Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you consider adding metoprolol succinate to a medication regimen for a patient with paroxysmal Afib on sotalol, known CAD, HF with mildly reduced LVEF, assuming hemodynamics could tolerate it?
Yes, the mechanism of action does not overlap entirely and metoprolol succinate would be indicated for HFmrEF.
When would you consider performing direct implantation versus prior dilatation with balloon aortic valvuloplasty during TAVR?
Severe calcification of the aortic valve and Valve area less than 0.5 cm² or very high gradients, which could cause difficulty of the TAVR valve to cross the native aortic valve. Bicuspid aortic valve with severe calcification. If the coronary heights are borderline low, concerning for post-TAVR co...
Would you ever consider switching a patient with an LVAD from warfarin to Eliquis, such as in the setting of recurrent GI bleeds?
In general, warfarin remains the agent of choice in VAD patients. However, in patients with INR non-adherence or recurrent GI bleeds, it is an option. In this situation, ensure that GI bleeding is stopped and start 2-3 days after warfarin is stopped. Monitoring with anti-factor Xa monitoring can be ...
Do you favor aspirin or P2Y12 inhibitor monotherapy following completion of 12 months of DAPT post-PCI in patients with elevated bleeding risk?
You could tailor based on bleeding risk. If prior upper GI bleed or symptoms - p2y12. If lower GI bleeds - aspirin. The field is moving towards p2y12 monotherapy. Also as mentioned should do genetic testing if thinking long-term clopidogrel monotherapy.
Should CT coronary calcium score be avoided in dialysis patients in light of presumed high prevalence of CAC in this population?
The incidence of coronary calcifications in patients on dialysis exceeds 80% and is between 50-80% in patients with CKD. In addition, dialysis and ESRD cause two types of vascular calcification - in the medial and intimal layers, the latter being the one that correlates best with atherosclerotic pla...
Are there any heightened risks for cardioversion following a recent PCI from a stent patency standpoint or hemodynamic concerns?
Most of our concerns about procedures soon after PCI revolve around the issue of anticoagulation. In this case, as long as the patient could receive an anticoagulant while on antiplatelet therapy (at a somewhat increased risk of bleeding), a cardioversion is possible. Though there is a hypothetical ...
How do you manage asymptomatic non-sustained atrial arrhythmia in patients with single ventricle and Fontan physiology?
This is an excellent, challenging question and I think experts will disagree and debate the issue depending if they are risk-minimizers or cost-minimizers and if patients are worriers (woulda, coulda, shoulda) or data-driven/evidence-based (need to see large studies with proof before action).I like ...
What cardiac testing do you perform for patients undergoing liver transplant evaluation?
Each institution I am aware of has slightly different approaches to cardiac testing for transplantation candidacy. In our institution, we have patients undergo a TTE with a bubble study at a minimum. However, patients with any risk factor for coronary disease will undergo coronary angiography (CT or...
When do you recommend screening patients with T2DM for heart failure?
Screening patients with T2DM for heart failure is recommended at the time of diagnosis. This recommendation is based on the increased risk of HF in this population, even in the absence of symptoms. The American Diabetes Association guidelines recommend that screening for asymptomatic heart failure i...
How do you choose between finerenone and traditional steroidal MRAs for patients with heart failure and mildly reduced or preserved EF, considering recent results showing finerenone's efficacy in reducing heart failure events?
Not only is cost coverage important, with reduced rates for commercial, but not Medicare/Medicaid pts, but the expected reduced adverse drug effect profile of finerenone over spironolactone or eplerenone. That is relevant when treating men with borderline hyperkalemia.