Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you decide between opting for semi-elective outpatient versus inpatient TAVR for patients with severe critical AS?
Most patients undergo semi-elective procedures, which are more favorable for hospital reimbursement and reduce the risk of acute kidney injury. However, in a small subset of patients (<20%) with critical aortic stenosis (AS) and severe symptoms, particularly syncope, inpatient management is required...
What factors should be prioritized when deciding the timing of CIED extraction in patients with high surgical risk or multiple comorbidities?
I'll do my best to respond, though the question isn’t entirely clear to me. If the intent is to determine which patients should be prioritized for CIED extraction, the key consideration is whether the benefits outweigh the risks. The most straightforward case is persistent bacteremia, especially in ...
What is your approach to medical management and echocardiographic surveillance for pregnant patients with severe aortic stenosis during the first, second, and third trimesters?
There is no need for routine echocardiographic surveillance during pregnancy if the patient is asymptomatic and there is no change in the level of BNP. The echo can be helpful for the assessment of pulmonary pressure in patient who develops symptoms .Change in the BNPlevel and echocardiographic PA p...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
Is there any data to support the use of bivalirudin over heparin in patients on VA-ECMO without ongoing concerns for HIT?
Multiple recent meta-analyses and retrospective studies suggest that bivalirudin may reduce the risk of circuit thrombosis, major bleeding, and in-hospital mortality compared to heparin in VA-ECMO patients, even in the absence of HIT.[1][2][3][4][5][6][7][8] Some studies also report improved time in...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
How would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
Proceed with coronary angiogram and dialysis after the procedure.