Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Can mavacamten be considered for patients with HCM and ongoing dyspnea in setting of an elevated LVEDP but without significant LV outflow obstruction on imaging?
Yes, mavacamten may be a viable option for patients with HCM who have persistent dyspnea and elevated LVEDP, even without significant LVOT obstruction. While most of the evidence for mavacamten focuses on obstructive HCM, emerging data suggest it may have a role in non-obstructive HCM as well.The MA...
For a patient with known CAD and low baseline HDL, would a PCSK9 inhibitor be a better option than a statin, given concerns for paradoxical lowering of HDL levels with statin therapy that we can encounter in the outpatient clinical setting?
Statin therapy would still be your first choice as we know that they reduce CVD related outcomes regardless of the HDL. In fact, studies show that patients with low HDL benefit even more from statin therapy.
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
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 ...
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.
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...