Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Could plasmapheresis be reasonably considered in pregnant patients for primary prevention in asymptomatic familial hypercholesterolemia, and if so, is there an LDL cutoff that would prompt consideration to proceed?
Plasmapheresis/LDL apheresis is considered a safe and effective option for maternal LDL-C lowering in pregnancy, especially in women with homozygous FH, where it is considered standard of care. In heterozygous FH, the use of plasmapheresis for primary prevention is reasonable in patients with a true...
In an asymptomatic patient who has had a routine TTE for non-cardiac reasons, would you order further work-up if there are any WMA or mild LVEF reduction?
Yes, I will follow up with Echo again if he develops symptoms. Yes, I will do a stress test.
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
Should CCTA be considered the diagnostic test of choice in the outpatient evaluation of chest pain?
CCTA can not likely stand as a way of perfectly excluding ischemic heart disease, but neither can any test, such as ETT, SET, MRA, etc. As such, it seems attractive to individualize screening tests and even employ a complementary array of techniques.
When pursuing complex PCI of the RCA (especially when lesion preparation is required), when do you consider placing a transvenous pacemaker in anticipation of conduction abnormalities?
There are a few options when using roto for the RCA or a dominant LCX. Upfront TVP if you want to play it safe. Pretreatment with aminophylline 100-250 mg 10 minutes. Test run without pre-treatment and having atropine and/or TVP nearby at the ready. Which you choose depends on gut instinct and how...
What criteria do you utilize in deciding when to treat or not treat frequent VPC’s?
Symptoms (burden and severity) PVC burden (>15-20% may lead to a cardiomyopathy) Presence of LV dysfunction Interference with bi-ventricular pacing PVCs triggering VT or VF
When would you consider AV nodal ablation in CRT-non-responders with persistent atrial fibrillation?
AV node ablation is the most definitive method for rate control. In this scenario where the patient already has CRT and is a nonresponder, what I do next depends on age of the patient, how symptomatic the patient is, whether the rates are elevated causing the CRT pacing percentage to be suboptimal a...
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...
What strategies do you employ to minimize the risk of cardiovascular collapse when intubating a patient with severe pulmonary hypertension?
Intubating patients with pulmonary hypertension is a challenging medical and critical care situation. Generally, I try to apply principles of right ventricular optimization of care before I proceed with endotracheal intubation. Intubating patients with pulmonary hypertension is a challenging medical...