di...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
When would you consider initiating patients with CAD and aortic stenosis on PCSK9 inhibitors (as an adjunct to statin therapy), given favorable findings in the FOURIER trial?
There are limited data to support PCSK9 inhibitors in the treatment of aortic stenosis, and in fact, most is theoretical. Elevation of lipoprotein (a) levels independently increases the risk of in early-onset CAD and calcific aortic stenosis. Lp(a) levels are lowered by PCSK9 inhibitors by ~20-30%, ...
Are there scenarios in which pericardiocentesis should be considered for large pericardial effusions without tamponade physiology?
Yes
Is there evidence to support empiric atrial flutter ablation for patients undergoing PVI for atrial fibrillation in the absence of clinical evidence of atrial flutter?
Presumably, triggers for typical atrial flutter, emerge from the left atrium. No randomized trial has shown the combined ablation is more sensible than performing one sided atrial ablation without evidence of typical right atrial flutter.
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
Which type of patients with asymptomatic peripheral arterial disease with an ABI score of less than 0.9, is it reasonable to offer antiplatelet and statin therapy to?
This is an important question. Unfortunately, there is no good evidence to help answer it. So what I am about to say is not evidence-based, but it is common sense. Since patients with PAD have an increased rate of MI, Stroke, and CV death, they should all receive maximum medical therapy. I believe t...
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...